Health Insurance in low- income countries Where is the evidence that it works? Esme Berkhout Health policy advisor Oxfam Novib Oxfam International, Action for Global Health, Medecins du Monde, Save the Children UK, Plan, Global Health Advocates and Act Up Paris

Content Global context Expectations National/local reality Coverage Main concerns Recommendations

Global context Right to health & social security 1.3 billion people lack access 100 million pushed into poverty User fees: inequitable Pre-payment and riskpooling preferred ILO global campaign (2001), WHA (2005) Berlin conference and plan of action (2005), Paris conference (2007 & 2008), Africa-EU strategic partnership (2007), IFC strategy (2007), Providing for Health (G8, 2007)

Expectations Increases resources More predictable Cross-subsidization Reduces uncertainty for citizens Contributes to better quality health care

National/local reality Does not live up to expectations Relatively few people are reached The poorest & vulnerable: most excluded Can only work for the poor through: – strong government stewardship – sufficient public funding NGOs jointly concerned

Private health insurance Coverage rate in LICs < 10% Premium related to risk profile: discrimination & exclusion Typically cover higher income groups Regulation: up to 30% of revenue

Micro health insurance Coverage worldwide ~35 million (mostly Asia) Targets poor people Low premiums & benefits package (India) Can reduce catastrophic health expenditure Has limited effect on reducing OOP

Community based health insurance Coverage ~2 million people in Africa (0.2%) Not for profit, based on solidarity among group of (poor) people Excludes poorest and most vulnerable groups (Armenia, Rwanda) Members continue to depend on OOP to cover 40% of health needs

Social health insurance Widespread in OECD, Latin-America and Eastern Europe Mandatory, premiums in proportion to income Difficult to extend to the poor & informal (Ghana 38% coverage 2006) Positive example of Thailand

Main concerns Waiting for realization of rights Policies for achieving universal access? Public funding too low Insurance won’t fill funding gap Potential threat to equity and universal access

Recommendations 1.Consider Insurance in relation to universal access, equity and efficiency 2.Set out a timeline towards universal access, and ensure financing 3.Consultation with civil society, including the most vulnerable groups 4.Pay particular attention to equity 5.Increase public resources 6.Support abolition user fees

Questions?