People all over the world depend on having access to health services for maintaining their health
or for their survival. It is crucial therefore that they are able to afford the treatment they need.
Payments for health care push an estimated 100 million people into poverty every year. Functioning
social health protection systems could prevent this. They entitle people to access the health services
Extending Social Protection in Health
International Labour Office
Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ) GmbH
World Health Organization
Extending Social
Protection in Health
Developing Countries’ Experiences,
Lessons Learnt and Recommendations
needed, they ensure that no one is impoverished by health bills, and they set prices and contributions
according to what people are able to pay. This book represents the combined insight into social
health protection from over 200 academics, policy makers and politicians, who gathered at the
2005. The book tackles issues as diverse as universal coverage, social dialogue, poverty reduction
or mixed financing systems and draws on experiences spanning four continents.
GTZ / ILO / WHO
International Conference on Social Health Insurance in Developing Countries in Berlin in December
ISBN 978-3-88864-425-2
SHI_Umschlag.pmd
1
29.03.2007, 14:45
Extending Social Protection in Health
Developing Countries’ Experiences,
Lessons Learnt and Recommendations
International Labour Office
Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ) GmbH
World Health Organization
Extending Social
Protection in Health
Developing Countries’ Experiences,
Lessons Learnt and Recommendations
This conference reader was compiled and edited by Jens Holst and Assia Brandrup-Lukanow on behalf of the German
Agency for Technical Cooperation and the Federal Ministry for Economic Co-operation and Development (BMZ).
The conceptual planning and preparation of the conference was done by a team of the WHO/ILO/GTZ consortium: Guy
Carrin, Ole Doetinchem, David Evans and Timothy Evans from the World Health Organization; Xenia Scheil-Adlung and
Michael Cichon from the International Labour Office; Bernd Schramm, Rüdiger Krech, Nicola Wiebe, Katja Bender, Jens
Holst, Assia Brandrup-Lukanow and Stefan Helming from the Deutsche Gesellschaft für Technische Zusammenarbeit.
The technical organisation of the Berlin Conference was coordinated by Lukardis von Studnitz with the support of Manique
Abayasekara, Marion Baak, Birgit Roehrig, Sabina Schnell, Aline Oloff, Christine Meyer, Heike Volkmer, Jens Marquardt,
Stephan von Bothmer, and Raphael Pfautsch.
The conference was hosted by the GTZ House Berlin, under the gracious hospitality of Franziska Donner and Jörg Schindler;
and facilitated by Michael Gabrisiak, Andrea Fischer, Assia Brandrup Lukanow, Timothy Evans, Michael Cichon, and David
Evans.
The organisers would also like to thank Mr. Uwe Gehlen, Director of the Department for Social protection, BMZ, and Dr.
Frank Schwarzbeck for their support and conceptual input into the conference; to Mr. Udo Scholten and the team from the
Division of European and International Health Policy of the Federal Ministry for Health and Social Security (BMGS) for their
contribution to the conference preparations; to Ms. Simone König and the team from the Foreign Office for their advice and
support; and to Ms. Marion Stark and Ms. Nicola Liebert for public relations and media support.
Finally, the organisers of the conference and the editors wish to thank all facilitators, presenters, authors, and participants
for their contributions to the conference and to the publication, and especially Mr. Anver Versi for his excellent work on
language editing.
Rights and Permissions
The findings, interpretations, and conclusions expressed here are those of the author(s) and do not necessarily reflect the
views of the Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ) GmbH.
GTZ cannot guarantee the accuracy of the data reproduced in this reader. The boundaries, denominations, and other
information shown on any map in this work do not imply on the part of the GTZ any judgment of the legal status of any
territory or the endorsement or acceptance of such boundaries.
The material in this reader is copyrighted. No part of this work may be reproduced or transmitted in any form or by any
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system, without the prior written permission of the GTZ. However, GTZ and the co-editing organisations encourage
dissemination of its work and will normally grant permission promptly.
For permission to photocopy or reprint, and for all other queries on rights and licenses, including subsidiary rights, please
send a request with complete information to the Division ‘Health, Education, Social Protection’,
GTZ, Postfach 5180, D-65726 Eschborn, Germany, Tel.: +49 6196 79-1258, Fax: +49 6196 79-80-1258,
e-mail [email protected].
© 2007
Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ) GmbH
Division 43 – Health, Education, Social Protection
Dag Hammerskjöld Weg 1-5
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Telephone: +49 6196 79-1445
Internet: www.gtz.de
E-mail: [email protected]
Photos: version (Chr. Ditsch, pp. 6, 11,
37, 40, 126; J. Holst, pp. 18, 20, 23, 28,
56 and cover (2); R. Maro, pp. 2, 5 ,9,
13, 15, 20, 26, 27, 55, 61, 74, 75, 80, 84,
90, 94, 97, 124, 126, 127, 129, 149, 173
174 and cover (6); H. Sachs, pp. 90 151,
171 and cover (1)).
Bibliographic information published by the Deutsche Nationalbibliothek
The Deutsche Nationalbibliothek lists this publication in the Deutsche Nationalbibliografie; detailed bibliographic data are
available in the Internet at http://dnb.d-nb.de.
© 2007
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Cover-Design:
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94065 Waldkirchen
ISBN 978-3-88864-425-2
Foreword
The provision of social protection systems in health which adequately respond to the
needs of citizens while keeping within the bounds of available resources is a challenge for every country and every government. Resource-poor nations are in a particularly difficult situation as the scarce resources available have to be shared among
many priority areas of development.
At the same time, this is the area where the needs are greatest, often exacerbated by
high population growth rates and epidemics such as AIDS, Tuberculosis and Malaria
affecting large segments of the populations. Chronically high maternal and infant
mortality rates, and the growing burden of non-communicable diseases place an additional strain on health care systems.
Many countries, along with their development partners, have worked on different national or regional models of sustainable health care financing. The International Conference on Social Health Insurance in Developing Countries, held in Berlin 5-7 December 2005, provided a forum in which the experiences from different countries and
regions could be shared and discussed.
The organisers of the Berlin Conference decided to collect and preserve the many
valuable contributions which emerged and to make them available to a broader group
of scientists, politicians and decision-makers. This book comprises a revised version
of most of the presentations made in Berlin as well as background information on
social protection in health. The editors hope this compilation will help to enrich the
ongoing debate on how best to protect people in developing countries against the
financial risks of ill health.
It was a pleasure and honour to host this conference on behalf of the GTZ-ILO-WHOConsortium, and we sincerely hope that you will find this reader useful for your work.
We look forward to continuing the dialogue and cooperation with those who were
present in Berlin, as well as with other interested partners.
Dr. Assia Brandrup-Lukanow
Senior Adviser on Health, Education, and
Social Protection
Dr. Rüdiger Krech
Head of Section Social Protection
Extending Social Protection in Health
Table of contents
1.
1.1.
Setting the Scene
Social Health Insurance in Development Cooperation
1
Heidemarie Wieczorek-Zeul
1.2.
ILO’s Decent Work Agenda: Goal for Fair Globalisation
3
Assane Diop
1.3.
Universal coverage: from concept to implementation
7
Timothy Evans
1.4.
The Role of Social Protection in Health in achieving the Millennium Development Goals
13
Stefan Helming
1.5.
Social health insurance: Economic development and poverty reduction
16
David Fuentes-Montero
1.6.
Poverty, health and social protection
22
Julio Frenk, Felicia Knaul, Eduardo González-Pier, Mariana Barraza-Lloréns
2.
Advancing the Socio-Economic Development Agenda: The concern for
Equity, Solidarity and Poverty Reduction
2.1.
Developing Urban Social Health Insurance in a Rapidly Changing Economy of
China: Problems and Challenges
32
Shenglan Tang, Xiaoming Cheng, Ling Xu
2.2.
From Universal Coverage of Healthcare in Thailand to SHI in China: What Lessons can be drawn?
42
Pongpisut Jongudomsuk
2.3.
Equity and solidarity in social health insurance: Chances and risks of the Costa
Rican way towards universal coverage
45
Alberto Sáenz Pacheco, Jens Holst
2.4.
Advances in Implementing Social Security: Lessons from Tunisia
52
Hedi Achouri
2.5.
Social health insurance in French-speaking sub-Saharan Africa: situation and
current reform
57
Oumar Ouattara, Werner Soors
2.6.
The Inclusion of the Poor in a Social Health Insurance Framework: The Strategies Applied in Viet Nam
63
Tran Van Tien
2.7.
Insuring the Very Poor against Health Risks in the Philippines
71
Claude Bodart, Matthew Jowett
2.8.
Reaching the Poor in Ghana with National Health Insurance – An Experience
from the Districts of the Eastern Region of Ghana
73
Ebenezer Appiah-Denkyira, Alex Preker
2.9.
The Impact of Global Health Initiatives on Fair Financing and Health Systems
Development: the case of Cambodia
Maryam Bigdeli
82
Contents
3.
Current Reforms Aiming at the Extension of Social Protection in Health:
Linking up Mixed Health Financing Sub-systems
3.1.
Myths, instruments, and objectives in health financing and insurance
87
Joseph Kutzin
3.2.
Implications of Enrolment Criteria for Social Health Insurance
96
William D. Savedoff, Jens Holst
3.3.
The Importance of Social Dialogue in the Extension of Coverage
100
Youssoufa Wade
3.4.
The German perspective on the Importance of social dialogue in the extension of
coverage: Lessons learnt from Senegal
104
Ursula Engelen-Kefer
3.5.
Working with Community-based Groups: The Experience of the Philippine Health
Insurance Corporation
106
Ruben John Basa
3.6.
Health Coverage for All: Strategies and Choices for India
111
Indrani Gupta
3.7.
Universal Coverage in Thailand: the Respective Roles of Social Health Insurance
and Tax-Based Financing
121
Viroj Tangcharoensathien, Phusit Prakongsai, Walaiporn Patcharanarumol, Pongpisut
Jongudomsuk
4.
Implementing Social Health Insurance: Learning from Evidence
4.1.
Impact of social health protection on access to health care, health expenditure
and impoverishment - A comparative analysis of three African countries
132
Xenia Scheil-Adlung,Guy Carrin, Johannes Jütting, Ke Xu
4.2.
Social Health Insurance Development as an Integral Part of the National Health
Policy: Recent Reform in the Indonesian Health Insurance System
146
Adang Setiana
4.3.
Achieving Universal Coverage through Social Health Insurance in Asia
155
Dorsjuren Bayarsaikhan
4.4.
Implementation of Health Insurance in Developing Countries: Experience from
Selected Asian Countries
158
Bong-min Yang, Jens Holst
5.
Berlin Recommendations for Action
168
6.
Annex
6.1.
Contributors
176
6.2.
Program
180
6.3.
Participants
183
6.4.
Bibliography for further reading
191
6.5.
Abbreviations
218
6.6.
Social protection in health: Links to Important Websites
223
6.7.
The Consortium
225
Extending Social Protection in Health
1.
1
Setting the Scene
1.1. Social Health Insurance in Development Cooperation
Heidemarie Wieczorek-Zeul1
The Berlin Conference on Social Protection in Health
has addressed an issue of vital importance, particularly
for people in developing countries. We are living at the
beginning of the 21st century – and yet we must
acknowledge, to our shame, a series of deplorable situations: Four out of five people in the
world have no form of social security whatsoever, and over 1.3 billion people have no access
to adequate or affordable health care. Health coverage is particularly bad for families living in
rural areas; health posts are sparsely scattered and the lack of doctors and nurses is severe.
Ten million infants die every year of preventable diseases – these deaths would not happen
in rich countries operating social health insurance systems. And 500,000 women die during
pregnancy and childbirth because adequate medical care is either not available or because
they are unable to pay for it. Currently, 40.3 million people are infected with HIV. In 2005,
there have been 4.9 million new infections and 3.1 million deaths.
That is the situation we are faced with at the beginning of the 21st century. It is a shameful
state of affairs. We must do something about it. We can do something about it. And that is
why we are here. Across the world, the challenge of fighting diseases and epidemics has
been taken up with growing vigour. Malaria, HIV/AIDS and tuberculosis have become the
focus of attention. But other, more "ordinary" diseases are also a threat to people in developing countries. When we talk about social health insurance, we are in fact talking about the
lives of millions, indeed billions, of people across the world. We are talking about enabling
everyone to have a fair share of the opportunities offered by globalisation. That is why social
health insurance systems – whatever specific shape they may take – are more than simply
technical answers to the complex questions of how to organise the health sectors.
Social health insurance systems are a reflection of certain values: They represent a value
system resting on the bedrock of a cohesive community and based on the solidarity of the
strong with the weak, the healthy with the sick. While social health insurance systems can
take different forms in specific cases, the one thing they must all have in common is to be an
expression of solidarity and equity. Only if they are transparent and accountable and only if
they facilitate a sense of responsibility will they be successful. Then they will be embraced by
the people concerned.
What are the real issues we can hope to tackle through social health insurance systems?
The WHO estimates that each year 178 million people are unable to pay for what they need
to restore their health. Of those who are able to find the money to pay for the care they need,
every year, over 100 million people are plunged into extreme poverty because they have
been forced to sell all they own to pay for medical treatment. Often, whole families get into
debt in order to pay for the medical treatment for one member of the family. When one family
member takes ill, it blights the future of the entire family. The lack of health insurance turns
into a poverty trap. In many societies, it is particularly hard for women to access basic medical care. They are at increased risk. That is why the high levels of child and maternal mortality are being addressed by the Millennium Development Goals. Poor women have long been
the worst hit by the AIDS pandemic.
93 % of illness across the planet hits the poorest 84 % of the world population and the poorest 84 % of people benefit from only 11 % of worldwide expenditure on health. This is one
striking example of the global inequities that the World Bank rightly highlights in its latest
World Development Report. We are meeting here because we cannot allow good health to
depend on where someone is born or how much money they have. We are here because we
1
Federal Minister for Economic Cooperation and Development of Germany since 1998.
2
H. Wieczorek-Zeul: Social Health Insurance in Development Co-operation
know of ways out of this plight: We know that social health insurance systems can offer the
poor access to health care. We know that social health insurance models can protect people
from crippling health care costs and a loss of income.
Social health insurance systems increase productivity and boost economic growth: The WHO
and the World Bank estimate that a 10% increase in life expectancy leads to up to a 0.4 %
increase in economic growth. If a developing country's per capita income increases by 10 %,
child mortality rates fall by over 3 %. We know that social health insurance systems are vital
if economic growth is to actually contribute to poverty reduction and an equitable sharing out
of resources rather than aggravating disparities.
Social health insurance systems
are a sure recipe for poverty
reduction; they are a driving
force for development. That is
why it is encouraging to see that
successful anchor countries and
newly industrialising countries
have now recognised the
importance of social health insurance. Some municipalities in
China, for example, have already
introduced
social
security
systems and Brazil has begun
creating a
uniform
health
system. I could mention many
other examples. All of them have one thing in common: They are united in the knowledge
that social health insurance is the only way of making globalisation successful in both economic and social terms. That is what we want and that is why we are here.
This conference has been the culmination so far of the work of a consortium made up of the
GTZ, the WHO and the ILO. The consortium was established just over a year ago and has
taken on the task of helping interested partner countries establish social health insurance
systems by offering them expert advice.
The key focus will initially be the exchange of experiences between the partner countries
involved and other donors. Through its work, the consortium provides us with a general overview of all donor activities in the field of health insurance. Health insurance has emerged as
a decisive strategic factor for success in the health sector. Many different paths lead to the
ultimate goal of improved health care. The consortium therefore responds to requests from
developing countries and arranges for them to receive concrete advice on their health sector.
This conference now offers us the opportunity to take stock.
We see social health insurance within the context of efforts to achieve the MDGs by 2015.
With our eyes fixed on that aim, we know that we have to further refine the standards for developing social health insurance systems. That is why it is important to achieve even greater
donor harmonisation in this key sector of development cooperation. Access to health care is,
at the same time, a decisive factor in economic development. That is one of the reasons why
a large proportion of the funds freed up by the Poverty Reduction Strategy Process (PRSP)
is to be invested in health. A successful system of social health insurance is not an obstacle
to, but rather the precondition for, economically successful, peaceful development.
Germany and Europe's experience of social security can be drawn on in many ways to help
build up social security systems in Africa, Asia and Latin America and ensure that economic
success and social equity complement each other. I hope that this conference will go some
way to ensuring that, through social security systems funded on the basis of solidarity, poor
people will have a better chance of becoming healthier, staying healthier and better able to
take care of themselves and their families.
Extending Social Protection in Health
3
1.2. ILO’s Decent Work Agenda: Goal for Fair Globalisation
Assane Diop2
Introduction
Access to social health insurance is a key component of the ILO's strategic objective to enhance the coverage and effectiveness of social protection for all. It is one of the cornerstones
of the ILO's Decent Work Agenda. The urgency of the issues addressed by ILO is clear. Four
out of five people today do not have adequate social security, and in some regions 90 % are
excluded from health protection schemes.
But statistics do not tell the whole story. We have to think of what it means to people's daily
lives. Living without social health protection is living in constant fear. It means that if you fall
ill and you can't work - you have no income, you have no food. It means older people living in
poverty because they have no pensions. It means people dying because they have no access to basic health care and medicine.
Access to health care and poverty
During a recent mission to Benin, a woman said to me she took a loan to start a small business activity. Her young son suddenly became ill and she took him to the health centre. The
doctor told her that her son needed surgery immediately and she had to pay $ 150.00 in advance for the operation and the medicine. Having no other resources, she used the money
she had borrowed. Now she cannot start her business activity, which means she has no
means to repay the loan. Unless she can find other resources, she will be unable to escape
the poverty cycle. Ample evidence show that while a significant number of people in developing countries are poor, and what pushes them over the edge to destitution is often a crisis
linked to health care.
Health care is very much at the heart of the Millennium Development Goals aiming at combating poverty. These include halving extreme poverty worldwide, reducing child mortality by
two-thirds, reducing maternal mortality
by three-quarters, and combating the
A New York Times article entitled "Neglected Poor
in Africa Make Their Own Safety Nets", which was
spread of HIV/ AIDS, malaria and other
published on August 28th of 2005, recounts the
diseases. Progress has been made, and
story of Nogaye Sow, a 40-year-old grandmother,
in many countries, social health insurwho struggles daily as a street vendor in Dakar. She
ance is providing the much-needed
recently became a member of the community health
safety net. But we also know that for
insurance plan, which means that when she, her
many developing countries achieving
seven children, her granddaughter and two other
the MDGs remains a distant goal. There
relatives become ill, they receive free consultations
is much to be done. This Conference is
at a clinic down the road, cut-rate medicine and
an important opportunity to examine
peace of mind. The chances are lower now that a
how social health insurance can contribout of illness will bring the family to total ruin. Ms.
Sow struggles to pay the 200 francs a month - less
bute towards paving the way - if not acthan half a dollar - that she must come up with for
celerating - the realisation of the MDGs.
There are, of course, many forms and
types of social insurance designed to
meet the needs of different groups and
a range of ways of financing them. A formidable challenge for developing countries is providing universal access to
basic health care, which is of good quality and, at the same time, affordable. But
as the vast majority of the population in
many developing countries, including in
2
herself and each of the other 10 beneficiaries in her
health insurance card. Before the plan, when her
children became sick with malaria, she had to wait
to take them for treatment until she could raise the
money, a delay that allowed the parasites to sap the
children's strength and endanger their lives. One
novelty of the scheme is that beneficiaries can come
together and make changes. Soon, Ms. Sow's premium will increase 50 francs, about 10 cents, but
she can choose from more than two clinics now
available and be covered for more specialised care.
Executive Director, International Labour Office, Geneva, [email protected].
4
A. Diop: Decent Work: Goal for Fair Globalisation
formal economy wage earners and self-employed persons, have no social protection whatsoever, a major focus must be on the extension of social protection.Workers in small- and micro-enterprises (still excluded from social security coverage in many countries) invariably
suffer far greater income insecurity than those in larger firms, which tend to offer better pay,
greater security of employment, and possibly, benefits in case of sickness or retirement. The
self-employed, especially those in the informal economy, face similar economic insecurity.
Both groups tend to be poor and have extremely limited capacity to contribute to social protection schemes.
Of course, there is no universal approach to expanding social security coverage. Each country has its own unique situation and requires tailored solutions. The fact remains, however,
that no matter how poor people may be, they are often better equipped to cope with certain
risks as a group or as a collective rather than as isolated individuals. That is why social
health insurance is a powerful weapon to buffer the poor from the vulnerability a heath crisis
could trigger. This has been confirmed in many instances in projects carried out under the
ILO's Strategies and Tools against social Exclusion and Poverty (STEP) programme.
Improving social protection
Equally important is enhancing the effectiveness of social protection. The quality of governance is a critical ingredient for ensuring the viability of and promoting public confidence in
social security systems. Governments are aware that neglecting or compromising social protection could aggravate poverty. They realise that poverty is expensive as it impedes development, hampers growth, lowers productivity, and fuels instability. Many are taking concrete
steps to improve the situation but it is also evident more investment in extending quality
health care is urgently needed. Let me briefly recount what is happening in Senegal:
The World Health Organization stipulated that as a minimum 9 % of the national budget
should be allocated to health. Senegal passed this threshold 5 years ago, and the country is
rated as the 4th in Africa for best performance in terms of geographic access to health care
and operational programmes. The hospital system has been reformed to improve management and an ambitious policy to use generic drugs was put in place. The health care system
was decentralised to make it closer to regions and local communities, community participation in health committees has been organised and sector programmes were developed within
the framework of a public health policy.
In spite of these initiatives, access to health care for all still remains a slogan. The main reason is the lack of social security as it is provided in developed countries and guarantees financial access to health. The challenge today is to help developing countries, particularly in
Africa, to build social health insurance. Again, that is feasible if we have the political vision to
look beyond the immediate and the conviction to move forward. This is a real-life challenge
that workers and their families all over the world are seeking solutions for. A broad-based
campaign is necessary to make it happen although in many developing countries financial
constraints limit the possibilities for action. To help overcome this, Senegal has targeted the
extension of health care to vulnerable groups, especially to those in the informal economy
and in rural areas, as a priority in its Poverty Reduction Strategy Process (PRSP).
The primary responsibility for ensuring access to health care obviously lies at the national
level. Access to social protection is often linked to jobs, which underscores the importance of
sound institutions and policies that encourage employment creation and enterprise development. People also expect their political and economic systems to give them the opportunity
to work out of poverty. This will also minimise the pressure on already stretched health-care
budgets. Individuals and families have the right to expect that authorities in the public and
private sector will blend economic and social policies within an enabling environment to create decent work for its citizens.
Each country will have to evaluate the choices and adopt an approach the meets its needs
and resources. Some countries will be able to achieve this by restructuring their existing social security systems and extend coverage in health. Other countries will need a more plural-
Extending Social Protection in Health
5
istic approach, devising complementary measures that embrace those not covered. This includes working closely with community schemes and groups of workers that have established their own systems of mutual support to share risks and resources. Such associations
make an important contribution and need to be fostered and developed. In most cases social
health protection comprises several components, including some proportion of tax-based
funding through the national treasury and individuals' out-of-pocket payments to meet their
medical needs.
However, it is increasingly recognised that different mechanisms can meet many of the
challenges in health financing.
There are specific, but quite
different roles here for insurance
schemes provided through the
commercial sector (based on the
mutuality principle of risk pooling) and for social health insurance systems in which the risk
sharing is solidarity-based. We
will be discussing these different
approaches in the course of the
Conference.
Social health insurance schemes are well-suited to the needs of workers for several reasons:
They provide quick and effective access to medical services; in addition, the scope for ‘natural’ contribution systems linked to payrolls and the scope for workers to participate in dialogue and governance mechanisms through trade unions contributes to a sense of ownership and long-term sustainability. Through various initiatives and movements, people are
also demanding participation in the decision-making that affects them and their communities.
As a result, other actors in the policy-making process, such as governments, health care
providers, employers, and international agencies are beginning to rethink and reconceptualise the role of communities - and those of other actors – in these process.
Challenges in a globalised world
But we also live in a competitive global economy, and globalisation triggers changes or repercussions in national economies. This means, as the Commission on the Social Dimension
of Globalisation recommended in its report ‘A Fair Globalisation - Creating Opportunities for
All“ that, as a minimum, systems of social protection are required that can stabilise incomes
and distribute some of the gains of globalisation to groups, which would otherwise be excluded.
In today's global economy a number of issues and trends on the relationship between work
and health are in the forefront of the debate between health and protection. These include,
for example, the extent to which lack of access to health services has significant impacts on
socio-economic development, particularly on economic growth due to lower productivity, high
absenteeism, and reduced life expectancy. It touches on the problem of the ‘exclusion’ of
significant groups such as the disabled, migrants, the rural population, the self-employed,
and the unemployed. Many of those "excluded" are living and working in what is variously
entitled the ‘informal economy’ or the ‘unorganised sector’, in any case those outside the
embrace of the formal economy.
Special attention is being devoted to the issue of gender and the specific needs of women. In
many cases women are the main earners of income in large families, they are carers for the
sick in their families and they bring up children. This has implications for the provision of
adequate health services and maternity health care. Another important factor in the international debate about health and protection is the implications of an ageing population. In many
6
A. Diop: Decent Work: Goal for Fair Globalisation
countries the elderly have no income, they cannot work any more and they have no pension.
They have, however, deteriorating health conditions and they have to look after their grandchildren and often after orphans. When it comes to financing, the costs of adequate health
care providing for people's ‘reasonable’ expectations are currently not matched with sufficient
funds. Often the poor are required to pay high direct payments. Solidarity mechanisms such
as social health insurance have the potential to reduce the financial and social burden of
disease mainly of the worse-off.
To many countries all over the world, the ILO has provided technical assistance and contributed to capacity building, exchange of experience and research in order to support the development of social health insurance. Our goal is to provide countries with a crucial contribution to alleviate health-related poverty and build the social dimension for globalisation,
through the practical implementation of the Decent Work Agenda. Our assets are our tripartite constituency - composed of workers' and employers' organisations, and governments our experience in social dialogue, our in-depth knowledge of social security, health insurance
schemes and policies and our understanding of and insight into informal economies.
Our starting points are equity, solidarity and social
justice and our strategy is the extension of social
protection in health to all. We can draw upon a
range of instruments to break the cycles of poverty
and ill health through social protection. The ILO has
joined forces with the WHO and the German
Development Agency (GTZ) and created a global
partnership on social health insurance because the
three organisations share the same values and
strive to achieve a better world for those in need of
health care.
The International Conference on Social Health
Insurance in developing countries was a major
result of the GTZ/ILO/WHO partnership based on
an Agreement established in 2004. The Agreement
covers co-operation in the broad area of social
protection, in particular social health insurance.
International action and solidarity are necessary. A
certain minimum level of protection must be
accepted worldwide. The lack of social protection is
more often than not the result of decent work
deficits in the global economy. The governance of globalisation is a common concern and
goal of developing and industrialised countries alike. It is as much a key issue at national and
local levels as it is for the global community. After all, as stated in the ILO's Constitution:
"poverty anywhere constitutes a danger to prosperity everywhere".
The world is waking up. Getting people and ideas together is essential to moving forward.
And the work of this Conference, the ideas of all of you to bring to the table - and the connections you make between the economic, the political, the social, the environmental - will help
make it happen. A change is coming. But we must continue to think and work together to see
it through. Everybody involved in the area of health financing and social protection has an
important role to play both intellectually - in conceptualising solutions - but also practically, by
generating the necessary action, movement and capacity to organise. That, my friends, is so
essential and it is what the world is looking for to advance the Decent Work agenda and build
a fair globalisation that creates opportunities for all.
Participating in the Berlin Conference reflects our common concern of the need to urgently
address the lack of access to social protection, the high levels of vulnerability to risks many
people face, and the need to help those trapped in poverty to escape. The Conference provided an excellent forum to share experiences of how different interventions are improving
the lives of many.
Extending Social Protection in Health
7
1.3. Universal coverage: from concept to implementation
Timothy Evans3
Health financing in the world
Policy-makers in all parts of the world, not only in low-income countries, are
continually reviewing the way their health systems are financed – either in
the way the funds are collected, how they are pooled to spread risks, what services are provided or purchased, and how providers should be paid. The objectives vary, but common
concerns are the need to generate sufficient funds for health, improving efficiency or reducing costs, reducing the financial risks involved in obtaining care, and ensuring that the cost of
care does not prevent people from receiving needed services.
Universal coverage is defined as access to key promotive, preventive, curative and rehabilitative health interventions for all at an affordable cost, thereby achieving equity in access.
The principle of financial-risk protection ensures that the cost of care does not put people at
risk of financial catastrophe. A related objective of health-financing policy is equity regarding
the economic burden: households contribute to the health system on the basis of ability to
pay. Universal coverage is consistent with WHO’s concepts of health for all and primary
health care.
Realisation of universal coverage is dependent on organisational mechanisms that make it
possible to collect financial contributions for the health system efficiently and equitably from
different sources; to pool these contributions so that the risk of having to pay for health services is shared by all and not borne by each person who is sick; and to use these contributions to provide or purchase effective health interventions. The way in which countries combine these functions determines the efficiency and equity of their health-financing systems.
Health financing for universal coverage
A great deal is spent on
Figure 1.3.1: In 2003, the World spent $ 4.4 trillion on health
health globally, but this
(International dollars)
amount is unevenly distributed and shows a high
reliance on out-of-pocket
OtherPrivate
payments in many coun4%
tries. Financial contribuSocial Insurance
Tax funded
tions to the health system
24%
32%
are raised in most countries from households
and businesses, although
external flows such as
Private Insurance
17%
official assistance are an
important source in many
Out of pocket
settings. Recent increaSource: National Health Accounts
23%
ses in the availability of
EIP/HSF/CEP, World Health Organization
external funding for health
have the potential to stimu
late major health improvements in poor countries. On the other hand, multilateral financial
institutions and some ministries of finance have expressed concern that these inflows could
affect macroeconomic stability. In addition, these funds are sometimes used to finance specific programmes, more or less independent of efforts under way to build long-term sustainable financing systems and institutions for the health system as a whole. It is important that
inflows of external funds for particular activities are managed in a way that is consistent with
3
Assistant Director-General for Evidence and Information in Policy, World Health Organization, [email protected].
T. Evans: Universal Coverage – from Concept to Implementation
8
the broader objective of developing sustainable financing systems and institutions and moving towards universal coverage.
Although various organisational options exist for achieving universal coverage, a key common characteristic of successful systems is that some part of the financial contributions of
households is prepaid and pooled. These contributions typically are the predominant source
of domestically generated health expenditure at the national level. Experience shows that in
addition there needs to be heavy reliance on compulsory sources of funding, such as taxes
of various forms, payroll deductions, or mandatory insurance contributions. Voluntary prepayment can play a role in certain settings, but universal coverage is unlikely to be achieved
on the basis of voluntary contributions alone.
Several options for establishing universal coverage exist, which can be classified into two
broad strategies. The first is use of general tax revenue as the main source of finance for risk
pooling, a system also referred to as tax-funded health financing. The second is introduction
of social health insurance, used here to describe the situation where specific contributions for
health are collected from workers, self-employed people, enterprises and the government,
and are pooled into a single, or multiple, ‘social health insurance fund’.
In the first option, all citizens (and sometimes residents) are typically entitled to services - so
coverage is automatically universal. With social health insurance, entitlement is linked to a
contribution made by, or on behalf of, specific individuals in the population. Universality will
be achieved only if contributions are made on behalf of each member of the population. For
this reason most social health insurance schemes combine different sources of funds - with
government often contributing on behalf of people who cannot afford to pay themselves. Social health insurance may be managed in various ways, including through a single government insurance fund or through multiple nongovernmental or parastatal funds.
In a number of countries, mixes of these broad approaches exist: part of the population is
covered directly through general taxes, whereas other specific population groups are covered either by compulsory contributions to a social health insurance fund or by various other
types of health insurance. In some countries, national agencies organise social health protection: citizens must be covered but have the right to choose private health-insurance funds,
which are usually subject to strict regulation.
No health system meets the full cost of health services out of the prepaid and pooled funds
collected by tax or insurance contributions. Most require some form of co-payment at the
time of use. The intention is to restrain demand and/or limit the cost to the government or
Figure 1.3.2: Inequality in health spending and income by WHO
Region* 2003 (international dollars)
80
70
60
%
50
40
30
20
10
0
AFR
Population
GDP
Health expenditure
AMR*
EMR
EUR*
SEAR
WPR*
OECD
* AMR, EUR and WPR do not contain OECD countries
Source: National Health Accounts,
EIP/HSF/CEP, World Health Organization
Extending Social Protection in Health
9
insurance fund. However, it is crucial that the relative contribution made by out-of-pocket
payments from patients at the time of service provision is not so high that it reduces access
to care and fails to proFigure 1.3.3: Impact of health expenditure
vide protection against
the financial risks associated with high individual
health-care costs. It is esEMR
impoverishment
timated that as many as
catastrophic
AFR
178 million people could
suffer financial catastroEUR
phe as a result of out-ofpocket health payments
SEA
each year, and that 104
AMR
million could be forced into poverty simply becauWPR
se of health payments.4
The tendency of governments to take the lead in
Number of people (million)
ensuring that funds are
raised and pooled to provide universal coverage does not mean that they must always provide the health services. All
organisational mechanisms for raising funds and pooling them are confronted with the need
to use these financial resources in the best possible way, purchasing or providing appropriate health services in an active, rather than a passive, way. These health services may be
provided by private or by public facilities, or some mix of both. In all cases, governments
need to ensure that incentives are in place to encourage providers to supply only the services that are required, at a high level of quality.
-
30
60
90
Transition to universal coverage
Universality in social protection in health means access to
needed personal and non-personal health services for all
people at an affordable cost. This is often called equity in
access with access interpreted as securing services to
everyone, given a specific need. However, universal coverage is also associated with equity in financing implying that
households contribute on the basis of ability to pay. In order
to implement universal protection against financial health
risks, organisational mechanisms are needed in order to
ensure that financial contributions are collected equitably
and efficiently; contribution-born resources are pooled in a
way that the financial risks associated with the need to pay
for care are shared by all; and effective and cost-effective
health interventions are purchased or provided with these
contributions.
Health-financing systems that provide universal coverage
have generally evolved over a number of years. For instance, both Japan and the United Kingdom took 36 years between the first law related to universal health protection and the final law to implement it. Korea, however, achieved universal coverage in only 12 years, and after many years of laying
the basis Thailand managed to implement coverage for Thai people not yet covered by SHI
in about one year. Population coverage was typically incomplete during this period. In coun4
Preliminary global estimates on the population subjected to catastrophic expenditure and impoverishment.
WHO, November 2004.
T. Evans: Universal Coverage – from Concept to Implementation
10
tries that do not yet have universal coverage, different groups are covered by different
mechanisms, for example, tax-based service provision; compulsory SHI-type coverage for
particular population groups; community, co-operative, enterprise-based and mutual health
insurance; or other forms of nongovernmental or private health insurance. These will continue to coexist for some time during the transition to universal coverage, but the disparate
parts will need to be brought together in a way that ensures universal coverage.
The most promising and best-suited organisational options have to be chosen from the broad
spectrum available that is essentially based on tax-based health financing (TBF), social
health insurance (SHI), and mixed health financing systems (MHF). In practically all countries, a variable part of the population is entitled to health care benefits financed by tax revenues or various types of health insurance, and some groups are even covered by both
mechanisms. Historical and social choices determine which type of system forms the basis,
but the most relevant goal is to achieve and guarantee that a high proportion of household
financial contributions is prepaid and pooled.
Figure 1.3.4: Prepayment in OECD countries
Number of countries
14
12
10
8
13
6
7
4
2
3
4
2
1
0
40-50%
50-60%
60-70%
70-80%
80-90%
> 90%
Prepayment ratio
The transition to universal coverage may take several years, even several decades. A number of factors determine the speed of transition. Essential elements are the relative acceptance of the value and concept of solidarity in society, the effectiveness of government stewardship and the population’s trust in government and its institutions. A critical limiting factor is
the ability of governments to mobilise tax revenues or insurance contributions. High economic growth enhances people’s capacity to contribute to a health-financing scheme. When
accompanied by a growing formal sector, it also makes it easier for any health-financing system to assess incomes and draw contributions from households (i.e. to collect taxes or insurance contributions). A further factor is the availability of skilled administrative personnel to
facilitate the effective administration of a nationwide system.
