1. Oxfam France 104 rue Oberkampf, 75011 Paris 01 56 98 24 40 info@oxfamfrance.org www.oxfamfrance.org Social Health Protection in Low Income Countries 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 : healthcare reform in LICs politically driven by influential institutions (WB, Usaid, OECD…), pro-market approach influencing research & policy making  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 ?  Previous assumptions: LICs lack the tax base to develop publicly funded healthcare  Solution : out of pocket spending/user fees inefficient in HSS ; failed to increase revenue failed to adress inequalities in access to health care  Recent paradigm shift and attempts to reshape healthcare systems to widen access Abolish user fees, subsidize free healthcare initiatives Risk pooling social health insurance…

4. The situation in LICs  « Inverse care law » : those most subject to ill-health are least able to pay for it  Low levels state and private HC spending  High level of diseases of poverty, preventable mortality // beginning of an epidemiological transition (NCDs burden)  Poor infrastructure of 1 ary & 2 ndary HC; shortages of skilled health staff; high cost of modern medicines and medical equipment  Inequalities in access : rich/poor; rural/urban; preferential access for the elite and formal sector  Lack of local and democratic control over health policies

5. What doesn’t work?  Charging even small user fees: financial barrier, complex, costly, inefficient  Two-tier systems with services targeting the poorest & general attempts to target and exempt poor people in LICs difficulty to identify those qualified inclusion/exclusion problems  Private health insurance: still no evidence that it can benefit more than a limited group of people  Profit driven private actors involved in delivery of services intended to benefit poor people Private sector of its own can nowhere deliver a comprehensive health care system Needs to be combined to public subsidy and provision for most demanding & unprofitable cases Oxfam 2006, In the public interest

6. What does work for the most vulnerable?  Universal, free or extremely low priced services are more effective to achieve equity & widen access  2% of GDP Govt spending on a UHC system would allow to reduce or eliminate user fees with a huge benefit for the poorest (2005 Equitap research health equity in Asia)  Well organized, upgraded and adequately funded universal public services  Supportive actions to ensure most vulnerable have access to & use these services

7. NEPAL 26.6 million 83% 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  Maternal health 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 all women in public health facilities  Free essential health care services 2008 : user fees removal in public health facilities throughout Nepal (for PHC; free essential medicine, targeted free 2 ndary 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 funding in 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  Mandatory enrolment + premium  Extension of covered health services  Concerns: risk of scraping the free healthcare policies, high premiums, inefficient exemptions for targeted groups  Evidence from Ghana and Tanzania shows that health insurance is often inefficient and exclude the poorest and most vulnerable

12. Evidence from African countries  RWANDA : 60% of population live with less than 1$/day  Mutual health insurance schemes Pilot scale in 1999 Rural/informal sector coverage 2$ (enrollment + 10% co-payment of cost of services) Laws enforcement requiring Mutuelle enrollment Scale up to more than 91% coverage in 2010 where most community insurance are far below 10% of coverage  Cited questionably as an example of how community health insurance can scale up to achieve large coverage

13. Rwanda achievements … can not be only attributed to Mutuelles !  Insurance coverage 2003 to 2010 : 7% to 91%  Services utilization 0.31 to 0.95 outpatient visits per capita  Under 5 mortality decreased 2005 to 2010 : 12,5% to 7,6% (similar to South Africa, India)  Secret n°1  massive increase in gvt health spending 2002 to 2010 : 10US$ to 48US$ per capita on health 2006 : of all health spending 53% from donors, 28% private, (of which 5% Mutuelles), 19% public

14. N°2: Improved service delivery + subsidization  Upgraded comprehensive service delivery Increased health personnel; Reinforced drug supply New equipment and general infrastructure improvement Improved management (strong leadership and political will, effective implementation…)  Combined to financial barrier reduction through subsidization Utilization rates doubled/tripled only after (2$)/year Mutuelles enrollment were subsidized & premium removed 37% of enrolled households sponsored by government 2011 study shows the impact of co-payment supression on utilization of PHC facility in Mayange district

15. Annualized utilization rates for Mayange and 2 neighbouring health centres Jan-2005 to September 2007 (Dhillon & al, 2011)

16. Gvt plan to raise premiums WHILE co-payments remain an important barrier to access !  Co-payment: minimal contribution to local healthcare financing while costly to levy & manage  Upgraded services alone did not generate a dramatic increase in utilization + combination with fees removal  Point-of-service payments discriminate against the poor  disproportionate use of healthcare by the wealthy  Lack of money = barrier to healthcare among 83% of the lowest wealth quintile // 52% in highest wealth quintile (2005)  Other economic costs : geographic barrier; opportunity costs for farmers…

17. “Higher coverage rates, often used to measure the success of insurance programmes are not sufficient to improve access (ILO, 2002)  Current cost of subsidising all mutuelle premiums and co- payment = 25 million US$  Total cost of absorbing co-payments + complete subsidization of Mutuelle = 75 million US$  Challenges : expand access without aid dependance  Possibilities : move to a centrally financed care free to the population (donor support) Middle ground: target lower utilization, provide timely access for the poor ? Examine ways of eliminating co-payments, increasing subisides for enrollment, expanding free services including curative care and free primary care to priority populations (children, pregnant women…)

18. DIRECT PAYMENT EXEMPTION POLICIES A 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

20. Coverage for indigent & priority population  Free coverage for women/Children under 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 (except co-payments Burkina/Kenya)  Access in public and private facilities 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

21. 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?

22. Positive impacts Evidence from West African Countries (report to be published early 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?

23. Oxfam France 104 rue Oberkampf, 75011 Paris 01 56 98 24 40 info@oxfamfrance.org www.oxfamfrance.org Many thanks for your attention ! Marame NDOUR mndour@oxfamfrance.org