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Oxfam France 104 rue Oberkampf, 75011 Paris 01 56 98 24 40 Social Health Protection in Low Income Countries Social.

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Presentation on theme: "Oxfam France 104 rue Oberkampf, 75011 Paris 01 56 98 24 40 Social Health Protection in Low Income Countries Social."— Presentation transcript:

1 Oxfam France 104 rue Oberkampf, 75011 Paris 01 56 98 24 40 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 Many thanks for your attention ! Marame NDOUR

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