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Social Health Protection in Low Income Countries Building up from the evidence

Social Health Protection in Low Income Countries Building up from the evidence . Marame NDOUR AfGH Seminar on UHC – Madrid - 25 October 2012. Social Health Protection in LICS : a global social challenge.

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Social Health Protection in Low Income Countries Building up from the evidence

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  1. Social Health Protection in Low Income Countries Building up from the evidence Marame NDOUR AfGH Seminar on UHC – Madrid - 25 October 2012

  2. Social Health Protection in LICS : a global social challenge • Huge inequalities in access to health services which reflect inequalities in wealth & power • HC spending inversely proportional to global burden of disease • 80’s : healthcarereform in LICspoliticallydriven by influential institutions (WB, Usaid, OECD…), pro-marketapproachinfluencingresearch & policymaking • 2000’: UHC push by WHO “the single most important concept in public health today” : new Alma Ata?

  3. Exit from a market style blueprint for healthcare protection in LICs ? • Previousassumptions: LICslack the tax base to developpubliclyfundedhealthcare • Solution : out of pocketspending/user fees • inefficient in HSS ; failed to increase revenue • failed to adressinequalities in access to health care • Recentparadigm shift and attempts to reshapehealthcaresystems to widenaccess • Abolish user fees , subsidize free healthcare initiatives • Riskpooling social healthinsurance…

  4. The situation in LICs • « Inverse care law » : thosemostsubject to ill-health are least able to pay for it • Lowlevels state and private HC spending • High level of diseases of poverty, preventablemortality // beginning of an epidemiological transition (NCDsburden) • Poor infrastructure of 1ary & 2ndary HC; shortages of skilledhealth staff; highcost of modern medicines and medicalequipment • Inequalities in access : rich/poor; rural/urban; preferentialaccess for the elite and formalsector • Lack of local and democratic control over healthpolicies

  5. Whatdoesn’twork? • Chargingevensmall user fees: financialbarrier, complex, costly, inefficient • Two-tiersystemswith services targeting the poorest & generalattempts to target and exempt poor people in LICs • difficulty to identifythosequalified • inclusion/exclusion problems • Private health insurance: still no evidence that it can benefit more than a limited group of people • Profit drivenprivateactorsinvolved in delivery of services intended to benefitpoor people • Privatesector of itsowncannowheredeliver a comprehensivehealth care system • Needs to becombined to public subsidy and provision for mostdemanding & unprofitable cases Oxfam 2006, In the public interest

  6. Whatdoeswork for the mostvulnerable? • Universal, free or extremelylowpriced services are more effective to achieveequity & widenaccess • 2% of GDP Govtspending on a UHC system wouldallow to reduce or eliminate user feeswith a hugebenefit for the poorest(2005 Equitapresearchhealthequity in Asia) • Wellorganized, upgraded and adequatelyfundeduniversal public services • Supportive actions to ensuremostvulnerable have access to & use these services

  7. NEPAL26.6 million83% of the population live on less than US$2/day • Enormous health challenges, wide inequalities, e.g in maternal and child care • 1 in 80 women will die in pregnancy or childbirth • Skilled birth attendance: richest 20% of women benefit 12 times more than the poorest 20%; • 1 in 19 children will die before their fifth birthday: twice likely to affect children in rural areas • Strong political will for UHC backed by donors- Right to health enshrined in 2007 constitution - Move from 7% to 10% of national budget on health

  8. Key Social Security Programmes • Maternalhealth programmes • Safe Delivery Incentive” in 2005 •  transport; user fees abolition in 25 poorest districts; financial incentive for health workers attending deliveries • “Aama”in 2009 •  free hospital deliveries, antenatal & post natal & family planning services for allwomen in publichealth facilities • Free essential health care services • 2008 : user feesremoval in public health facilities throughout Nepal (for PHC; free essential medicine, targeted free 2ndary care for senior, disabled, minorities...)

  9. Positive impact • General increase in utilization of healthcare • outpatient care doubled • inpatient care increase by 6-10 folds in 2 years of user fees removal • < 50% increase : number of women giving birth in health facilities • remarkable increase : 6% to 20% in most poor districts • significant reductions in the cost of care for women • Improved equity in access to services • the poor, senior citizens, women and marginalized people are benefiting more than other groups

  10. Nepal Free healthcare initiatives challenges • Low awareness about the free healthcare initiative • Low fundingin 2010/11 • government spending around 7% • per capita health gvt allocation US$7.60 (far lower than the WHO recommended US$60) • Health systems shortfalls • Inadequate health infrastructure; poor referral system, Inadequate human resources (trained health workers shortages go abroad/private), 1:30 000 doctor ratio

  11. Gvt plans: introduce mandatory health insurance • Pilote scheme in selected districts in 2012  nationwide in 5 years • Mandatoryenrolment + premium • Extension of coveredhealth services • Concerns: risk of scraping the free healthcarepolicies, high premiums, inefficient exemptions for targeted groups • Evidence from Ghana and Tanzaniashows thathealthinsuranceisoften inefficient and exclude the poorest and mostvulnerable