No specific health-financing mechanism is optimal and recommendable in all settings. Indeed, of the 30 OECD Members, 15 have a system funded predominantly from contributions
that are pooled in social health insurance funds, 12 have largely general tax-funded systems,
and three have a mixed health-financing system. Virtually all countries that rely on pooled
contributions also receive financing from government budget revenues in order to provide
coverage for particular population groups, such as the poor. In addition, all have some copayments for specific types of services or for pharmaceuticals. Little advantage is discernible
in one financing system over another in terms of impact on health outcomes, responsiveness
to patients, or efficiency.
Extending Social Protection in Health
11
Current challenges across countries
However, the impact of a health-financing system depends on the way in which funds not
only are raised, but also are pooled and then used to provide or purchase health services.
Attention should not focus solely on the question of revenue collection, which lies sometimes
outside the control of the ministry of health. Improvements in efficiency and equity can also
be made by examining the way in which revenues are pooled, then used to purchase and
provide health services and interventions. Organisations that are part of the health-financing
system – whether ministry of health, other ministries, health insurance funds, or private providers – require appropriate incentives in order to reach the objective of universal coverage
through adequate revenue collection, and suitable arrangements for pooling and purchasing.
At some point various constraints and possibilities of a social, economic and/or political nature will entail specific choices in the transit of a health-financing system towards universal
coverage. An initial crucial factor is the organisational context: the possibility of building upon
successful existing institutions. Second, government stewardship and notably a strong political will to engage in a particular health-financing reform are essential. Third, the state of the
economy is important, in terms of both overall growth and the extent of formalisation of employment; economic growth and a growing formal sector facilitate the ability of governments
to mobilise compulsory funding for universal coverage. Lastly, a concern common to all
health-financing options is whether skilled administrative staff is available in sufficient numbers to undertake all the financing functions.
Ultimately, a country’s decision
on how to modify its health-financing system should be guided by decisions on collection,
pooling, and purchasing, and the
associated organisational arrangements that are most likely to
lead to universal coverage in the
context of that particular country,
taking account of its society’s
values and collective objectives.
Methods of prepayment and
pooling of resources and risks
are basic principles in financial
protection that require special
attention in cases where these mechanisms are not well developed. The way to purchase or
provide services using the pooled funds also needs careful consideration so that the needs
of the population and the question of equity are optimally addressed.
When reforming a health-financing system, governments need to retain their important stewardship role in order to steer implementation while maintaining a certain degree of pragmatism, since societies and economies are dynamic, and the transition to universal coverage is
likely to spread over several years. Therefore, it is crucial that general design features are
analysed adequately and regulations are adequate with respect to the compliance with the
law. The allocation of revenues and the provider payment methods have to be well defined.
In addition, the proper definition of the benefit package or packages is as important as the
implementation of effective financial control mechanisms.
Conclusion
For implementing viable and sustainable health financing systems that enable a society to
reach universal coverage, the context of the country is preponderant and has to be closely
analysed and taken in account. Whichever the choice is regarding the mechanisms and
schemes to be implemented, prepayment and risk pooling are overriding principles that prevent households as well as the system as such from serious financial constraints and col-
12
T. Evans: Universal Coverage – from Concept to Implementation
lapse. International empirical evidence shows that government stewardship is indispensable
for steering the process during the implementation and transition period, for maintaining a
certain level of pragmatism and for achieving a more conducive international support to policies oriented towards universal coverage.
On the more specific country level, universal social protection in health requires a certain
structural, professional and organisational capacity. Strong institutions are a must for implementing effective and reliable health financing mechanisms, and the need of a sufficient
number and qualification of skilled workforce is often underestimated. Besides the existing
‘fiscal space’ and the socio-historical options of sustainability, a series of instruments have to
accompany the implementation of universal coverage at the country level - mainly budget
support, medium term expenditure framework (MTEF), poverty reduction strategies (PRS),
sector-wide approaches (SWAPs), etc. The international community has the potential to influence the socio-political processes in developing countries by putting adequate incentives
through the modalities to access resources available for development and especially for
health, like the global funds, loans and other forms of donor support.
References
Akal, Afsar; Harvey, Roy (2001). The Role of Health Insurance and Community Financing in Funding
Immunization in Developing Countries. WHO, Geneva
(http://www.who.int/immunization_financing/options/en/role_chf.pdf).
Carrin, Guy (2002). Social health insurance in developing countries: a continuing challenge. International Social Security Review 55, 57-69, ISSN: 0020-871X.
Carrin, Guy; James, Chris (2004). Reaching Universal Coverage via Social Health Insurance: Key
Design Features in the Transition Period. WHO, Department of Health Systems Financing and Resource Allocation. Geneva (http://www.issa.int/engl/initiative/projects/2carrin-james.pdf).
Carrin, Guy (2004). Linking health and economic policy to speed up increased household welfare.
Bulletin World Health Organization 82 (12), p.12 (http://www.who.int/bulletin/volumes/82/12/947.pdf).
Gesellschaft für Technische Zusammenarbeit (GTZ) (2003). Social Health Insurance: Systems of Solidarity. Experiences from German development cooperation. Bonn/Eschborn
(http://www.gtz.de/de/dokumente/en-social-health-insurance.pdf).
World Health Organization (2000). World Health Report 2000 - Health Systems: Improving Performance. WHO, Geneva (http://www.who.int/whr/2000/en/).
World Health Organization (2003a). World Health Report 2003. Shaping the Future. WHO, Geneva
(http://www.who.int/whr/2003/en/).
World Health Organization (2003b). Millennium Development Goals: The health indicators: scope,
definitions and measurement methods. WHO, Geneva
(http://www.who.int/mip/2003/other_documents/en/MDG_Indicators_HFS032.pdf).
World Health Organization (2004). Social Health Insurance. Report by the Secretariat. Geneva.
World Health Organization (2005a). Fifty-Eighth World Health Assembly A58/20, Provisional agenda
item 13.16. WHO, Geneva (http://www.who.int/gb/ebwha/pdf_files/WHA58/A58_20-en.pdf).
WHO (2005b). Sustainable health financing, universal coverage and social health insurance, World
Health Assembly Resolution WHA58.33. WHO, Geneva
(http://www.who.int/health_financing/HF%20Resolution%20en.pdf).
World Health Organization (2005c). Designing Health Financing Systems to Reduce Catastrophic
Health Expenditure. Technical Briefs for Policy Makers No. 2 – 2005, WHO, Geneva
(http://www.who.int/health_financing/pb_2.pdf).
World Health Organization (2006). Working together for health. World Health Report 2006. WHO, Geneva (http://www.who.int/whr/2006/whr06_en.pdf).
Xu, Ke (2005). Distribution of health payments and catastrophic expenditures Methodology. Discussion Paper No. 2 – 2005, Department "Health System Financing" (HSF), Cluster "Evidence and Information for Policy" (EIP), WHO, Geneva
(http://www.who.int/about/iag2005/distribution_of_health_pay_dp_05_2.pdf).
Extending Social Protection in Health
13
1.4. The Role of Social Protection in Health in achieving the
Millennium Development Goals
Stefan Helming5
Background
It is high time to place this issue on the political agenda. Worldwide, 1.3 billion people in developing and countries in transition do not have access to adequate and affordable health
care. Apart from the poor coverage and low quality of health provision in rural areas, a particular problem is the high cost of using medical services. There is nothing abstract about this
topic. It is interwoven with human destinies. In Rwanda recently a young man was brought
into the clinic in excruciating pain. His family had hesitated for far too long before deciding to
sell their only cow, so as to have enough money to for to pay the hospital fees. Then of
course, because they were selling in haste, at the market they only got a fraction of the cow’s
real value. By the time the patient reached the operating theatre, his appendix had ruptured.
The operation came too late to save him. In the end, not only did the young family lose their
father, the main breadwinner, but also their cow, their productive capital, which had safeguarded them from poverty until then.
Social health insurance as an instrument for poverty reduction (MDG 1)
Every year, 100 million people are reduced to poverty because they are unable to afford the
costs of medical care. Social protection – which includes insurance against the risks of ill
health – is an important element of poverty prevention and reduction. Social health insurance
for all is thus a step towards achieving the first of the Millennium Development Goals.
Setting up a health insurance scheme is a matter of some technical complexity, and the conference has been engaging with these issues in depth. But what it calls for above all else, is
a firm and united political will. The reduction of world-wide poverty by half over the next 10
years, the Programme of Action 2015 and Germany’s contribution towards achieving these
goals may be ambitious, but are not utopian.
In Berlin, about 125 years ago,
one Robert Koch used to work
just a few kilometres from the
conference location, at the old
Institute for Infectious Diseases
that now bears his name. There
he discovered the tuberculosis
bacterium and the corresponding vaccine. But there is something else which not so many
people know of: he was also
very concerned about the social
causes of tuberculosis and
strongly supported the introduction of state health insurance for
all. This first took shape in 1883
with the Bismarckian Reich Insurance Code; since then it has contributed to better social
protection for people in countries all over the world.
Many called it utopian at the time, and after all, it did take another 80 years for Germany to
achieve health insurance coverage for all. And even today, it remains an ambitious project.
The current debate and reform efforts surrounding the German health system make it clear
5
Director General, Department of Planning and Development, Gesellschaft für Technische Zusammenarbeit
(GTZ), Eschborn, Germany, [email protected].
14
St. Helming: The Role of Social Protection in Health Towards Achieving the MDG
that our system is far from perfect. This is why the purpose of the work at GTZ is certainly not
to transfer the German health insurance system to other countries. Within the framework of
German development cooperation, GTZ aims to be a supportive partner to countries wishing
to set up sustainable financing structures, based on solidarity and on the pooling of risks,
which are geared towards universal access to health services and thus contribute to poverty
reduction.
Social health insurance as an instrument for achieving MDG 4 and 5
When introducing and implementing a health insurance scheme, it is crucial that poor population groups have some say in the framing of necessary reforms, and in their implementation. In this respect, so far women and girls have been at a disadvantage. Although many
countries now have good programmes for reproductive health, generally the costs are not
fully covered and often have to be met unofficially from people’s own pockets. As a consequence, families are often confronted with even tougher decisions than the Rwandan family
mentioned above. The decision to pay for the main breadwinner’s medical treatment by selling the family’s means of production is a very difficult one to take indeed. But when the family
members in question are female, which means being at a disadvantage to males in many
cultures, the decision is even less likely to go in their favour.
In many countries, this results in unacceptable rates of child and maternal mortality. Here
again, health insurance can make a considerable contribution to improving national health.
Therefore efforts to set up sustainable systems for financing health care in our partner countries should always be gender-specific. This would bring considerably more progress towards
Millennium Development Goals 4 and 5, reducing child and maternal mortality by threequarters by the year 2015.
Restoring a sound basis for health care financing - working towards MDG 6
To meet the global challenges of HIV/AIDS, tuberculosis, malaria and the escalating risk of
infectious diseases, global funds were established in the 1990s to tackle the individual diseases, with support from the German government and many others. This is undoubtedly
good and important work, and GTZ is supporting it actively on behalf of the Federal Ministry
for Economic Cooperation and Development (BMZ).
However, these funds were set up on the assumption that medical care and financial coverage would be available to populations through the existing channels and structures of the
countries’ own systems of health care. But this is not always the case, because these structures tend to be unstable and are not sustainably financed. As a result of inadequate financing, the quality of services is poor. This gives rise to inefficiencies, not only in primary care
but also in the treatment of HIV patients, as well as malaria and tuberculosis prevention and
treatment. Both systems of social health insurance and workplace policies can contribute to
the sustainable financing of health care systems.
Meanwhile, we should not forget that international donors are already investing large
amounts of money in health care systems. Yet often there is no coordination of investments
from different sources. We should therefore make better use of these existing resources. If
one adds up all the money currently being channelled through these funds into the financing
of systems, one quickly arrives at a figure in the hundreds of millions. If these funds were
coordinated, they would be sufficient to cover at least part of the necessary infrastructure
now.
A key element for success: clear governance structures
But even if existing funds were put to better use and sustainable insurance systems were set
up, the current resources are not sufficient to permit comprehensive coverage for all citizens
in all countries. The huge challenge the international community is facing can be expressed
in three figures: 90, 80, 10. This is what they stand for: 90 % of the burden of ill health is
borne by the poorest 80 % of the world’s population. But only 10 % of global health funding is
Extending Social Protection in Health
15
spent on this group. This is a big scandal. Making provision for the poorest of the poor is the
role of the state, in Germany and in most other countries that have built up a solidarity-based
health insurance system. On the other hand, there are people who are in a financial position
to afford more than the minimum package of health benefits. For these people there should
be additional products on offer, and naturally this is a good market for private providers.
Health is an inalienable human
right, but it also happens to be
the largest sector in the world
economy. These two sides of
the same coin prompt the state
to take on a role. Our experience
shows that clear and binding
agreements are needed on the
different roles of stakeholders.
These roles must be defined and
scrutinised by the state. It should
give individual actors – including
the private sector – sufficient
flexibility to allow them to develop within the clearly defined
framework.
Promoting international technical co-operation from a single source – the GTZ-WHOILO consortium
Clear structures should also be created for the international actors in health development
work. In many ways the scene is redolent of a chaotic marketplace, with a huge number of
actors clamouring from every side to appeal to the customer. Multiply this by the number of
donors supporting these initiatives and substantial transaction costs result.
The purpose of coordinated multilateral work in this field is to provide advisory expertise from
a single source. And indeed, this is the purpose of the consortium that GTZ, at the request of
BMZ, has formed together with WHO and ILO. The structure makes exemplary use of the
different roles of the United Nations organisations and the executing agencies. A number of
other donor countries, international organisations and civil society partners have joined the
consortium during the conference.
Social health insurance schemes are certainly no panacea. They are unable to achieve by
themselves, four of the eight Millennium Goals closely related to health. However, they have
an important part to play. This is why the German technical cooperation is keen to ensure
that countries that require expertise and technical support in this field will also be able to
count on it in future.
References
Federal Ministry of Economic Cooperation and Development (BMZ) (2001). Poverty Reduction A
Global Responsibilty. Program of Action 2015. The German Government’s Contribution towards Halving Extreme Poverty Worldwide. Information Materials No. 108, BMZ, Bonn
(http://www.bmz.de/en/service/infothek/fach/materialien/materialie108.pdf).
Federal Ministry of Economic Cooperation and Development (BMZ) (2005). Germany's Contribution to
Achieving the Millennium Development Goals, Information Materials No. 141, BMZ, Bonn
(http://www.bmz.de/en/service/infothek/fach/materialien/materialie141.pdf).
German Technical Co-operation (GTZ) ed.) (2005). Social Health Insurance . A contribution to the
international development policy debate on universal systems of social protection. Discussion paper.
Eschborn (http://www.gtz.de/de/dokumente/en-contribution-international-policy-debate.pdf).
16
D. Fuentes M.: Social health insurance: Economic development and poverty reduction
1.5. Social health insurance: Economic development and poverty reduction
David Fuentes-Montero6
Economic development in Costa Rica and Central America
Over a period of time, Costa Rica has tested out different development strategies the results
of which are shown today by the living standard of the ‘ticos’, the nickname used to identify
Costa Ricans. According to the 11th Report on the Country Situation on Human Sustainable
Development, measured for the year 2004, the quality of life and living conditions of ‘ticos’ is
fairly high. With a Human Development Index of 0.838 the Central American country is in
position 47, while the Gender Empowerment Index of 0.664 puts Costa Rica in the 19th place
(UNDP 2005, pp. 219ff). Life expectancy at birth is 75.0 years for males and 80.0 years for
females; child mortality rate is 9.25 per 1,000 live births; 28.95 % of the 4.25 million population are younger than 15, and 5.65 % older than 64 years (WHO 2006). The official unemployment rate is 6.5 %; 97.6 % of the population has access to water pipelines; 40 % are
currently served by sewer systems and in 5 years this ratio will rise to 65 % (Nets@lud
2005).
89 % of Costa Rican children have access to primary schools, 90.5 % have approved primary and secondary education and 80 % have a high school or another diversified schooling
degree. The per capita gross domestic product is €3,461.28, and 78.3 % of the population is
living above the poverty line. However, our situation has not always been like that. Let us
briefly review the road that has leaded us up to this point.
National productive and commercial strategies
Until the end of the decade of 1950, the Costa Rican economy was underpinned by the agricultural sector which was the driver of economic and social development. The agrarian sector absorbed most of the manpower, around 55 % of the economically active population. Two
principal commodities – coffee and bananas – contributed more than 40 % of the GDP and
constituted almost 90% of exports. The agricultural sector was also the main generator of
fiscal revenues. However, the almost exclusive dependence on these two primary products
made the national economy very vulnerable to external pressures.
A substantial change in the country’s development strategy began at the end of the 1950s.
An Import Substitution Model, involving a wide-based industrialisation and economic integration process and which had been previously applied in other Latin American countries, was
adopted. This new development strategy sought, in first place, to achieve high economic
growth rates in order to increase employment, to enhance productivity and, consequently, to
raise salary levels and population incomes. A higher income level would improve living conditions and standards, reduce poverty and lead to better income distribution.
This model contributed towards the transition from a dominantly rural economy to a more
modern one, where secondary and tertiary activities were given more support. At the end of
the1970s, various programs to fight poverty and to support the weakest groups in society
were promoted by government institutions. Through the intervention of the State in the social
area, Costa Rica joined the best-ranked countries in Latin America in terms of education and
health. This progress was achieved in an environment of peace and democracy.
The removal of the army by constitutional order in 1949, the creation of the Supreme Elections Court and the establishment of the Civil Service in 1953 are examples of political institutionalisation that served as a framework to the socioeconomic measures applied during the
three decades between the early 1950´s and the end of the 1970´s.
6
Minister of Finance of the Republic of Costa Rica, Central America, 2005 – 2006, [email protected],
[email protected].
Please compare Chapter 2.5: A. Sáenz Pacheco, J. Holst: The role of equity and solidarity within social health
insurance: Chances and risks of the Costa Rican way towards universal coverage (pp. 55-61).
Extending Social Protection in Health
17
In spite of the positive results, some aspects of the Costa Rican development turned out to
be unsustainable and even contributed to deepening dependency on and increasing vulnerability on external forces. At the end of the 1970s, a combination of internal and external
phenomena produced the worst crisis the Costa Rican economy had ever gone through. Between 1980 and 1982, GDP decreased almost 10 % and the national income fell by 22 % which led to over 25 % contraction in per capita income in this period.
The next stabilisation program, applied from May 1982 and whose positive results became
palpable in less than three years, was successful because of the support that the Costa Rican Government obtained from international organisations. Through several loans and donations, the country obtained the resources required for fulfilling its external commitments and
maintain its balance of payments equilibrium. The measures applied from 1982 were intimately linked to a ‘new development model of exports promotion’ and established changes in
order to recover medium and long term growth. This new strategy, based on opening up the
economy, was the antithesis of the ‘imports substitution’ policy and expressed the necessity
of the reinsertion of the Costa Rican economy into international markets.
From the politico-economic perspective, the new model required a series of unavoidable
conditions, for example the elimination of political influence on the allocation of resources,
less participation by the state, attracting external investments and increasing internal savings
to finance the growth. Although the new development framework was taking shape through
agreements that different Costa Rican governments had signed with international financial
organisations, social provisions and benefits that Costa Rican workers had achieved decades ago were not affected – unlike the case in other places and they are in place until today.
Costa Rica has now become a small-size but large-scale exporting country with excellent
social and development indicators comparable, in parts, to those of the developed world.
This has been done through a clear historical policy of protecting the wellbeing of its people
by consistently investing significant resources on health and education nation-wide. That is
the so-called ‘Costa Rican way’ of doing things – which has recently been used in the negotiations of the Central American Free Trade Agreement (CAFTA) with the United States of
America.
Table 1.5.1: WHO core health indicators
Total expenditure on health as percentage of gross domestic product
7.3
General government expenditure on health as percentage of total expenditure on health
78.8
Private expenditure on health as percentage of total expenditure on health
21.2
General government expenditure on health as % of total government expenditure
22.8
External resources for health as percentage of total expenditure on health
Social security expenditure on health as % of general government health expenditure
Out-of-pocket expenditure as percentage of private expenditure on health
2.7
88.6
88.70
Private prepaid plans as percentage of private expenditure on health
2.1
Per capita total expenditure on health at average exchange rate (US$)
305
Per capita total expenditure on health at international dollar rate
616
Per capita government expenditure on health at average exchange rate (US$)
240
Per capita government expenditure on health at international dollar rate
486
Source: World Health Organization 2006b.
18
D. Fuentes M.: Social health insurance: Economic development and poverty reduction
Costa Rican educational strategy
The 78th Article of the Costa Rican Constitution establishes the following: "Pre-school and
elementary education are mandatory. These and the diversified education (7th to 9th grade) in
the public system are free and financed by the government. According to the law, the public
expense will not be lower than 6 % of the yearly gross internal product in public education,
including higher education,... The State will facilitate access to higher studies for those who
lack pecuniary resources. The award of scholarships and other aids will be in the charge of
the Ministry of the field, through the body that the law stipulates."
In 1891, during the administration of President Bernardo Soto and thanks to the initiative of
his Education minister, Mr. Mauro Fernández, the first educational reform was made within
the legal framework of the General Law of Common Education that ratified the mandatory
and gratuitous nature of elementary education for all children aged between 7 and 14. It also
established ‘kinder gartens’ in the county capitals, adult school in barracks and jails and travelling schools for the rural populations.
Thanks to the reforms of Mr. Mauro Fernández, the educational system was strengthened in
such a way that in 1900, Costa Rica had 362 schools with 21,000 students taught by 870
teachers. At the end of the 19th and the beginning of the 20th centuries, new high schools
facilities were created, elementary instruction programs were reformulated and the Escuela
Normal of Costa Rica was established in 1914 that would become the ‘Alma Mater’ of the Costa
Rican education.
Between 1940 and 1977, the
four state universities were
founded, including the Instituto
Tecnológico and the Universidad
Estatal a Distancia, and in 1978
the first private institution of
higher education, the Universidad Autónoma de Centro América was established. Since then,
private university facilities have
proliferated to the point that 48
private universities were officially authorised in 2000. By the creation of the Public Education
Ministry, the current Political Constitution (1949) established that public education should be
organised as an integral process, related in its diverse cycles, from elementary through university education.
In 1958, the Fundamental Education Law was enacted, and starting from the analyses carried out in 1967 to identify the problems of the educational sector, the National Plan of Educational Development was consolidated and begun in 1972. It was the most important aspect
of educational reform that sought to raise the average level of education of the population
and bring about the modernisation of the educational system in order to respond to the socioeconomic necessities of the country.
The overall goal was to enhance the development process by maintaining the percentage
proportion of public expenses for education as part of the national budget. As a result, in
1973 the Political Constitution was reformed in such a manner that it has remained unchanged to the present: "The Basic General Education (elementary school) is mandatory,
and establishes that the preschool, the elementary and the Diversified Education are free of
charge and financed by the State." Finally, since June 23 of 1997, preschool education is
also mandatory, and public expenditure on education is not permitted to drop below 6 % of
the Gross Internal Product. This guarantees funding of public education until today, with coverage from preschool to higher education.
Extending Social Protection in Health
19
Social reforms in Costa Rica and social provisions established
A key purpose of this paper is to review the social security system that the country has built
up throughout the past decades. Before 1940, the Costa Rican socio-political model was
influenced by the political-economic tendencies of the so-called ‘liberals’ of the day led by
constant demonstrations and protests by workers demanding better social conditions. The
decade between 1940 and 1950 was an equally convulsed time, marked by the Second
World War and constant demonstrations for political, economic and social changes, complicated by an unfavourable fiscal situation. In Costa Rica, this period ended in the promulgation of a new Political Constitution in 1949 and the principles of the Second Republic that are
the bases of the contemporary Costa Rican society.
With the assumption of President Calderón Guardia (1940-1944), the country began to suffer
a transformation as the socio-political model started to move away from the traditional liberalism. The new model tried to reconcile elements of the previous model with state interventionism and the social doctrine of the Catholic Church. As a result of the Calderón Guardia administration, the Department of Sanitary Units and Rural Hygiene was created (1940), and
the Assistance and Social Protection Law introduced in 1940. The reform process ended with
the implementation of the Costa Rican Board of Public Health one year later. Finally, in 1942
the Executive Power announced a project of Social Guarantees and formed a group in
charge of writing the Labour Law. Both bills were later on ratified by the Congress and became core pillars of the current social security and protection system.
Recent indicators - social security and health 2004
Population share covered by Health Insurance
99.1%
Population covered by primary care programs
87.4%
Gross birth rate (per 1000 inhabitants)
Gross mortality rate (per 1000 inhabitants)
Vaccination coverage for children
Measles (1 year)
Poliomyelitis (younger than 1 year)
17,01
3,75
88%
90%
Rate of Diseases with mandatory reporting
HIV/AIDS (per 100.000 inhabitants)
Measles (per 100.000 inhabitants)
Hepatitis (per 100.000 inhabitants)
Diarrhoea (per 100.000 inhabitants) (NOT SO GOOD)
4,6
0,0
22,1
2813,6
Coverage of Labour Risks Insurance
71.5%
Consultations to Health Insurance Services
Emergency + outpatient consultations (per 100 inhab.)
Specialised outpatient care (per 100 inhabitants)
Total Consultations to Health Insurance Services
3,7
63,7
15.570
Laboratory tests for hospitalisation (per 100 inhabitants)
29,6
Hospital beds (per 1000 inhabitants)
2,05
Average number of beds in Health Insurance hospitals
5.830
In 1948, the wining side of
the civil war took over
power and constituted the
provisional Government of
the Eighteen Months presided by José Figueres.
The interim legislation expanded the Constitution of
1949 and a series of interventionist economic measures that went beyond
those implemented by
Calderón.
The most relevant aspects
were to maintain the social
and labour legislation of
the 1940s (Labour Law,
Social Guarantees and
Public Health Law); to
raise the wages of coffee
and sugar plantation workers and part of public
employees; to transform
the Mixed Committee of
Minimum Wages into the
nationwide National Council of Wages (CNS); and to
establish a charity tax.
Although the social demo
cratic constitutional project
presented to the Legislative Congress dominated by a reformist majority was rejected, the
social democratic party was able to incorporate important aspects of their concept in the development of a Welfare State model. As a very first statement of politics, a series of autonoSource: CCSS 2006
20
D. Fuentes M.: Social health insurance: Economic development and poverty reduction
mous public institutions were defined, such as the state-run banks and insurance companies,
the National Health System, and the railroad company, among others.
Building upon the achievements in social security and
health insurance during the 1940s, and after a strong
negotiation by the Executive Power, in 2000 the Congress approved the Workers’ Protection Law (Ley de
Protección Obrera). This relatively recent law creates a
framework to regulate the new labour capitalisation
funds owned by the workers; universalises pension
schemes for the elderly living in poverty; broadens coverage of the Invalidity, Elderly and Death Scheme as
the main solidarity system oriented towards workers
protection and establishes a framework for supervising public and private complementary
pension schemes.
The main changes introduced by the new law were focused on the concept and application
of the right to severance benefits in cases of breach of contract, and the implementation of a
second pension scheme complementary to the one managed by the Costa Rican Social Security Board. In particular, the law has created a new labour savings system completely
owned by the workers, grouped under a Labour Capitalisation Fund; established a compulsory complementary pension regime and a voluntary saving and complementary pension
scheme, and modified deeply the Costa Rican Social Security Law in order to strengthen its
autonomy and improve its performance. Although some stakeholders intended to hamper
this progress through legal means, the Constitutional Court ratified the full legality of the implemented reforms in 2003.
Provision of social health insurance by the central government and other public sector
bodies; and social health indicators
The Central Government dedicated 17 % of the total budget for 2005 – around US$4 billion –
to finance the different pension schemes already in place in Costa Rica, covering 230,780
beneficiaries. 36.7 % of the budget relied on payroll
deductions from public employees – the social provisions
granted to them by the Costa Rican Government represent
an extra disbursement of more than 40 % over the basic
salary. Among others, the provisions include: social health
insurance (with overall family coverage) – by far the most
costly and significant provision; severance, thirteen month
pay (Christmas bonus), sickness benefits and School bonus
(at the beginning of the academic year).
Despite the year per year recurrent fiscal deficits, the strong
commitment of the Costa Rican Government in financing
these social provisions (and the educational ones as well)
has been consistently proven and even further improved by
increasing service coverage and mobilising additional resources to maintain the social health insurance systems in operation.
With regard to the budget allocation in the overall public sector, public entities working within
the social security and assistance field spend annually about US$1 billion.7 45 % of the social
budget for 2004 went to the different pension schemes, 25 % to the Costa Rican Social Security Board, and 10.5 % to the Fund for Social Development and Family Provisions (FODESAF). In the three-year period 2002-2004, the public sector has invested an average of more
than 6 % of the annual Gross Domestic Product (GDP) in social security and assistance. The
7
Namely the Costa Rican Social Security Board, the National Insurances Institute, the Institute for Social Assistance, the Board for Social Protection in San José, the National Authority for Childhood, and others.
Extending Social Protection in Health
21
policies implemented and sustained since the early 1940’s have contributed to a continuous
improvement of social health insurance.
Costa Rica has stacked a good deal on the relationship between health insurance, education, social mobility and poverty reduction. Therefore, the country has oriented its limited resources to investment priority areas addressing key health and educational issues. Currently,
the most recent decisions are yielding good results manifested by a well-educated and
healthy labour force. Due to social protection and adequate education of its population,
Costa Rica is competitive on the international market, and multinational companies chose the
country to handle their worldwide operations in cutting-edge industries like computer microprocessor manufacturing or specialised software development. Headquarter offices established in Costa Rica are managing global businesses and international call centres.
Various lessons drawn from the Costa Rican experience in social security are worth attention
and reproduction. All stakeholders in the field of social protection in health, the international
community, and the media are invited to work closely together in order to make a serious
effort at exchanging empirical and reliable information that can help to ensure sustainable
development of social health insurance in developing countries all over the world.
References
Caja Costarricense de Seguridad Social (CCSS) (2006). Anuarios Estadísticos. Departamento de
Estadística, Dirección Actuarial y de Planificación Económica, San José (www.ccss.sa.cr).
Ministerio de Educación Popular (MEP) (2006). Educación. Homepage of the Ministry of Security, San
José, Costa Rica (www.mep.go.cr).
República de Costa Rica (1949). Estado de la Nación y la constitución Política. San José, Costa Rica
(http://www.constitution.org/cons/costaric.htm).
Ministerio de Seguridad (2006). Seguridad. Homepage of the Ministry of Security, San José, Costa
Rica (www.msp.go.cr).
Ministerio de Salud (2006). Salud. Homepage of the Ministry of Health, San José, Costa Rica
(www.netsalud.sa.cr).
Ministerio de Trabajo (2006). Trabajo. Homepage of the Ministry of Labour, San José, Costa Rica
(www.ministrabajo.go.cr).
Rodríguez-Clare, Andrés; Sáenz, Manrique; Trejos, Alberto (2002). Economic Growth in Costa Rica:
1950 – 2000. Interamerican Development Bank (IDB), San José
(http://www.econ.psu.edu/~aur10/Papers/EconomicGrowthCR.pdf).
United Nations (UNDP) (2005). World Development Report 2005.
(http://hdr.undp.org/reports/global/2005/pdf/HDR05_complete.pdf;
http://hdr.undp.org/statistics/data/countries.cfm?c=CRI).
World Bank (2003). Implementation Completion Report (CPL-36540; SCPD-3654S) on a loan in the
Amount of US$22 Million to the Republic of Costa Rica for a Health Sector Reform Project, Report No:
25713, World Bank, Washington DC (http://wwwwds.worldbank.org/external/default/WDSContentServer/IW3P/IB/2003/06/18/000112742_2003061817
4647/Rendered/PDF/257130CR0ICR.pdf).
World Bank (2003). Costa Rica. Social Spending and the Poor. Report No. 24300-CR, World Bank,
Washington DC
(http://web.worldbank.org/WBSITE/EXTERNAL/COUNTRIES/LACEXT/COSTARICAEXTN/0,,content
MDK:20252791~pagePK:141137~piPK:141127~theSitePK:295413,00.html).
World Health Organization (2006a). Working together for health. World Health Report 2006. WHO,
Geneva (http://www.who.int/whr/2006/whr06_en.pdf).
World Health Organization (2006b). National Health Accounts – Costa Rica. Geneva
(http://www.who.int/nha/country/cri/en/).
J. Frenk, F. Knaul, E. González P., M. Barraza Ll.: Poverty, health and social protection
22
1.6. Poverty, health and social protection
Julio Frenk8, Felicia Knaul9, Eduardo González-Pier10, Mariana Barraza-Lloréns11
Introduction
Fairness in finance is an intrinsic goal of health systems. Achieving fair financing continues to
challenge health systems in countries at all levels of economic development. Complex and
differentiated healthcare institutions evolved during the 20th century alongside technological
breakthroughs, yet effective, fair and sustainable methods to finance these systems are still
lacking even in the most economically advanced countries.
In most developing countries financial protection for health is partial and segmented. Mexico,
a middle-income country characterised by social inequalities and a complex epidemiological
transition, fits this description. The health system must still address the unfinished agenda of
infectious diseases and reproductive health problems while facing the increasing pressure on
health expenditure associated with chronic disease and ageing.
In 2000, the WHO health system performance assessment ranked Mexico 51th overall out of
191 countries, yet 144th on financial fairness. The poor performance on fairness of finance
reflects the fact that more than half of Mexican households lack health insurance and therefore financial protection. Lack of universal social protection in Mexico is intertwined with the
existing health system segmentation between the formal sector, with access to social security, and the rest of the population that is excluded from this type of protection. This situation
has contributed to the prevailing health inequalities and unfair health financing.
Mexico recently devised a structural reform in order to extend social protection in health to
families not covered by conventional employment-based social insurance. The reform
passed into law in April 2003, and the System for Social Protection in Health started operating on January 1st, 2004. The reform comprises an operational programme called Popular
Health Insurance, which offers uninsured Mexicans voluntary access to publicly subsidised
coverage for a comprehensive set of services at the primary and secondary levels, as well as
a gradually expanding set of costly high-specialty interventions. It is expected that by 2010,
at the end of a seven-year transition period, universal coverage will be reached.
Through the new System for Social Protection in Health, the reform will reduce economic
barriers to timely care and prevent catastrophic expenditures while promoting efficiency, a
more equitable resource distribution and better quality care. Thus, universal access to social
protection in health should contribute towards avoiding impoverishment due to illness. This
paper will focus on the ethical basis of the reform, its financial features, expected benefits,
and future challenges. Finally, it will highlight some relevant aspects for other countries that
are also striving to promote universal social protection as a means of achieving fairness, improving health and reducing risks that all too often generate poverty.
Poverty and health
Health has an intrinsic value (it produces well-being) and an instrumental value (it is an important determinant of economic development). The instrumental value is the result of the
direct impact of health improvements on labour productivity and the economic burden of illnesses; but it also reflects an indirect impact on economic growth through education. Better
health during childhood increases the opportunities to benefit from education and thereby to
improve future income. Due to its direct and indirect impact, health is one of the important
determinants of the incidence of poverty as well as its persistence over time, known as “pov8
Minister of Health of Mexico 2000-2006, [email protected].
General Coordinator for Modernisation of Education in the Ministry of Public Education, Mexico and principal
economist at the Mexican Health Foundation.
10
Head of the Economic Analysis Unit in the Ministry of Health, Mexico.
11
Assistant Director in the Economic Analysis Unit, Ministry of Health, Mexico, [email protected].
9
Extending Social Protection in Health
23
erty traps”. Poverty traps that are created by an adverse health shock not only expose numerous people to poverty, but also exclude them from contributing productively to the economy. To avoid these consequences, it is important to have an adequate social protection
framework that minimises the impact of these shocks on families.
Health insurance is one mechanism that individuals can use to
protect themselves from possible adverse health events.
Individuals can protect themselves by acquiring private medical insurance or accessing state-sponsored insurance. Nevertheless, access to formal private insurance mechanisms is
limited by insufficient information as well as by practices in
which certain private providers
of insurance get the most profitable part of the market. And
access to state-sponsored insurance is often restricted to
workers in the so-called formal
sectors of the economy.
