1. The effectiveness of the Health Card as an instrument to ensure access to medical care for the poor during the crisis Fadia Saadah Menno Pradhan Robert Sparrow

2. Outline East Asian Crisis and Healthcard program Utilization patterns and research questions Data Sources Targeting Impact on Utilization Concluding remarks

3. Evolution of poverty December 1995 - April 1999 Source: Suryahadi et all, 1999.

4. Health Card Program Program started in fall 1998 Distribution: More for poorer districts, then for poorest households Free health care at public providers for all household members Providers compensated through lump sum transfer, based on expected demand

5. Evaluation design Build on existing surveys Healthcard ownership and use was included in the 1999 household survey In combination with qualitative studies to provide immediate feedback And adminstrative data on disbursements

6. Changes in provider choice 1997-1999 public/private mix, outpatient care, percentage of reportedly ill

7. Research questions What would outpatient utilization have been if there had been no Healthcard program? Is there substitution between privately and publicly provided outpatient services? What are the implications of the indirect compensation of providers? How were the poor affected?

8. Use of Healthcard for outpatient care Head of household reports to have received a Healthcard 11 percent Head of household reports not to have received a Healthcard Received outpatient care15.1012.91 Went to public provider10.616.75 Went to public provider and used Healthcard 6.740.15 Went to public provider and did not use Healthcard 3.886.60 Went to private provider4.826.48 Did not seek health care84.5786.77

9. Targeting of ownership of Health Card by per capita consumption decile (percentages)

10. Impact of Health Card on outpatient utilization = Supply effect as a result of additional resources for public sector providers + “Pure” Healthcard effect resulting from increased demand from Healthcard owners

11. “Pure” Healthcard effect Utilization of Health Card owners Utilization of control group: non - Health Card owners Control group constructed by matching on observable characteristics

12. “Pure” Healthcard effect

13. Total Effect Exploit different budget allocation across districts Relate increase in utilization to increase in budget RegionBudget per capita (*1000Rp) Number of districts Java Bali1.121116 Sumatra0.91673 Sulawesi1.24040 Kalimantan0.98229 Other islands1.82935 Indonesia1.120293

14. Total effect

15. Estimated trend in utilization, with and without Health Card program

16. Impact of Health Card on outpatient utilization = All outpatient care Public outpatient care “Pure” Healthcard effect 24%48% + Quality effect76%52%

17. Conclusions Health Card incidence and utilization distributed pro-poor Health card ownership increased utilization for the poor Health Card ownership caused a substitution from private to public health care providers, both for poor and non-poor Increased spending on public health clinics increased utilization Largest impact through quality improvements of public sector as result of health card program.- no difference between poor and rich Better targeting could have been achieved if a closer link had existed between utilization and budget. This in turn would have led to net health gains for the poor.