  12. Evidence fromAfrican countries • RWANDA: 60% of population live withlessthan 1$/day • Mutualhealthinsuranceschemes • Pilot scale in 1999 • Rural/informalsector coverage • 2$ (enrollment + 10% co-payment of cost of services) • Lawsenforcementrequiring Mutuelle enrollment • Scale up to more than 91% coverage in 2010 wheremostcommunityinsurance are far below 10% of coverage • Citedquestionablyas an example of how communityhealthinsurancecanscale up to achieve large coverage

  13. Rwanda achievements … can not beonlyattributed to Mutuelles ! • Insurance coverage • 2003 to 2010 : 7% to 91% • Services utilization • 0.31 to 0.95outpatientvisits per capita • Under 5 mortalitydecreased • 2005 to 2010 : 12,5% to 7,6% (similar to South Africa, India) • Secret n°1 massive increase in gvthealthspending • 2002 to 2010 : 10US$ to 48US$ per capita on health • 2006 : of all healthspending 53% fromdonors, 28% private, (of which 5% Mutuelles), 19% public

  14. N°2: Improved service delivery + subsidization • Upgradedcomprehensive service delivery • Increasedhealth personnel; Reinforceddrugsupply • New equipment and general infrastructure improvement • Improved management (strong leadership and politicalwill, effective implementation…) • Combined to financialbarrierreductionthroughsubsidization • Utilization rates doubled/tripledonlyafter (2$)/year Mutuelles enrollmentweresubsidized & premium removed • 37% of enrolledhouseholdssponsored by government • 2011 study shows the impact of co-paymentsupression on utilization of PHC facility in Mayange district

  15. Annualizedutilization rates for Mayange and 2 neighbouringhealth centres Jan-2005 to September 2007 (Dhillon & al, 2011)

  16. Gvt plan to raise premiums WHILE co-paymentsremain an important barrier to access ! • Co-payment: minimal contribution to local healthcarefinancingwhilecostly to levy & manage • Upgraded services alonedid not generate a dramaticincrease in utilization+ combinationwithfeesremoval • Point-of-service payments discriminate against the poor  disproportionate use of healthcare by the wealthy • Lack of money = barrier to healthcareamong 83% of the lowestwealth quintile // 52% in highestwealth quintile (2005) • Othereconomiccosts : geographicbarrier; opportunitycosts for farmers…

  17. “Higher coverage rates, often used to measure the success of insurance programmes are not sufficient to improve access (ILO, 2002) • Currentcost of subsidising all mutuelle premiums and co-payment = 25 million US$ • Total cost of absorbingco-payments + completesubsidization of Mutuelle = 75 million US$ • Challenges : expandaccesswithoutaiddependance • Possibilities : • move to a centrallyfinanced care free to the population (donor support) • Middle ground: targetlowerutilization, providetimelyaccess for the poor ? • Examine ways of eliminatingco-payments, increasingsubisides for enrollment , expanding free services including curative care and free primary care to priority populations (children, pregnantwomen…)

  18. DIRECT PAYMENT EXEMPTION POLICIESA critical component in promoting universal access to social health protection ? • Gradually became prominent in a large number of low income countries • First dedicated to increase success of HIB/TB patients with international funding • Lately focus on maternal and child mortality & morbidity, PHC, elderly... • Requirements : precise planification, broad quality services coverage, adequate and sustainable funding • Potentially play a role in providing social health protection for the most vulnerable

  19. Coverage for indigent & priority population • Free coverage for women/Childrenunder five • Geographic SENEGAL: delivery care costs totally subsidized everywhere except in the capital Dakar • Services NIGER: free contraceptive services, antenatal care, deliveries, c-sections, breast & uterus cancers treatment ; consultations, surgery, medicines, and laboratory tests for children under 5 • 100% subsidization (exceptco-payments Burkina/Kenya) • Access in public and privatefacilities • Niger, Senegal, Sierra Leone : childbirth free only on public hospitals • Benin, Burkina, Burundi : also in private not for profit health centres • Kenya: private for profit and private not for profit sector

  20. Sustainability challenges of these policies • Difficulties in implementation: lack of planification, acute funding shortfalls (unpaid healthcare bills, lack of external aid support predictability if any) • Targeting uneasy: complex definition of “poor” beneficiaries • People uninformed of their rights • Risk of non-compliance with free policies, informal fees • Complexity to articulate different co-existing free policies • Scaling up and transition to UHC?

  21. Positive impactsEvidence from West African Countries (report to bepublishedearly 2013) • On population • promote access to essential care, remove financial barriers • empower populations • benefit all, including the disadvantaged • On health services • opportunity to improve the quality of care (prescription, rational use) and improve health services efficiency • reinforce resources and strengthen community participation • If well prepared and funded remain a realistic intermediary option for West-African countries striving to achieve UHC • Strong political will needed + accountability to populations • What about the Abuja promises?

  22. Many thanks for your attention ! Marame NDOUR mndour@oxfamfrance.org

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