When people cannot insure
themselves in the formal market, they can resort to informal
mechanisms. Thus, when exposed to an adverse health
shock, families can react by
selling assets, using credit or
finding additional sources of
income, which can include child
labour, and/or decreasing the consumption of other goods and services. All these methods,
depending on their magnitude, can trap a family already in poverty or impoverish a family
that was not previously poor. These mechanisms that protect against health risks are actions
that reflect the self-protection of individuals, households or communities. Despite the fact that
informal markets and self-insurance are widely used by poor households, there is evidence
that they are not enough to protect the household against the effects of adverse events on
well-being. The lack of formal or informal insurance reduces an individual’s ability to smooth
the inter-temporal consumption of health-producing goods.
Low-income people who have no access to formal insurance mechanisms are exposed to a
vicious cycle of illness and poverty. The money they must set aside to finance medical expenses frequently is a considerable burden, and the situation can become catastrophic.
Based on existing literature, a family faces catastrophic expenses when it spends more than
30% of its total ‘payment capacity’ to cover health costs. When this occurs, families must
adjust expenses for other goods, including perhaps money spent on the health and nutrition
of young children. A catastrophic health shock could create a poverty trap for a large number
of households. This situation does not affect all the population in the same way. Families are
more likely to incur catastrophic health expenses or fall into a poverty trap as the income
level decreases.
In order to comply simultaneously with the goals of equity and efficiency, the most appropriate option to protect the population is via health insurance. The advantages of insurance
compared to other financing mechanisms lie in breaking away from accessing services by
paying for care on an individual level, and establishing access according to the expected
24
J. Frenk, F. Knaul, E. González P., M. Barraza Ll.: Poverty, health and social protection
cost. Health insurance is also an instrument to subsidise health care financing between income groups or health risks. In sum, social protection in health can contribute to alleviate
poverty in two ways. First, through reductions in out-of-pocket expenses, and thus in healthrelated impoverishment. Secondly, lower financial barriers increase access to services thus
increasing their potential to improve health status.
Social protection as a strategy to promote fair financing: the recent Mexican reform
A fragmented system at the origin of the reform
The challenges faced by the Mexican reform of 2003 are rooted in the original design of the
modern health system. In 1943, the Ministry of Health was established. The Mexican Social
Security Institute (Instituto Mexicano del Seguro Social, IMSS) was created in the same year
to attend to formal, private sector, salaried workers and their families. In 1959, the Institute of
Social Services and Security for Civil Servants (Instituto de Seguridad y Servicios Sociales
de los Trabajadores del Estado, ISSSTE) began to cover government employees and their
families. The system was thus segmented -from its inception and through to the reform of
2003 - between the insured, formal, salaried employees and their families with the right to
social security, and the rest of the population (the self-employed, the unemployed, nonsalaried and informal-sector workers, and those who do not work). All citizens - other than
salaried workers - were excluded from formal social insurance schemes, and health care
needs of this ‘residual’ group were attended by the Ministry of Health. The benefit package
was undefined and funded from a combination of federal funds and, to a lesser degree,
state-level contributions, as well as fees paid by families at point of service.
When the reform was passed in 2003, about 40 % of the population were covered by IMSS,
7 % by ISSSTE and no more than 2-3 % by private health insurance. As a result, insurance
coverage was regressive both between households and across states, there was an overreliance on out-of-pocket spending to finance the health system and impoverishing health
spending was common particularly among the lowest income deciles. The reform addresses
these issues by offering subsidised, publicly provided health insurance to the 50 million
Mexicans who are not covered by social security and are concentrated among the poor.
The reform was passed into law in April 2003, and the new insurance scheme called the System for Social Protection in Health (SSPH) went into operation on January 1st, 2004 with the
goal of achieving universal health insurance coverage by 2010. The Popular Health Insurance is the operational programme of the new system. The affiliation process runs from 2004
to 2010, so that 14.3 % of the approximately 11 million families that make up the uninsured
population will be included each year. Preference must be given to families from the lowest
income deciles.
Ethical basis and key values behind the reform
There are five basic values behind the design of the reform: equal opportunity, social inclusion, financial justice, co-responsibility and personal autonomy. Based on these values, the
reform seeks to change the Mexican health system from being segmented by population
group, to being organised so that each institution fulfils only one of the three major health
system functions of stewardship, financing and delivery, yet serves all of the social groups
that make up the Mexican population.
Mexico is undergoing a profound political transition. As now civil and political rights can be
exercised by all citizens, it is necessary to complete the democratic transition by also guaranteeing the effective exercise of social rights, including the right to health protection. Although
this right was formally recognised by the Mexican Constitution two decades ago, in practice,
not all persons have been able to exercise it equally. Half of the population, by virtue of their
occupational situation, enjoy the protection of social insurance and face fewer barriers to
attaining health care than the other half who do not enjoy such protection.
For this reason, the guiding concept underlying the structural reform of 2003 is the ‘democratisation of health’, meaning the effort to extend democracy to social as well as political and
Extending Social Protection in Health
25
civil rights. The process of democratisation is defined as the application of the norms and
procedures of citizenship to those institutions that had been governed by other principles,
such as coercive control, social tradition, judgement of specialists or administrative practices.
The new system is based on five key values that underlie the democratisation concept:
a. Social inclusion, because all persons, regardless of socio-economic or labour market
status, have the same right to health protection based on needs, so that the system is
universal;
b. equal opportunity of all members of the society to the same quality of care and the same
set of services defined by an explicit process of prioritisation;
c. financial justice, whereby families contribute to the health system according to their financial capacity and at the same time receive health services according to their health
needs, services are free at point of delivery, and a large financial pool of resources is
generated that permits financial solidarity between the wealthy and the poor, the healthy
and the sick, the young and the old;
d. co-responsibility between the different levels of government and among citizens;
e. personal autonomy based on subsidiarity so that decisions are made as close as possible to the source of needs, and public institutions remain accountable to citizens.
Financial disequilibria in health care
The financial structure of the Mexican health system before the 2003 reform was marked by
serious imbalances including: low overall budgets, high out-of-pocket spending, inequity in
allocations between the insured and the uninsured, inequitable distribution among states,
and excessive current versus investment expenditure.
First, in 2003 Mexico spent only 6.1 % of GDP (approximately €290 per capita) on health
care. This proportion was below the Latin American average and was too low to face the
challenges of the epidemiological transition. Second, out-of-pocket spending accounted for
more than 50 % of total health spending and was above many Latin American countries including Brazil, Chile, Colombia and Costa Rica. Third, the distribution of public funds between population groups and states was also inefficient and inequitable. Although the uninsured accounted for almost half of the population, they received only a third of the federal
funding for health. Fourth, the difference in expenditure per capita across states was 5 to 1 in
2003, and the difference in state contributions was much more dramatic. Finally, investment
in new facilities and equipment had fallen leading to poor quality.
Regressive insurance coverage worsened the situation. While more than 60 % of the
wealthiest quintile of the population was insured, the figure was approximately 10 % for the
poorest quintile. Further, in the poorest states only one-fifth of households were insured.
Each year, between two and four million households either spent 30 % or more of disposable
income (total income less spending on food) on health or crossed the poverty line due to
health spending. Further, 85 % of these households were uninsured and the majority was
from the poorest deciles.
As a source of financing for a health system, out-of-pocket payments tend to be inequitable
and inefficient. In Mexico, the predominance of this form of payment was both a cause and a
result of the imbalances discussed above. Reducing it was thus a target of the reform.
Social Protection in Health: objectives of the reform
The structural reform of 2003 aims at assuring that all persons, independent of their labour
market or socio-economic status, can exercise their social right to health care as recognised
by the Mexican Constitution.
There are four main objectives to be achieved by the reform:
a. Generate a gradual, predictable, financially sustainable, and fiscally responsible mechanism to increase public expenditures in health so as to correct existing disequilibria;
26
J. Frenk, F. Knaul, E. González P., M. Barraza Ll.: Poverty, health and social protection
b. Stimulate greater allocative efficiency by protecting expenditure for public health interventions that are cost-effective but tend to be under-funded;
c. Protect families from excessive health expenditures by offering a collective mechanism
that manages in a fair way the risks associated with paying for personal health services;
d. Transform the incentives in the system by moving from supply-side to demand-side subsidies in order to promote quality, efficiency and responsiveness to users.
Key features of the reform
Organisation of financing according to the classification of health goods
The allocation of federal funds in the new health system is divided into four main components: the stewardship role of the Ministry of Health; community health services; noncatastrophic, personal health services; and catastrophic, high-cost, personal health services.
The financial logic of the reform separates funding between personal and community health
service by establishing a separate Fund for Community Health Services that is used exclusively to finance public health goods. This separation of funding is based on public goods
theory and on the lessons learned from reform experiences that have neglected public health
programs.
Funding for personal health services is based on an insurance logic to deal with uncertainty.
The instrument devised by the reform to finance personal health services is a new scheme
called Popular Health Insurance (PHI, Seguro Popular de Salud - SPS). For funding purposes, personal health services are divided between an essential package of primary and
secondary interventions in ambulatory settings and general hospitals, and a package of highcost tertiary-level care financed through the Fund for Protection Against Catastrophic Expenditures.
The essential package of interventions is a quality-assurance tool.
These services are decentralised to the state level as they are
associated with low risk, high probability health events. The
package of catastrophic interventions is financed in a fund that
aggregates risk at the national level because their low-probability
and high cost imply that the state risk pool is too small to finance
these interventions. Further, on the supply side, the requirements
for highly-specialised interventions imply that it is efficient to
aggregate services.
The essential package includes comprehensive ambulatory care
at the primary level and outpatient consultation and hospitalisation
for the basic specialties at the secondary level. The Fund for
Protection Against Catastrophic Expenditures covers a package of
services that will be updated annually. This constitutes a prioritysetting mechanism based on explicit, transparent criteria. The
General Health Council is charged with defining the interventions covered by this fund, which
currently includes: cancers, cardiovascular problems, cerebrovascular diseases, severe injury, long-term rehabilitation, HIV/AIDS, neonatal intensive care, organ transplants and dialysis. The criteria to select specific interventions are based on the burden of disease, costeffectiveness, and resource availability.
Structure of financial contributions
The new Popular Health Insurance was designed so its financial structure would be similar to
the tripartite logic of the other major social insurers (IMSS and ISSSTE). Thus, there are
three public insurers for each of the three major population groups: PHI for previously uninsured families; IMSS for private sector workers and their families; ISSSTE for public-sector
workers and their families.
Extending Social Protection in Health
27
There is a fixed contribution (the social quota) from the federal government that is equal for
all families and guarantees solidarity among the three population groups. In January 2004,
the federal social quota was set at 15 % of the mandatory minimum wage. This is equivalent
to €185 per year per affiliated family.
The second source of funding is from the co-responsible contributor and guarantees solidarity within each population group and redistribution between states. For IMSS, this is the private employer and for ISSSTE it is a public employer. In the case of the PHI, since there is
no employer, co-responsibility is established between the federal and the state governments
in a solidarity scheme that recognises the huge differences in
level of development among states. The federal solidarity
contribution is on average 1.5 times the social quota, but is increased for poorer states at the expense of those that are
wealthier. The state solidarity quota is the same in all of the
states, set at half of the federal social quota and the source of
funding is state-level revenue.
The third contribution is a premium paid by beneficiaries. In the
case of the IMSS and ISSSTE, the employee contribution is set
as a proportion of the wage and deducted from the payroll. The
family contribution to the PHI is progressive and designed to
promote fairness in finance. The upper limit on the family
contribution is 5 % of disposable income, which is defined as
total spending less spending on basic needs. Families in the lowest two income deciles do
not contribute in monetary terms, but are required to adhere to participation rules associated
with health promotion. One contribution level is defined for each of the other income deciles.
Allocation of funding for personal health services
The allocation of funding from the reform is divided between federal and state levels. Based
on actuarial calculations, the Fund for Protection Against Catastrophic Expenditures receives
8 % of the federal social quota plus the federal and state solidarity contributions. The remainder of the social quota and the federal and state solidarity contributions are allocated to
the states to fund the essential package of health services included in the PHI. The family
contribution is collected and maintained at the state level.
The federal solidarity contribution is allocated to the states using a formula that considers a
fixed component per family, a health needs-adjusted component, a component aimed at
promoting additional state contributions, and a portion based on health system performance.
The formula is designed to make up for historical imbalances and inequities, to respond to
differential needs across population groups, to provide incentives for performance and affiliation, and to promote solidarity, universality and financial justice. For the first few years, the
formula is heavily weighted on affiliation to accommodate the transition phase of the reform.
The weights and indicators used in the formula are updated annually.
This funding model implies a radical change in incentives for state governments and providers. Funding for the states will be largely determined by affiliation to the PHI. Thus, the reform provides a legal framework to break out of discretionary allocations and move toward a
demand-driven funding model that enables the effective use of an expanded health budget.
In the past, federally allocated state budgets in health were largely determined by historical
inertia and the size of the health sector payroll.
Affiliation is voluntary, although states have the budgetary incentive to achieve universal
coverage. Families who choose not to affiliate by 2010 will continue to receive health care
through public providers, but will have to continue to pay fees for services received at point of
delivery. The voluntary nature of the affiliation process is an essential feature of the reform
that facilitates the process of replacing supply-side with demand-side subsidies so that
money follows people. This process includes incentives for improving the quality and efficiency of health service delivery. In order to convince families to enrol the states must pro-
28
J. Frenk, F. Knaul, E. González P., M. Barraza Ll.: Poverty, health and social protection
vide higher quality services than in the past. This process, combined with the focus during
the first years on the poorest families, will help to prevent problems of market failure such as
adverse selection.
Although the financial trigger is a demand-side subsidy, the additional funding mobilised by
the reform is channelled to strengthen the supply side in line with the expansion in affiliation.
This is changing the inertial aspects of historical budgets that were mostly used to pay for
personnel costs. In contrast, the new funds cover drugs, equipment, extended hours at clinics, and enhancing or building facilities. Providers may be public or private.
Implementation phase of the reform: results and challenges
Implementing the reform presents a series of challenges, yet progress after the first year is
positive. In order to achieve the goal of affiliating all uninsured families by 2010, roughly 1.5
million families (about 6 million people) must be enrolled each year. This process is moving
ahead. The affiliation goal was achieved in 2004 and is on track in 2005 with an average of
45,000 new families affiliated each week. Affiliation must continue to proceed as rapidly as in
2004 in order to achieve universal coverage by 2010. Another positive result is that the new
system is fully operational and gradually expanding coverage in all of the 32 Mexican states.
While most states are still at partial coverage, it is expected that five will reach universal coverage in 2005 and another seven in 2006.
It is important to note that, as
stipulated by law, the enrolment
process has focused on the
poorest families who do not contribute financially. Based on data
from the affiliation rosters of the
Ministry of Health, over 90 %
beneficiaries are from the poorest quintile of the income distribution. Further, an important result in promoting equity is that
more than 70 % of the affiliated
families are female-headed. This
reflects the over-representation
of single mothers among nonsalaried workers. A behavioural
indicator of satisfaction is the willingness of families to renew their yearly enrolment. The
data are encouraging as 98 % of families that participated in the 2003 pilot phase decided to
re-affiliate in 2004. A challenge for the future is to maintain this rate of re-affiliation as the
reform proceeds to cover larger numbers of families and those that will be contributing financially.
Additional public funding is required for the reform to achieve universal coverage. Initial estimates suggest that total public spending should increase by about 1 % of Gross Domestic
Product (GDP) to complete the reform in 2010. Again, initial results are encouraging as the
reform has generated an increase in funding for the uninsured through the Ministry of Health
and the states. In order to be able to accommodate the new entitlements, the authorised
budget of the Ministry of Health for 2005 increased by 55 % in real terms over the 2002, prereform level, and 37 % as compared to 2004. This has generated a gradual yet continuous
trend of improvement in the distribution of public funding between the insured and the uninsured. In 2001, 33.3 % of all public funds for health were allocated to the uninsured population and the rest to families with some form of social security. In 2004, the proportion spent
on the uninsured and families affiliated to the Popular Health Insurance scheme reached 35
%. The balance should further improve in 2005.
The budgetary increase comes from improvements in taxation and reductions in other areas
of the federal government. Additional resources to accelerate access to priority, high-cost
Extending Social Protection in Health
29
interventions, such as childhood cancer, come from an earmarked contribution on cigarette
sales that supplements the Fund for Protection Against Catastrophic Expenditures.
If universal coverage is to be achieved, this process of increasing investment in the health
sector, and in particular in the population not covered by social security, must continue. The
funding commitment was a particularly important issue in the face of the change of government that will took place at the end of 2006. Maintaining the pace of enrolment and improving
the quality of care were key to garnering the policymaker and patient support that will be
necessary to cement the reform in the face of the political transition.
Another set of challenges are related to converting the system to being more client-oriented
and responsive. The population must have greater confidence in public services to be convinced to make a financial contribution and to re-affiliate. This is particularly important in the
face of the rising expectations that have been generated by the reform. On-going monitoring
of patient satisfaction, affiliation, and re-affiliation, as well as in-depth, regular surveys are
being undertaken.
An important ingredient for the reform is strengthening provider incentives and developing a
more competitive environment on the supply-side. Shifting the focus of incentives to the demand side, while also strengthening and making more competitive the supply side, constitutes a delicate balance. This is related to the portability of insurance coverage, which in turn
depends on establishing compensation mechanisms among states and providers, and on
improving the availability and quality of services, particularly in more remote regions.
To meet these challenges in the face of rapid organisational and systemic change, specific
measures to strengthen the health care system include increasing the number of hospitals
and clinics, building up human resources particularly at the management level, and improving drug procurement. This work is part of a national programme launched in 2001 to improve technical quality and interpersonal responsiveness throughout the system. The program includes accreditation of providers and, by law, only certified providers will be able to
participate in the new system. It also seeks to empower consumers to demand accountability
through a bill of rights for users and a procedure for incorporating complaints and suggestions.
Evidence and information are important tools for successfully meeting the challenges of implementation. Rigorous analysis has been part of the reform since the design phase and a
comprehensive regime of monitoring and evaluation accompanies the implementation process. One example of this is the comparative analysis of performance indicators across states
that has been published in annual reports since 2001. Publishing these data promotes institutional improvement as they are used for the budgeting formula for states and as public reference points on system performance.
A final challenge is to involve in the reform process the diversity of actors in the Mexican
health system including the Congress, IMSS, ISSSTE, the states, other government agencies and the private sector. It was particularly important for the change of administration in
2006 that the reform must maintain a broad support base among policy makers as well as
the population to assure continuity.
Conclusions and relevance to other countries
The reform of the Mexican health care system is designed to gradually correct major financial
disequilibria. The source of health finance is shifted toward publicly organised insurance. The
distribution of finance among population groups and among the states is balanced.
To accomplish this, funding for public health services is protected and separated from funding for personal health services. Services at the tertiary level are covered by a national fund
to aggregate risks. The package of covered services is based on explicit criteria of costeffectiveness and social acceptability. The allocation of funds to the states is based on a redistributive formula to transform budgeting from an inertial, bureaucratic supply-side logic to
a performance-based, demand-side subsidy.
30
J. Frenk, F. Knaul, E. González P., M. Barraza Ll.: Poverty, health and social protection
The reform presents a series of challenges that are being met as part of its implementation
and others that are evolving with the extension of coverage and changes in the policy climate. Meeting these challenges is producing knowledge on the management of the health
reform process.
The Mexican reform experience is relevant to other countries in at least three senses. First,
the reliance on out-of-pocket spending, inequality in the distribution of health contributions,
and catastrophic and impoverishing spending on health are issues that face many societies,
particularly middle-income countries. The reorganisation of financing in the Mexican health
reform seeks to respond to these issues, and this experience may be of value to other countries. The Mexican reform builds on earlier and on-going experiences in other Latin American
countries such as Chile and Colombia, where the expansion of insurance coverage was a
driving force. Second, the Mexican reform was designed and is being implemented subject to
budgetary restrictions so that incentives, efficiency, consumer satisfaction and accountability
aspects are especially important. Again, these lessons are of relevance since improving
health systems typically occurs in a context of resource scarcity. Finally, the reform has
stressed the role of health in the process of economic transition and thus provides lessons
on how to position the health sector in the context of economic development and in the
minds of economic policy makers.
The Mexican case is relevant to other countries as it also illustrates the importance of simultaneously building the three pillars of any reform effort: ethical, technical and political. With
regards to the first pillar, the Mexican reform was formulated on the basis of ethical deliberation that made explicit the values and principles underlying the proposal.
The technical pillar was built on the basis of extensive evidence derived from national studies
and also from the adaptation of knowledge-based global public goods, such as conceptual
frameworks (e.g., the WHO Framework on Health System Performance), standardised methods (e.g., the household income and expenditure surveys) and analytical tools (e.g., national
health accounts). In this way, the Mexican case goes beyond the false dilemma between
knowledge and action, showing how formal analysis serves to place a hitherto neglected
problem at the centre of the policy arena. It also demonstrates the falseness of another
common dilemma, between global and local realities, as it adapted global public goods to
national decision making that may further build the global pool of knowledge about health
system reform. The process of developing the reform benefited from, and seeks to contribute
to, the evidence on health sector reform, health system finance, the analysis of the fairness
of finance, and health system performance assessment.
Finally, the political pillar was developed through a strategy that included bringing the ethical
and technical elements to bear on the consensus-building process that eventually yielded a
solid legislative majority in favour of the health reform. Perfecting evidence as a global public
good implies promoting its use for national policy formulation, as well as intensifying the use
of national analysis in developing international evidence.
The Mexican reform contributes to this process. International evidence, frameworks and
methodologies were extensively used for advocacy, design and implementation. National
evidence, such as the information put forward in this paper, should be important for stimulating a process of shared learning among countries that face the common challenge of improving health through equity, quality and financial protection.
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Sh. Tang, X. Cheng, L. Xu: Urban Social Health Insurance in China
32
2.
Advancing the Socio-Economic Development Agenda: The
concern for Equity, Solidarity and Poverty Reduction
2.1. Developing Urban Social Health Insurance in a Rapidly Changing Economy of China: Problems and Challenges
Shenglan Tang12, Xiaoming Cheng, Ling Xu
Introduction13
During the last two decades China has enjoyed impressive and sustained economic growth.
Living standards of the vast majority of its population have increased significantly since the
early 1980s. More than 100 million people have moved on to above $ 1 per day and another
130 million to $ 2 per day. However, the social agenda in China is incomplete. Inequity in
health and health care remain a major concern. Some health indicators, e.g. the under-five
mortality rate, have remained stagnant since the mid 1980s (World Bank 1996). The collapse
of co-operative medical schemes in most rural areas (Tang et al 1994) and the crippling of
the Government Insurance Scheme (GIS) and the Labour Insurance Scheme (LIS) in urban
areas (Gu/Tang 1995) have widened inequity in health (Liu et al 1999). In both rural and urban areas, there are many serious problems in the financing of, and access to, health care
between the rich and the poor. Out-of-pocket payment by service users in China has increased from 20 % in 1978 to around 60 % in the early 2000s (Huong et al. 2005).
Until the early 1990s, the GIS and the LIS covered fully or partially more than half of China’s
urban population. According to the national household health surveys conducted in 1993,
1998 and 2003, there was only 27.3 % of the urban population not covered by any health
insurance or health plan. However, the figure rose to 44.1 % in 1998 and remained unchanged in 2003. The decrease in urban health insurance coverage in the 1990s can be attributed to at least three factors. The first is the continuously increasing urbanisation of the
past two decades. Many rural counties, where the percentage of the population covered by
the GIS and the LIS or other health plans were low, have been upgraded to urban cities.
Second, more adults in urban areas are unemployed now compared to the early 1990s. The
vast majority of these people lost work-related benefits including health insurance, when they
lost their jobs. Third, although there are no official figures reported, a significant number of
rural-to-urban migrants are living and working in urban settings. It was estimated that around
120-140 million rural-to-urban migrants were living in urban cities in 2005, according to a
study done by the Ministry of Labour and Social Security. Most of them are working in building construction sites, factories, and informal service sectors and their employers do not
support them to affiliate either to social or to commercial health insurance schemes.
This demographic shift has created a sense of urgency for urban health and health care.
Since the late 1980s, the central and some local governments in China have supported a
number of experiments with various insurance schemes to increase efficiency and coverage.
From 1997, the Ministry of Labour and Social Security of the central government was established to oversee the development of the urban employee Basic Medical Insurance scheme
(BMI) intended to replace the old GIS and the LIS.
By 2004, more than 124 million people - 90 million urban employees and 34 million retirees had been covered by the BMI (MoLSS 2005). It should be noted that while enhanced equity
and access were major objectives of these reforms, policy-makers have practical concerns
about financing and cost containment. The objective of this paper is to review the experiences with reforming urban social health insurance schemes, identify main achievements
and problems of the reformed urban social health insurance schemes, and discuss challenges in developing equitable and sustainable social health insurance in urban China.
12
Liverpool School of Tropical Medicine, UK, Fax: +44-151-7053364; Email: [email protected].
The first two sections of this paper has quoted significantly the text from a working paper entitled “Addressing
inequity in access to health care in urban China” published by the World Bank (Tang et al 2003).
13
Extending Social Protection in Health
33
Experiences with reforming urban social health insurance (SHI)14
Before starting to describe the experiences with reforming urban health insurance, it would
be useful to understand why these reforms were introduced from the late 1980s to the late
1990s. Both the LIS and the GIS were set up in the early 1950s, immediately after the founding of the People’s Republic in 1949. The two schemes provided virtually free health services
to the employees in the formal sector in China and partial coverage for their dependents in
the case of the LIS. As for the financing of the GIS, a fixed amount of money per person was
allocated by the finance department of a local government to the GIS management office that
was responsible for managing the use of the fund resources. As for the LIS, individual enterprises and factories allocated around 11-14 % of the gross salaries/wages from their benefit/welfare budgets to cover the full cost of medical care for their employees and partial cost
for their dependents (Tang et al 2003).
The gravity of the financing and management problems of the GIS and LIS is nothing less
than alarming. There was a rapid increase of beneficiaries from 92 millions in 1978 to 153
million in 1997. The total amount of GIS and LIS expenditure rose from 3.2 billion to 77.4
billion Chinese Yuan over the same period. Not surprisingly, both governments (central and
local) and enterprises/factories underwent formidable difficulties paying these medical bills. It
was quite common that the GIS management offices or enterprises/factories owed lots of
money to their so-called designated service providers during that period of time.
Several key problems of the GIS and LIS were identified in the 1980s. The regulation of the
GIS and LIS required central and local governments and enterprises to pay almost the entire
medical care costs incurred by their employees. In other words, they acted as “Third Party
Payers”, but they did not have any capacity for monitoring and supervising the provision of
services, nor did they have the means to influence the behaviour of service providers. The
latter took significant advantages from the existing fee-for-service payment mechanism.
Some loss-making enterprises asked their employees to pay for medical care from their own
pockets first and delayed in reimbursing the expenses for several years. Employees of profitable enterprises, on the other hand, received superfluous services from their service providers. The system offered a strange mixture of feast or famine.
Another problem was that neither the GIS nor the LIS had sufficient capacity for risk-sharing.
Each institution or enterprise was only responsible for its own beneficiaries, and there was no
financial pooling or risk sharing either between the various GIS institutions or between enterprises belonging to the LIS. Therefore, catastrophic health expenses defrayed on a couple of
employees could bankrupt the health plan of a small enterprise.
These problems pressured the central and local governments into reforming the GIS and LIS
with the aim of transforming the two crippled insurance schemes into more equitable, affordable and sustainable ventures. The reform of the GIS and LIS began in the early 1980s; it
consisted of three distinct phases: Phase 1 from early 1980s to 1987, Phase 2 from 1988 to
1997, and Phase 3 from 1998 to the present.
During Phase 1, the GIS and LIS reform can best be described as local initiatives. These
initiatives included 1) the introduction of cost sharing to the beneficiaries (i.e. 10-20 % of the
required co-insurance payment); 2) the establishment of catastrophic disease insurance arrangements in several industrial sectors in order to increase risk pooling; and 3) the use of
capitation in the management of the GIS in some cities.
It is difficult to assess the impact of the reforms undertaken in this period due to the lack of
scientific research in this area, since health economics was a new field before the late 1980s
in China. The first two approaches mentioned above focussed on the demand-side of health
service provision, while the last one tackled problems associated with supply-side behaviour.
However, as a whole, few reforms attempted to influence the practice of health care provid-
14
Social health insurance (SHI) is used in this paper to indicate the GIS and LIS, as well as the new BMI for urban employees introduced in the late 1990s.
34
Sh. Tang, X. Cheng, L. Xu: Urban Social Health Insurance in China
ers. This uneven approach may have reduced the demand for services in general rather than
those that were unnecessary.
Phase 2 began in 1998 when the central government established a group to guide the reform
of the GIS and LIS. The team was headed by the Ministry of Health, but it also involved nine
ministries including finance, personnel,15 and labour, among others. A draft government
document entitled “Considerations on the reform of the employee health insurance system”
was issued in 1988 to set out the direction of the reform. Four mid size cities: Dandong, Siping, Huangshi and Zhuzhou were selected to launch an experimental reform in 1989. The
main purpose of the experiments was to establish city-wide health insurance systems and
introduce cost control mechanisms. Unfortunately, the systems in the four cities did not develop as expected, mainly because of the lack of interest of local governments and the fiscal
difficulties these cities were facing.
In 1992, the ministerial group responsible for the GIS and LIS reform selected two cities as
demonstration sites. The experiment carried out in Zhengjiang and Jiujiang played the most
important role in shaping new employee BMI in urban China during Phase 3.
The Zhengjiang and Jiujiang Experiment
In 1994, a health insurance reform experiments under the auspices of the State Council began in Zhengjiang City in the Province of Jiangsu and in Jiujiang City located in the Province
of Jiangxi. The two cities, each of which has about 2.5 million inhabitants, set out to develop
new models of urban health insurance. And, in both cities every GIS and LIS scheme was
required to participate.
Newly established health insurance management centres collected financial contributions
from government agencies, public institutions, and enterprises, then committed these funds
to individual and social pooling funds according to formulae similar to the one utilised in
Hainan. Three tiers of payment were developed using both individual accounts and social coordinating funds (Box 2.1.1).
The personal accounts and co-payment mechanisms were expected to encourage moderation in the demand for medical care in the two cities. In addition, the new health insurance
schemes also developed an essential drug list consisting of about 1,400 Western and 500
traditional Chinese medicines. Coverage was strictly limited to the drugs on the list.
However, as the social pooling fund in Zhengjiang was in deficits in the first couple of years,
in 1999 the health insurance management committee decided to adopt the approach used in
the Hainan experiment. There, the fund from the personal accounts could only be used to
pay for outpatient services, while the social pooling fund was mainly used to pay for inpatient
treatment and specialised outpatient services (Wang/Wang 1999). Such an approach has
implications for equity in the financing of and access to health care - these issues will be discussed later.
After more than one year of experience in the two cities, the State Council decided to expand
the experiment to 57 cities in 1996, using the same principles, but allowing these cities to
modify the model according to their local circumstances. About 40 cities actually reformed
their GIS and LIS while some of the municipalities modified only the GIS but not the LIS.
Poor participation in these schemes was largely due to the inability of enterprises or unwillingness of managers to join.
While Zhengjiang and Jiujiang were experimenting with new health insurance schemes under the leadership of the State Council, many other cities in China launched reforms of the
GIS and LIS. It is neither possible nor practical to describe all of these reforms in one report.
However, experiments worth mentioning are the ones in Shanghai and Beijing. In order to
increase the capacity and scope of social pooling, the Shanghai Municipal Government developed the ‘Hospital Insurance Scheme’ in 1996. This was mainly funded by payments from
15
Ministry of the People’s Republic of Chine dedicated to human resources development and management.
Extending Social Protection in Health
35
employers, initially 4.5 % of the employees’ wages or salaries; the figure was raised to 6.5 %
from 1997. In 1995, the Beijing Municipal Government had introduced the ‘Serious Diseases
Insurance’. All enterprises were asked to contribute 6 % of the average municipality employees’ income to the fund for all employees and retirees, while employees paid 1 % of their
wage/salary to the fund that was mainly used to cover inpatient services.16
Box 2.1.1: Three tiers of payment for medical care in the Zhengjiang and Jiujiang
Health Insurance Experiment
The first tier – All individuals first used their own personal accounts to pay for medical care. The amount deposited into their personal accounts depended on their
wage/salary and age. Approximately 5-7 % of the wage/salary was deposited periodically into their personal accounts with some variation by age bracket.
The second tier – Once the insured had used up the funds in his/her personal account, medical care was paid out-of-pocket until the payments reached 5 % of annual income. Then the social pooling fund was accessed to cover the costs of
medical care.
The third tier -- After paying out-of-pocket 5 % of their annual wage/salary for medical care, the insured were eligible to use the social pooling fund to pay for medical
care. However, the new health insurance schemes in both cities required a copayment of up to 20 % of medical care expenditure at this tier.
Phase 3 started with the arrival of a new government led by Premier Zhu Rongji in 1997. The
new government was restructured in a manner consistent with the new socio-economic order
in China. One significant change related to urban health insurance was that the Ministry of
Labour and Social Security (MoLSS) was established, building upon the old Ministry of Labour. The Department of Medical Insurance of the MoLSS was created to oversee the reform
of the GIS and LIS.
Having learned the lessons and experiences from Phase 2, the objectives of reforming the
GIS and LIS in Phase 3 aimed to provide 1) a low level of health service benefit (low depth);
2) a high level of population coverage (width), and 3) variation, which means that different
levels and types of health insurance (from basic health care coverage to sophisticated and
supplemental insurance) could be developed. The following is an introduction to the Basic
Medical Insurance scheme for urban employees (BMI) implemented since 1998.
Population coverage
According to the national household health surveys conducted in 1998 and 2003, the percentage of urban population covered by the GIS and LIS or the new BMI fell from 44.7 % in
1998 to 38.8 % in 2003. According to statistical data of the MoLSS, at the end of 2003 the
new BMI had a total beneficiary number of 109 million urban employees and retirees, which
accounted for around one quarter of the urban population. This also implied that there was
still more than 10 % of the urban population covered by old GIS or LIS and other health insurance schemes. Among other reasons stated in the introduction, the decline of urban
population coverage by social health insurance (GIS and LIS or BMI) between 1998 and
2003 might be attributed to the fact that the dependents are no longer covered by the BMI,
and that many private-owned small and middle size enterprises have not yet participated in
the BMI, albeit the number of the beneficiaries had been rising steadily over the past years.
16
Quoted from the document entitled “Regulations on Beijing Basic Health Insurance Scheme” issued by Beijing
Municipal Government in 1995.
Sh. Tang, X. Cheng, L. Xu: Urban Social Health Insurance in China
36
Sources of finance
Official national regulations on BMI development stipulate that all employers have to contribute at least 6 % of the wages/salaries paid to their employees to the BMI fund, while employees contribute 2 % of their earnings. In reality, employees in almost all Chinese cities are
asked to pay 2 % of their wages/salaries to the fund, however, in many cities and municipalities, the employers have been required to contribute between 6 % and 10 % of the wages
and salaries. For example, employers in Shanghai have to contribute 10 % to the social pooling fund plus another 2 % to the so-called supplemental medical insurance, while employees
are required to pay 2 % of their income to the individual saving account. Retirees do not
need to make any financial contribution from their pensions received, nor are the employers
asked to make any contribution to the fund, although the elderly enjoy more benefits than
active employees.
Allocation and use of the BMI fund
The BMI fund is divided into two parts: individual saving account and social pooling fund.
Generally speaking, the financial contribution from employee’s salary/wage goes to their individual saving account, while the employer’s contribution is split between the individual saving accounts and the social pooling fund, using different percentages according to the age
group of employees.
The use of funds from the individual saving accounts and the social pooling fund may vary
among cities as shown in Table 2.1.1. Each municipal government has developed its own
regulations on the use of the resources of individual saving accounts and social pooling
funds. Generally speaking, a majority of cities and municipalities allocate resources from individual saving accounts should be spent for outpatient services. Once the individual savings
are used up, beneficiaries have to pay out of pocket for outpatient services, while the social
pooling fund is meant to cover inpatient expenditures. Most cities located in the developed
areas (i.e. eastern coastal areas) are more likely to stipulate that the social pooling fund
should also cover the expenditure of outpatient services, once the fund from the individual
saving accounts have been consumed and the beneficiaries have already paid a certain
amount of money out of pocket for outpatient services. It is clear that the approach adopted
in the most developed areas implies a higher degree of protection for the beneficiaries and
particularly those who suffer from chronic illness and, thus, require frequent outpatient visits.
