Poverty-Targeted Social Assistance and Health Utilization in Armenia

1. Poverty-Targeted Social Assistance and HealthUtilization in Armenia Edmundo Murrugarra Nazmul Chadhury Jeff Hammer Rodica Cnobloch REACHING THE POOR CONFERENCE February 18-20, 2004 World Bank Washington, D.C.

2. Contents • Introduction • Health sector background • Fee waivers and targeting reform • Effects on utilization • Conclusions

3. 1. Introduction • How to improve health care access among the poor? • Price: Fee-waivers • Income transfers • Exploit a natural experiment • Eligibility expansion change in Armenia • Effects on utilization (not OOPs, type of provider)

4. 2. Background • Armenia: Fiscal collapse, low public expenditures on health (less than 2% GDP) • High poverty incidence (>50%) • Decreased utilization • Relying on OOPS • Marked inequality in health care utilization

5. 2. Background

6. 3. Fee waivers (1) • Social Assistance Reform (1998-1999) Improved incidence of social assistance

7. 3. Fee waivers (2) • Basic Benefit Package (BBP), part of the reform • Provided freely for eligible individuals • A.Demographics (4+ kids, orphans) - Majority • B. Disability • Previous findings (1996-1998) • Improved utilization for those disabled (group B) • No effect on other groups • Group A: largest decline in utilization • Worked as an income transfer.

8. 3. Fee waivers (3) • 2001 Reform: Eligibility expansion • Poverty Family Beneficiaries entitled to BBP freely: poverty targeting in health care

9. 3. Fee waivers (4) • Data: • National Household surveys 1998/99 , 2001 • Similar sample design and instruments • Focus on health care utilization

10. 4. Effects on utilization

11. 4. Effects on utilization

12. 5. Conclusions • After dramatic adverse effects on utilization, gradual reduction in inequality • Reflects the financial protection of the poor • The better off suffered declines anyway • Also reflects improvements in institutional and budgetary arrangements