NHI for UHC:

Final Thoughts and Reflections

ADB

Sep 29, 2016

Soonman KWON, Ph.D.

Chief of Health Sector Group (Tech Advisor)
Asian Development Bank

Former Dean, School of Public Health

Seoul National University
Disclaimer: The views expressed in this paper/presentation are the views of the author and do not necess
arily reflect the views or policies of the Asian Development Bank (ADB), or its Board of Governors, or the
governments they represent. ADB does not guarantee the accuracy of the data included in this paper and
accepts no responsibility for any consequence of their use. Terminology used may not necessarily be con
sistent with ADB official terms.

Kwon: Reflections on NHI UHC

I. Paradigm Change
NHI as a means to achieve the goal of UHC
NHI: putting various sources of revenue in a big pool for effective
purchasing of health care for people

- Contribution: Korea, Taiwan

- Earmarked consumption tax (Ghana), earmarked non-wage income
tax (France, Taiwan)
- General revenue: China, Thailand

Political Economy of NHI and UHC:

need to consider both evidence and politics
Kwon: Reflections on NHI UHC

2. How to help more people have Access to Health

Care?: Extension of Population Coverage?:
Mandatory public financing
- Principle of social solidarity
- Income-based contribution is not possible in voluntary financing
Political mobilization and commitment: role of subsidy
e.g., China, Thailand
Unique ID and ICT: targeting, enrollment management (India)
Social marketing, health insurance literacy
Virtuous circle: make benefits more attractive to people
e.g., outpatient benefits package
Kwon: Reflections on NHI UHC

3. Where the Money Comes from?

Contribution and Tax as a major source of financing
Fiscal Space

- Expanded contribution base: contribution on all types of income,

e.g., financial income
- Efficiency gain, e.g., rational use of medicines, provider payment
- Political prioritization on health: health as investment
- Sin tax: limited impact on revenue generation
-> crowding out?, need policy prioritization on health
-> Sin tax for public health purpose (behavioral change)
rather than revenue generation
Kwon: Reflections on NHI UHC

4. Which Services to Offer?: Benefit Coverage

Purchase continuum of care
- need good referrals, quality primary care
Cannot cover every service
- Need priority setting, How?
- Benefits are still loosely defined, and the process to determine
benefits package is not transparent in most countries
Should institutionalize a formal process based on
- Evidence: economic evaluation, reduce political manipulation
- Social value judgement: citizen participation,
high-level committees
Kwon: Reflections on NHI UHC

5. Purchasing
How to motivate health care providers to provide care in a
cot-effective way?: Incentive and regulation

How to pay
- Move away from fee-for-service toward bigger units of
payment, e.g., capitation, case-based payment (DRG:
Diagnosis-related Group)?
How much to pay
- Costing: capital cost, operating cost
- Differential or same payment to public and private
providers?
Kwon: Reflections on NHI UHC

6. Governance
How to ensure the performance and accountability of NHI agency?
(especially when it is a monopoly (single insurer))
- Citizen participation in policy making: procedural justice
- Relation between government ministry and NHI agency:
optimum autonomy?
Conflicts among government ministries
- MoF, MoH, MoSW, Social Security Agency
- Social Security Agency or Separate Health Insurance agency?:
Different nature of pension and health insurance
Local/state governments: Coordination problems
- India, China, Japan, Indonesia
Kwon: Reflections on NHI UHC

7. Unfinished Agenda:
Service Delivery and Provider Behavior
How to maximize purchasing power
- Single pool rather than multiple pools
- Pooling of tax and insurance reimbursement to public providers:
reduce direct budget allocation to public providers and use them
as subsidy for those who cannot afford to pay contribution ->
position of MoH, MoF, H Insurance agency?
Contracting with providers
- Quality of care: incentive and regulation (or accreditation)
e.g., minimum quality standard
- Financial burden on patients (e.g., balance billing)
Kwon: Reflections on NHI UHC

7. Unfinished Agenda:
Service Delivery and Provider Behavior (continued)
Should Revitalize Primary Care
- Gatekeeping for efficiency
- Front-line providers in health security issues
e.g., infectious disease
- Focal point for the continuum of care for older people
- Prevention and promotion for NCDs:
e.g., physical exercise, health education,
community-based interventions
Kwon: Reflections on NHI UHC