Table 2.1.1: Policies and regulations on the use of funds
Personal account fund
Social pooling fund
Outpatient and emergency services
Eligible for the use of the Eligible for the use of the fund in
fund
some cities under certain conditions
Special treatments at
outpatient department
Eligible for the use of the Eligible for the use of the fund in
fund
some cities under certain conditions
Inpatient services
Eligible for the use of the Eligible for the use of the fund, but
fund in some cities
deductible, co-payment and ceiling
arrangements made
Sources of data: compiled by the authors.
Provider payment methods and management of the BMI fund
Each city or municipality has set up a centre for managing the BMI fund. These centres are
responsible for collecting contributions from participating institutions and enterprises and
purchasing services from so-called designated service providers. In most cases, the centre
also issues an individual IC card for beneficiaries that can be used to pay for outpatient services or co-insurance payment for inpatient services, or buy drugs from designated pharmacies.
Extending Social Protection in Health
37
The IC cards with photos in most cities record the amount of money in the individual saving
account. The centres also manage the purchasing of inpatient care, and specified outpatients
services in some cities, using the social pooling fund. The traditional method used for provider payment was fee-for-service (FFS), however an increasing number of BMI fund management centres have started to use a set of flat rates or fees per case to pay for inpatient
services. In addition, centres have increasingly adopted so-called diagnosis related groups
(DRGs) of type to purchase inpatient services from designated hospitals.
Measures taken for cost containment
Various cities and municipalities
have applied a number of measures to control the rapid increase of medical costs and expenditure. In general, these measures
aim rather to reduce the demand
for health care services from
user-side than to control the
provider-induced increase of
service demand. For example,
the beneficiaries of the BMI are
required to make a series of outof-pocket payments, including
deductibles, co-insurance and
the additional payments beyond
the ceiling level. In addition, most cities and municipalities have developed lists of essential
drugs and services that are not covered by the BMI. The fact that the social pooling fund is
not allowed to cover, even partially, the expenditure for outpatient care of the beneficiaries is
another significant measure for controlling medical costs.
Flat rate payment and the application of DRG’s are the only mechanisms applied to influence
the behaviour of service providers and to control provider-induced demand. Moreover, not
even all municipalities have adopted these measures so far so that actions to influence actively the behaviour of hospitals and other health care providers in urban China is generally
insufficient.
Main achievements and problems of the reformed urban social health insurance
Over the past decade, the reform of urban social health insurance has brought several major
achievements. At the same time many problems have arisen in reshaping the social health
insurance. The following section analyses and discusses the main achievements and problems arising from the process of reforming urban social health insurance schemes in China.
Achievements
Undoubtedly, the reform of the urban social health insurance in the world’s most populated
country has produced a series of relevant achievements over the past years. The number of
institutions and enterprises that have participated in the BMI has been increasing steadily,
thanks to the efforts made by the BMI fund management centres with the support from the
municipal governments and under the auspices of the Ministry of Labour and Social Security.
Thus, the number of urban population covered by the BMI reached 124 million by the end of
2004 and over 130 million by the mid 2005, albeit including the old LIS operating in some
enterprises and the GIS implemented for VIPs from the governments and honoured veterans
and professionals.
Pooling financial resources under the new BMI at a municipal/city level, instead of an individual enterprise has significantly strengthened the capacity of risk sharing. The participating
institutions with a large proportion of elderly retirees who are most likely to suffer chronic illness are now cross-subsidised by those organisations who have a younger working force.
Sh. Tang, X. Cheng, L. Xu: Urban Social Health Insurance in China
38
Making the healthy subsidise the sick via social health insurance, a core element of social
protection in health, has been achieved in this regard. The problem of delay in reimbursement of medical care expenses, frequently seen at the period of the former GIS/LIS, has
been largely overcome, and the beneficiaries are now satisfied with the reimbursement system. In the meanwhile, profitable enterprises are making higher wage-related financial contributions to the social pooling fund than loss-making enterprises. This is another equity gain
and core issue of social health insurance, making the rich (employees with high incomes)
subsidise the poor (employees with low incomes).
As a progressive step towards improving efficiency of the health care system, various BMI
fund management centres have been able to use their growing purchasing power to negotiate with service providers for the use of non-retrospective payment methods (such as FFS)
in order to reduce perverse incentives that have caused a rapid rise of medical care expenditure. As mentioned above, flat rates or DRG have been used to pay for inpatient services
and cost containment has been achieved to some extent in many places (Meng et al 2004,
Liu et al 2002). In addition, the introduction of deductible and co-insurance payments also
helped to reduce the utilisation of health services that may or may not be necessary.
Problems
Though the BMI has been partly successful in several areas of action, as discussed above,
many problems are still to be solved or mitigated in the near future. First of all, the projected
width of population coverage in urban China has not yet been achieved, as almost half the
urban population in China is still not covered by any health insurance scheme. An increasing
number of rural-to-urban migrants are working in the informal sector (construction sites, private factories, restaurants, etc.) where they are excluded from social security and especially
from health insurance. Moreover, a clear-cut decision on whether or not the central and local
Table 2.1.2: Insurance coverage by income level in urban China
Insurance status
SHI
No insurance
Income
2003
1998
No.
%
No.
%
Very low
1065
10.74
2741
24.58
Low
2711
26.88
5529
43.84
Middle
4562
40.71
6976
53.60
High
4848
54.23
5673
63.94
Very high
6084
63.67
3459
38.94
Very low
7577
76.43
7260
65.11
Low
5595
55.48
5989
47.49
Middle
4656
41.55
4848
37.25
High
2608
29.18
2390
26.94
Very high
1902
19.91
3586
40.37
Source: National household health surveys conducted by the Centre for Health Statistics and Information, MoH, China.
governments should take a major responsibility in tackling the financial difficulties of moneylosing enterprises in paying for health services is lacking. Thus, according to the results from
the national household health surveys, people with low income are less likely to be covered
by health insurance than those with higher wages (Table 2.1.2). Between 1998 and 2003, the
share of urban residents with very low income covered by SHI declined from one quarter to
Extending Social Protection in Health
39
11 %, while the percentage of urban residents with high income levels rose from 39 to 64 %.
The statement in a report written by the Development Research Centre of the State Council
and published in 2005 is not surprising: The BMI is a club for the rich, not the poor.
Furthermore, the old GIS and LIS used to partially cover the expenses of medical care for
direct dependents, but the BMI does not. Some cities/municipal governments have organised
commercial hospital insurance schemes for school children to offset the problem arising from
the transformation from the GIS and LIS to the BMI, but not all the urban municipalities have
done so.
The regulations developed by almost all BMI fund management centres stipulate that retirees
and their former employees are not required to make any financial contribution to the social
health insurance, but that retirees are entitled as long as their employers have participated in
the BMI to enjoy more favourable service benefit packages or reimbursement policies. This
has started to cause a problem of sustainability with regard to the financial resources of the
BMI in the long run since the Chinese population is rapidly aging. A growing number of the
elderly are consuming a substantial proportion of the social pooling fund for the health care
services they need while no financial contributions are made on their behalf either by themselves or by their former employers. Such a financial arrangement cannot be sustainable in
the short and even less in the middle term.
Table 2.1.3: Hospital admission and non-use of inpatient service rates of the SHI beneficiaries
by income level
Admission rate %
Income level
Non-use of inpatient service
rate %
1997
2002
1997
2002
Very low
5.29
4.04
29.53
36.36
Low
5.08
3.69
22.85
27.49
Middle
5.71
5.24
19.97
20.99
High
5.89
5.34
23.79
28.64
Very high
6.71
5.75
15.59
18.72
Source of Data: Source of data: National household health surveys conducted by the Centre for
Health Statistics and Information, MoH, China.
Note: non-use of inpatient service rate indicates that the proportion of the patients who were refereed by doctor to hospital admission, but were not hospitalised owing to a variety of reasons.
A majority of the BMI fund management centres have developed a policy that the social pooling funds are in principle not allowed to pay, even partially, for emergency and outpatient
services. The individual saving accounts should be the only funds to be used for covering the
expenses for emergency and outpatient care. Such a policy brings obvious disadvantages for
low-income groups and for people with chronic diseases requiring extensive outpatient health
services. The idea was to mitigate the financial burden placed on the social pooling fund, but
it turned out to induce major equity problems for the sick. Likewise, while the introduction of
deductibles and co-insurance by almost all the BMI schemes in urban China, while might
have reduced unnecessary use of health care, it has also deterred poor beneficiaries from
using services they require. As Table 2.1.3 shows, the poor are less likely to use inpatient
services than their rich counterparts.
The situation was worsening over the period of study.
ferred to inpatient treatment without being hospitalised
come group, while only one out of five referred patients
hospitalised. Apparently, the applied cost controlling
About two thirds of the patients rein 2002 came from the very low infrom the high income group was not
measures (i.e. deductible and co-
40
Sh. Tang, X. Cheng, L. Xu: Urban Social Health Insurance in China
insurance payments) have prevented many low-income beneficiaries from using necessary
and required inpatient services.
Another problem existing in the BMI is that in many Chinese cities fee-for-service is still the
most common method of provider payment, nonwithstanding if health care services are paid
from individual saving accounts or social pooling funds. This is one of the main reasons why
medical care costs have rapidly increased in the BMI scheme. It seems that the BMI fund
management centres did not have the adequate managerial capacity - including the lack of
health insurance expertise - to influence the behaviour of health providers. In many cases
they turned out to be unable to take more effective measures to prevent moral hazard on the
supplier side due to political and institutional reasons. Furthermore, most BMI schemes allow
the beneficiaries to use both outpatient and inpatient services at a number of designated
health facilities. They also give the beneficiaries the free choice to use the individual saving
accounts for buying drugs from many designated pharmacies. In other words, the beneficiaries do not need to be referred by their GPs or family physicians to a specialist or to an outpatient department of a tertiary hospital. The lack of guidance through the system has major
implications for the development of health care costs.
Developing equitable and sustainable social health insurance: challenges ahead
China faced formidable difficulties in developing equitable and sustainable urban social
health insurance for the past decade and is also facing large challenges ahead. One of the
biggest issues deals with the question how to ensure long-term financial viability of SHI in
urban China. The average annual increase of BMI health expenditure was much faster than
the average annual rise of employees’ incomes. Furthermore, the proportion of contributionfree insured retirees with greater health care needs than the active and contributing employees has risen significantly. It is vital for the central and local governments in China to mobilise more financial resources to sustain the BMI schemes in urban conglomerations. One
option is to increase the financial contribution of employees above the current 2 % of their
salaries/wages. Pensioners with decent pensions might also be required to contribute a certain percentage of their income to the BMI fund.
In terms of the fund allocation and
use, it is important to avoid social
pooling funds being used only for
inpatient services, as it happens in
most Chinese cities. The function of
this fund is to ensure social
protection of unhealthy people after
having spent the individual saving
accounts. However, the financing of
emergency and outpatient services
by individual saving accounts
and/or out of pocket would deter
equity in the financing of health care
through SHI. Increasing population
coverage by including rural-to-urban
migrant workers in the BMI can not
only help to protect this vulnerable group, but also provide more financial resources to the
fund. The central government may introduce compulsory health insurance and enforce enterprises/factories or firms/companies with a certain number of employees to join the BMI.
Recently, several large municipalities, such as Guangzhou, have started to consider such an
approach to increase population coverage and mobilise financial resources.
However, the funds mobilised by the BMI alone appear to be insufficient for developing sustainable health insurance. Additionally, effective control of rapidly rising SHI expenditures
should also be implemented seriously. The cost escalation of the BMI, mainly caused by
supply-induced service utilisation, deserves special attention by Chinese policy makers and
Extending Social Protection in Health
41
the BMI managers in developing adequate cost-containment strategies in service purchasing. During the last two decades, effective pressure on health care providers in order to
achieve more efficient service delivery was lacking. This is a huge issue closely related to
price policies on pharmaceutical products and medical devices, financing of hospitals and
other health facilities, incentives for health care providers, etc.
Moreover, it does not seem very reasonable for the BMI scheme in China to allow their beneficiaries to seek care from almost any provider according to personal choice. The BMI has
not yet established a functioning referral system using GPs or family physicians in China, as
‘gatekeepers’ or ‘pilots’ in order to rationalise the use of secondary and tertiary services and
to increase the efficiency of health care provision. Many municipal governments have developed community-based health centres where general physicians are providing preventive
and primary care to the beneficiaries in order to reduce the increase of medical care costs.
This approach should be actively pursued and refined in the future to make a referral system
more efficient and sustainable.
While the design and implementation of the BMI have to be improved for achieving more
equity, efficiency and sustainability of health care financing, the Chinese health sector reform
including providers and the medical industry (pharmaceutical and medical devices/equipment) is also vitally important to ensure that the vast majority of Chinese living in urban settings has equitable access to efficient and effective basic health care.
References
Gu, Xingyuan; Tang, Shenglan (1995). Reform of the Chinese Health Care Financing System. Health
Policy 32 (1-3), pp 181-191.
Huong, Dang Boi; Phuong, Nguyen Khanh; Bales, Sarah; Chen, Jiaying; Lucas, Henry; Segall, Malcolm. Alternative approaches to ensure health care for the rural poor: lessons for Vietnam from the
Chinese experience, submitted to Health Policy and Planning.
Liu, Yuanli; Hsiao, William; Eggleston, Karen (1999). Equity in Health and Health Care: the Chinese
Experience. Soc Sci & Med 49 (10), pp. 1349-1356.
Liu, Gordon; Cai, Renhua; Chao, Shumarry; Xiong, Xianjun; Zhao, Zhongyun; Wu, E (2002). China’s
urban health insurance reform experiment in Zhengjiang: cost and utilization analysis. In: The-Wei,
Hu; Hsieh, C (eds).The Economics of Health Care in Asia-Pacific Countries. Edward Elgar Publishing.
Liu, Gordon; Zhao, Zhongyun (2006). Urban employee health insurance reform and the impact on outof-pocket payment in China. Int J H Plann Mgmt 21 (3), S. 211-228
(http://www3.interscience.wiley.com/cgi-bin/fulltext/112771005/PDFSTART).
Ministry of Labour and Social Security (MoLSS) (2005) (http://www.molss.gov.cn/index_tongji.htm).
Martineau, Tim; Gong, Youlong; Tang, Shenglan (2004). Changing medical doctor productivity and its
affecting factors in rural China. Int J Health Plann Mgmt 19 (2), pp. 101–111
(http://www3.interscience.wiley.com/cgi-bin/fulltext/108568148/PDFSTART).
Meng, Qingyue; Rehnberg, Clas; Zhuang, Ning; Bian, Ying; Tomson, Goran; Tang, Shenglan (2004).
Impact of urban health insurance reform on hospital charges: A case study from two cities in China.
Health Policy 68 (2), pp.197-209
(http://www.journals.elsevierhealth.com/periodicals/heap/article/PIIS0168851003002173/pdf).
Saxenian, Hellen; McGreevey, William (1996). China: Issues and Options in Health Financing. World
Bank. Report No. 15278-CHA, World Bank, Washington, D.C. (Chinese version:
http://www.worldbank.org.cn/chinese/content/343l6160684.shtml).Tang, Shenglan et al. (1994). Financing Health Services in China: Adapting to Economic Reform. Research Report No. 26, Institute of
Development Studies, Brighton.
Tang, Shenglan; Liang, Hong, Meng, Qingyue; Baris, Enis (2003). Addressing inequity in access to
health care in urban China. Working Paper Series No. 2004-5. The World Bank, Washington DC
(http://siteresources.worldbank.org/INTEAPREGTOPHEANUT/Resources/5027341129734318233/China-Inequity-Health-Access.pdf).
Wang, Y.Q.; Wang, J.H. (1999). Practice and Thoughts on Zhengjiang Health Insurance Reform. Chinese Journal of Health Service Administration 12, pp. 629-630 (in Chinese).
42
P. Jongudomsuk: From Universal Coverage in Thailand to SHI in China: What Lessons can be drawn?
2.2. From Universal Coverage of Healthcare in Thailand to SHI in China: What
Lessons can be drawn?
Pongpisut Jongudomsuk17
Introduction
Regarding social protection in health focussing on urban settings, the country experience
from Thailand offers a series of specific experiences that are on the one hand different from
those of other Asian societies, and on the other hand allow for some more general conclusions for the developing world. In order to elaborate on some broader implications of social
health insurance (SHI) for urban populations, it is necessary to start with some basic indicators of the two countries in focus, China and Thailand. At the same time, some critical differences between the Chinese and Thai policy approaches need to be discussed in order to
understand the historical and socio-economic backgrounds for different system designs and,
thus, the results of social policy.
A crucial difference between the two countries is
the higher share of GDP
that China is spending on
health, including a high
proportion of private expenditure, while Thailand
had higher government
health expenditures (17
% compared to 10 % in
China).
Thailand has already
achieved universal coverage in health through the
three most important public health insurance schemes. However, the social
security expenditure on
health accounted only for
21.8 % of total government expenditure on
health. This is because
the biggest scheme in
Thailand, the 30 Baht or
UC Scheme, is financed
by general tax revenue.
Table 2.2.1: Some Basic Indicators in 2003
China
Total population in million
Thailand
1,311
62.8
1.6 trillion
143 billion
1,100
2,190
GDP annual growth (%)
9.3
6.9
Urban population (% of total population)
35
40
Life expectancy at birth
71
70
Under 5 mortality rate (per 1,000)
37
26
THE as % of GDP (2002)
5.8
4.4
66.3
30.3
GDP in US$
GNI/capita in US$
Private health exp. as % of THE (2002)
Government expenditure on health (%
total government exp.) in 2002
Health insurance coverage as % of total
population (year)
10
17.1
22 (2003)
96 (2005)
Number of main public health insurance
schemes
2 (SHI,
CMS)
Social security exp. on health (% total
government exp on health) in 2002
3 (SSS,
CSMBS, UCS)
50.8
Source: WHO report (2005) and the World Bank
SHI = Social Health Insurance
CMS = Co-operative Medical Scheme
SSS = Social Security Scheme
CSMBS = Civil Servant Medical Benefit Scheme
UCS = Universal Coverage Scheme (30 Baht Scheme)
21.8
Table 2.2.2 on the following page provides an
overview on some country- and scheme-specific
facts and characteristics
that have to be taken in account for any kind of comparison between social health insurance
in China on the one hand, and the SSS- and UC-Schemes in Thailand. The SSS scheme
receives contributions from three parties including the national Government, while the UCS
applies general tax revenue. Risk pooling of the Chinese system occurs at city level and
foresees relatively high cost sharing, whereas the Thai funds pool risks at the national level
and apply minimal co-payments. Capitation payment becomes the dominant source of fi17
National Health Security Office (NHSO), Thailand, [email protected].
Extending Social Protection in Health
43
nancing for health care providers in Thailand, inducing rather low expenditures per capita.
Additionally, the policy of UC Thailand tends to promote clearly the use of primary care facilities.
Table 2.2.2: Social policy and protection in China and Thailand
China (SHI)
Thailand (SSS)
Thailand (UC)
Cost escalation
Social security
Equity
Population covered
(number and share)
110 million (10%)
Formal sector employee
both public & private
8.6 million (13.7 %)
Formal sector employee in
firms >1 employee
47.2 million (75 %)
Source of financing
Contribution
8% of payroll (employer
6%+ employee 2%)
Tripartite contribution
4.5 % of payroll (employer+ employee+ government 1.5 % each
General tax revenue
City
National
National
SIB (local government)
SSO
NHSO
Co-payment & deductible
(approx. 40 % of med.
expenditure)
A fixed budget for the
provision of services
(global budget?)
None
Minimal co-payment
(0.75US$/visit)
Capitation
Capitation for OP & PP
and case based payment (DRG)
Driving forces
Risk pooling
Financing agency
Cost sharing
Provider payment
Choice of provider
Per capita budget/
expenditure
Any of contracted provid- Contracted hospital and its
Contracted primary
ers
network both public &
care unit both public &
private
private
72.25 US$ (2003)
37.5 US$ (2004)
41.48 US$ (2006)
Lessons learnt
Independent from the specific country context and other conditions in China, the recent social protection reform comprises some outstanding systemic approaches that make the Chinese experiences relevant for many other countries. The four wing elements might be characterised as the most relevant strengths of the social protection in China. Firstly, the Chinese
health care sector is changing fundamentally from a system that provides services almost
free of charge to a contributory system with high cost-sharing. At the same time, it is changing from a small risk pooling size (business unit) to a larger risk pooling size at municipal
level. Additionally, Medical Saving Accounts (MSA) have recently been implemented for increasing households’ resources for ambulatory care. And, last not least, the sector reform
includes also strengthening the role of the local authority in financing and managing SHI.
The most interesting one seems to be the decision of the Chinese government to change
from almost free of charge service provision to a contributory system. This is not easily implemented and could create large public resistance. The strength of the Chinese system is
also the use of local authorities to manage the system. However, even in a centralised system like Thailand, we are facing the problem of limited system capacity, including the adequate number of competent and trained human resources to maintain and improve the system. One possible consequence of this situation is a difference of the system performance
according to regions and areas that has unavoidable effects on equity, quality and overall
efficiency.
The recent policy on social protection in health as well as the experiences on SHI in the
Peoples Republic of China allow for a series of more general conclusions that are worth to
44
P. Jongudomsuk: From Universal Coverage in Thailand to SHI in China: What Lessons can be drawn?
point out to developing countries and countries in transition. First of all, to define universal
coverage of health care as an ultimate goal of health system reforms is not an exclusive
privilege of the developed world. However, in developing and transitional countries SHI alone
is unlikely to achieve universal access to essential health care for all because of the existing
system limitations. Mainly in countries with a huge informal sector, such China and Thailand,
tax funded health care financing has proved to be a possible option, complemented to SHI,
for ensuring universal access to adequate health care for entire population. Secondly, financial protection should focus on catastrophic health expenditures to prevent impoverishment
of households due to medical spending. In many cases this demands reconsidering coverage and reimbursement ceilings implemented in SHI funds.
Thirdly, demand side interventions may not be effective for cost containment and could even
create access barriers for the poor who might turn out to be excluded from health care. Effective socio-political interventions should rather focus on the supply side and on provider payment mechanisms that send positive signal towards the efficient and equitable use of resources. Thus, the Chinese system should reconsider the effectiveness of high co-payments
for containing costs and envisage the deterring effects on access to essential health care.
Independent from the specific approach a country chooses for implementing broad social
protection in health, governments play a key role for achieving sustainable and financially
viable social security systems. It seems to be of utmost importance that the central government should focus first of all on tasks like ensuring adequate health financing especially in
the poorer regions and areas; contributing to the SHI fund in order to decrease the contribution rate of employer and employees and to make the system more attractive for stakeholders; sharing the risk among cities (national risk pooling) by establishing risk equalisation
mechanisms and standardising provider payment and fee schedules for referral cases beyond regions and cities.
At the same time the limited management capability of the local governments in purchasing
health services should be taken into account during the implementation of SHI. Central and
local governments should handle the transfer of responsibility appropriately and create learning mechanism to improve system efficiency and sustainability in the long run.
References
Bennett, Sarah; Mills, Anne; Russell, Stephen; Supachutikul, Anuwat; Tangcharoensathien, Viroj
(1998). The health sector in Thailand. The Role of Government in Adjusting Economies Research
Programme, Paper 31, Development Administration Group, University of Birmingham
(http://www.idd.bham.ac.uk/research/Projects/Role_of_gov/workingpapers/paper31.htm).
Jongudomsuk, Pongpisut; Thamnatuch-aree, Jadej; Chittinanda, Prae (2003). Pro-Poor Health Financing Schemes in Thailand: A Review of Country Experience. Working paper series no. 2004-9,
World Bank, Washington DC (http://wwwwds.worldbank.org/external/default/WDSContentServer/IW3P/IB/2004/12/27/000090341_2004122709
5123/Rendered/PDF/310090TH0Pro1p1lth020041901public10.pdf).
Jongudomsuk, Pongpisut (2002). Achieving Universal Coverage of Health Care in Thailand through 30
Baht Scheme. Paper prepared for presenting in the SEAMIC Conference 2001 FY14-17 January, the
Westin Riverside Plaza Hotel, Chiang Mai, Thailand, Health Care Reform Office, Ministry of Public
Health.
Tancharoensathien, Viroj; Jongudomsuk, Pongpisut (eds.) (2004). From Policy to Implementation:
Historical Events during 2001-2004 of Universal Coverage in Thailand. National Health Security Office,
Bangkok.
World Bank (2005). World Development Indicators Database. World Bank, Washington DC
(http://devdata.worldbank.org/wdi2005/).
World Health Organization (2005). The World Health Report 2005: Make Every Mother and Child
Count. WHO, Geneva (www.who.int/whr/2005/en/).
Extending Social Protection in Health
45
2.3. Equity and solidarity in social health insurance: Chances and risks of the
Costa Rican way towards universal coverage
Alberto Sáenz Pacheco18, Jens Holst19
Background
Costa Rica relies traditionally on agricultural exports with a more recent tendency towards
diversification and added value by agro-industry.20 Meanwhile, computer parts represent the
most important single export product. Costa Ricans tend to look for quality jobs in industry,
services and tourism. The latter is one of the main income sources benefiting from the country’s biodiversity, national parks and protected areas representing about one quarter of the national
Costa Rica
territory. But Costa Rica is also a shining example
Territory: 51,100 km2
for successful social policy that has achieved very
important results in social development. The aboliPopulation: 4.211.692
tion of the army in 1948 has permitted the country
Inhabitants/ km2: 77
to invest in health and education to pursue the peoImmigrants: 7,8 % of total population
ple’s social progress and the reduction of poverty
that has remained around 20 % during the last few
Indigenous: 1,7 % of total population
years with approximately 5 % of the population being
extremely poor. With regard to social expenditure in the region, the last report of the Economic Commission for Latin America and the Caribbean (CEPAL 2005) ranks Costa Rica
fifth among 21 countries - almost doubling the average expenditure in Latin America. The
majority of social spending is dedicated to health. A worrisome fact is that the GiniCoefficient has moved from 0.433 in 2001 to 0.418 in 2004. The Human Development Index
for Costa Rica is 0.838 according to the 2005 Human Development Report of the United Nations Development Program.
Table 2.5.1: Costa Rica – Basic data of 20051
Human Development Index
Position in Latin America
Position among 177 countries
Life expectancy at birth (years)
Males:
Females:
Birth rate (/1000 inhabitants)
0.834
4
47
Unemployment rate (%)
79.0
76.52
81.54
Poor households
21.4
Fertility rate
2.5
General mortality rate
4.0
Infant mortality rate (1000 L.B.)
Gross National Product (per capita)
9.25
Inflation rate
6.5
10.2
Minimum wage
$ 226
21.1 %
Investment in Health (% of GNP)
per capita
9.5
€ 185
Investment in Soc. Sec. as % of
GNP
of Public Expenditure
of Social Expenditure
8%
36 %
57 %
$ 4028
Source: UNDP 2005, ECLAC 2005
Achievements in Health
Costa Rica has achieved outstanding results with regard to health care compared to other
countries. For instance, the relationship between income and life expectancy at birth places
Costa Rica amongst other countries with a much higher GDP. Compared to other countries
18
Executive Director of the Costa Rican Social Insurance Fund (Caja Costarricense de Seguro Social – CCSS)
until March 2006, [email protected].
19
Senior Health Advisor, Berlin, Germany, [email protected].
20
For further details, additional data and more country information please see Chapter 1.5, D. Fuentes-Montero:
Social health insurance: Economic development and poverty reduction (pp. 16-21).
A. Sáenz P., J. Holst: Equity and solidarity in social health insurance: Costa Rica’s way to universal coverage
46
of the region, the structure of expenditure in health is very different, and this has implications
for the development of social security systems. This political and cultural component is part
of the nationality characteristics that cannot be ignored because they constitute important
elements for governance and social stability.
Figure 2.5.1: Deliveries attended by skilled personnel in Latin American and Caribbean
Guatemala
Bolivia
Honduras
Ecuador
Peru
Nicaragua
El Salvador
Paraguay
Latin America
Mexico
Panama
Colombia
Brazil
Costa Rica
Dom. Republic
Venezuela
Cuba
0%
20%
40%
60%
80%
100%
Table 2.5.2: Years of Potential Life Lost in Costa Rica 1980 - 2000
1980
Total
1985
1990
1995
2000
1,070.5
911.5
773.4
729.6
625.4
st
996.9
778.4
627.4
624.5
605.5
nd
2 group*
993.0
876.0
733.9
724.3
632.2
3rd group*
1 group*
1045.7
875.8
750.2
676.0
574.5
th
1132.5
986.7
824.7
744.5
649.7
th
5 group*
1294.8
1096.3
994.6
920.2
673.7
GII
320.11
331.85
366.33
263.89
63.69
RII
1.35
1.45
1.62
1.44
1.11
4 group*
Source: Bortman 2002, pp. 14ff. *: Group of districts (cantons) according to social development index. GII: Gradient inequality index; RII: Relative inequality index.
Since 1999 the Costa Rican Ministry of National Planning and Economic Policy (MPNyPE Ministerio de Planificación Nacional y Política Económica) has developed the Social Development Index (SDI) as a synthesis of seven indicators related to the education infrastructure
Extending Social Protection in Health
47
Figure 2.5.2: Regional distribution according
to the SDI in Costa Rica
N
th
5 Group
th
4 Group
rd
3 Group
nd
2 Group
st
1 Group
Source: Bortman 2002, p. 11
Figure 2.5.3: Population share according to socioeconomic standard of living conditions
5th group
14%
1st group
15%
4th group
18%
2nd group
32%
3rd group
21%
Source: Bortman 2002, p. 10
and special education
programs, infant mortality, child mortality impact, growth retardation,
electricity consumption,
and single mothers. According to these criteria,
the Central American
country started to assess and catalogue the
communities called cantons (cantones) all over
the country. According
to the SDI, the cantons
were ranked in five
groups reflecting the
living conditions and
standards of the population.
The inequality index
concerning premature
mortality was almost cut
in half between 1980
and 2000 (from 1,070 to
625 per 10,000 people).
However, the relationship between life years
lost and social groups remained evident since this indicator was clearly
lower in the better-off cantons compared to the poorer living areas. The
main progress is to be observed in the
second decade between 1990 and
2000 when the mortality curves of different social groups showed a tendency towards flattening (Bortman
2002, p. 14f).
One may think that it is easier to implement widespread health services
under the responsibility of Social Security in countries where public expenditure in health represents the larger portion, as in Costa Rica. The
country started the development of its
modern Health Services early in the
19th century, creating the Ministry of
Health and the Social Security Bureau
in 1922 and 1941 respectively. The introduction of Primary Health Care in
1970 and the Health Reform of the
mid 1990s are major events.
The 1994 reform that transfers all public health services to Social Security is still in process
and Costa Rica has resisted the pressure of lending and international organisations to privatise and dismantle its public health system administered by the social security fund CCSS.
The results of this effort can be seen in the country’s Health and Social Indicators shown
48
A. Sáenz P., J. Holst: Equity and solidarity in social health insurance: Costa Rica’s way to universal coverage
partly in Table 2.5.1 above. One essential question is if the Costa Rican improvements in the
last 20 years have induced a reduction of the gap between the better off and the worse off, or
if the inequalities have remained or even increased. A sensitive indicator for the overall
health status of the Costa Rican population is the continuous reduction of the infant mortality
rate between 1980 and 2001 that has been highest in the 5th quintile, but has been relevant
also in the lowest income groups:
Table 2.5.3: Reduction of infant mortality, percentage of non-institutional deliveries between
1980 and 2001
Reduction of
infant mortality
1st group*
Reduction of noninstitutional deliveries
Change of Maternal mortality
36,6 %
65 %
- 48,8 %
2 group*
49,8 %
83 %
- 31,1 %
3rd group*
44,7 %
79 %
- 28,5 %
4 group*
43,6 %
77 %
+ 69,5 %
5th group*
46,2 %
85 %
+ 184,3 %
Total
44,5 %
nd
th
+ 5,9 %
Source: Bortman 2002, pp. 21ff, and own calculations.
The overall results have been good and show a continuous improvement, in spite of some
exceptions that have to be analysed and tackled accordingly. The progress in health is based
on the Social Security principles of solidarity, universality and equality. However, the Costa
Rican social health insurance system is not free of problems. The current and forthcoming
challenges for the institutional sustainability are enormous, and the reasons are both internal
and external.
Universal Coverage
Social Security started in 1941 as a small Bismarkian type tripartite social insurance for urban low-wage workers. Health insurance coverage has progressively been extended to almost 90 % of the population. A series of political steps were needed in order to make palpable progress on the ongoing way towards universal coverage. Today, Costa Rica is offering
100 % geographical access to health services, and 87.8 % statistical or administrative coverage. Access to Primary Health care and
attention to emergencies is universal.
Relevant steps towards universality
About 96 % of deliveries are attended by
•
1945 Family benefits
specialised personnel. Access to good
quality medicines is universal and ex•
1959 Pensioners, contributory
ceeds the WHO recommendations for a
•
1974 Pensioners, non contributory
basic drug list. This list in our system in•
1975 Voluntary insurance
cludes 460 active substances in 608
presentations. Costa Ricans have access
•
1984 Self employed
to pharmaceutical products for all types
•
1985 Collective insurance agreements
of pathologies, including antiretroviral
•
2000 Law for the protection of workers
drugs for citizens living with HIV/AIDS.
Integral access to medication has become
possible through a policy of generic drugs and centralised buying by public bidding through a
special law for the acquisition of medicines, which provides economies of scale.The system
is looking at the possibility of electronic procedures that have produced savings up to 15 % in
the expenditure for medicines in other countries. Another strength of the system is the widespread network of services that has developed in over 60 years of performance. This net-
Extending Social Protection in Health
49
work is organised by hierarchical levels of health care in regions, areas and sectors in which
the whole country is divided and covered.
In primary health care, a very strong emphasis has been placed on the Basic Integrated Number of Public Health Care Facilities
st
nd
rd
Health Teams (Equipos de Salud Básicos In- at the 1 , 2 and 3 Health Care Level
tegrados). These teams comprise a medical
7 Regional Managing Offices
doctor, a nurse, a pharmaceutical and a pri29 Hospitals
mary health technician. They provide integra104 Health Areas
ted health services to a population of 4,500 to
5,000 people. For pharmacy, laboratory, ima893 Primary Care Facilities
ging, dental care and administrative services
1800 Temporary Health Care Dethey depend on a Health Area that supports
livery Facilities
several basic teams. An important comple7 Mobil Health Care Facilities
ment to the network has been the inclusion of
2837 Health Care Facilities
community participation through the Local
Health Board, a voluntary organisation associa
ted with each health centre that plays an important role in the social production of health.
They have representatives of the workers, the employers and the local NGO organisations.
Demographic challenges for Social Health Insurance in Costa Rica
Facing the future of the Social Health Insurance Fund in Costa Rica, a series of demographic
factors will influence the further development and demand special attention. From 2010, the
population share above 59 years will increase dramatically. In developing countries and in
countries in transition, the demographic tendency towards aging populations and progressive
urbanisation change the epidemiological patterns and thus tend to increase costs. A well
• Aging population
known phenomenon is the change from acute
infectious and environment-related diseases to
• Changes in population distribution
chronic and high cost illnesses like cardiovascu• Strong immigration
lar diseases and cancer.
• Increase in non-traditional family
Rising operational costs are especially attributsettings
able to increasing expenditures for pharmaceu• Changes in nupciality patterns
tical products and medical supplies, the intro• Longevity
duction of new technologies and rising salaries.
In the case of drugs, the Costa Rican Social
• Reduction in family size
Insurance Fund has been able to continue the
• Reduction in dependency
essential medication program for everybody
based on the use of generic drugs.21
In our society, the appearance of many control instances is another threat to the financial
sustainability of the system. The Constitutional Jury, the Ombudsman Office, the press and a
more informed public in general lead in to make large expenses in high cost medications and
procedures for the benefit of small populations. This can cause an ethical problem regarding
the distribution of resources and the interests of the population at large. The pressure of
these external forces is particularly important in the problems we face with long waiting lists
and periodic shortage of supplies.
There is a high, not well-established number of illegal workers that represent the most important population segment currently excluded from social protection. The indigenous population
accounts for 1.7 % of Costa Rican citizens and represent another group with inequitable access to health and educational services. Due to fiscal problems, however, the state is facing
serious difficulties in co-financing the social security system and especially the contributions
21
The essential drug program will be affected if Costa Rica signs the Central American Free Trade Agreement
(CAFTA) as it will include the protection of patents and influence the price and the availability of a series of drugs.
