Combating Exclusion and Removing Barriers: Improving Health

1. Combating ExclusionandRemoving Barriers: Improving Health The World Bank Roma in an Expanding Europe: Challenges for The Future Budapest, Hungary June 30-July 1, 2003 Cristian Baeza

2. Health interventions Health Systems as contributors to health Producers HR, Goods and Services Health Providers Utilization Financing Contributors

3. Health interventions Health Systems as contributors to health Producers Citizens Sector Governance and Stewardship HR, Goods and Services Health Providers Utilization Demand Financing Preferences, believes and behaviors Consumers Contributors

4. Health interventions Objectives of Social Protection and Inclusion in Health Housing Income Producers Citizens Financial Protection Human Development Household Welfare Production Function PRS Health Utilization Providers Dignity Food Consumers Contributors Education Social Integration

5. The Objectives of Social Protection and Inclusion in Health • To maintain and improve the health status, ensuring inclusion to those excluded from access socially accepted level effective and needed health services. Health not only as an essential component of their human capital for overcoming poverty but as an essential part of the Human development objective. • To do so ensuring sufficient financial protection to avoid excess contribution that could force households into poverty or make it impossible for them to overcome it. • All under strict respect for the dignity, freedom and human rights. The Key Importance of an Explicit Society Guaranty: Entitlement

6. Causes of Exclusion • Not defined or poorly defined priorities of interventions and/or lack of enforcement of the GHP (under-coverage) • Incongruities between the type of intervention and the financing and/or health care delivering mechanisms Supply problems Demand problems

7. Exclusion Due Problems With Access and Utilization of Health Services Problems Possible Solutions No providers. Increase “eligible” providers: - Investments - Reduction of barriers to enter - Purchasing of Services Supply Non-eligible providers Training and education Incentives Inefficient or low-productive providers Providers that discriminate against particular users Strengthening purchasing function Purchasing and regulation mechanisms Need to address the specific cultural characteristic of the target population “Dignity” barriers Demand Educational campaigns to the population Increasing effectiveness of providers Services considered unnecesary Services considered necessary, but there is no WTP for it Ensure the congruence between interventions and instruments in GHP Services considerednecessary, but there is no ability to pay or high oportunity cost Improving the efficiency and magnitude of the “equity subsidy”; negative prices?

8. Innovations for Problems on the Demand of Health Services • Bolivia: Maternal and Child Insurance • Responding to the cultural context • Mexico: “Progresa” / “Oportunidades” • Stimulating demand via conditional cash transfers

9. LURATANAKASA(THE PERFECT EQUILIBRIUM: THE COLORS OF THE LIFE AND GOOD OUTCOMES)BLACK: LIFE AND GOOD OUTCOMESRED: SUN, PREVENTION AND PHISYCAL HEALTHGREEN: LAND, NUTRITION AND INCOME YELLOW: DIGNITY AND QUALITY OF LIFEWHITE: DEATH Maternal and Child Insurance in Bolivia

10. Maternal and Child Insurance in Bolivia • Basic health insurance (1998): 92 interventions with impact on the 56% of all causes of disease and death in Bolivia. • The cultural dimension: 10 more non medical services such: • Rescue of the soul, • Returning back the placenta to the land (pachamama) • Traditional vademecum • Yanapiri (to hear and give a wise-health advice in ancient medicine, etc.)

11. Causes of Exclusion Due to Problems in the Financing Function

12. Exclusion Due to Problems in the Risk Pooling Mechanism Possible solutions Problems There are no pooling arrangememts or those existing are inefficient Development and promotion of pooling schemes “Pooling” problems (Problems with cross-subsidization from low to high risk groups.) Pooling schemes working but users are not eligible Elimination of eligibility barriers for the self-employed and small businesses owners, modification of legislation, community rating, and equity subsidies There are pooling schemes but users consider them unnecessary (no demand) Educational campaigns Mandatory affiliation to insurance schemes (avoid free riders) There are pooling schemes but no ability to pay from users Expand risk pools and development of equity subsidies

13. Innovations in Pooling • Targeting and adaptations of public health insurance to excluded populations • Bolivia: Maternal and Child Insurance • Chile: Guaranteed Health Plan (AUGE) • Demand side subsidy for Insurance coverage for the poor • Colombia: Subsidized modality • Community Based Health Organizations

14. Exclusion due to Problems of Equity Subsidies Problems Possible solutions Users do not participate in existing pooling schemes because they can not pay the premiums (insuficient equity subsidy) • Ensure an adequate level of equity subsidies: • Within pooling schemes • Among pooling schemes (solidarity funds) • From public sources (general taxes) Users participate in existing pooling but pay in excess due to insuficient equity subsidies Problems with the equity subsidy Pooling schemes with sufficient equity subsidies available but with no “portablity of subsidies” Develop “portability” of subsidies among public sector or insurance schemes Improve risk adjustments according to the number of members of the household Improve purchasing efficiency in private and public sectors. Pooling schemes where users pay too much due to the inefficient “portability of subsidies”

15. Combating ExclusionandRemoving Barriers: Improving Health The World Bank Roma in an Expanding Europe: Challenges for The Future Budapest, Hungary June 30-July 1, 2003 Cristian Baeza

16. Effects of risk pooling Cross-subsidization from lower to higher risk individuals Required household contribution Higher Risk Before risk pooling Lower Risk Required household contribution Lower Risk Higher Risk After risk pooling

17. Risk pooling Cross-subsidies from lower to higher risk Equity Cross-subsidy from higher to lower income High income Required household contribution Required Household contribution Higher Risk Lower Risk Low income Required household contribution Required household contribution Lower Risk Higher Risk High income Low income