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Investigating the impact of micro-health insurance and user fees on health care utilization and financial equity in Rwanda. Analysis based on data comparing service use, household income, and poverty levels. Recommendations for policymakers to improve access to health care for the poor.
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Micro-Health Insurance and User Fees: Quanitifying Horizontal Equity and Impoverishment in Utilization and Financing of Health Care Evidence from Rwanda Reaching the Poor Conference Washington DC - Feb 19, 2004 Pia Schneider London School of Hygiene and Tropical Medicine (LSHTM) Abt Assoc. Inc.
Outline of Presentation • Financial access to care under: • Micro-health insurance (MHI) and User fees • Methods • Indirect standardization to compare horizontal inequity in service use • Minimum standard approach to compare poverty impact of health spending • Findings and Policy Implications
Uninsured Individuals Pay User fees Source: Rwanda Household and Living Condition Survey 1999/2001
MHI Enrollment (6/2000 and 6/2003) Enrollment is independent of SEG 19% 8% Source: MHI routine data and PHR reports
Methods • Compare Impact of health spending under MHI and UF on service use and hh income • Indirect standardization • to examine horizontal inequity (HI) in utilization of care: equal use for equal need? • Minimum standard approach • to quantify the extent to which user fees compared to MHI protect household income against dropping below the poverty line (PL) • Household survey data collected in Sept/00
Horizontal Inequity (HI) In Utilization • Equal use for equal need? • Method: Indirect standardization • Concentration Indices (CI) for: • actual use • need-adjusted (expected) use • CI = 0: equal use across soc-econ groups • HI = CI (need-adjusted use) – CI (actual use) • HI = 0: equal use for equal need • Need-adjusted (expected) use: • Pr(need-visit) = F[SAH, age, gen, preg, bed]
Sick MHI Members Have Significantly Higher Actual Visit Rates Across SEG User fees: Pro-rich visit distribution Source: PHR household survey 2000
Equal Need Across Income Equal need distribution Source: PHR household survey
Horizontal Equity in Utilization of Care for MHI Members User fees: Pro-rich visit distribution even when visit adjusted by need User fees: Pro-rich distribution of actual visit Equal visit distribution expected Source: PHR household survey 2000
Income Income before health Income after health payment PL A B C Cumul % of pop ranked by income Ho H1 Minimum Standard ApproachPoverty Impact of Health Payments
Poverty Measures • Headcount ratio: • % of households below poverty line before and after out-of-pocket health payments • from Ho to H1 • Poverty gap: • average shortfall of income < PL • sum of all shortfalls, divided by population, and expressed in % of PL • A+B+C
Similar Poverty Impact Under MHI and User Fees but at Different Use Levels Source: PHR household survey 2000
Conclusions • Equal MHI enrollment across SEG : • But the poor may have endured economic hardship to pay annual premium • Health service use: • Uninsured report significantly fewer visits • User fees: Utilization is independent of need but depends of SEG • MHI: Horizontal equity in utilization • OOP health spending: • Similar low impact on headcount and poverty gap if uninsured don’t seek care
Recommendations for Policy Makers Expansion: • MHI to other districts • Current MHI benefit package to full district coverage Demand-side subsidies of premium: • MHI enrollment should be associated with targeted measures to ensure that the poorest enroll in MHI