50
A. Sáenz P., J. Holst: Equity and solidarity in social health insurance: Costa Rica’s way to universal coverage
for those who cannot afford them. Immigration in a country with a low fertility rate has a positive potential as long as immigrants are covered by national social protection schemes and
therefore participating in solidarity contribution systems. However, in many countries migrant
workers are either excluded from existing social protection schemes or rely on social security
systems of their home country.
New regulations are in view, and probably a general amnesty will be needed in order to legalise and formalise the status of immigrants in a country whose work force relies partly on
foreigners. The participation of immigrants in social security and, especially, their regular
payment contributions will be important for the sustainability of health and pension schemes.
Changes in family structure have a social impact that makes contributions more difficult to
calculate and to raise. The increase of life expectancy in a middle-income country like Costa
Rica is associated with a higher prevalence of chronic illnesses and, thus, increased costs.
As social and income conditions, supported by scientific and technological progress, have
contributed to longer life expectancy, society faces new challenges to provide quality of life to
the increasing number of the elderly. The last two aspects have a beneficial effect that needs
to be taken advantage of.
Costa Rica experienced two ‘baby boom’ periods in the last half of the past century. This is
providing the country a ‘Demographic Bonus’ between years 2000 and 2020. This phenomenon that reduces dependency during a period only happens once and has been seized by
countries in the Asian Pacific to improve its institutions. Costa Rica needs to take advantage
of this opportunity and is determined to do it. While the growing number of economically active individuals are catering for increased contribution revenues, the Social Insurance Fund
has to invest in equipment and human resources in order to be prepared for the increased
independency and higher costs of health care and pensions that will gradually appear after
2020. The epidemiological changes during the last decades demand the introduction of carefully evidence-based diagnostic and treatment protocols and to ascertain if the Costa Rican
social health insurance fund can continue offering all kind of services to everybody or if it has
to define positive lists of services, procedures, drugs, and supplies to be explicitly covered by
the CCSS.
The Costa Rican Social Insurance system has evolved from a tripartite Bismarckian model to
a mixed one where the contribution of the state is crucial. In addition to the important contribution as employer, the government subsidises both the health and pension schemes. In the
Central American country, the Human Development Index has evolved similar to other countries whose tributary load (taxes as a percentage of production) is three to four percentage
points of the GDP higher. This remains the same when the contributions to Social Security
are added.
Furthermore, the government makes transfers to cover the one very important factor for the
sustainability of the system, the Quality Assurance Program aiming at the three objectives of
quality improvement, quality control, and quality design. The strategy used during the last 10
years under the name of Evidence Based Participatory Quality Improvement in Health (EPQI;
Mejoramiento Participativo de de la caliudad en salud basada en evidencia) has been applied in different quality projects throughout the Costa Rican health care network. In 2005, for
example, the quality projects within this strategy focussed on patient safety.
As shown in the following table 2.5.4 it is evident that salaried employees and workers pay
contributions that clearly exceed the expenditure related to the services they ask for. This
causes a problem because formal sector workers use to have higher salaries, and they tend
to under-declare their income. This reduces the intra and inter-generational redistribution
and, thus, the solidarity of the system. On the other hand it is also evident that the State is
sufficiently paying the monetary transfers for the non-contributory programs he is responsible
for.
Extending Social Protection in Health
51
Table 2.5.4: Costs and financing of the health insurance according to affiliation in 2004
324.305 ¢
172.337 ¢
1.88
14.634 ¢
50.082 ¢
0.29
26.632 ¢
68.097 ¢
0.39
2.793 ¢
117.437 ¢
0.02
368.364 ¢
407.953 ¢
0.90
Source: Análisis Técnicos de Ingresos y Gastos, Dirección Actuarial (in million CRC (¢); 1 € = 521,5 CRC, 1
CRC = 0.0019 € (1.7.2004).
This final conclusion is very important: if the Costa Rican society wants to continue enjoying
the results and improving our social health and pension insurance system, the State has to
increase the tax load and the transfers to the social security institutions. This should lead us
to a stronger public health system with fewer but better institutions. We believe that a good
sign of progress is that people use and show satisfaction with its public health system. In that
sense I would like to end this presentation quoting Mr. Hans Horst Konkolewsky, ISSA Secretary General, who said: “I believe that Social Security is the only way to guarantee the social dimension of globalisation. Therefore, the question is not whether we can have Social
Security but rather if we can allow ourselves not to invest in it. Those countries with consolidated Social Security Systems are also in the leadership in terms of competitivity and social
peace”.
References
Bortman, Marcelo (2002). Indicadores de salud. Mejoró la equidad? Ministerio de salud, Organización
Panamericana de la Salud, Oficina Regional de la Organización Mundial de la Salud, Representación
en Costa Rica. San José (http://www.cor.ops-oms.org/TextoCompleto/documentos/indicadores_salud.pdf).
Carrin, Guy; James, Chris (2004). Reaching Universal Coverage via Social Health Insurance: Key
Design Features in the Transition Period. WHO, Dep. of Health Systems Financing and Resource
Allocation. Geneva (www.who.int/entity/health_financing/issues/en/reaching_universal_dp_04_2.pdf;
whqlibdoc.who.int/hq/2004/EIP_FER_FOH_PIP_04.1.pdf; http://www.issa.int/engl/initiative/projects/2carrinjames.pdf).
Economic Commission for Latin America and the Caribbean (2005). Social Panorama of Latin America
2005. ECLAC/CEPAL, Santiago (http://www.eclac.cl/cgibin/getProd.asp?xml=/publicaciones/xml/4/24054/P24054.xml&xsl=/dds/tpli/p9f.xsl&base=/dds/tpl/top-bottom.xsl).
Miranda-Gutierrez, Guido (2003). La seguridad socialy el desarrollo en Costa Rica. 3rd Edition, EUNED, Ed. Universidad Estatal a Distancia. San José.
Rosero-Bixby, Luis (2004). La situación demográfica general de Costa Rica. In: Herrera, Reinaldo;
López Gretel (eds.). Evolución demográfica de Costa Rica y su impacto en los sistemas de salud y
pensiones. Academia de Centroamérica, San José
(http://ccp.ucr.ac.cr/bvp/pdf/cambiodemografico/Rosero-demografica-2003.pdf).
Molina, Raúl; Pinto, Matilde; Henderson, Pamela; Vieira, César (2000). Gasto y financiamiento en
salud: situación y tendencias. Rev Panam Salud Publica/Pan Am J Public Health 8 (1/2), pp. 71-83
(http://www.paho.org/spanish/dbi/es/ARTI--Molina.pdf).
Montero, Sary; Barahona, Manuel (2003). La estrategia de lucha contra la pobreza en Costa Rica.
Institucionalidad -Financiamiento Políticas - Programas. Serie Políticas Sociales No 77, ECLAC, Santiago (http://www.eclac.cl/publicaciones/xml/0/13950/lcl2009.pdf).
United Nations Program for Development (2005). Human Development Report 2005. International
Cooperation and a crossroads. Aid, trade and security in an unequal world. UNPD, New York
(http://hdr.undp.org/reports/global/2005/pdf/HDR05_complete.pdf).
H. Achouri: Advances in Implementing Social Security: Lessons from Tunisia
52
2.4. Advances in Implementing Social Security: Lessons from Tunisia
Hedi Achouri22
Situation and background
Coverage of illness and health risks in Tunisia has been assured, since the end of the
1950’s, through two parallel systems that offer Social Security for civil servants and workers
in public as well as private enterprises. Two social protection schemes managed by different
bodies cover two out of three Tunisians: private sector employees are covered by the Social
Security Fund (CNSS), and the National Pension and Social Prevision Fund (CNRPS) covers
public sector employees. In addition, the government is providing health care services in
public facilities run by the Ministry of Health for the poor and low-income population. And, last
not least, some private societies or public bodies offer private health insurance for their employees, covering the same package as the public insurance.
Health care is free of charge for the poorest population as well as for some socio-professional groups (army, police, health professionals, etc.) while uninsured people of low-income
are entitled to get medical services, provided by MoH facilities at reduced tariffs.
In the 1990s, the Tunisian health insurance system was facing a series of problems and difficulties regarding efficiency, quality, equity, and satisfaction of stakeholders and users. Increasing inequities were appearing between people enrolled in the two social health insurance
institutions. These involved the burden of contriFigure 2.6.1: Health insurance coverage: Current Situation
butions on employers
and employees; and at
the same time, in terms
Private Insurance
of benefits, direct care
delivery in the MoH facilities for CNSS beneficiaries and limited access to
Mutual profes
the private providers for
sional bodies
some of the CNRPS’s insured. On the other
hand, among the beneficiaries of each social seFree of charges for
curity institution contribusocio-professionals
tion payment was inequitable between the economically active and
Source: Estimations of the Ministry of Public Health
pensioners. Furthermore,
the regional distribution of
CNSS polyclinics and, thus, access to adequate health care varied clearly from one region to
another. In addition of the social coverage by the state or social security bodies, employees
of some private enterprises can also benefit from private insurances funded by themselves
together with the employers. The same is valid for a group of public sector employees who
can affiliate to professional mutualities offering health insurance benefits.
Private insurance companies as well as mutual organisations cover the same health risks
and benefits as the social security funds. The existing level of information about the coverage
and health expenditure of private insurance companies and social health insurance organisations does not allow identification of the share of total health expenditure as they are included
in the array of private household spending.
22
Ministry of Public Health, Tunisia; mail: [email protected].
Extending Social Protection in Health
53
A very small share of the population (1 % or less) is not covered by the social health insurance systems or any of the government programs (free of charges or reduced fees). In this
case, users have to pay all charges to the public or private providers by themselves. Some
are entitled to be partially reimbursed by private insurance companies or social health insurance organisations according to the contractual arrangements in place; others have to pay
the whole charges out of pocket.
Table 2.6.1: Social protection institutions and health care provision
CNSS
The “health care booklet”
The CNSS’s polyclinics
The particular conventions
CNRPS
Mandatory Regime
Public providers of MoH
23
24
Public & Private Providers
25
Option 1- The refund regime
26
Public & Private Providers
23
Option 2 - The “health care booklet”
Public providers of MoH
27
Public & Private Providers
24
Public & Private Providers
Optional Regime (Refund)
The particular conventions
In addition of the coverage through social health insurance, employees might have a private
or mutual health insurance policy allowing for access to private providers. Some of these civil
servants are also entitled to health care free of charge in the MOH facilities (army, police,
health professionals, customs officers).
The overlapping of multiple coverage modes induced palpable inefficiencies in the Tunisian
health insurance system, while the overall expenditure for health care was continuously increasing due to the implementation of high-cost interventions like heart surgery, dialysis, etc.,
rising prices of drugs and medical devices, and an increasing demand for health care. The
quality of services and health care benefits was negatively affected by the long delay of provider payment and low reimbursement rates due to various ceilings and exclusions, and by
long waiting periods for some benefits like inpatient care and dialysis.
The socio-economic environment and the epidemiological transition associated with the expansion of health care supply and the transformation of demand generated disappointment
which illustrated the coverage limits of the existing social security schemes. The continuous
under-funding of the public sector and insufficient financing of private health care facilities
induced a high degree of dissatisfaction of providers, while the felt quality mainly in public
providers, the lack of resources, and increasing out-of-pocket payments were responsible for
low satisfaction rates among beneficiaries. One important indicator for the increasing financial burden that health care costs imply currently for private households is the fact that during
the last 15 years, household expenses for health have increased continuously and amount to
almost 50 % of the total health expenditure.
23
The ‘health care booklet’: access to all health care services in public facilities run by the Ministry of Health.
The ‘particular conventions’: in order to promote national abilities in heavy health care and to reduce abroad
services and expenditures, social security bodies concluded conventions with public hospitals and private providers to develop local health care in cardiology and cardiac surgery, organ transplantation, dialysis, CT Scan, MRI
and lithotripsies.
25
The ‘mandatory regime’: The civil servants newly enrolled have to choose between two options in the mandatory regime, for the same rates of employers and employees’ contributions.
26
Option 1- The ‘refund regime’: coverage limited to some long-term treatments of chronic diseases and surgical
interventions, excluding all common diseases.
27
Optional Regime (Refund): extension of option 1 to common diseases coverage through higher contributions.
24
H. Achouri: Advances in Implementing Social Security: Lessons from Tunisia
54
Figure 2.6.2: Health Financing in Tunisia
60%
50%
40%
30%
20%
10%
0%
1985
Government
1990
1995
Social Security
2002
Households
Source: Ministry of Development and Ministry of Health
Social Health Insurance Reform
The ongoing health financing reform in Tunisia aims to overcome the shortfalls and problems
mentioned before and to prevent some predictable consequences of the demographic, epidemiological, technological and other transitions affecting health care.
As extending social protection in health and, thus, social security coverage is a priority for the
Tunisian Government, the health insurance reform pursues three major goals. Firstly, the
benefits of the different health insurance regimes currently in place have to be harmonised
and a sole mandatory basic regime has to be adopted and managed by one health insurance
body, the Caisse Nationale d’Assurance Maladie (CNAM). Secondly, optional complementary regimes will be implemented in order to bear the costs that remain uncovered by the
basic regime and have to be paid directly by the patients. With regard to the health system
as a whole, all health care providers should be involved, whether they are public or private
through contracts that include and determine quality standards and norms of health care delivery, mechanisms of cost containment, tariffs and provider payment methods.
In more specific terms, the Tunisian reform process is battling with a series of technical challenges and proposals that have to be checked and balanced in order to find the most suitable
options for the country. A series of important tasks have to be tackled in the near future in
order to make relevant steps towards a substantial improvement of the Tunisian health care
system.
First of all, the content of the basic regime and its financial balance status have to be defined
and cost containment mechanisms selected and applied, e.g. organising and implementing a
medical reference system (consensus, guidelines), and classifying positive drug lists and
reimbursement rates. The implementation of a continuous quality assurance program with
regard to standards and procedures has to accompany the sector reform. A major challenge
is the definition of the future structure of the National Health Insurance Fund (Caisse Nationale d’Assurance de Maladie) to be created and implemented, including the management of
the current system of two different social security funds, the mobilisation of additional resources and skills, and the promotion of medical control monitoring cost trends and features
as well as quality assurance.
It will also be essential to prepare public and private providers to manage the regime regarding the necessary procedures and technical infrastructure (computerisation, data collection
Extending Social Protection in Health
55
and processing, human resources training, etc.), to define tariffs and modes of provider payment for outpatient care based mainly on fee for services after abandoning capitation, for
inpatient care implementing flat rates (DRG) and for future negotiations of fees and tariffs.
Therefore - and for administrating the system - the design and implementation of an appropriate information system (CNAM and providers) will be required; this must include the definition of procedures, the level of computerisation and data transmission and the training of
personnel.
The definition of necessary regulatory measures like standards and rules of good practices
are required, including the substitution of prescribed medicines, standardisation of professional acts, incentives and punishment measures. The implementation of a ‘health care map’
regarding service infrastructure and mainly specialised equipment, and effective marketing
mechanisms, public relations and information of providers and beneficiaries have to accomplish the efforts for implementing a better health care system all over the country.
Since the political initiative began in 1996, the health insurance reform is under a national
debate that involves all stakeholders in order to achieve the necessary consensus on the
content of the basic regime and the package of care to be covered; the financial balance;
mechanisms of cost containment including provider payment methods; continuous quality
assurance; new management procedures of health insurance and in particular the information system; and regulation tools
and guidelines. Conscious that
this important reform of health
care financing will deeply modify
the national health system, the
government and the various
stakeholders have to assure and
improve equitable access to
health care and the efficiency of
the health system taking in
account the available management capacities and the publicprivate mix of the healthcare
supply and financing.
From 1996 until the end of 2005, several commissions have discussed the strategic approaches and continuously negotiated with the various stakeholders. In 2004, Parliament
passed Law 2004-71 and a series of decrees that define the framework and create the new
health insurance fund (CNAM). The transition from the existing schemes (CNSS+CNRPS) to
the single fund, CNAM, has been initiated through the implementation of facilities, training of
human resources and other measures. The next steps will comprise the elaboration and negotiation of contracts and tariffs with private providers. At the same time, the regulatory basis
has to be completed and medical and financial control to be implemented. In addition, public
sector financing has to be improved and put on a solid basis.
The Tunisian Health Insurance Reform has to face a series of short, middle and long-term
challenges that include technical as well as managerial and operational aspects. In the short
run, the stakeholders involved have to negotiate and find agreements with regard to the financing of the basic regime, the implementation of cost-sharing mechanisms and the overall
goals to achieve equal access to health care. A major challenge will be the definition of
methods of provider payment in order to find a balanced relationship between fees for services and flat rates to enhance efficiency and credibility. Equally, managed care elements
and free choice options have to be combined in a way that helps to prevent or even avoid
false incentives and misuse. For the voluntary complementary insurance scheme to be implemented, information and awareness about experiences and expectations are crucial.
In the mid term, the improvement of accessibility to adequate health care, continuous quality
assurance and cost containment are priority challenges for the Tunisian Government. The
existing Health Insurance Fund requires consequent decentralisation in order to guarantee a
56
H. Achouri: Advances in Implementing Social Security: Lessons from Tunisia
higher proximity of insured people and providers for
delivering benefits in time. Additional technical and administrative support is expected with the introduction of
a health care booklet - or even a magnetic membership
card - that might improve and rationalise control and
data processing of the social security bodies.
The introduction of competition among providers will
demand a clear-cut distribution of roles between providers including greater autonomy for public hospitals,
and especially for a determination of how far the public
sector should act as last resort. The satisfaction of both
beneficiaries and users has to be monitored through
regular surveys, a complaint management system and
better information plus communication. At the same
time, continuous monitoring of the quality of health care
will be necessary. Statistical coverage of both providers’
data on use, output and expenditure and surveillance of
morbidity and mortality trends has to be improved in order to allow for current adjustments
with regard to organisation, benefits, financing and other relevant aspects of health care.
References
Abdesselem, Hichem, Achouri, Hédi (2001). La couverture du risque maladie de la population démunie et à revenus limités. La Tunisie Médicale 79 (5), pp.293-297
(http://www.medscape.com/medline/publicationbrowser/9584/79_5/dt_05012001).
Achouri, Hédi (2001). Assurance maladie: les questions à débattre. Communication à un séminaire
organisé par le ministère de la santé publique sur les modalités de paiement des prestataires de soins. Tunis.
Achouri, Hédi; Khaled, M. Kheireddine (2001). Assurance maladie: les défis de la réforme. Communication à un séminaire organisé par le ministère de la santé publique sur les modalités de paiement
des prestataires de soins. Tunis.
Blel, Sayed (2001). L’assurance maladie en Tunisie: contexte actuel et perspectives d’avenir. La Tunisie Médicale 79 (5), pp. 278-284
(http://www.medscape.com/medline/publicationbrowser/9584/79_5/dt_05012001).
Chaabane, Mohamed (2003). Vers l’universalisation de la sécurité sociale: l’expérience de la Tunisie.
Extension de la Sécurité Sociale (ESS), Document no 4 (http://www-ilomirror.cornell.edu/public/english/protection/socsec/download/esspaper4french.pdf).
Fathallah, Magid; Ben Abbes, Riadh, Chebbi, Faïçal, Kechrid, M. Ridha (2001). Mise en en oeuvre de
la réforme de l’assurance maladie. La Tunisie Médicale 79 (5), pp. 285-292
(http://www.medscape.com/medline/publicationbrowser/9584/79_5/dt_05012001).
Ministère des Affaires Sociales (1999). Politique Sociale en Tunisie: Les Acquis du Changement. Tunis.
Kasmi, M.Salah (1996). Sécurité Sociale dans les Secteurs Public et Privé. Editions Internationales,
Tunis.
Organisation Internationale du Travail (OIT) (1988). L’intervention de la sécurité sociale dans le secteur des soins de santé. Le cas de la République de Tunisie. ILO/OIT, Département de la sécurité
sociale. Geneva.
World Health Organization, Eastern (2001) - Technical Discussions: Health systems development 48th session of the regional Committee, Riyadh, Saudi Arabia, 30 September - 3 October 2001. Riyadh, Saudi Arabia. EM/RC48/Tec. Disc. 1. WHO, Mediterranean Regional Office
(http://www.emro.who.int/RC48/Documents/EMRC48TechDisc1.doc).
Wouters, Annemarie (1999). Méthodes alternatives de paiement des prestataires: incitations pour
l’amélioration de la qualité des soins. Notes à l’intention des décideurs, Partnerships for Health Reform (PHR). Bethesda (http://www.phrplus.org/Pubs/pps1f.pdf).
Extending Social Protection in Health
57
2.5. Social health insurance in French-speaking sub-Saharan Africa: situation
and current reform
Oumar Ouattara28, Werner Soors29
Introduction
In Africa, since independence, we have seen a multitude of reforms, strategies and alternative systems to guarantee some access to more quality health care for the populations of our
developing countries. But we have also seen too many failures, for which we can legitimately
ask the questions: have we learned our lessons? In fact, since the failure of free health care
and the introduction of cost recovery mechanisms – with its corollary of exclusion and inequity – access to quality health care remains a remote mirage for most of our populations. In
Mali, curative utilisation stagnated at 0.23 new contacts per person per year (Audibert, Martine/de Roodenbeke 2005). What about all the sick people? Where are they heading for?
Where do they end up?
The role of ill health in the creation of poverty at community level has been documented for
years now (ILO 2003; OECD 2003; Schultz/Tansel 1997; Whitehead et al. 2001). During our
many missions in African villages, how many heads of households told us that they had to
sell oxen and the crops of the year to come, just to face the sickness of a family member,
and at what price? Most of the time, the money was not even sufficient or came too late, as,
for example, in the case of an urgent caesarean section to be performed hundreds of kilometres away with no efficient or adequate transport at hand.
Faced with this setback, social health insurance is seen as a means to alleviate the suffering
of our populations (Waelkens et al. 2005). Social health insurance – be it voluntary like
Community Health Insurance (CHI), compulsory and/or universal – is now high on the political agenda. What has been realised? What are the current reforms? What can we expect in
the near future? We try to find an answer to these questions based on information from the
following sources:
Country reports from 13 out of 14 countries (Benin, Burkina Faso, Burundi, Chad, Gabon,
Guinea, Ivory Coast, Mali, Mauritania, Niger, Rwanda, Senegal and Togo, but not Comoros), presented at the symposium L’amélioration de l’accès aux services de santé en Afrique francophone: le rôle de l’assurance (Improving access of health services in Frenchspeaking Africa: the role of health insurance), organised by the World Bank Institute and
the Institut Multilatéral d’Afrique in Paris, from 26 till 30 April 2004;
Reports from the Coordination Network La Concertation entre les acteurs du développement des mutuelles de santé en Afrique, commonly referred to as La Concertation, in
particular of the inventories made and of the forums held;
Our own investigations in several sub-Saharan countries;
The existing literature.
Diagnosis
With independence, the French-speaking sub-Saharan African countries inherited a system
of free health care at the point of use. For this reason and since the 1960s, their emerging
social protection policies barely took in account health insurance. Most social security documents of the time touched only minimal measures regarding health, such as occupational
health, with the establishment of infirmary posts, company health centres and inter-company
health centres (Centre Médical Inter Entreprise, CMIE). Gradually, laws have been adopted
to allow free health care for privileged population groups such as civil servants, the military
and students.
28
General Director of Union Technique Mutualité Malienne, [email protected].
Research assistant at the Public Health Department of the Institute of Tropical Medicine, Antwerp,
[email protected].
29
58
O. Ouattara, W. Soors: Social health insurance in French-speaking sub-Saharan Africa
Very soon the young African states faced their first and massive financial problems. Hospitals and other health care structures ran short of all basic requirements: drugs, medical consumables and surgical items. Thus, the populations’ direct financial contribution to access
health care became a fact, first informally, then more formally. In 1987, the Bamako initiative
generalised the concept of cost recovery.
In order to enable a more equitable access to health care, several mechanisms were explored to reduce unwanted financial barriers. These mechanisms can be grouped in three
main categories: prepayment systems, community and other voluntary health insurance
schemes, and compulsory and/or universal health insurance.
Community and other voluntary health insurance schemes
Set up as a response to failing health care access, community health insurance schemes
(CHIs) first appeared in Africa in the mid eighties. Health care providers from faith-based
organisations initiated the first two initiatives. These were the CHI scheme of CDI Bwamanda
(Moens 1990) in the Democratic Republic of the Congo (DRC, then Zaire) and the Fandène
scheme in the Thiés region of Senegal.
The Congolese Bwamanda scheme – despite the political and military problems of the DRC
– remains statistically the most important one of French-speaking sub-Saharan Africa, with
over 114,000 members in 2004 (47,000 in 2002, at the height of the war). The Senegalese
Fandène scheme was unable to manage its own growth: it refused membership to a
neighbouring village (Ouattara/Colas 2003) and has now about 3,050 beneficiaries.
Back in 2003, the Coordination Network La Concertation provided a third inventory of West
African CHIs. The inventory included different kinds of health insurance schemes (HIs), both
CHIs, strictly speaking, as well as solidarity funds. The inventory was presented at the 2004
Forum of the Coordination Network La Concertation at Bamako:
Table 2.7.1: Health Insurance Coverage in West Africa
Country
All HIs
Functional HIs
Functional / all HIs
in this country
HIs in this country/
HIs in the region
Benin
54
43
79.6 %
8.7 %
Burkina Faso
92
36
39.1 %
14.8 %
Cameroon
38
22
57.7 %
6.1 %
Chad
7
7
100 %
1.1 %
Guinea
11
55
49.5 %
17.8 %
Ivory Coast
40
36
90.0 %
6.4 %
Mali
80
56
70.0 %
12.9 %
Mauritania
7
3
42.9 %
1.1 %
Niger
19
12
63.2 %
3.1 %
Senegal
149
87
58.4 %
24.0 %
Togo
25
9
36.0 %
4.0 %
All countries
622
366
58.8 %
100 %
Source: Letourmy 2004, slide 3-4
In total, 622 Health Insurance schemes were recorded, among which 58.8 % were operational at the time (2003). Among these health insurance schemes, only 10 % were solidarity
funds. The remaining vast majority were community health insurance schemes. What are the
features of these CHIs?
Extending Social Protection in Health
59
Generally speaking, the setting up of the CHIs did not respond to a national vision: only in
recent years have African countries started to integrate CHI development in their social and
health development plans and programmes. Most CHIs are new organisations, only 12 %
were set up before 1996. Most CHIs are small-size organisations as 72 % have less than
1,000 beneficiaries (median: 678 beneficiaries). The typical benefit package prioritises drugs,
small risks and pregnancy. Most CHIs formalise the relationship with their health care providers in a convention, whereby fee-for-service reimbursement is the standard, fee-forepisode reimbursement is applied in only 18 % of the schemes. Membership seems to be
affordable and in 60 % of the cases it is about 500 FCFA (less than € 0.80) per family and
per month. In three out of four schemes (76 %), the end-user has to make a co-payment,
which is usually around 30 % of the benefit cost. In nearly one out of five schemes (18 %),
contributors cross-subsidise the membership of (poorer) non-contributors.
Compulsory and/or universal health insurance
In French-speaking sub-Saharan Africa, very few compulsory and/or universal health insurance systems have been developed. Instead, waivers were established for the privileged
such as civil servants, the military and salaried employees, but also for vulnerable groups like
the very poor. The limitations of these waiver policies have nowadays become obvious: all
public health care providers expected to deliver these free services have serious financial
problems. This is one more reason why health insurance reforms are appearing on the national agendas.
Moving away from the waiver policy, some French-speaking sub-Saharan African countries
have been developing compulsory health insurance schemes. Such is the case in Senegal
(Institutions de Prévoyance Maladie), in Rwanda (Rwandaise d’Assurance Maladie), in Ivory
Coast (various occupation-based compulsory schemes), in Guinea and in Gabon. As most of
these schemes deal with the formal sector only (or even a part of it), they are still far from
universal and might increase inequity.
Current reforms and prospects
The ongoing health sector financing reforms in French-speaking African can be grouped in
two main categories. On the one hand, the followers of universality (mainly Gabon and Ivory
Coast) aim to reach coverage for the whole population. Gabon does so by integrating a
health care division in both of the existing social security schemes (one for the private sector,
another one for the rest of the population). Ivory Coast works towards the creation of two
central schemes, under the umbrella of a National Fund for Health Insurance.
On the other hand, the strategy in the other countries includes different approaches for specific population groups: the creation of a compulsory scheme for the formal sector (in the
Senegalese variant, this might implicate the merging or reinsuring of the existing health insurance institutions in one national insurance scheme); the creation of CHIs for the informal
sector and the artisans; and the implementation of assistance funds for the very poor.
Taking into account the vivid dynamics of these ongoing reforms, the situation in Frenchspeaking sub-Saharan Africa looks promising. In our opinion, however, none of these reforms will solve the continent-wide problem of access to health care without a series of additional urgent collateral efforts. These include targeted support for the demand side of health
care – in particular for the development of social health insurance – in French-speaking subSaharan Africa, to counterbalance the support for the supply side that for years was unable
to bring about the expected results. Secondly, long-term support for the development of social health insurance in French-speaking sub-Saharan Africa is needed in order to overcome
the thousands of short-term small projects that created more problems than solutions.
Thirdly, the creation of a human resources training programme for the French-speaking subSaharan social health insurance sector is a felt need since a skilled health financing work
force is absent at present. Lastly, sufficient guarantees for the financial and managerial
autonomy of national and community health insurance schemes, independent from the highly
O. Ouattara, W. Soors: Social health insurance in French-speaking sub-Saharan Africa
60
Table 2.7.2: Overview of health insurance mechanisms in francophone sub-Saharan Africa
Country
Public sector
Private sector
Other sectors
Benin
Non-contributory
scheme, related to
the Code of Civil
Service
Contributory scheme according to the Labour Code.
Covers work-related injuries
and illnesses, maternity and
daily allowances
Contributory scheme according to the Labour Code.
Covers work-related injuries
and illnesses, maternity and
daily allowances
Compulsory scheme created
in 2000, but not functional.
Application presently dependent on the goodwill of
the employers
CHIs and private-forprofit insurance companies
Burkina
Faso
Non-contributory
scheme, related to
the Code of Civil
Service
Burundi
Compulsory contributory scheme (Mutuelle de la Fonction Publique), since 1980, in
theory for 600,000
beneficiaries, in practice only 10 %.
Contributory compulsory scheme. Covers
75% of ambulatory
care, hospitalisation
and referral
Chad
Contributory scheme according to the Social Security
Code. Covers work-related
injuries and illnesses, maternity and daily allowances.
Some non-occupational
schemes exist
Health care division of the
National Social Security
Fund, based on a 4.1 %
salary contribution of the
employers only. Ambulatory
care is fully covered, copayment applies for hospitalisation and referral
Gabon
Non-contributory
scheme, about
160,000 beneficiaries.
Ambulatory care is
fully covered, 10%
co-payment applies
for hospitalisation,
20% for referral
Guinea
Non-contributory
scheme, related to
the Code of Civil
Service
Health care division of the
National Social Security
Fund since 1994, based on
third party payment + 30%
co-payment on behalf of the
insured
Semi-contributory
compulsory scheme
(Mutuelle Générale
des Fonctionnaires et
Agents de l´État).
Civil servants have
the option to withdraw
from the scheme
Non-contributory scheme, related to the Code of Civil Service.
Similar schemes for
the elderly and war
orphans.
Non-contributory
scheme, related to the
Code of Civil Service.
Similar schemes for
the military, students
Well developed occupational
medicine, with insurance
contracts in some cases
Ivory
Coast
Mali
Mauritania
CHIs and private-forprofit insurance companies
Ongoing reforms
Creation of a compulsory health insurance scheme for the
formal sector
Medical Assistance
Card for independents
and farmers. Should
cover 20% of the population but faces major
operational difficulties
CHIs and private-forprofit insurance companies
Planning of the creation of a broader
compulsory scheme,
a pilot committee
has been installed
National Fund of Social Guarantee for government contractors,
independents and the
very poor; based on a
budgetary contribution,
about 300,000 beneficiaries. Supplementary
private insurance
scheme, 65,000 beneficiaries
CHIs, MURIGA (Mutuele pour la prise en
charge des Risques
associés à la Grossesse
et aux Accouchements)
for obstetrical risks and
private-for-profit insurance companies
CHIs and private-forprofit insurance companies
Creation of universal
health insurance,
provided by a sovereign Gabonese
public institution:
contributory and
compulsory for all
workers, noncontributory for the
very poor
Contributory scheme according to the Labour Code.
Covers work-related injuries
and illnesses, maternity and
daily allowances
CHIs, emergency
obstetrical funds and
private-for-profit insurance companies
Contributory scheme according to the Labour Code.
Covers work-related injuries
and illnesses, maternity and
daily allowances
CHIs, obstetrical fund,
private-for-profit insurance companies, fund
for the very poor
Creation of universal
health insurance
(Fonds National),
based on two schemes (Caisse Sociale
Agricole and Caisse
Nationale d’Assurance Maladie)
Creation of a compulsory health insurance
scheme for the formal
sector and of a medical assistance fund
for the very poor
Extending Social Protection in Health
Country
Niger
Rwanda
Senegal
Togo
Public sector
and the very poor
Non-contributory
scheme, related to
the Code of Civil
Service. Similar
schemes for the military, students and the
very poor
Contributory scheme
of the Rwandaise
d’Assurance Maladie,
based on third-party
payment + 15% copayment on behalf of
the insured
Non-contributory
scheme related to the
Code of Civil Service.
Similar schemes for
the military, students
and the very poor
Coverage for civil servants should be assured in the newly established Lomé hospital.
Government shares
the medical costs of
expatriate civil servants.
Government assumes
the medical costs of
the military.
Private sector
Contributory scheme according to the Labour Code.
Covers work-related injuries
and illnesses, maternity and
daily allowances
Contributory compulsory
schemes, diverse benefit
packages and service level
coverage according to the
different employers
Contributory compulsory
schemes of the Health Insurance Institutions (Institutions de Prévoyance Maladie) with defined benefit
packages, co-payment percentage according to the
different schemes
Compulsory scheme of the
Social Insurance Institute
(Institut de Prévoyance Social) for the retired
Contributory scheme according to the Social Security
Code. Covers work-related
injuries and illnesses and
maternity
61
Other sectors
Ongoing reforms
CHIs and private-forprofit insurance companies
Creation of an overall HIs for the civil
servants
National fund for genocide victims (Fonds
National pour l’Assistance aux Victimes les
plus nécessiteuses du
Génocide et des Massacres), about 283,000
beneficiaries
CHIs, 7,388,647 beneficiaries: probably the
biggest African CHI
network
CHIs and private-forprofit insurance companies
Restructuring of the
different schemes,
with extension of the
benefit package
CHIs and private.forprofit insurance companies
Source: World Bank Institute/Institut Multilatéral d’Afrique 2004.
indebted social security institutions in our failing states, is vital for implementing sustainable health insurance mechanisms. Only if these conditions can be satisfied will social health insurance in French-speaking
sub-Saharan Africa be able to improve access to health care as
expected and also to boost the quality of the care offered by giving a
voice to our suffering populations.
References
Audibert, Martine; de Roodenbeke, Eric (2005). Utilisation des services de santé de premier niveau au Mali : Analyse de la situation et perspectives. Département du développement humain, Région Afrique, Banque Mondiale, Washington (http://siteresources.worldbank.org/INTAFRICA/Resources/Mali_sante_final.pdf).
Planning of the creation of a National HIs
for the civil servants
Planning of the creation of a Agricultural
Social Scheme, in
the framework of the
existing agricultural
laws
Reinforcement of the
legal framework for
CHIs and for the
National Solidarity
Fund
Planning of the creation of a compulsory
scheme
62
O. Ouattara, W. Soors: Social health insurance in French-speaking sub-Saharan Africa
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Waelkens, Maria-Pia; Soors, Werner; Criel, Bart (2005). The role of social health protection in reducing poverty: the case of Africa. Extension of Social Security paper no. 22. Strategies and Tools against
social Exclusion and Poverty, International Labour Office, Geneva.
Whitehead, Margaret; Dahlgren, Göran; Evans, Timothy (2001). Equity and health sector reforms: can
low-income countries escape the medical poverty trap? The Lancet 358, pp. 833-836.
