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MAPs, HSR, and Safeguarding the Health Sector

MAPs, HSR, and Safeguarding the Health Sector. D Narayana, 2 July, 2008 Based on, Haddad, Baris, and Narayana (eds.) Safeguarding the Health Sector in Times of Macroeconomic Instability: Policy Lessons for Low- and Middle-Income Countries, IDRC and Africa World Press Trenton, NJ, 2008

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MAPs, HSR, and Safeguarding the Health Sector

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  1. MAPs, HSR, and Safeguarding the Health Sector D Narayana, 2 July, 2008 Based on, Haddad, Baris, and Narayana (eds.) Safeguarding the Health Sector in Times of Macroeconomic Instability: Policy Lessons for Low- and Middle-Income Countries, IDRC and Africa World PressTrenton, NJ, 2008 Workshop 33: Social Inequalities in Health The 33rd Global Conference of the International Committee for Social Welfare, June 30- July 4, 2008, TOURS, France

  2. Social Inequalities and Health Sector • Social inequalities in Health and Mortality • A fact the world over, many countries • Root cause- social and income inequalities • Inequality along the full gradient • Deliberate social policies protecting social benefits flatten the gradient, e.g., Canada • Major influence on policy change- MAPs, HSR • Focus on Safeguarding the Health Sector under Adjustment

  3. Macroeconomic Adjustment Policies and HSR • MAPs high diversity and implemented variously • HSR- Commonalities, within given health systems • Enshrine health as a constitutional right • Colombia, Mexico • Universal coverage through National Health Insurance Act- Thailand • India- health in the Directive Principles but not a fundamental right • Three different structures • Govt + social insurance, Mexico, Col. • Govt + pvt (insurance absent) Thai, Ind • Govt with donor assistance, Zim, B Faso

  4. Health Sector Developments • Burkina Faso- 53 health districts • Colombia- devolve responsibilities, resources to municipalities, Mayors responsible for health • Mexico- decentralized state secretaries responsible for package of services • Since 1986 expand social insurance cover • India- decentralisation but health still under the ministry • Kerala, highly decentralised, but health budget not devolved • Universal coverage with focus on poor • Thai- since Thai Medical Welfare scheme, later universal coverage scheme

  5. Access to care • Burkina Faso • High margins on drugs • Country with the most expensive drugs • Outlying villages, primary care less accessible • Mexico • Access to health care of the poor improved • More resources for states with worst conditions • Access to secondary care inadequate • Colombia • Health insurance coverage improved • Has become equitable across income levels, age, educational level • 62% subsidies going to bottom 40% • Highest quintile subsidy, -5.3%

  6. Access to care • Thailand • Insurance coverage 33% in 1991 to 80% in 98 • Better access for the poor nearer home • India • Public resources have not increased • Population increasingly going to private • Out of pocket exp- heavy burden • No financial protection • Zimbabwe • High pub exp on health care • (Cushioned poor from –ve effects of Adjustment)

  7. Findings in terms of six questions • Do MAPs lead to HSR? • Eco growth necessary for increased public spending? • Have the poor been protected? • Does increased public expenditure lead to better access? • Have inequalities in access come down? • Is there a lesson for World Bank in policy design?

  8. Do MAPs lead to HSR? • No simple relationship • All countries implemented MAPs • Content, timing, sequencing varied • Content of HSR varied • HSR canvas broader than “pro efficiency” sectoral reform • Broader canvas: health as a right, decentralisation, equity • Only in Burkina Faso, HSR integral to MAPs • Elsewhere, HSR an “extension” or independent of MAPs

  9. Eco Growth necessary for increased public spending? • Economic Growth not necessary • Low growth not a deterrent. • Egs Zimbabwe, Colombia • Thailand- high growth- steady increase • High growth no guarantee • India- consistent high growth • HSR- narrow economic concern • Still no increase in public spending

  10. Have the poor been protected? • Yes. To a large extent. • Almost every country is concerned • Rich or poor, high growth (Thailand, Burkina Faso) • Low growth (Zimbabwe, Colombia) • Major exception- India • Health care of the poor not a central issue, not even in the celebrated Kerala!

  11. Have Public Expenditure increased? Inequalities in access come down? • HSR does not lead to Pub Exp Increase • Complementary processes needed, E.g. Burkina Faso • Broader political concern called for • Have inequalities come down? • Mixed experience • Colombia, Thailand- poor benefited • Zimbabwe- to an extent poor benefited • Mexico- primary care access improved • Burkina Faso- access unequal • India- not a concern, no improvement

  12. A Lesson for the World Bank • Best technical HSR has poor chance of success • If, political concern is lacking-Burkina Faso • “Inefficient” reform might deliver-Zimbabwe • Best solution- lot of political concern plus technically sound HSR- Thailand, Colombia • Decentralisation is a strong catalyst • Decentralisation improves the chance of success • But lack of political will could be detrimental • E.g., India, Kerala in particular

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