1 / 23

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.

jerod
Télécharger la présentation

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

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  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

More Related