World Bank Institute/Institut Multilatéral d’Afrique (2004). Colloquium L’amélioration de l’accès aux
services de santé en Afrique francophone: le rôle de l’assurance. Paris (http://www.cesasso.org/Pages/index.php?redir=http://www.ces-asso.org/Pages/ESPAD-ColloqueWBI-IMA-CESactes.html).
Extending Social Protection in Health
63
2.6. The Inclusion of the Poor in a Social Health Insurance Framework: The
Strategies Applied in Viet Nam
Tran Van Tien30
Background
By shifting from a centrally planned to a market economy since 1986, Viet Nam has been
undergoing a dramatic economic and social transformation. In the last two decades, the ‘doi
moi’ (renovation) process led to considerable improvements in overall well being, with more
than 7 % GDP per capita annual growth rate. The transition of the health care system contributes positively to the health status of the population. Despite being a low-income country,
vital health indicators of Viet Nam are comparable to those of middle-income countries. In
terms of life expectancy adjusted for years lost to disabilities, Viet Nam ranks 116 among 191
members of the World Health Organization (WHO) - not very different from much wealthier
countries such as Greece and Brazil (World Bank 2004).
Although Viet Nam has recently been considered as one of the most successful countries
in poverty reduction, there is still 24 % of its
population living under the poverty line (at the
end of 2004), many people still live just above
the poverty line31 and the risk of falling back
into poverty remains high. In addition to the
Hunger Eradication and Poverty Reduction
program and program 13532, a number of
measures have been applied to ensure health
care for the poor. Equity, efficiency and development are the objectives that have been
identified by the Party and the Government
for the health care system in the strategies of
health care of the population into 2010.
Viet Nam – Basic data of 2005
Population: 83 million
Estimated growth rate: 8.4%
Estimated GDP/capita: 620 US$,
PPP: 3000 US$/capita
Total GDP: 51 billion US$
Life expectancy: 71 years
Maternal mortality ratio to below 70/
100 000live births
IMR <25/1000 live births
Under-five MR <32/1000 live births
Reforms in financing health care have been considered as the backbone policy to
achieve equity in access to health care. Social Health Insurance (SHI) implementation has
been the most important policy among the health financing reforms. Other notable health
sector reforms are the introduction of user charges, the public-private mix of provision and
the opening up of the pharmaceutical market. There is broad consensus in the country that
achievement of universal SHI coverage appears to be the best way towards equity, efficiency
and development. But how can SHI cover the poor and the near poor in a developing country
like Viet Nam? Why did Viet Nam shift from other protection mechanisms to SHI policy for the
poor? What are complementary health policies to health insurance for the poor? Is SHI appropriate for the poor in every condition? Those issues will be presented in this paper.
Development of SHI in Viet Nam
SHI was introduced quite early in the renovation process in Viet Nam. Being aware of the
importance of accessibility to health care services for those who cannot afford to pay user
fees at health facilities, the Government has piloted social health insurance schemes since
1989. The first Decree on SHI regulation was promulgated 3 years later, in 1992. At the end
of 2004, more than 18 million people were covered by SHI schemes, including 3.9 million
30
Health Strategy and Policy Institute, Hanoi, Viet Nam, [email protected].
Using in both cases the Viet Nam poverty line, which is different for the WB poverty line.
32
The national program HEPR was launched in 1998, providing poor households with a range of benefits, including exemption of school fees, health care cards, access to subsidised credit, exemption from compulsory public
work, exemption from agriculture tax and other contributions and food provision between harvest seasons. Program 135 provided poor communes with a resource allocation that they most often use to invest in a local infrastructure project, including roads, health centres, schools, irrigation systems, water supply systems, etc.
31
T. Van Tien: The Inclusion of the Poor in Social Health Insurance Framework in Viet Nam
64
poor citizens. According to the new Decree on SHI in 2005, approximately 20 million poor
people are eligible to become SHI beneficiaries.
Current SHI Coverage
The new SHI regulation (effective since July 1, 2005) continues applying compulsory coverage for all active and retired workers in the public and salaried workers in the private sectors,
regardless of the size of the private enterprises. In addition, very old age people (90 years
and older), foreign students, dioxin victims and especially the poor are newly eligible enrolees of the compulsory scheme. Other affiliates of mandatory health insurance are the
members of socially protected groups, such as revolution merit people, heroes, veteran invalids etc (see box 2.3.1).
Box 2.3.1. Eligibility of the SHI compulsory (according to the 2005 regulation)
Employees in the formal sector, civil servants
Pensioners, very old age people (90 years), disable old people;
Special social groups (veteran-invalids, revolution merit people, revolution prisoners, heroes, dioxin victims …)
The poor (from 2003);
Foreign students (having government fellowships).
The current contribution rate is 3 % of their salary for salaried workers (employees pay 1 %
and employers 2 %). The contribution rate of those who cannot count on a regular income is
fixed at 3 % of the national minimum salary and paid from the state budget. The temporary
contribution of the poor is subsidised by the Heath Care Fund for the Poor and amounts to
50.000 VND (€2.4).
Table 2.3.1: Number of SHI members in the last 5 years (2000 – 2004)
Number of SHI members (in millions)
Year
Voluntary
scheme
Compulsory
scheme
The poor
Total
Percentage
of total
population
2000
6.469
3.089
0.841
10.399
13.4
2001
6.979
3,089
1.488
11.556
15.8
2002
6.977
4.393
1.655
13.025
16.5
2003
8.124
4.847
3.253
16.224
20.0
2004
8.142
6.245
3.889
18.276
22.2
Source: The Viet Nam Social Security Agency
While compliance in the public sector is nearly 100%, the coverage in the private sector, particularly in small sized enterprises, is low, amounting to about 20%. The major reasons of low
compliance in the private sector include: instability of private companies, problems of registration and weak enforcement measures. However, the SHI coverage has been continuously
increasing duringthe last five years asshown in Table 2.3.1 describing the trend of coverage.
In addition to the compulsory schemes for the above-mentioned eligible groups, the Viet
Nam Social Insurance Agency encourages the remaining population to enrol in voluntary
schemes. The voluntary health insurance for pupils is the largest scheme; it has been operating since 1995 and covers more than 5 million persons or 25 % of all students and schoolchildren in Viet Nam. There are also some minor schemes covering farmers and members of
local mass organisations (such as the Women’s Union, veterans, etc.).
Extending Social Protection in Health
65
Figure 2.3.1: HI Membership in 2000- 2004 (x 1.000.000)
25
20
20
15
10
5
0
3,254
0,841
1,214
1,665
2000
2001
2002
2003
3,889
2004
2006 (est)
Benefit package
Although the contribution rate of the SHI schemes is quite low (see Table 2.3.3), the benefit
package includes outpatient and inpatient services at all levels of health care, laboratory exams, x–ray and other diagnostic imaging procedures, as well as drugs listed as reimbursable. The health insurance fund covers even expensive high tech services, e.g. MRI,
haemodialysis, and open-heart surgery. Insured patients are eligible not only for health care
provided at public health facilities, but also in private facilities that have contracts with the
health insurance agency.
Table 2.3.2: Annual premium of SHI schemes (in € per capita)
Year
2000
2001
2002
2003
2004
Compulsory
7,2
8
8,4
11,2
11,6
The poor33
1,6
1,6
1,6
1,6
2,8
Source: Calculation by the author based on data of Viet Nam Social Security Agency.
Utilisation of health care services: While members of the compulsory schemes make on average 2.6 visits to health facilities per year, the frequency of health facility visits by the poor
was only 1.06. However, the poor have increased the utilisation rate of outpatient services
since 2000, when the number of visits per capita was only 0.55. The low health care utilisation by the poor might be attributable to a lack of awareness of the benefits of SHI at the beginning and/or to other barriers in access to health care for the poor, such as unofficial payments and the opportunity costs of health care.
Table 2.3.3: Number of visits to health clinics per capita in 2000 – 2004
SHI scheme
2000
2001
2002
2003
2004
Compulsory
2,04
2,21
2,28
2,28
2,6
The poor33
0,55
0,64
0,74
0,75
1,03
Voluntary
0,4
0,44
0,44
0,5
0,61
33
The SHI scheme for the poor has become compulsory since July 2005.
66
T. Van Tien: The Inclusion of the Poor in Social Health Insurance Framework in Viet Nam
Research on utilisation of inpatient services of people enrolled to the various SHI schemes
also shows similar results (see Table 2.3.4). The hospitalisation rate of the poor was only
one third that of compulsory scheme members. The poor faced greater constraints in using
hospital care that used to cause higher opportunity costs; thus, the poor are facing higher
and often too expensive out-of-pocket payments for inpatient care. All these issues should be
taken into consideration when discussing the development of health care policy for the poor
in Viet Nam.
Table 2.3.4: Number of hospitalisation per 100 SHI members in 2000 – 2004
Number of hospital admission per 100 members per year
2000
2001
2002
2003
2004
Compulsory scheme
16
18
17
16
17
Scheme for the poor
5
6
5
5
6
Voluntary scheme
4
6
6
5
5
Inventory of Health Care Polices for the Poor in Viet Nam
Health protection for the poor was one of the priority tasks for the government of Viet Nam,
and different policy instruments have been used to achieve that. Policies on health care for
the poor in Viet Nam are complementary to each other and can be divided into three categories: (i) to cope with common health problems of the poor; (ii) to improve access of the poor
to basic health care services, and (iii) to reduce the burden of health expenditure for the
poor. Inclusion of the poor in the SHI framework as one of the mechanisms to protect the
health of the poor has been applied in recent years. The health insurance scheme for the
poor in combination with the Health Care Fund for the Poor has proved to be an effective
mechanism.
Policies to cope with common health problems of the poor
Infectious diseases and malnutrition have been the most common health problems of the
poor. For decades, a series of national public health programs has been implemented and
has successfully prevented many contagious diseases such as TB, leprosy, malaria, dengue
fever, cholera, dysentery, typhus, HIV/AIDS and recently SARS and bird flu H5N1. The national health programs have achieved high efficiency. While in the first years of the 1990s,
thousands died from malaria, there were only 190 deaths and 50 deaths due to malaria in
1999 and 2003, respectively. Leprosy and polio have been eradicated. The whole population,
particularly the poor and people living in disadvantaged areas have benefited from these
public health programs.
Policies to improve access of the poor to basic health care services
Viet Nam has developed a health care network covering the whole population from urban to
rural areas, fulfilling one of the Vietnamese health policy targets pursued since the 1950s.
The current health facility network reaches the most remote and disadvantaged areas, enabling effective implementation of national health programs and basic health care services.
Before the ‘Doi moi’-period, the grassroots level of primary health had deteriorated seriously
due to the economic crisis. To sustain the health care network, a series of policies and
measures was put into practice. Firstly, the Prime Minister decided to pay the salaries of
health workers at commune health stations as well as village health workers from the state
budget. This measure contributed to restoring the grassroots health care in the middle of the
1990s.
Secondly, the policy of ‘deleting white communes’ (communes that lacked health care stations) was implemented. There were 66 communes without health stations in 1993; however,
Extending Social Protection in Health
67
‘white communes’ no longer existed in 2002.34 Not only has the infrastructure of health posts
been improved and the number of health workers increased, but the capacity of health workers at the community level has also remarkably improved. In 2002, 61.5 % of community
health facilities had a doctor, 91.3 % trained midwives and active health workers are present
in 89.8 % of Vietnamese villages. Implementation of policies that improved primary health
care contributed to improve access to health care for the people, particularly for the poor.
The grassroots level of the health care system played an important role in achieving national
health targets, as 80 % of health services for the poor and people living in remote and disadvantaged areas is provided through primary care level.
Policies to reduce the burden of health expenditure of the poor
A series of measures have been implemented to reduce the health expenditure burden on
the poor, including a) macroeconomic measures such as increasing government health
spending for poor areas, priority in resource allocation for poor areas, development of health
insurance etc., and b) direct subsidisation of the poor, such as provision of meals and transportation for the neediest. The most significant direct support consists of different mechanisms to provide free health care and in user fee exemptions for the poor.
Development of policies on user fee exemption for the poor, different mechanisms and
option of SHI scheme for the poor
The economic crisis in the period before ‘doi moi’ resulted in a serious deterioration of health
care facilities. Due to chronic budget shortages, the health care system was unable to provide basic health care services. The Government had to introduce user fees in public health
facilities in 1989. To support the poor in accessing health care, different mechanisms of user
fee exemptions were implemented. They have been applied officially since 1994 (by Government Decree 95 from 1994) and have undergone various changes over time. From 1999
to 2002, a set of strategies, including poverty booklets (‘so ngheo’), free health cards, community committee certification, health insurance schemes and other forms of exemption have
been used to provide free health care for the poor.
In 2003, the Government established the Health Care Fund for the Poor (HCFP) by Decision
No. 139. Provincial governments used this fund for paying health insurance contributions for
the poor or to reimburse the health facilities directly. SHI for the poor has proved to be the
most appropriate mechanism to protect the most vulnerable groups from high health care
expenditures. Thus, the Government issued a new regulation on social health insurance in
2005 in order to promote the inclusion of the poor in the SHI framework.
Poverty Certification Booklet
Poor households received certification booklets that could be used for different purposes,
such as exemption from school fees, from user fees for health care, for credit loan, etc. According to the regulation, the health care expenditure of the exempted patients was to be
covered by the regular health budget of health facilities, but it was not stated where health
facilities could get the financial resources needed to cover the health expenditure of the poor.
Therefore, the level of exemption was dependent on the local government’s financial capacity. Additionally, the identification of entitled beneficiaries was difficult to achieve. And, even
for those people that had received a poverty certification booklet, access to health care remained limited for many poor households Patients with a poverty booklet without funding
resources were not welcome at some hospitals.
Free Health Insurance for the Poor and Social Protection Fund
In 1999, a new inter-ministerial circular partially resolved the above-mentioned funding problem and represented an important step on the way towards user fee exemption mechanisms
for the poor. The budget to cover the health insurance contribution of 30,000 VND/person/
34
There were 10.732 communes in Viet Nam on April 1, 2004.
68
T. Van Tien: The Inclusion of the Poor in Social Health Insurance Framework in Viet Nam
year (US$2) for the poor was allocated from the social protection fund on the provincial level.
Due to the limited funding, only the poorest were exempted from user fees: Only households
classified as “hungry” and 30% of the poorest were given free health insurance cards or
health cards.
The Provincial Bureaus of Labour, Invalids and Social Affairs were responsible for preparing
the lists of the poor, and provincial Social Health Insurance Agencies issued health insurance
cards. The health benefit package included direct health expenditure of outpatient and inpatient care. Public health facilities provided the holders of the health cards with health care
services and requested provincial authorities to reimburse the expenses. Provincial governments were free to choose the HI scheme or the health card scheme for implementation. In
addition, directors of health facilities could also approve user fee exemption for the poor who
did not have health insurance cards, but could submit recommendation or certification letter
from Commune People’s Committees. At health facilities, qualification for exemption was
based sometime only on the appearance of the poor.
At the end of 2000, the health insurance and the health card scheme for the poor were implemented in 45/61 provinces (74 %), covering 1.4 million poor people, which accounted for
one third of the total 4.5 million eligible poor people. The 2002 Living Standard Survey shows
that 29.3 % of the poor households were given health insurance cards and health cards. The
percentage of coverage was lower in the Central Highlands and Northeastern mountainous
provinces (13.9 % and 17,4 % respectively).
According to the National Health Survey 2002, the utilisation rate of health insurance cards of
the poor was 24.6 %. The main reasons for the low utilisation rate are work obligations, distance to public health facilities, convenience of private services, lack of money for transportation and meals, limited quality of care at public health facilities, poor knowledge of the health
insurance benefit package, etc.
The coverage of the poor increased remarkably but there was still a problem of inadequate
funding as provincial social protection funds had to cover many activities in the HEPR program. Another problem was that only 30% of the poor were eligible for exemption and again,
it was not always easy to identify which households were among the 30 % poorest. It was
necessary to have more specific funding for health care for the poor, which could cover all
the poor.
Utilisation of health care services in the poor population who were given free HI cards was
much higher than in the group that were issued health cards. Results of the survey that was
carried out in 2000 in 10 provinces showed that the frequency of visits to outpatient health
facilities in the HI group was 2.016 times higher than in the health card-holder group. Utilisation of inpatient health care was also significantly higher in the HI member group (e.g. in the
Northern provinces, it was 2.46 times higher). The survey also found that there was no difference in health care utilisation between the poor group with health cards and without health
cards. In other words, the HI scheme for the poor has proved to be a better mechanism in
improving access to health care of the poor, in comparison with the health card scheme.
Health Care Fund for the Poor (HCFP) and the Option of SHI Scheme for the Poor
To improve the financial mechanism of user fee exemption for the poor, the Prime Minister
has established the Health Care Fund for the Poor (Decision 139/2002/QDTTg). This decision united all previous mechanisms into one single scheme that provides free health care at
public facilities for all poor people. Beneficiaries of the fund are all poor people (by the
MOLISA poverty criteria),35 residents of communes belonging to the ‘Program 135’ (which
were the most disadvantaged, economically undeveloped communes), ethnic minority people
of the Central Highlands and extra-disadvantaged Northern mountainous provinces.
35
New MOLISA updated criteria of poverty: income of less than 200,000 VND (€ 10.35) per capita per month in
rural areas, and less than 260,000 VND (€ 13,43) per capita per month in urban areas.
Extending Social Protection in Health
69
The current per capita allocation to the HCFP is 70,000 VND (approximately € 3.5). The central government is responsible for funding 75 % and the remaining amount is to be raised by
provincial governments from domestic and other donors. The benefit package includes free
inpatient and outpatient services, laboratory tests, x-ray and drugs on the health insurance
reimbursement list at all levels of the public health system (commune, district, province, central).
The HCFP is administered by Provincial Fund Management Boards (PFMB). From 2003 to
July 1, 2005, PFMB could either purchase health insurance cards from the Viet Nam Social
Security Agency (VSS) for a flat price of 50,000 VND per card or directly reimburse providers
of health services to the beneficiaries. In the latter case, the eligible beneficiaries were given
health cards. The surplus of the fund (20,000 VND/capita that would come from local fund
raising activities) is to be used to subsidise catastrophic health care expenditure of the near
poor.
In 2003, 14.3 million people in Viet Nam were eligible beneficiaries of the HCFP, accounting
for 17.5 % of the total population. The numbers for 2004 were 13.1 million and 15.9 % respectively (table 1). As noted above, with the new, higher poverty line issued by the Ministry
of Labour, Invalids and Social Affairs, it has been estimated that the number of beneficiaries
will increase to 20 million.
Table 2.3.5: Number of beneficiaries of HCFP as percentage of total population in 2003 and
2004 in different areas
Years
North
Red River
North
South
Central
East
Mekong
Mountain
Delta
Central
Central
Highland
South
Delta
Provinces Provinces Provinces Provinces Provinces Provinces Provinces
Total
2003
33,3
6,4
21,5
12,5
41,1
8,0
14,7
17,5
2004
32,9
5,1
18,9
12,9
37,7
8,2
11,6
15,9
The HCFP had revenues of 520.6 billion VND (€ 26.9 million) in 2003 and 717.7 billion VND
(€ 37.616 million) in 2004. The spending rate of the fund was low: 58.2 % of the fund in 2003
and 66 % in 2004. Explanations for the low spending of the fund are the following: the poor
did not have enough information about the policy; low utilisation rate of health care; low user
fees and ceiling on reimbursement from the social security agency and the poor used health
services mainly at the grassroots level of the health care system.
Although the HCFP has been operating for a short period (since 2003), there is already consensus on moving from dual mechanisms (HI cards and health cards) to only one mechanism, and that is the SHI scheme for the poor. The following are the justifications:
Inclusion of the poor in SHI can take full advantage of existing SHI agency in administration of the scheme, in financial management of the HSFP;
Provincial authorities don’t need to recruit more human resources to manage the
health care fund for the poor;
Health providers can save paper work by contracting only with SHI agency;
The poor can benefit from comprehensive benefit package designed for health insurance members; and
Inclusion of the poor in the SHI system is in line with the current government strategy
and vision of SHI universal coverage.
The establishment of HCFP was a milestone in health care policy for the poor. HCFP enabled financial support for more poor people and with a higher level of support. The volume
of funding and allocation of the fund for health care of the poor became much more secured.
The inclusion of the poor in the SHI system represents a further step in the improvement of
protection from health expenditures for the poor.
70
T. Van Tien: The Inclusion of the Poor in Social Health Insurance Framework in Viet Nam
Inclusion of the Poor in the Compulsory SHI Scheme and Future Trends
According to the new regulation on social health insurance that came into effect on July 1,
2005 all the poor are eligible for membership in the social health insurance scheme. The
health insurance premium of the poor remains unchanged (50.000 VND/capita/year) and is
covered by the HCFP. By this decision, about 20 million poor people are eligible for compulsory SHI membership, adding to the current 18 million HI members. Currently, the government is considering increasing the per capita contribution for the poor and the option of SHI
for children under 6 years old.
To increase the quality of health care and satisfy the growing number of SHI members, the
Government also decided to implement a project on upgrading more than 600 district hospitals and other components of the primary health care network. The reform of hospital management continues to be on the policy agenda of the government. The economic transition
and health transition, as well as new diseases and infections such as SARS and avian flu,
create more and more new challenges for Viet Nam’s health care system. Viet Nam is trying
to develop its policies and strategies based on more evidence and we are aware of our
needs in improving our current policies. There are many issues that need further studies,
such as catastrophic health expenditure, sustainability of SHI membership for those people
who escaped from poverty, as well as capacity of the state budget in subsidising higher SHI
contribution of the poor etc. We appreciate experiences from other developing countries to
promote equity in access to services and improve the quality of health care for the whole
population.
References
Axelson, Henrik; Cuong, Dam Viet; Phuong, Nguyen Khanh; Mai Oanh, Tran Thi et al. (2005). The
impact of the health care fund for the poor on poor households in two provinces in Viet Nam. Paper
submitted to the Global Forum for Health Research, Forum 9, Mumbai, India, 12-16 September 2005
(http://www.globalforumhealth.org/filesupld/forum9/CD%20Forum%209/papers/Axelson%20H.pdf).
Tuan Đuc, Duong (2005). Study on disease structure and health expenditure of the insured patients in
Hanoi 2004. MPH Thesis, The Hanoi School of Public Health, Hanoi.
Nhat Tan, Pham Đo (n.y.). Social Security Policy: Current situation and future trends, Website of Ministry of Labour, Invalids and Social Affairs (http://www.molisa.gov.vn).
Tinh, Luu Viet (2005). Determinants of purchase and utilisation of household health insurance scheme
in the Thịnh Hưng commune, Yên Bình District, Yên Bái Province. MPH Thesis, The Hanoi School of
Public Health, Hanoi.
Government of Viet Nam (2002). Prime Minister’s Decision No. 139/2002/QĐ-TTg on health care for
the Poor. Hanoi.
Government of Viet Nam (2005). Decree No. 58/1998/NĐ-CP and N. 63/2005/NĐ-CP on Health Insurance Regulation.
The Viet Nam Ministry of Health (2004). Health Statistics Yearbook 2004. Hanoi.
The Viet Nam Ministry of Health (2002). Vietnam Health Report 2002. Hanoi.
The Viet Nam Ministry of Health (2004). National Health Accounts. MoH/WHO, Hanoi,
(http://www.wpro.who.int/NR/rdonlyres/7A81DB31-4899-42CA-98353281C799DEA0/0/vtn_hdb.pdf#search=%22%22National%20health%20account%22%20Vietnam%20
%22Ministry%20of%20Health%22%22).
The Viet Nam Health Insurance Agency (2002). Health Insurance Statistics Book 1992-2002. Hanoi
Tien, Tran Van (2005). The Overview of the Social Health Insurance Development in Viet Nam. The
RHINCAV Workshop, Hanoi.
World Bank (2004). Vietnam Development Report 2005 (VDR 2005): Governance. Prepared for the
Vietnam Consultative Group Meeting December 1-2, 2004, Hanoi.
World Health Organization (2005) Country Health Information Profile. Viet Nam. Health Databank,
2005 Revision. WHO/WPRH, Manila (http://www.wpro.who.int/NR/rdonlyres/7A81DB31-4899-42CA9835-3281C799DEA0/0/vtn_hdb.pdf).
Extending Social Protection in Health
71
2.7. Insuring the Very Poor against Health Risks in the Philippines
Claude Bodart36, Matthew Jowett37
Introduction
The Philippines is a lower middle-income country with a per capita income of € 4.207 (in
2002) with significant regional and urban-rural inequalities (Gini-coefficient 0.46 in 2004
(World Bank 2004, p. 259). Total health expenditure represented 2.9 % of GDP in 2003 with
44 % out-of-pocket payments and 9.41 % covered by Social Health Insurance (2003). 24.7 %
of the population is considered poor (NSCB 2003). Infant and maternal mortality are 29 per
1,000 live-births and 172 per 100,000 live-births respectively, reflecting a high poverty level,
wide inequalities in the country, and poor access to health care.
The country is highly decentralised with administrative and financial autonomy given to 79
provinces, 118 cities and 1,492 municipalities. In this context, the Philippine Health Insurance
Corporation (PhilHealth), a government corporation created in 1995, provides coverage to
53.9M or 63 % of the Philippine population (September 2005). The enrolment of the very
poor into PhilHealth is initiated by local governments, which are responsible for their identification. The local government pays its share of the annual premium of Pesos 1,200,38 which
varies according to their class39 and the number of years the local government has been participating in the program. It can be as low as 10 % for the poorest local governments. The
remainder of the contribution is paid to PhilHealth by the central government. Hospital benefits are the same for those enrolled including indigents (those considered very poor, without
any means). The latter are additionally entitled to an Outpatient Consultation and Diagnostic
Package (OCDP) in accredited public facilities at the primary level.
PhilHealth’s performance in insuring indigents
PhilHealth “sells” social health insurance for the very poor to local governments who have to
allocate part of their budget to enrol their constituents identified as poor. The Indigent Program of PhilHealth started in 1997 and the number of participating local government has increased gradually. As of September 2005, 98 % of cities, 92 % of municipalities and 86 % of
provinces are participating. The number of beneficiaries has increased gradually over the
years to reach over 30 million by the end of 2004 after a massive enrolment campaign leading up to the 2004 Presidential elections (Plan 5M). In August 2005, almost 12 million beneficiaries were covered. The premium contribution for this massive enrolment was funded entirely by central government (through the charity sweepstakes office). Whilst controversial,
the programme was successful in increasing coverage and in highlighting social health insurance for the poor as a vote-winning strategy.
Fund utilisation amongst the different membership categories - from January to September
2005 - shows that collection exceeded benefits payments for all except for those in the indigent programme. Hence, the very poor are effectively cross-subsidised by other sectors.
Benefit utilisation is highest for pensioners (non-paying members) at 20 %, followed by government beneficiaries (3 %), the very poor (2.5 %), individually paying and private sector
beneficiaries at 1.6 %. Average financial protection (the proportion of the total cost of care
covered by PhilHealth) shows that on average 88 % of the hospital bill is covered in public
facilities, falling to 53 % in private hospitals. These figures do not include payments made
outside of the hospital. A study covering 937 hospitalised children under the age of six,
where expenses outside the hospital were recorded, shows financial protection to be 53 %,
which is probably closer to reality.
36
GTZ Program Manager, German support to the Philippine Health Sector, Manila, [email protected].
GTZ advisor to the Philippines Health Insurance Corporation, Manila, [email protected].
38
Exchange rate on November 15, 2005: Php. 63,78 = EUR 1.
39
The class of an LGU depends on their total income, rather than the degree of poverty.
37
72
Cl. Bodart, M. Jowett: Insuring the Very Poor against Health Risks in the Philippines
Two main issues of Social Health Insurance in the Philippines
This review of PhilHealth’s performance points to two main issues that threaten the program
for the indigents:
(i) The enrolment of the very poor by government is NOT mandatory. The decision to enrol
its poor constituents is entirely left to the local government and they may decide to prioritise other activities. Although the Indigent Program is gaining popularity amongst Local
Governments, PhilHealth still devotes much time and resources to marketing and administering the program, which in turn results in high transaction costs. The very poor are not
necessarily enrolled in a continuous manner i.e. the priority of local government may
change or there may be administrative delays which break the terms of the agreement
between PhilHealth and the Local Government.
(ii) Low financial protection constitutes an important barrier to accessing health care, especially for the very poor who require hospital services. In many cases, the current benefits
package does not provide adequate coverage for catastrophic medical expenses, as a
result of the low benefit ceiling. The absence of fee regulation, coupled with the fee-forservice approach to paying providers, often results in excessive financial costs falling to
the patient. Social health risk pooling is still far from being reached and the patient, not
PhilHealth, ends up bearing the risk associated with increased fees and volume when
providers are able to extract profit out of insurance benefits.
Vietnam – Philippines: Different paths leading to Rome!
Since the mid 1990s, both countries have started specific programs to increase access to
health care for the poor. In 2002, while Vietnam was still testing the best way to protect the
poor financially from the risk of ill health, the Philippines was accelerating the enrolment of
the poor into social health insurance. After reviewing the health care policy for the poor in
2004 and acknowledging the advantages of social health insurance, Vietnam decided to include all the poor in the national health insurance programme. The Philippines has introduced both temporary and long-term fiscal measures that give central government a wider
responsibility in funding social health insurance for the poor (Plan 5M; sin taxes, E-VAT).
In conclusion, both countries have chosen social health insurance as the way to protect the
poor from ill health. It looks like the Philippines are experimenting with measures to allocate
funds from the central government to enrol the very poor directly as a way to increase the
sustainability of the indigent program. Both countries are slowly converging with respect to
how they want to achieve financial protection for the poor resulting from ill health.
References
Akhal, Afsar (2004). Social Health Insurance Development in Vietnam: A Quick Country Assessment.
World Health Organization. Hanoi, Vietnam.
Kwon, Soonman (2005). Strengthening Financial Protection for PhilHealth Members’ Commissioned
by GTZ.
Obermann, Konrad; Jowett, Mathew; Alcantara, María O.; Banzon, Eduardo; Bodart, Claude (2006).
Social health insurance in a developing country: The case of the Philippines. Soc Sc & Med 62 (12),
pp. 3177-318.
Philippine Health Insurance Corporation (2004). Annual Report 2004. Manila.
Philippine Health Insurance Corporation (2005). Stats and Charts 2005. Corporate Planning Department. Manila, Philippines.
World Bank (2004). A Better Investment Climate for Everyone. World Development Report 2005.
World Bank, Washington DC
(http://siteresources.worldbank.org/INTWDR2005/Resources/complete_report.pdf).
Extending Social Protection in Health
73
2.8. Reaching the Poor in Ghana with National Health Insurance – An Experience from the Districts of the Eastern Region of Ghana
Ebenezer Appiah-Denkyira40, Alex Preker41
Abstract
The National Health Insurance scheme in Ghana is a mixture of Social and Mutual Health
Insurance. It focuses on the poor and corresponds to the Ghana Poverty Relief Strategy. The
unique feature is that it is compulsory for all and exempts paupers, dependant children under
18 years covered through insured adults, as well as the elderly above 70 years. Management
is decentralised to the district level within a national co-ordinated framework. The National
Health Insurance Scheme is financed from taxes, flat-rate contributions paid by informal sector workers (minimum Ghana Cedi (GHC) 72,000 = € 6,73 or US$ 8), payroll deductions as a
part of the overall contributions to the Social Security and National Insurance Trust paid by
formal sector employees, and a special National Health Insurance Levy over goods and services. The benefit package covers 95 % of the disease burden and takes on board both outpatient and inpatient services.
After one year of operation, the overall population coverage in the country is over 10 % with
some districts covering more than 50 %. All the 138 districts, however, are at various stages
of establishment, with 83 in full operation. The mixed membership from both the formal and
informal sector as well as the universality of its coverage is meant to provide a spirit of belongingness, solidarity and social responsibility. Though pro-poor, the major challenges the
scheme is currently facing that of low enrolment, management of risks at the local level and
sustainability of the whole program.
Background
Ghana has a population of 20.1 million (census 2000), zoned into 138 political districts. The
GNP is about € 320 with about 44 % of the population below the poverty line of GHC
700,000/ year42. The country recently came out of the Highly Indebted Poor Country initiative
(HPIC) when it reached the completion point.
Ghana’s effort at making health care pro-poor has been a long one. At independence in
1957, user fees in government health facilities were abolished in all public health facilities
throughout the country. With increase in population and worsening economic conditions in
the course of time, financing health services became an onerous burden. This resulted in the
introduction of user fees through a cost sharing mechanism at all public health facilities with
the enactment of Hospital Fees decree (NLCD 360), later amended to hospital Fees Act
(3870 of 1970). In 1985 however, a full cost recovery for drugs was introduced with PNDC
law LI 1313 and popularly known as ‘cash and carry’ This law also provides exemptions to
paupers, health workers and during conditions of public health significance such as epidemics, tuberculosis, leprosy immunisations and psychiatric ailments (Nyonator/Kutzin 1999).
To alleviate the burden of the poor, further exemptions were provided for other categories of
vulnerable groups. These included children under five years, people aged above 70years,
paupers and antenatal mothers (Nyonator 2005). There was agitation for the inclusion of
more categories, and the latest addition was deliveries in 2003, starting from the four most
deprived regions in the country in line with the Ghana Poverty Reduction Strategy (GPRS),
and the health sector’s 5-year Program of Works which has the objective of bridging the inequalities in health between regions. Though this facility was extended to six other regions in
40
Director of Health Services, Eastern Region, Ghana, [email protected].
Senior Health Economist, Human Development Department, World Bank, Washington DC,
[email protected].
42
In December 2005, 1 CGH was equivalent to 0.00009330 Euro (€) or 0.0001105 US$; CGH 10,720 = 1 €, and
CGH 9,050 = 1 US$.
41
74
E. Appiah-Denkyira, A. Preker: Reaching the Poor in Ghana with National Health Insurance
2004, the venture proved unsustainable as refunds become erratic and left a number of
health facilities in debt (Appiah-Denkyira et al. 2005).
The obvious option for government was therefore to adopt and speed up its campaign promise of abolishing the ‘cash and carry’ and introducing an alternative health financing strategy
such as a National Health Insurance, that will not only support the poor, but will also be sustainable. This paper focuses on Ghana’s attempt at establishing a National Health Insurance
that has a focus on the poor, and uses one of its regions to illustrate the details.
Evolution of health financing in Ghana
Previous attempts at formal health insurance is documented: a private insurance established
by the private clinic (Vanguard Assurance) which collapsed because of poor management,
and facility faith based Health insurance schemes such as those at Nkoranza and West Gonja Districts which were for admission only. The health programme
for civil servants in the Ashanti
Region for the formal sector and
the Dangbe West district community health insurance were
the first to cover both out patient
and in-patient services (Agyapong 2003). By close of 2001,
registered mutual health organisations (MHOs) have proliferated
from two to 47 (barely two years
ago) with many more, especially
in the informal sector using traditional systems such as welfare,
Susu, etc being formed almost in
every community and evolving into a mutual health schemes (Atim et al. 2001). These received great support from the donor communities such as DANIDA, PHR+ and ILO.
Following the political campaign promise of 2000 to abolish ‘cash and carry’, the National
Patriotic Party, upon attaining power, ushered in the District-wide National Health Insurance,
affirmed by Act 650 of parliament in 2001, to the strong resentment of most donors who are
already supporting MHOs.
Aims and Objectives
The aim of the health insurance scheme in Ghana is to enable the government achieve its
set goal within the context of the Ghana Poverty Reduction Strategy and the Health sector
Five Year program of Work, 2002-2006.
Specifically, it is to provide a more humane and a sustainable health financial mechanism
that focuses on the poor. To this end, a policy document was developed with the object of
providing accessible, affordable and good quality service to all people living in Ghana and
especially the poor and the most vulnerable in society.
Policy
The policy makes it compulsory for residents in Ghana to belong to a scheme and hopes to
achieve 10 % in the first year rising to 30 % within five years and 50 % within 10 years. Two
main types of health insurance region are described the social type health insurance made
up of District Mutual Health Insurance Scheme (DMHIS) and the Private Mutual Health Insurance Scheme; and Private Health Insurance Scheme (MoH 2004).
