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Improving Access to Health Care through Insurance . Catherine Connor, MBA Abt Associates Inc. February 2010. What we will do in this session. Produce technically sound, responsible policy recommendations regarding insurance for our health ministers Technical and political working together
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Improving Access to Health Care through Insurance Catherine Connor, MBA Abt Associates Inc. February 2010
What we will do in this session Produce technically sound, responsible policy recommendations regarding insurance for our health ministers • Technical and political working together • Why health insurance? • What type of health insurance? • Political promises and technical realities • Group discussion of recommendations
How can policy makers and technical experts work together?
Health insurance is primarily a political process 5% technical 95% political
Politicians and technocrats often do not “speak the same language” Political Leaders Leave a legacy Drive to achieve universal coverage Accountable to voters Fulfil an electoral mandate Enlarge electoral base Sensitive to social groups (poor and vulnerable) or powerful interests Success stories Technocrats Worry the details and complexities Ensure sustainability Control costs Use purchasing power to increase quality and efficiency among providers Learn what works Atim,Chris 2009
Together they can build consensus for health insurance Political Leaders Provide the vision and direction Push diverse stakeholders to compromise Task technocrats to design and implement Technocrats Evidence-based decisions Objective analysis Design must be attuned to political leaders’ objectives while offering best advice Atim,Chris 2009
Effective technical advocacy for health insurance Before we analyze the political and technical aspects of health insurance, take a minute for personal reflection: What are your country’s political priorities? What are your minister’s priority political commitments? How does health insurance link to these priorities?
Why Insurance? African countries have 2nd highest level of out-of-pocket (OOP) health expenditures No financial protection! ECSA countries have lower OOP expenditures than the average for SSA High OOP Low OOP
Why insurance? Absence of financial protection leads families to sell assets or borrow A. Leive and K. Xu 2008
Why insurance? “Big picture” reasons for MoF and Presidents Out-of-pocket health payments increase poverty and inequity Poor can’t access services – never reach the MDGs Healthy population and equity are key to economic growth and stability
After presentation – Group Discussion What will be our recommendation to Health Ministers regarding Why health insurance is needed
What type of health insurance? Universal coverage We are here Mix of tax-based and social health insurance Intermediate stage of coverage Mixes of community, cooperative, and enterprise-based health insurance, SHI, and limited tax-based financing Absence of financial protection Dominance of out-of-pocket spending Carrin, Mathauer, Xu, Evans. 2008
After presentation – Group Discussion What’s our recommendation to Health Ministers regarding Type of health insurance
Political promises and technical realities Insurance increases funding for health Yes, if: New taxes on companies and workers (social health insurance). Affect on formal economy? Insurance pays providers fee-for-service, utilization and costs rise. Can be good or bad. Insurance attracts new donors funds. Sustainable? Depends, if national health insurance budget is negotiated each year No, if administrative costs are high (Kenya’s hospital insurance in 90’s)
After presentation – Group Discussion What’s our recommendation to Health Ministers regarding Potential for health insurance to increase funds for health
Yes, if designed to do so Financial contributions based on wealth vertical equity in financing Service utilization based on need horizontal equity in service Political promises and technical realitiesInsurance will benefit the poor
Yes, if designed to do so Revenue collection General taxes are progressive (the rich pay higher income or property tax rates; no consumption tax on staples such as food) Earmarked taxes for health are progressive (taxes on luxury goods) Poor populations are exempt from user fees or copayments; or fees are based on income Pooling Compulsory universal coverage so the rich cannot opt out Outreach to enroll poor populations Redistribution among multiple fund pools, e.g. rich districts subsidize poor districts Political promises and technical realitiesInsurance will benefit the poor
Purchasing Exclude high-end, expensive, elective care from the benefit package. Shift from inpatient to outpatient care (Kyrgyz) Adequate supply of health providers and facilities where the poor live (Korea, Thailand) Incentives for providers to serve poor populations Vouchers or other incentives for poor to use priority services Political promises and technical realitiesInsurance will benefit the poor
Insurance can worsen inequities: US (Filmer 2003), Africa (Gwatkin 2004), China (Wang 2005); Brazil, Sri Lanka (Wagstaff 2007) Insurance can improve equity, if: Design prevents richer groups from gaining more from public spending than poorer groups Target populations where access is limited (rural,urban poor) Adequate supply of health providers and facilities Vouchers Community outreach Provider incentives Political promises and technical realitiesInsurance will benefit the poor
After presentation – Group Discussion What’s our recommendation to Health Ministers regarding The potential for health insurance to benefit the poor
Yes, if: Benefits package covers priority services (reproductive health, infectious diseases) Target populations with low use of priority services Adequate supply of health providers and facilities for these services Vouchers Community outreach Provider incentives Political promises and technical realitiesInsurance will increase use of priority services (MDGs)
After presentation – Group Discussion What’s our recommendation to Health Ministers regarding The potential for health insurance to increase use of priority services and contribute to health MDGs
Political promises and technical realitiesLet’s implement universal coverage next year Transition getting faster 100 YEARS - UK, Germany, most European countries 25 YEARS - Costa Rica,Thailand, Korea – progress since 1970s 15 YEARS - Columbia, Chile, Brazil – progress in 1980s and still working YEARS Carrin and James 2005, Mills 2007
Thailand: Expanding Access in Stages Source: Thaworn Sakunphanit, “Universal Health Care Coverage Through Pluralistic Approaches: Experience from Thailand”, http://www.nhso.go.th/eng/content/uploads/files/research_pub_04.pdf; accessed Oct 17, 2009
Political promises and technical realitiesLet’s implement national health insurance next year Formal sector focus and exclusion of rural and informal sectors Directly imported from and based on European models Legitimized and validated HI for rural /informal sectors Provided model, tools, skills, etc for renewed state interest and approach to SHI – decentralized, participatory, etc User fees Growth of private sector and civil society Economic crises threaten welfare state Collapse or deterioration of services Atim,Chris 2009
Group Discussion Our recommendations to Health Ministers • The need for health insurance • Type of health insurance • How insurance can: • increase funding for health • benefit the poor • Increase use of priority services (MDGs) • How long it takes to expand health insurance (reach universal coverage)