Government has elected to support the DMHIS to serve as a strategy to deliver its pro poor
policy to the underprivileged segment of the society. The DHMIS is therefore a fusion of two
concepts - the traditional Social Insurance Scheme for the formal sector workers and the
Extending Social Protection in Health
75
traditional mutual health organisation for the informal sector of the society. The mixed membership from both sides as well as the universality of its coverage is meant to provide a spirit
of belongingness, solidarity and social responsibility.
Design principle
The unique design of the DHMIS is based on the principles of equity, risk equalisation, cross
subsidisation, solidarity, quality care, efficiency in premium collection, community or subscriber ownership, partnership, reinsurance, and sustainability. It is meant to be district- wide,
managed locally by management teams and supported by a governing board to bring about
best managerial practices, good governance and democracy.
The schemes will all be regulated by a National Health Insurance Council, a body formed
under Act 650 to register, license and regulate health insurance schemes, and to accredit
and monitor health care providers (public and private) operating under the scheme. This
body is also responsible for the management of the National Health Insurance Funds into
which the levy is deposited.
Benefit Package and providers
The policy adopts a minimum benefit package covering most common disease in Ghana or
about 95 % of the burden of disease, and forms the basic health services provided at primary
and secondary levels. All health providers will have to meet the accreditation criteria to enable them to offer services - however public and mission health providers have been given
an initial accreditation. Private health insurance companies are encouraged to provide cover
for the exclusions of the DHMIS.
Financing mechanism
The health insurance is financed by the contributions from taxes (consolidated fund) by way
of subsidy to health sector facilities, general levy and contributions from both the formal and
informal sector. The formal sector contributes 2.5 % of their 17.5 % Social Security and National Insurance Trust (SSNIT) contribution, whilst the
informal sector contributes at least GHC 72,000 (€ 6.73)
per person per year. The public are encouraged to pay
according to their ability hence a classification into core
poor, very poor, poor, middle income, rich and very rich.
The exempted categories are – dependants under 18
years of age of paid up members, indigenes and those
aged beyond 70 years.
A government National Health Insurance Levy of 2.5 %
on selected goods and services, together with the others
are pooled into a National Health Insurance Fund which is used to subsidise the premium of
the under privileged, pay the premium of the core poor and other vulnerable groups, as well
as serving as reinsurance and support fund for start up of the schemes in the districts.
Experience from the Eastern region
The Eastern Region with a population of 2.1 million is one of the 10 regions in Ghana. 50%
of the population is 18 years or below whilst those above 70 years form 3 %. Poverty is rife
and 44 % of the population earn below GHC 700,000/ annum (€ 65). The region is 70 % rural; the terrain in mountainous areas is difficult and there are island communities created by
the Volta Lake. The main occupations are farming and trading.
Structure of the District Mutual health Insurance Scheme
All 15 districts in the region operate a district wide Health Insurance Scheme. The schemes
are manned by five to six member management teams supported by locally constituted
boards of directors. At the community level are Health Insurance Committees constituted by
E. Appiah-Denkyira, A. Preker: Reaching the Poor in Ghana with National Health Insurance
76
subscribers in the community who supervise the dues collectors. District Health Assembly
made up of representatives of subscribers hold half-year meetings to review progress.
Process
The National Health Insurance Council sent out seed capital to the 15 District Assemblies for
the establishment of the scheme. This included acquiring and furnishing District Mutual
Health offices, recruitment and training of staff which includes management team, board
members, coding of houses as well as paying for technical assistance. NGOs such as
DANIDA, PHR+ and the ILO provided free technical and material support to the schemes
using Regional task teams as the supervisors and champions. The support they provided for
the establishment and functioning of Regional and National Associations of Mutual Health
Organisations (MHOs) provided a forum for sharing experiences, updating the schemes and
engaging the providers. To a large extent, this helped in getting smaller MHOs fused into the
government funded district-wide schemes.
Achievements
By September 2005, all the 138 districts in the country were at various stages of setting up
the scheme with 83 districts fully operational. The total enrolment was 2,900,000 (14.42 % of
the population), well above the target of 10 %. In the Eastern Region all 15 districts were
operational with a total coverage of 361,949 (16.25 %) as at September 2005 (table 2.8.1).
The numbers could have been greater but for the misconception of the idea and the dismissal of the scheme by some politicians, especially in the rural areas, as a fruitless venture.
Table 2.8.1: Implementation Status of District-Wide MHOs - Eastern Region Oct. 2005
Name of
District
District Dues per Paid
populaAdult
up
tion
adults
Kwahu South
226,74
Afram Plains
≤ 18
years
indi- ≥ 70
SSNIT
gents years Pensioners
SSNIT
Total
Total amount
mem'ship
collected
for Ben.
(GHC)
80,000 24,159
34,966
188
6,222
210
4,568
70,313 1,600,000,000
148,412
72,000
7,595
17,057
127
1,301
1
1,108
27,189
Kwaebibirem
186,842
72,000 12,875
23,054
364
2,115
24
3,28
Asuogyaman
103,1
84,000
898
30,76
558
9,75
4,722
12,347
59,035
75,000,000
Akuapem
North
109,215
77,000
4,348
6,092
89
1,972
242
2,832
14,548
235,512,000
S-K-C
173,562
72,000
2,543
5,492
465
1,347
65
1,672
12,37
182,000,000
New Juaben
146,612
100,000
5,451
7,4
97
2,04
606
5,169
20,763
547,000,000
Manya Krobo
160,783
100,000
2,13
12,386 1,336
1,736
406
5,056
23,05
191,700,000
Fanteakwa
89,823
77,000
2,15
4,706
58
1,198
114
1,841
10,067
173,558,440
West Akim
160,227
77,000
1,924
3,961
32
921
52
2,191
9,081
131,299,000
East Akim
198,454
80,000
6,458
11,606
63
2,181
252
2,976
23,536
373,120,000
Birim North
Akuapem
South
127,41
77,000
5,89
11,497
31
886
39
1,389
19,732
382,000,000
121,299
77,000
2071
6653
182
1,09
117
3,003
13,116
149,251,000
Birim South
184,576
72,000
3,763
8,107
37
1,476
290
5,284
18,957
245,582,000
Yilo Krobo
89,708
80,000
1,169
3,422
533
349
156
1,502
7,131
62,024,000
4,16 34,584
7,296
54,218
Total
Percentage
2,226,780
83,424 187,159
22.495 50.468 1.122 9.325
1.967
14.62
547,000,000
41,712 1,009,228,000
370,841 5,904,274,440
Regional
16.64
Extending Social Protection in Health
77
Table 2.8.1 reveals that out of the total registered, fully paid up members constituted 22.61 %,
whilst the formal sector employees were 14.83 %. The majority (62.56 %) constituted the
exempted categories. Enrolment ranges from 57 % in Asuogyaman District to 6 % in Yilo
Krobo district. Registration of indigenous in the region falls within the 1.5 % ceiling provided
in the national guideline (figure 2.8.1). Districts such as Asuogyaman and Kwahu South that
has high coverage have a year round registration with premiums collected in instalment and
sometimes in kind if arrangement can be made for marketing of products.
59.035
7.131
16.357
13.116
19.732
20.763
29.727
9.081
23.050
12.370
18.957
41.712
23.536
50000
86154
100000
10.067
103100
109215
121299
127410
146618
148412
160227
160783
173562
184576
150000
70313
DISTRICT POPULATION
200000
186842
198454
250000
89708
226748
Figure 2.8.1: District Population against Registered Members by each District, November 2005
Eastern Region
DISTRICT POPULATION
Fa
nt
ea
kw
a
Kr
ob
o
Yi
lo
N
or
th
As
uo
gy
am
an
So
ut
h
Ak
ua
pe
m
N
or
th
Ak
ua
pe
m
DISTRICTS
Bi
rim
Ju
ab
en
N
ew
Pl
ai
ns
Af
ra
m
W
es
tA
ki
m
Kr
ob
o
SKC
M
an
ya
Kw
ah
u
So
ut
h/
W
es
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t
st
Ak
im
/A
tiw
a
Kw
ae
bi
bi
re
m
Bi
rim
So
ut
h
0
POPULATION COVERED
Figure 2.8.2: Percentage of Various Categories of Registered Members
Percentage of Various Categories of Members, Eastern Region
Nov. 2005
60
50.31
Percentage
50
40
30
22.30
20
14.50
9,47
10
1,94
0
Under 18 Years
Paid Up Adults
70 and Above
SSNIT Contributors
Category
SSNIT Pensioners
1,11
Indigents
E. Appiah-Denkyira, A. Preker: Reaching the Poor in Ghana with National Health Insurance
78
Use of Facility
There was quite a remarkable increase in utilisation of services after the six months grace
period allowed after payment (figure 2.8.3). Holy Family and Atibie Hospitals in the Kwahu
South/West District have more insured patients attending clinic than the non-insured, even
though only 31 % of population were insured.
Figure 2.8.3: O.P.D ATTENDANCE (INSURED & NON-INSURED) AT THE VARIOUS HOSPITALS - SEPT. 2005
E/R
10.000
9.000
8.000
ATTENDANCE
7.000
6.000
5.000
4.000
3.000
2.000
1.000
pi
ta
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FACILITIES
Insured
Non-insured
Analysis and Discussions on the district health insurance scheme focus on the poor
Ghana’s attempt at supporting the poor has been a persevering one, judging from the evolution of health financing from the independence era. The current scheme is driven by the political commitment to the Ghana Poverty Reduction Strategy - hence the ‘unrealistic’ design
that the ILO experts find unsustainable.
The design of cross subsidisation and risk pooling is not alien to Ghana which has numerous
local pre-payment or welfare schemes. The low coverage in many areas, such as 6 % in Yilo
Krobo, is not only due to politicisation, misconception of the concept, an attitude of ‘wait and
see’, but also an expression of genuine poverty. This low coverage is not peculiar to Ghana,
in Denmark 10 years after the passage of the Sickness Fund Law in 1901, registration of
people above 15 years stood at approximately 20.6 %. This however increased to76 % by
1951 (Dzikunu/Thorup 2003).
The apparent excessive utilisation at Holy Family Hospital smacks of moral hazards. Whilst
many reasons may be attributed to the increased work load at the OPD, the genuineness of
increased admissions at Holy Family Hospital can not be disputed, and hence underscores
the fact that finance has been a major obstacle to accessibility to health services (figure
2.8.4) (Nyonator/Kutzin 1999).
The wide benefit package without any co-payment was to prompt enrolment and also cover
most diseases that affect the poor. Exclusions in the benefit package provides arena for
complementary private schemes.
The decentralised management, as well as government election to finance only the DMHIS,
facilitated the absorption of most small schemes such as church schemes into the DMHIS
Extending Social Protection in Health
79
and strengthened the local government decentralisation program especially in governance
and exercising of oversight responsibility.
The DMHIS, as a part of the overall Ghana Poverty Reduction Strategy (now Growth and
Poverty Reduction Strategy) and Medium Term Strategy of the Health Sector provides
enough impetus in health reforms to trigger a holistic health development.
Figure 2.8.4: In-Patient Attendance at the Various Hospitals
INPATIENT ATTENDANCE (INSURED &NON-INSURED) AT THE VARIOUS HOSPITALS IN THE
REGION -SEPT. 2005 E/R
1400
1287
1200
756
800
575
554
82
14
32
15
5
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FACILITIES
Insured
Non- insured
Challenges
Five key Challenges to the government are – dealing with the low enrolment and especially
of those who genuinely cannot afford the premium; financial sustainability; local management
capacity; improving access to health care especially to deprived areas and provider motivation to encourage quality health care services. Innovative and practical strategies need be
adopted in a way they improve enrolment. Such strategies could be a year round registration,
premium payment in kind as in Asuogyaman district, promoting group premium among Civil
Society organisations such as religious bodies, especially Christians and Moslems who constitute 85 % of the Ghanaian population (2000 Population Census).
Financial sustainability is the biggest challenge, especially when all DMHIS are in full operation with all the attendant risks This may call for adjusting certain ‘triggers’ such as the premium, raising the National Health Insurance levy and SSNIT contributions, trimming of the
benefit package and introducing co-payments. DMHISs have the flexibility to adjust the premium locally at a general assembly, but not the other triggers. Local Management capacity is
another challenge. Seminars have been outlined for local managers who were recruited
through advertisement. So far there have not been records of embezzlement. Refunds to
health providers are based on fee for service, using advances from the premium collected or
quarterly advances from the central level on behalf of the exempted category. Currently
80
E. Appiah-Denkyira, A. Preker: Reaching the Poor in Ghana with National Health Insurance
managers of the district health insurance scheme (DHIS) are paid by government, but may
be weaned off into self-financing status soon.
Geographic access to health
service delivery is still poor in
many parts of Ghana. The policy
of the health sector therefore to
improve
access
through
Community
based
Health
Planning and Services is well
under way throughout in all
districts (Nyonator et al 2005).
There is increased training of
community health personnel who
will be placed in communities
and supported by Community
committees to provide close to
client services and fulfil this
vision.
Provider behaviour has always been a challenge to all health insurance schemes. In Ghana
the accreditation of health provider institutions using manuals recently developed, adherence
to Essential Drug list, provider sensitisation, and signing of Memorandum of Understanding
with DMHIS are some measures taken to ensure quality. The growing complaints from public
health provider of work over-load may need specific motivation packages.
Strengths of the NHIS in Ghana
The driving force for the Ghana initiative can be identified in five main area: political commitment, focus on the poor, involvement of GHS - especially the Regional task team, support
from some donors and accumulated funds to set the system moving. A strong political commitment in fulfilling campaign promises and the impatience of Ghana to see the ‘cash and
carry’ system abolished culminated in policy development and a charge to District Chief Executives to get involved in the DMHIS set up.
A second strength is the focus on DMHIS as a strategy to reach the poor as part of the
GPRS (National Development Planning Commission 2000). This brings on board other
strategies such as resource shift and wealth creation and inter-sectoral action. The involvement of managers of the Ghana Health Service provided champions in the establishment of
the scheme. Support from Donors, especially DANIDA, PHR+ and the ILO was timely even
though there was an initial resentment to the approach adopted by government. A training
manual on health insurance (Atim 2000), training, setting up of information systems, logistics
as well as support for District and Regional associations of Mutual Health Organisations, all
of which the DMHIS joined, helped in keeping the schemes confident and on track. Finally,
funds accumulated into the National Health Insurance Fund from the various sources before
the start of the schemes provided enough capital for disbursement to DHIS.
Way Forward
There is need for sustained efforts at improving enrolment, especially to capture the most
vulnerable in the society. This calls for Sustained public education. Government may also
consider varying the premium according to the poverty mapping currently ongoing by the
National Development Planning Commission (NDPC), or raising the level of the very poor to
be registered in deprived and poor areas to capture many poor people.
A system for monitoring the performance of DHIS, using the appropriate data management
tools is required to prevent schemes running bankrupt. Regular reviews of the design are
therefore of utmost importance. Health financing in Ghana may have to look beyond replacing out of pocket payment with health insurance, to making the NHIS the main purchaser of
Extending Social Protection in Health
81
services, whilst permitting the health providers to charge economic fees. This will imply phasing out the ‘exemption facility’ in the public sector and channelling all government support
(recurrent budget) into the DMHIS (Appiah- Denkyira et al. 2005).
This will have a dual role of improving quality of care as well as freeing funds to direct support for the poor and into public goods. To ensure sustainability, provider motivation, networking within facilities and improving referral mechanisms among the health providing facilities will need fine-tuning.
Conclusion
The Ghana Health Insurance Scheme adopts it own unique way of financing health service
with focus on the poor. It applies Social Insurance and Mutual Health Organisation principles
Though it has a potential of improving access to health care, solidarity and governance in
general, what is debatable is whether it is sustainable.
References
Agyapong, Armartefio Irene (2002). Dangbe West District Mutual Health Organisation. Annual Report
2001, Dodowa, Ghana.
Appiah-Denkyira, Ebenezer; Nartey, O.A.; Enemark, U. (2005). Review of Financial Strategy and
Source Allocation Criteria in Ghana. Accra, Ghana.
Atim Chris (ed.) (2000). Training of Trainers manual Mutual Health Organisations in Ghana. Published
by Partners for Health Reforms. Abt associates, Inc. Bethesda.
Atim Chris et al. (2001). A Survey of Health Financing Schemes in Ghana. 1st Edition. Accra, Ghana.
Berman, Peter; Bossert, Thomas (2000). A Decade of Health Sector Reforms in developing Countries:
What have we achieved?. A DDM Symposium paper. Washington D.C.
(www.hsph.harvard.edu/ihsg/publications/pdf/closeout.PDF).
Dzikunu, Helen; Thorup, Hanne (2003). Health Insurance Policy Development in Denmark 1860 to
1974. Its relevance to Emerging Health Insurance Movement in Ghana. DANIDA health sector support
office, Accra (www.opi.org.uk/pdf/Dzikunu%20Denmark-Ghana%202003.pdf).
Ministry of Health (2004). National Health Insurance Policy Framework for Ghana. Revised Edition.
Accra, Ghana.
Nyonator, Frank; Kutzin, Joseph (1999). Health for Some? The Effects of User Fees in the Volta Region of Ghana. Health Pol & Plan 14 (4), S. 329-341
(http://heapol.oxfordjournals.org/cgi/reprint/14/4/329).
Nyonator, Frank; Awoonor-Williams, Koku; Phillips, James; Jones, Tanya; Miller, Robert (2005). The
Ghana community-based health planning and services initiative for scaling up service delivery innovation. Health Pol Plan 20 (1) pp. 25-34 (http://heapol.oxfordjournals.org/cgi/reprint/20/1/25;
www.popcouncil.org/pdfs/wp/180.pdf).
Nyonator, Frank (2005). Roll out of the national health Insurance and the coverage of the poor in
Ghana. Mera, Ghana Edition.
Policy Planning Monitoring and Evaluation Unit (2001). Community based Planning and Services.
Ghana Health Service, Concept paper, Accra Ghana.
Smithson, Paul; Asamoa-Baah, A; Mills, Anne (1997). The case of the health sector in Ghana. The
Role of Government in Adjusting Economies Research Programme, Paper 26, Development Administration Group, University of Birmingham
(http://www.idd.bham.ac.uk/research/Projects/Role_of_gov/workingpapers/paper26.htm).
Sulzbach, Sara; Garshong, Bertha; Owusu-Banahene, Gertrude (2005). Evaluating the Effects of the
National Health Insurance Act in Ghana: Baseline Report. PHRPlus, Bethesda
(http://www.phrplus.org/Pubs/Tech090_fin.pdf).
82
M. Bigdeli: The Impact of Global Health Initiatives on Fair Financing and Health Systems Development
2.9. The Impact of Global Health Initiatives on Fair Financing and Health Systems Development: the case of Cambodia
Maryam Bigdeli43
Health care demand and financing in Cambodia
The Cambodian Demographic and Health Survey 2000 revealed that the Cambodian population prefers to use private providers: 68 % reported seeking treatment with private hospitals, clinics, drugstores or traditional practitioners, while 11.4 % did not seek treatment at all
(NIS 2001). Only 18.5 % of the population trusted public facilities for their health care needs.
The Cambodian Socio-Economic Survey 2004 reports an average spending of € 4.8 (US$ 6)
per illness episode over the past 4
weeks (NIS 2004b). Taking into account
Cambodia – Basic social and health data
the average household size and inciPopulation: 13.09 million (2003)
dence of illness, the World Bank PovTotal GDP: 3,5 billion € (2004)
erty Assessment 2006 estimates out-ofGDP/capita: 265 € (2004)
pocket expenditures to be around € 12
per capita and year (World Bank 2006)
Nat. poverty rate: 35 %
Pop. share below poverty line: 20 %
The Health Financing Charter was introduced in 1996 and allows the estabGov. health budget: 48 million € (2005)
lishment of user fees in health facilities.
Health expenditure as % of GDP: 1.26 %
In 2004, the income from user fees was
OOP:
reported to be € 5.2 million. Sixty perTotal donor spending: 76 million € (2003)
cent of this income is redistributed as incentives for the staff, with the positive
Donor spending/capita: 5.9 € (2003)
impact of reducing under-the-table payments (Wilkinson et al. 2001). However,
Sources: NIS 2004a+2005, MoH 2005+2006, CDC 2004
combined with inadequate quality of care,
mistrust of the population in public services and the burden of transportation costs, user fees
still represent a considerable barrier to health care for the poor. The bottlenecks are numerous but the most important one is probably the low salary of under-motivated health staff,
which results in reduced opening hours at public facilities and moonlighting in private practice.
Alternative financing schemes have been introduced in Cambodia since 2000. These are
contracting, health equity funds and community-based health insurance (CBHI). Contracting
is not a direct financing mechanism of health services but aims at better management of services and staff, resulting in improved service delivery. Contracting contributes to adequate
staff payment, with a significant impact on access to services. Health equity funds channel
donor funds (e.g. from Asian Development Bank (ADB), World Bank (WB), UNFPA, UNICEF,
United States (USAID), British (DFID) and Belgian Co-operation (BTC), and others) through
local implementers (international and local NGOs) in order to pay for the health care for the
poor in public facilities. Currently three NGOs are operating a total number of 5 CBHI
schemes in Cambodia. This form of voluntary insurance establishes a pre-payment mechanism and purchases health care on behalf of its members, also at public facilities.
External Resources for the Cambodian Health Sector
Donor spending in Cambodia was reported to be € 78 million or almost € 6 per capita in 2003
(CDC 2004), amounting roughly to 1.5 times the government budget. In the same year, an
analysis of the external resource flow to Cambodia was carried out on behalf of the Commission on Macro-Economics and Health (Michaud 2005). The study was able to identify and
43
Health Financing Advisor, World Health Organization, West Pacific Region, Pnom Penh, Cambodia,
[email protected].
Extending Social Protection in Health
83
track € 70 million (i.e. 93 % of total donor spending officially reported by the Cambodian Development Council). As shown in Figure 1, the United States of America is the principal donor for the health sector while other bilateral organisations together come in second and UN
agencies in third position. Additional funding of the health sector budget came from the
Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) and the Global Alliance for
Vaccines and Immunization (GAVI).
Figure 2.9.1: Cambodia: External sources to the health sector
2003
GFATM 8%
GAVI 1%
NGO funds 7%
UN Agencies 20%
Development banks
6%
EU 5%
Other bilaterals 21%
USA 32%
Source: Michaud 2005
The first issue is the adequacy of external funds compared to disease patterns and major
public health priorities in Cambodia. There are no adequate studies of the country’s burden
of disease, and they are likely to be very difficult to realise. However, as shown in Figure 2
below, it has to be pointed out that € 25 million or 35 % of total donor funding in 2003 were
channelled to HIV/AIDS that has a prevalence rate of only 1.9 %. At the same time, only €
11.5 million or 16 % of donor funds went to Maternal and Child Health while infant, child and
maternal mortalities in Cambodia are among the highest in the region and in the world.44
Figure 2.9.2: Cambodia: allocation of external funds in 2003 (in €)
Health sector
strengthening: 11,4
million (16%)
Maternal & child
health: 11,5 million
(16%)
Other: 8,8 million
(12%)
TB, Malaria,
dengue: 9,6 million
(13%)
AIDS: 25,3 million
(35%)
Reproductive
health: 5,4 million
(8%)
Source: Michaud 2005
44
Infant mortality rate 95/1000, under-five mortality rate 125/1000, maternal mortality rate 437/1000 (NIS 2001).
84
M. Bigdeli: The Impact of Global Health Initiatives on Fair Financing and Health Systems Development
In both HIV/AIDS and Maternal and Child Health, United
States funding represents a major share (52 % and 27 %,
respectively). The GFATM contributes 13 % of funding for
HIV/AIDS (smallest share after UN agencies and all
bilaterals), while GAVI contributes 8 % of funding for mother
and child health (MCH) and reproductive health (RH),
ranking after the United Nations Population Fund (UNFPA),
the Japan International Cooperation Agency (JICA) and the
Kantha Bopha Foundation, a foundation that funds
children’s hospitals.
The second issue is the adequacy of funding channels for
existing resources. Twenty percent of donor funds were
channelled through government institutions in 2003.
Sources of funds in these cases were WB-ADB-DFIDUNFPA grants and loans or the Health Sector Support
Project, GAVI, the United States Centres for Disease
Control and Prevention (US CDC) and some bilateral
organisations. Eighty percent of funding was channelled
outside government institutions. For instance in HIV/AIDS, the major partners are Cambodian and International NGOs, implementing 75 % of GFATM funding and all USAID supported activities.
Off-budget funding and health sector bottlenecks
Off-budget funding copes better with delays in disbursements. It is also a major shortcut to
avoid the main bottlenecks of the sector, i.e. coordination mechanisms and human resources. In 1999, the Ministry of Health decided to implement a Sector Wide Approach
(SWAp). However, the preparatory analyses to SWAp showed that donors were not necessarily ready to participate in this strategy. At that time, some stakeholders indicated that they
would not participate in SWAp under any conditions while others were unlikely to participate
within the defined timeframe. Therefore the Ministry of Health decided to adopt a Sector
Wide Management (SWiM) approach in 2000 instead. This modified approach involved a
common strategy as well as clear goals and objectives and thus includes most features of
SWAp. However, its weakness is a lack of commitment from major donors to fund pooling
and common implementation arrangements, adding to the fragmentation of the health sector.
Human resources for health constitute a major bottleneck in the Cambodian health sector.
Public servants salaries are below minimum living wage (€ 20/month). Donor funded projects
prefer to hire their own staff, better paid and, hence, more productive. This represents an
interesting financial and career opportunity for many civil servants and therefore drains valuable human resources. Those who stay in the system tend to use other coping mechanisms,
including under-the-table payments at various levels.
Innovative financing mechanisms
Until recently, Health Equity Funds were another off-budget funding channel to pay for health
services for the poor. Donor funding was allocated to local or international NGOs with the
aim of establishing a purchasing mechanism, which would benefit the lowest quintiles of the
population. Health Equity Funds do not usually target specific diseases but organise purchasing for all services routinely delivered at referral hospitals (and in some cases, health
centres). Although they do not correspond to this official definition of Health Equity Funds,
global health initiatives now act in Cambodia as funding sources for targeted equity funds, in
the sense that they address the need for free treatment for specific diseases, reproductive
health needs or vaccines through national institutes, NGOs and civil society organisations. In
an attempt to rationalise their resource allocation, Health Equity Funds therefore exclude
those treatments and interventions from their benefit packages in order to avoid double funding. While this arrangement makes practical sense in the current Cambodian context, it does
Extending Social Protection in Health
85
however contribute to fragmentation of the health system in various aspects, from service
delivery to reporting, supervision, monitoring, planning and policy-making.
The MoH has recently issued monitoring and implementation guidelines for equity funds, with
three different implementation models. The new implementation arrangements prescribe disbursement of donor funds for equity funds through government channels. The MoH becomes
the funds recipient for both donor and government counterpart funds (to date around €
680,000). Implementation is coordinated at central level by a new Equity Funds Management
Unit within the central Department of Planning and Health Information (DPHI), while field implementation can be either through NGOs and civil society organisations (model 1) or District
Health Offices (model 2). Centralised monitoring by DPHI will also replace fragmented monitoring arrangements specific to each donor, each implementer or each geographical location.
Both models will significantly contribute to create capacity at central level for financial management, coordination and monitoring, preparing the staff and the system for a smoother
transition from SwiM to SWAp. However, a bigger challenge would be to integrate the global
initiatives’ targeted funding into the centralised fund pooling and administrative arrangements
for equity funds. It is not guaranteed that implementing organisations nor their global donors
will be ready to consider such implementation model.
In order to address the constraints faced by many equity funds donors, direct disbursement
of donor funds to Equity Funds Implementers is still possible within one of the guidelines’
models. In those cases, the disbursement channels bypass the MoH. However, the reporting
and monitoring channels are similar to the above two models, through DPHI.
As long as disease or intervention-specific components of global initiatives remain independent from coordinated financing and administrative arrangements, they will initiate and maintain fragmentation at service-delivery level. However, GFATM and GAVI have recently
launched specific health systems strengthening (HSS) components. Cambodia is one of the
few recipients for GFATM Round 5 HSS component and this funding will be used for
strengthening the SWiM process, the existing operational planning, monitoring and evaluation in place as well as technical planning capacity. GFATM HSS Round 5 proposal also includes objectives related to support to national procurement processes. In addition, Cambodia has recently accepted a proposal for a GAVI HSS component in 2007.
At national level, Cambodia is undergoing major administrative and budgetary reforms, with a
commitment to assess SWiM and implement SWAp, redesign human resources management through performance-based salary schemes and improve financial management with
program-based budgeting. The MoEF is leading this reform process and the health and education sectors are priority sectors for pilot implementation. These reforms will contribute to
more effective channelling of external as well as government resources.
Despite these encouraging efforts, the binding constraint in Cambodia is and will remain human resources. In 2003, GFATM and GAVI together represented 9 % of donor funding to the
sector, i.e. less than 6 % of overall health sector resources. However, these two and other
global health initiatives come with requirements in terms of local expertise, as well as heavy
salary budgets that pull highly qualified staff out of the system. Such loss to the health system in terms of staff and capacity is not valued in monetary terms and deserves further scrutiny.
References
Council for the Development of Cambodia (CDC) (2004). Rehabilitation and Development Board, 7th
Consultative Group Meeting 2004. Phnom Penh, December 6-7 2004 (http://www.cdccrdb.gov.kh/cdc/7cg_meeting/default.htm).
Jacobs, Bart; Price Neil (2004). The impact of the introduction of user fees at a district hospital in
Cambodia. Health Pol & Plann 19 (5), S. 310–321
(http://heapol.oxfordjournals.org/cgi/reprint/19/5/310.pdf).
Michaud, Catherine (2005). External Resource Flows to the Health Sector in Cambodia. Coordination
of Macroeconomics and Health, World Health Organization, Geneva
(http://www.who.int/macrohealth/documents/external_resources_cambodia.pdf#search=%22Michaud
86
M. Bigdeli: The Impact of Global Health Initiatives on Fair Financing and Health Systems Development
%2C%20Catherine%20(2005).%20External%20Resource%20Flows%20to%20the%20Health%20Sect
or%20in%20Cambodia%22).
Ministry of Health (2005). National Budget Book 2005, Phnom Penh.
Ministry of Health (2006). Joint Annual Performance Review. Phnom Penh.
National Institute of Statistics (2001). Cambodian Demographic and Health Survey 2000. Ministry of
Planning and Directorate General for Health, Ministry of Health of Cambodia Phnom Penh June 2001
(http://www.measuredhs.com/pubs/pub_details.cfm?ID=342).
National Institute of Statistics (NIS) (2004a). Cambodia Inter-Censal Population Survey 2004. Ministry
of Planning and Directorate General for Health, Ministry of Health of Cambodia, Phnom Penh
http://www.nis.gov.kh/SURVEYS/cips2004/cips04_pub.htm and
http://www.nis.gov.kh/SURVEYS/depth-cips04/pro-cips/summary_projection.htm
National Institute of Statistics (NIS) (2004b). Cambodian Socio-Economic Survey 2004. Ministry of
Planning and Directorate General for Health, Ministry of Health of Cambodia, Phnom Penh
(http://www.nis.gov.kh/SURVEYS/CSES2003-04/indexcses.htm/http://www.nis.gov.kh/Publications.htm)
National Institute of Statistics (NIS) (2005). National Accounts of Cambodia. Ministry of Planning and
Directorate General for Health, Ministry of Health of Cambodia Phnom Penh
(http://www.nis.gov.kh/Publications.htm).
Wilkinson, David; Holloway, John; Fallavier, Pierre (2001). The Impact of User Fees on Access, Equity
and Health Provider Practices in Cambodia. Health Economics Task Force, MoH/WHO Health Sector
Reform Phase III, Phnom Penh.
World Bank (2006). Cambodia: Halving poverty by 2015? Poverty Assessment 2006. World Bank,
East Asia and the Pacific Region, Phnom Penh
(http://web.worldbank.org/WBSITE/EXTERNAL/COUNTRIES/EASTASIAPACIFICEXT/CAMBODIAEX
TN/0,,contentMDK:20815621~pagePK:141137~piPK:141127~theSitePK:293856,00.html).
Extending Social Protection in Health
3.
87
Current Reforms Aiming at the Extension of Social Protection
in Health: Linking up Mixed Health Financing Sub-systems
3.1. Myths, instruments, and objectives in health financing and insurance
Joseph Kutzin45
An important principle for public policy, and for those who advise on public policy, is to be
very clear on the difference between policy objectives and policy instruments. This is a major
risk in discussion and analysis of health financing issues and options, particularly with regard
to health insurance. In this light, two phrases from the presentation of Indrani Gupta (Health
Coverage for All: Strategies and Choices for India, Chapter 3.2, pp. 92-101) should be highlighted: “Health insurance is any arrangement that helps to defer, delay, reduce or altogether
avoid payment for health care incurred by individuals and households.” In the future, India
needs “…to take an integrated instead of a piecemeal approach to health insurance”
The first quote reflects an obvious but important conceptual point: insuring the population is a
policy objective. There is no mention of an ‘insurance scheme’; instead, the statement is focused on the goal of financial protection against health risks. Associated with this is the objective of ensuring financial access to care for those who need it. The second quote suggests
a systemic perspective rather than one focused on the implementation of particular instruments or schemes, such as social health insurance (SHI) or community-based health insurance (CBHI). Further, the success of particular schemes should be assessed from the systemic perspective: a scheme can serve public policy objectives if it contributes to the overall
‘insurance objective’ for the health system and the population as a whole. Merely benefiting
its members is not sufficient, and hence
the unit of analysis (and policy concern)
Four harmful myths in health insurance:
is the population, not the scheme or just
Countries that do not have social health
the covered groups.
insurance and wish to introduce it, start best
The simple logic and objectives descriwith formal sector workers and gradually exbed above is often lost in the rhetoric of
pand to the rest of the population
‘health insurance’. Indeed, the focus on
There are essentially two broad options
implementing insurance schemes rather
for
health
financing: SHI systems or “taxthan the objective of insuring the populabased
systems”
tion has led to the development of certain harmful myths about health insurIntroducing SHI will inject more money
ance that can lead to inappropriate polinto the health system
icy advice and choices, particularly in
Increasing social protection in health
the context of low and middle income
requires increasing SHI coverage
countries.
Myth 1: Start with the formal sector
As it is generally easier to collect compulsory contributions from employers and employees in
the formal sector of the economy, a common recommendation to ‘begin insurance’ is to first
cover those in formal employment and then gradually extend to the rest of the population
(see, for example, Shaw/Griffin 1995). This recommendation is based on a conceptual flaw:
the assumption is that because there is no insurance scheme, there is no insurance. However, every country in the world, no matter how poor, has some form of public expenditure on
personal health care services, and it is possible for at least part of the population to use services at an out-of-pocket price that is less than the cost of delivery (i.e. some people benefit
from public subsidies to health). In other words, even public subsidies made directly to government health facilities provide an insurance function (Kutzin 1999). In many low and mid45
WHO/EURO Regional Advisor, Health Systems Financing; Visiting Fellow, Imperial College Centre for Health
Management, [email protected].
88
J. Kutzin: Myths, instruments, and objectives in health financing and health insurance
dle-income countries, of course, financial access to these services remains inequitable, with
urban and wealthier populations (groups more likely to be employed in the formal sector)
making more use of publicly funded services, especially hospitals. By ignoring the role of
existing public funding of health services, therefore, ‘beginning health insurance’ with the
formal sector effectively means providing explicit coverage for that part of the population that
already has the best access and financial protection. In addition, in contexts in which most of
the population is in the informal sector and hard to reach, choosing an approach that links
entitlement to contribution seems to contradict the aim of universal coverage.
There is a pro-equity potential in a decision to start compulsory health insurance with the
formal sector that does, in principle, consider the role of existing public budget funding. The
argument is that by getting the relatively well-off formal sector into an insurance scheme, the
remaining budgetary funds will benefit the poor (the ‘freeing up’ of resources for the poor).
However, the conditions for equity improvement through the introduction of compulsory insurance for the formal sector are stringent, given that the small formal sector tends to be better
off than rest of population. Newly insured persons must effectively ‘self-finance’ the scheme,
both in terms of contributions as well as switching their utilisation to privately provided care to
such an extent that the sum of the public revenue liberated by this switching is greater than
the government subsidies used to expand insurance. For insured people who continue to use
government health facilities, fee and reimbursement levels need to be set at rates high
enough to recover costs fully; or possibly to allow for some cross-subsidisation of services for
the uninsured. This requires government providers to determine the costs of care and ensure
that persons covered by insurance are charged at a rate that is at least equal to that unit
cost. And, last not least, government resources freed by implementing health insurance must
be retained and reallocated within the health sector. Increasing revenues from contributions
should not be offset by a decline in public budget allocations; instead, the retained revenues
should be targeted to services used by those not covered by the SHI (Kutzin 1997).
Behind these stringent
Figure 3.3.1: SHI and segmentation in countries with small
technical conditions is a
formal sector: the Mexican case, 1990s
political concern. The initially insured group tends
General
to be a well-organised and
Payroll
Voluntary
Source/
taxation
contribution
taxation
influential interest group in
collection
countries with small foruninsured
SHI insured
VHI and OOPS
mal sectors. Their econoMoH
SHI
mic interest is not to enPooling
able redistribution to the
poor or expansion of covMoH
SHI
erage with the scheme,
Purchasing
but instead to expand
their benefits and reduce
their contributions. Hence,
MoH
Provision
one can question whether
Coverage
this process will, in fact,
‘free up’ resources for the
poor, or if there will be
poor
middle
rich
even greater concentraPopulation
tion of public funds on the
relatively well-off. Examples cited in earlier docu
ments (Kutzin 1997, Gertler/Solon 2000) suggested that the latter was more likely, and more
recent articles (Lloyd-Sherlock 2006) continue to challenge this belief. Evidence from low and
middle-income countries to support the ‘freeing up’ hypothesis is in short supply, if it exists at
all.
If the policy objective is to improve access and financial protection for the entire population, it
is essential that the design of a health financing reform process, including the introduction of
Extending Social Protection in Health
89
compulsory health insurance, be based on a comprehensive view of how to combine various
sources of funds to ensure that the consequences are pro-poor. By not doing so, the introduction of compulsory health insurance can be a source of fragmentation and inequity.
The example of Mexico (characterised in Figure 3.3.1) has been cited frequently as reflecting
the problem of ‘segmentation’: different health financing systems for different social groups in
the population (Frenk 1995, Londoño/Frenk 1997). There was no mechanism for coordinating these financing systems, and their vertical integration with service delivery meant duplication of infrastructure as well. In this context, the existence of separate ‘social health insurance’ and ‘MoH’ health financing systems is an obstacle to equity and solidarity. Indeed, the
health system almost seems to have been designed to be unequal (and inefficient). Addressing this segmentation, and particularly the ‘wall’ that exists between the MoH and the Social
Security systems, has been a priority for the MoH in recent years (see Frenk et al.: Poverty,
health and social protection, Chapter 1.6, pp. 22-31), and recommended for at least a decade before that (Frenk 1995). These concerns are at the heart of the functional approach to
health financing that is derived from this earlier work (Kutzin 2001).
The introduction of compulsory health insurance into a context of relatively low levels of formal labour force participation does not have to result in segmentation, however. Experience
from two low-income countries that were formerly part of the Soviet Union illustrates a comprehensive approach in which the introduction of the SHI scheme was at the heart of reforms
that resolved existing problems of fragmentation. As shown below, the key to this was a
comprehensive approach to reform with explicit coordination of general budget revenues with
new payroll tax revenues. To understand this, however, requires understanding the problem
of fragmentation within the inherited Soviet health financing system. This analysis also illustrates the usefulness of the functional approach to health financing.
The health financing system of the USSR that was inherited by its 12 successor states in
1990 is summarised in the following figure (Kutzin et al. 2002). This mapping of the organisation of health financing functions and population coverage illustrates the following points: Revenue collection and
Figure 3.3.2: Health financing functions and coverage
distribution of general
arrangements in the USSR
revenues came from
oblast (province), rayon
Source/
Oblast, rayon and
Capital City
Republican
(district), city, and Recollection
city administrations
Finance Dept.
budget
publican (central) levels
of government adminiRayons
Oblast
City
city
rayon
oblast
stration (essentially, the
finance
MOH
finance
finance
Pooling
Ministry of Finance at
departdepartdeparteach administrative lement
ments
ment
vel of the government).
rayon
oblast
city
MOH
Tax and state enterprifinance
finance
Purchasing finance
se revenues flowed to
departdepartdepartments
ment
ment
these local and central
state budgets. Pooling
rayon
oblast
hospitals,
City hospitals
Republican
of funds and purchasProvision
polyclinics, hospitals and
and polyclinics
health facilities
polyclinics
ing of services was orgSUBs, FAPs
anised by level of govCoverage
Coverage
ernment and integrated
Each oblast
Capital city (and nearby)
Population
with service delivery
units through a hierarNote: FAP = rural physician assistant and midwife post; SUB = rural hospital.
chical budget allocation
process. ‘Purchasing the allocation of resources from each pool to providers - was via strict line item budgets driven by centrally determined input-based norms (e.g. budget per number of hospital beds). And, population coverage was universal but not clearly specified. Importantly, coverage responsibilities overlapped, particularly in urban areas.
90
J. Kutzin: Myths, instruments, and objectives in health financing and health insurance
Health financing arrangements in the USSR were in fact a decentralised ‘budget funded system’ that provided universal coverage but was extremely fragmented in terms of financing
and delivery. Unlike Mexico (and many other low and middle income countries with separate
SHI and MoH funded systems), this did not manifest principally in population segmentation,
but rather in duplication and inefficiency. Fragmented pooling arrangements, combined with
vertical integration of pooling, purchasing and provision, capacity-expanding incentives in the
budgeting norms, and overlapping responsibility for population coverage, led to the existence
of a very infrastructure-intensive system. For example, in the capital city of an oblast, one
could (and often still can) find the oblast maternity hospital and the city maternity hospital, the
oblast children’s hospital and the city children’s hospital, etc. However, prior to 1990, the system (and its effective universal coverage) was ‘sustainable’ in the context of artificially low
input prices (e.g. energy, drugs) and high public revenues. The economic transition that occurred after 1990 changed the context and led to falling public revenues (Cheasty 1996) and
rising input prices, e.g. unit prices for energy consumption (Checheybaev 2002). This led to
shortages of critical treatment supplies, arrears in paying public utilities and health workers,
and a growing need for patients to supply their own inputs and pay health workers under-thetable, with greatest burden on the poor.
It was in this context that Kyrgyzstan and Moldova, two of the most severely affected exUSSR countries, introduced comprehensive health financing reforms. Given the problems of
the inherited system, the strategy was aimed at reducing the fixed costs of the system by
downsizing the infrastructure and re-orienting the system from an input to an output orientation. In each case, part of the implementation strategy included the establishment of a new
compulsory health insurance fund as an independent public agency.
In late 1996 in Kyrgyzstan, approval to implement a World Bank-funded health project was
delayed until the government developed a plan to show how the newly announced Mandatory Health Insurance Fund (MHIF) would not be a source of further fragmentation. The
strategy that was developed was called the ‘joint systems approach’, by which the MHIF and
the administration of the ‘budget-funded health system’ agreed to share systems for information and accounting in each oblast of the country. The development of a single, unified hospital information system for all patients regardless of their insurance status was a critical step.
So too was the decision of the MHIF to not fund a separate benefit package for the insured,
but instead to use its limited resources (funded from a 2 % payroll contribution) to pay additional amounts to budget funded hospitals and primary care practices for the insured persons
using the facilities. Beyond this coordination, it was decided from the start that certain groups
of non-contributors (pensioners, registered unemployed, and later children under 16) would
have MHIF coverage funded from other sources (e.g. transfers from the pension fund to the
MHIF for pensioners, transfers from the central budget for children, etc.).46 Unlike the budgetary system, the MHIF paid the hospitals on a case-based system (a Kyrgyz DRG system)
and primary care according to capitation. As a result of these actions, the development of
parallel health financing systems was avoided (Kutzin et al 2002).
In 2000, the government took a decision to eliminate the oblast level of many ministries,
including health. The Minister of Health responded by requesting the government to take
the budget funds provided for health by local governments and put them in the oblast departments of the Health Insurance Fund. This meant that the Territorial Department (TD) of
the MHIF managed both the budget revenues for the entire population and the payroll tax
revenues for the insured. Working closely together, the MoH and MHIF made plans to transform the health system by not only having the MHIF administer budget funds but to pay providers from these funds according to the same methods it used for the insured. The existence of the joint information system enabled the staff of the MHIF to simulate what the
46
In this context it is worthwhile to point out that no country with SHI coverage that has reached universal population coverage has done so without subsidising the non-contributing population. This approach is crucial for lowmiddle income countries when starting to implement or extend social protection in health. To maintain the traditional ‘MoH system’ in parallel with the newly created ‘SHI system’ is most likely to create segmented systems
with inefficiencies and inequities.
Extending Social Protection in Health
91
revenues of each hospital would be under the full implementation of the new system, and
they worked with the hospitals to implement downsizing plans so that they could live within
these budgets.
The single payer system provides universal coverage from
each oblast level pool, and complementary coverage from the
national pool for the ‘insured’;
the package for the insured consists of a reduced co-payment
rate for specialised referral care
and access to an outpatient drug
package.
Summary of critical changes:
Elimination of fragmentation of pools within
oblast by accumulating all local budget (rayon, city,
oblast) funds in the TDMHIF.
End of vertical integration with providers (purchaser-provider split introduced).
National MHIF pool for the insured was maintained, so that in fact there were two pools – oblast
pool for the entire population, and national pool for
the insured. One organisation, the MHIF was responsible for managing both.
Despite these two pools, the system appears as
a single entity to the providers – they only have to
complete one set of paperwork for each patient and
submit to the TDMHIF; if the patient is insured, this
triggers an additional payment from the MHIF national pool.
Providers were given increased autonomy to
manage their internal resources.
Promulgation of an explicit but not highly detailed benefit package with formal co-payments.
There was no major change to
funding sources, apart from the
formal co-payment, and even
that was not actually a new
source of funds but rather a
transformation of the existing
informal out-of-pocket payments
in hospitals (Kutzin 2003). There
is a universal entitlement funded
from general budget revenues
and a contribution-linked entitlement funded from payroll taxes
and transfers from the central
budget for groups covered by statute (pensioners, children under 16, etc.). Unlike the Mexican example, however, the different
sources of funds did not result in different health financing systems. Beveridge and Bismarck
work together in Kyrgyzstan in an explicitly complementary manner.
Moldova’s 2004 health insurance reform shares some important similarities with the Kyrgyz
experience, but also has important differences. Unlike the Kyrgyz reform that developed over
a period of five years after the introduction of the MHIF, Moldova’s implementation was rapid.
Following a 6-month pilot of its National Health Insurance Company (NHIC) in one region of
the country, nationwide implementation took place in 2004. The NHIC is financed by a 4 %
payroll contribution introduced on formal sector (shared equally employer - employee), and in
the same year responsibility for providing budget funds was centralised from local governments to the central government. There are also much less contributions from the selfemployed than it had been hoped reflecting the general difficulty to enrol the informal sector,
but also aggravated by the migration to and from neighbouring countries.
The Insurance Company manages a single national pool for the insured population, ending
the fragmentation of the previous decentralised post-Soviet system. Approximately two-thirds
of its revenues come from central government budget transfers for defined non-working
population groups (e.g. pensioners), and about one-third comes from payroll contributions.
For primary health care the NHIC uses a simple capitation payment and for inpatient care,
also a simple case-based payment (with volume caps), reflecting a major change from the
previous system of budgeting. As with the Kyrgyz MHIF, there is a purchaser-provider split,
ending the previous vertical integration. The basis for entitlement was shifted entirely to a
contribution basis, made either by the insured or on their behalf through budget transfers. As
a result, there are uninsured persons with no legal entitlement beyond emergency care. It is
estimated that about one-third of the working age population and 13 % of the total population
are uninsured (Shishkin et al. forthcoming). This more purely ‘SHI’ arrangement is different
from that of Kyrgyzstan.
92
J. Kutzin: Myths, instruments, and objectives in health financing and health insurance
The experience of Kyrgyzstan and Moldova illustrates that the introduction of compulsory
health insurance in a context of low formal employment does not have to result in fragmentation and segmentation. But political intent backed by solid design is an essential element.
The key design issues concern changing the role of general budget revenues in the system
and the organisation of pooling with regard to all sources of funds. Hence, there is no general
answer on whether initiating contributory compulsory
health insurance with the formal sector will improve
Universality must be deor worsen the efficiency and equity of the health syssigned into the reform from
tem. Key design aspects include financial changes
the start, rather than hoping
that re-direct general budget revenues to enable
that the system will eventunon-contributors to be in the same pool as contribually reach those outside the
tors, or at the minimum aim to use all available sourformal sector.
ces of funds in a complementary manner rather than
establishing separate health financing systems for
the insured and uninsured populations. This is espe
cially relevant to low income countries that have very low levels of public revenues, and is an
issue of system efficiency as much as it is a question of equity. A technical approach to universality is also essential, such as ensuring a unified information system for all patients and
citizens, regardless of their contributory insurance status.
Myth 2: When it comes to deciding on a health financing system, countries have
essentially two choices
Stewardship (governance,
regulation and information)
The population
The notion that health finFigure 3.3.3: Functional framework for health financing policy
ancing policy can be reduced to an exclusive
choice between Beveridge and Bismarck is a funHealth services
damentally flawed persProvision of services
pective that limits the
Cost sharing/user fees
scope for adapting health
financing systems to the
context of low and middle
Coverage
income countries. The
Purchasing of services
Choice?
functional approach to
health financing (Figure
Coverage
3.3.3) was in part develPooling of funds
Choice?
oped in the belief that the
source of funds need not
determine how the funds
ment?
Entitle
are pooled, how providers
Collection of funds
are paid, nor the specificContributions
ity with which benefit entitlement is determined. As
revealed in the figure and
Source: Adapted from Kutzin 2001
shown by the examples of
Kyrgyzstan and Moldova,
there are a wide variety of policy choices to be made in health financing, of which decisions
on the source of funds and entitlement criteria are only one part.
Myth 3: Social Health Insurance will increase the level of funding for the health sector
Low levels of public funding for health combined with severe fiscal constraints facing many
low and middle income countries is often the motivation for efforts to find new sources of
funds. Certainly, in several countries of the ex-USSR, compulsory health insurance funded
from employer-employee payroll contributions was developed in response to the collapse in
the level of state budget spending on health during the 1990s. The evidence on the experi-
Extending Social Protection in Health
93
ence of these countries suggests that it is a mistake to assume that introducing SHI will
automatically increase total public spending. The most extreme case of this unintended impact was the short-lived experience of SHI in Kazakhstan that introduced its payroll tax-funded Mandatory Health Insurance Fund (MHIF) in 1996. The MHIF was cancelled three years
later after 1998. During this time, new payroll revenues brought in about 0.5 % of GDP to the
health sector. However, the introduction of SHI in Kazakhstan led to a decline in public funding for health by a full percentage point of GDP from 1996 to 98 even though total government revenues increased as a share of GDP over that period. The new payroll tax revenues
were more than offset by a radical decline in general budget allocations to health, from 13 to
only 7 % of the state budget, mainly caused by a lack of co-ordination of the new scheme
with local government authorities that provided most budget funds for the health system.
Kazakhstan’s experience was not unique. Russia had the same experience of offsetting declines in budget health spending after it introduced compulsory health insurance in the early
1990s. Kyrgyzstan also suffered from this, despite extensive coordination and planning with
local government agencies in an attempt to maintain budget spending. Only in Moldova has
this offsetting decline not been experienced, perhaps due to a decision to shift responsibility
for budget spending on health from local governments to central government at the same
time that payroll-tax funded health insurance was introduced (Shishkin et al. forthcoming).
This suggests, again, the importance of explicitly coordinating any new source of funds with
existing sources. Nothing should be taken for granted.
Figure 3.3.4: Government health spending trends by
Health spending as %GDP
3.5%
3.0%
2.9%
3.0%
2.5%
2.7%
2.0%
2.5%
2.0%
2.1%
1.5%
1.5%
0.6%
1.0%
0.5%
0.0%
2.4%
0.5%
0.4%
1995
1996
All public
1997
State budget
1998
1999
MHIF
Source: Kazakhstan Expenditure Statistics produced by Agency for Health Care, reported in Kutzin/Cashin 2000.
Myth 4: Improving social protection in health requires the introduction of Social Health
Insurance: there is no other way
This is simply wrong and reflects a ‘classic’ confusion of a policy objective with a policy instrument. Increasing social protection in health is not synonymous with increasing or expanding a SHI scheme; any suggestion to the contrary is at best conceptually flawed and at worst
misleading and self-serving for those with a vested interests in a particular policy instrument.
On this point, it is simply sufficient to point out that, for example, German citizens are not
somehow more insured than the British simply because one country’s health financing system has the word ‘insurance’ in its label and the other does not. The idea that universal coverage does not necessarily refer to the percentage of the population that is registered in an
insurance scheme but is achievable without any kind of ‘insurance’ as such is more than just
a concept. It has important practical implications, both for policy makers and those that ad-
94
J. Kutzin: Myths, instruments, and objectives in health financing and health insurance
vise them. This ‘non-traditional’ way of thinking about insurance has some implications that
have to be taken in account when it comes to design or reform of the health sector.
The direction of health financing reform should be oriented by a clear focus on the policy objectives associated with universal coverage, but the starting point for any reform is the current system in its entirety, including all sources of funds, the arrangements for pooling them
and purchasing services and the
defined and effective benefit
entitlements and obligations of
the population. Countries need
to build on what they have, including their own experience as
well as the investments in systems and people that they have
made. Imported models of
health financing, such as Beveridge and Bismarck, are of
limited value in helping a country define its reform path. Systems (and reform options) must
be understood in terms of functions, not labels. Health financing schemes, including SHI, are instruments, not objectives.
They should be analysed in terms of their potential contribution to the objectives of the system and the population as a whole.
Most countries, and especially poor countries, cannot afford to have more than one health
financing system. A useful target for reform efforts is to minimise fragmentation, both because it is directly contrary to the objective of solidarity and also because it is inefficient from a
systemic perspective. By focusing reform efforts to reduce fragmentation, it is essential to
use available funds in an explicitly complementary manner. The experience of Kyrgyzstan
and Moldova shows that the key instrument is policy on how different sources of funds are
pooled.
Those providing technical assistance must be extremely clear on the difference between policy objectives and instruments; otherwise, we may do
more harm than good. In this regard, it is useful to
remember the words of Deng Xiaoping, China’s
leader from 1978-89: “It doesn't matter if a cat is
black or white, as long as it catches mice.”
There is no one “right way”
or blueprint.
Complementarity is essential for “low tax revenue”
countries.
Universal coverage and fair
The ‘bottom line’ is that, when considering the introduction of contributory compulsory health insurfinancing are not linked to a
ance in countries in which a large share of the
particular institutional form
population is outside the formal sector of the econor model.
omy, policy makers must focus on reforming the
entire national health financing system, not merely
on the creation and sustainability of an insurance scheme. If the introduction of SHI is considered from this perspective, there is a possibility it can help to improve financial protection,
equity of access to care, and system-wide efficiency by explicitly coordinating new payroll
contribution revenues with pre-existing budget revenues for health. Conversely, where attention is focused more narrowly on the establishment and sustainability of the SHI scheme
without reference to existing health financing arrangements, the results will be harmful to
both the equity and efficiency of the system.
References
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(http://www.imf.org/external/pubs/ft/fandd/1996/06/pdf/cheasty.pdf#search=%22Cheasty%2C%20A%2
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Checheybaev, E (2002). Feasibility of achieving planned savings from restructuring of the health system. Policy research paper 18, MANAS Health Policy Analysis Project. World Health Organization:
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Frenk, Julio (1995). Comprehensive policy analysis for health system reform. Health Policy 32 (3), pp.
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96
W. Savedoff, J. Holst: Implications of Enrolment Criteria for Social Health Insurance
3.2. Implications of Enrolment Criteria for Social Health Insurance
William D. Savedoff47, Jens Holst48
Introduction
Social health insurance has been on the agenda of public policymakers around the world for
over 100 years. In that time, some of the objectives and strategies have remained the same:
such systems generally try to protect households against high medical costs in the event of
an illness by levying mandatory contributions on employees and employers and then reimbursing health care professionals for services that are rendered.
Nevertheless, some objectives and conditions have changed substantially. For example,
many developing countries that are considering introducing social health insurance are trying
to mobilise more funds for health care or creating new mechanisms for promoting efficiency
in health care provision. In addition, the income levels and formal structures of the labour
market tend to be much smaller in the developing countries that are trying to introduce such
insurance systems today than they were in the countries that pioneered social health insurance. Furthermore, medical practice was quite limited in what it could offer in the past and
cost substantially less than it does today. Changes in health care technology have generated
much higher expectations for social insurance than people have ever had before.
A common thread in the papers presented in this chapter is the tension between the goal of
universal coverage and the pragmatic strategy of gradually incorporating people into social
health insurance by defined groupings. While the process of gradual inclusion was successful in some Western European and Latin American countries in the past, today expanding
coverage by population groupings generates substantial problems, making it preferable to
move directly toward universal coverage without distinction.
Basis of enrolment is not the only important issue
Most of the available literature addressing the introduction of social health insurance
schemes focuses on three questions: Who should be covered? What services should be included? And what premium should be charged? While universal coverage is generally a central objective, the most common experience has been for countries to make participation
mandatory for particular groups and gradually extend coverage to wider and wider segments
of the population (Carrin 2002). Similarly, reformers would like to cover the widest possible
package of health services, but budgets and supply limitations generally constrain what can
be offered. Finally, payroll contributions are not popular, but they generally play a significant
role in providing the funds for the health insurance, at least initially. Many countries have
later moved toward subsidising social health insurance out of general revenues (Savedoff
2004).
In addition to these three questions, there are structural elements of social health insurance
that have significant implications for its development and its success. One of these structural
elements is whether the system integrates or separates financing and provision. For example, Costa Rica’s social security institution owns and operates its own health care facilities;
while Estonia’s health insurance fund is strictly separated from any medical care providers.
For systems that separate financing and provision, further questions arise about how prices
and volumes are negotiated, whether all providers (public and private) can participate, and
what kinds of payment mechanisms are used (e.g. capitation, fee-for-service, case-based
reimbursement).
Another structural element that has to be considered is how the social health insurance system will be governed. Social health insurance funds can be managed as departments of the
executive branch of government, as in the Philippines, or as fully autonomous financial enti47
48
Senior Partner, Social Insight, [email protected].
Senior Health Advisor, Berlin, Germany, [email protected].
Extending Social Protection in Health
97
ties, as in the Netherlands. These governance arrangements have critical implications for the
institution’s accountability, and, therefore, how it evolves over time and in response to what
kinds of pressures. Different governance arrangements may encourage appropriate costcontainment and capital investments, improved service quality and financial protection of
members, and expansion to new populations; or they may encourage excessive spending,
inefficiency, and insulate institutions from serving their members or reaching new groups.
Difficulties in expanding coverage by groups
While all of these different issues will affect the social health insurance system’s ability to
achieve goals of universal coverage, access, and quality care, the choice about the basis for
enrolment in the social health insurance system is one that clearly has far-reaching implications. As mentioned earlier, the first countries to introduce social health insurance – largely in
Western Europe and Latin America – started by covering particular categories of the population and gradually extending it to more and more groups. Between the initial legislation making making contributions to social insurance mandatory in Germany, Chile, or France for
blue-collar workers, and reaching universal coverage for the population as a whole, there
was a lag of more than 50 years in most cases. In countries like the USA, Mexico, Vietnam,
or Colombia, the effort to universalise social health insurance coverage is still incomplete.
If there is any lesson here, it appears to be that extending coverage for defined population categories may be politically easier in
the short run but ultimately generates three kinds of problems:
incomplete population coverage, boundary problems, and financial inequities.
First, extending coverage by categories generally means that
some residual category of people, no matter how small, gets left
out. In Estonia, the 6 % of the population that remains without
health insurance coverage are of working age, but are not formally employed nor are they disabled. In Colombia, by contrast,
the 38 % of the population without health insurance coverage include both informally employed individuals but also many disabled, elderly, and young groups.
Thus, countries need to think hard about whether conditions for
enrolment have any advantages that cannot be attained in other ways. For example, one
common argument for tying benefits to salaried employment is to make it easier to assure
that premiums are paid. But reaching universal coverage will still require the use of general
revenues to pay for the non-working population unless the working population is willing to
subsidise others through their contributions.49 A broader perspective in many countries might
reveal that improved collection of general revenues could assure funds as effectively as a
payroll deduction and without creating obstacles to universalising coverage.
The second problem with extending coverage on the basis of group definitions is that society
is dynamic and individuals frequently move from one category to another. For example, in
the Netherlands, the social insurance funds were restricted to covering individuals below a
certain income level. Thus, people with highly variable incomes might find themselves required to contribute to a sickness fund in one period and left to seek out private insurance at
other times. The Netherlands responded to this problem, in the 2006 health reform, by eliminating the income ceiling completely and bringing the sickness funds and private insurers
into a unified insurance system on more equal footing. In other countries, moving in and out
49
This is the case in Chile, one of the few Latin American countries that has almost reached universal coverage.
Although Chile is often discussed as a model of private health insurance, the public insurance fund (FONASA)
actually covers 70% of the population - including most of the elderly, the indigent, and a large share of the working force. Those affiliated with FONASA who do not make payroll contributions are subsidized, in part, by those
who pay direct contributions, but mostly through general tax revenues that account for almost half of FONASA's
total income.
98
W. Savedoff, J. Holst: Implications of Enrolment Criteria for Social Health Insurance
of formal employment might leave a worker only occasionally covered by health insurance; or
changing definitions of disability, poverty, vulnerability, or dependency might make an individual eligible at one time but not another.
A third problem occurs when extension of benefits by groups includes a differentiation in levels of financial protection and benefits. Many systems that extend coverage to new groups
end up with separate risk pools for a variety of understandable reasons. Schemes that cover
individuals who make payroll contributions are often better financed and more generous in
their expenditures than those that cover individuals out of general revenues. For example, in
the 1990s, health expenditures by Mexico’s Social Security Institute were regularly 3 to 4
times higher for its affiliates than for those paid for by the Ministry of Health’s ‘Solidarity’ program. Colombia’s health reform extended insurance coverage to an additional 39 % of the
population between 1993 and 2003, but the benefits package for those in the ‘subsidised
regime’ is not as complete as for those covered by the ‘contributory regime’ (Escobar 2005).
When such divisions become rigid and protected politically by vested interests, it becomes
difficult to reform or change the system. Nevertheless, countries have tried with varying success to either merge the different pools, gradually shift away from premiums toward general
tax support or create secondary pooling mechanisms to equalise spending per member
across schemes. Brazil confronted the inequities by creating a unified health system in 1986
(Sistema Único de Saúde). Britain, Spain and Sweden are all countries that had health insurance financed by payroll contributions but moved to a reliance on general tax revenues
that allowed them to eliminate distinctions among citizens. Japan, Germany and France all
have elaborate schemes for cross-subsidising insurance pools, trying to assure that expenditures are more closely related to the risk profile of their membership than to their capacity to
generate revenues.
Some country experiences
However, reforms tend to have unintended consequences. Brazil’s effort to create a single
health system explicitly ended the distinction between contributors who were part of the national social security system and those who depended on less well financed services from
the Ministry of Health. Because the quality of care under the new publicly financed system
did not satisfy middle and upper-class Brazilians, they moved, in massive numbers, to the
private sector. While private health insurance accounted for only 4 million Brazilians in 1986
when the health reform was passed, only 10 years later, some 44 million Brazilians were
covered by private health insurance. In this way, the divisions of the earlier system were recreated at private initiative (Medici 1999).
The best answer to such a phenomenon is to improve the quality of care available under the
publicly-financed system – both to assure good quality of care for those it serves and to
compete the private insurers into as small a niche as possible. After all, the public sector
generally offers its services at an unbeatable price! If only it can provide access to quality
services, it should do fine. Mexico’s ‘Crusade for Quality’ is a recent initiative aimed at improving the quality of public services even as it moves to equalise spending across different
insurance pools. The pattern of affiliation in Chile, which allows individuals to ‘opt out’ of the
public insurance system and buy private coverage, shows how effective this can be. The
private insurers in Chile gained substantial market share during their first 15 years (reaching
a peak of 27 % in 1997), during a time when the public social insurance system was generally starved of funds and the private insurance companies were new and untried. Since the
mid-1990s, however, successive governments have invested substantially in the services
provided under national public insurance and private insurers have seen their share of the
market decline to only 16 % (as of 2005).
The countries discussed in this session have all grappled with the question of how to extend
coverage. In India, insurance coverage overall is extremely low and highly fragmented. Efforts, at this stage, appear aimed primarily at generating new alternatives for insurance coverage without confronting the problems that such fragmentation might engender in the future.
Extending Social Protection in Health
99
The Kyrgyz Republic started with a system of public health services that were divided geographically. By introducing a national health insurance scheme, additional funds were mobilised and used to standardise payments and access to care. Nevertheless, it appears that
the direct beneficiaries of the national insurance (formal sector workers and children under
16 years of age) benefit from lower co-payments than those without coverage. This is the
kind of differentiation that could generate future problems.
Three countries discussed in this chapter – Thailand, Taiwan and South Korea – have
moved decisively away from extending coverage by distinct groups and toward extending
coverage without distinction. Until 2002, Thailand had separate health schemes for formal
sector workers and their dependents, government workers and their dependents, vulnerable
groups (poor, elderly, and children) and a public voluntary insurance plan for others. In 2002,
the government replaced the vulnerable groups and voluntary insurance plan with a new
‘universal coverage’ scheme that makes no distinction. Though this does not subsume the
formal and government workers, it does unify coverage for the rest of the population and
creates conditions for equalising in the future.
Until 1995, less than two-thirds of Taiwan’s population was covered by some 10 different
insurance programs – the largest ones being for government employees, formal sector workers, farmers, and members of the military. The National Health Insurance program, launched
in 1995, made health insurance mandatory for all residents and retained the distinctions by
employment status only for the purposes of determining premiums. In Korea, social health
insurance started with larger enterprises (more than 500 employees) and extended coverage
stepwise for smaller sized firms. Schemes for Civil servants and school employees started in
1981 and nationwide coverage was achieved in 1989. South Korea also unified multiple insurance societies into a single insurer in its 2000 reform In order to enhance risk pooling and
improve administrative efficiency (comp. Chapter 4.4, p. 158).
The advantages of such non-discriminating extension of universal coverage are that they
avoid population gaps, and boundary problems, and hold potential for eliminating inequities
in health care across the population. As Brazil shows, most countries cannot legislate a unified system without seeing part of the population flee to the private sector (unless they are
willing to outlaw it – as in Cuba – or raise the costs of private care by keeping providers from
receiving public payments if they have private patients – as in Canada).
Perhaps the greatest advantage of non-discriminatory extension of universal coverage is that
the debate shifts away from the boundaries (unemployed vs. employed, formal vs. informal,
high vs. low income, dependent vs. independent, disabled vs. capable) and toward better
ways of mobilising sufficient resources and improving the efficiency and quality of care.
In sum, health insurance systems are most likely to reach true universality if they extend
coverage without categories. Their success will depend critically on the existing gaps in
spending between different population groups, the existence or potential for cross-subsidies,
and the possibility of delivering good quality care under publicly-financed insurance. While
this route is certainly not easy, and not always available, it does hold the promise of avoiding
a number of pitfalls that many countries have struggled with for decades.
References
Carrin, Guy (2002). Social health insurance in developing countries: A continuing challenge. International Social Security Review 55 (2), pp. 57-69.
Escobar, María L. (2005). Health Sector Reform in Colombia. Development Outreach, World Bank
Institute, Washington DC. (http://www1.worldbank.org/devoutreach/may05/article.asp?id=295).
Medici, André (1999). Uma Década de SUS (1988-1998): Progressos e Desafios. In: Galvão, Loren;
Diaz, Juan (1999). Saúde Sexual e Reprodutiva no Brasil. Ed. Hucitec&Population Council, São Paulo.
Savedoff, William (2004). Tax-Based Financing for Health Systems: Options and Experiences. Discussion Paper Number 4, EIP/FER/DP.04.4, Geneva, World Health Organization
(http://www.who.int/health_financing/taxed_based_financing_dp_04_4.pdf).
100
Y. Wade: The Importance of Social Dialogue in the Extension of Coverage
3.3. The Importance of Social Dialogue in the Extension of Coverage
Youssoufa Wade50
General Background
Under colonial rule for a long period of time, and despite several years of sovereignty, Africa
is marked by a state of under-development. Poverty, un- and sub-employment, political instability, weak infrastructure, lack of good governance and an accelerated demographic development have a negative impact on health for all, but mainly for poor population groups.
Problems exist at the level of supply (lack of coherent policy, health care infrastructure, human resources, etc.) as well as at the level of demand. The supply side is mainly lacking political will, adequate health care infrastructure, the level of quality medical care, and the necessary human and financial resources.
The demand side is changing continuously due to demographic pressure and increasing financial constraints regarding access to health care. In view of this situation, social protection
is becoming a worldwide problem facing a crucial need for financing. Despite the political will
of states and numerous local experiences, however, public means remain insufficient to satisfy essential needs. That is the reason why mainly in Africa the challenges of social protection are at the very centre of international development concerns. Initiatives undertaken in
various places in order to make the population participate in the financing of their health
should be considered within this framework.
The National Senegalese Context
Senegal went through a long period
marked sharply by the application of
drastic structural adjustment measures that have left important economic and social traces. One of the
most visible consequences has been
the shut-down of enterprises with a
relevant loss of workplaces. This difficult situation became even more
complicated after several years of
disastrous drought in the 1970s, the
state’s retreat from various areas of
action, reduced productivity, falling
revenues, and decreasing resources.
Senegal is one of the Sub-Saharan Africa countries located on the coast of West Africa. It has a total population of 10.6 million (in 2003) of whom 48.1 % live in urban areas. The total area is 196,190 km2. Nearly 58 %
of the population is under the age of 20 and over 92 %
of the population is Muslim. Early marriage and polygamy are widespread practices and more than half of the
women give birth before the age of 20 (U.S. Embassy
Dakar). Wolof (36 %), Fulani, and Serer (each 17 %) are
the dominant ethnic groups in the country followed by
Toucouleur, Diola, and Mandingo (each 9 %).
With a per capita income of € 475 (2002), the country is
grouped in low-income and moderately indebted countries and its economy is highly tied to the former colonial
power, France. It has limited natural resources and fishing, mining, agriculture, tourism, and services are the
major sources of foreign exchange earnings. Since
January 1994, the country has undertaken various economic reforms including devaluation of its currency by
half and reducing price controls and subsidies. As a result (coupled with good weather conditions), the country
has shown considerable economic growth with relatively
low inflation rates and fiscal deficit. However, the country is still poor in many indicators and suffers from high
level of poverty, very high rural-urban migration, unemployment (as high as 45 %), illiteracy (nearly two thirds
of the adult population is illiterate) and poor access to
primary health care services (Asfaw 2004, p. 4f).
In spite of the devaluation of the regional currency, CFA, and the following increase of the growth rate from 2
to 5 %, the situation described before
had a very negative impact on the living conditions of the population living
below the poverty line - over 50% of
private households. In this difficult
context and with the support from
development partners, Senegal has
worked out a poverty reduction strategy paper (PSRP) in 2002. It is important to point out that the first generation of PSRPs did
not sufficiently take into account the problem of social protection. With the impulse of the
ILO, numerous concerted actions regarding this issue were initiated together with the government and led to the inclusion of social protection in the second generation of PSRPs.
50
President of the Comité National du Dialogue Social (National Social Dialog Committee), Dakar, Senegal,
[email protected].
Extending Social Protection in Health
As in the case of other SSA countries, income
and geographical inequalities in access to
health care facilities, shortage and irregular
supply of drugs and other basic materials, inefficient allocation of resources, etc. hampers the
performance of the health sector in Senegal.
The small tax base of the government and the
failure of the market in the health insurance
sector also aggravate the problem. The combined effect of these problems is reflected in
high morbidity, infant and maternal mortality
rates, low life expectancy, exclusion of the vast
majority of the population from access to basic
health care services, catastrophic health expenditure, etc. Appendix 1 gives some basic
health indicators for Senegal.
Life expectancy at birth in Senegal is higher
than the African average of 49 years but still
lower than the 64.6 years of the developing
countries. The infant and under five mortality
rates are also high in Senegal even compared
to the developing countries’ average rates. Except in improved water sources, the performance of the country in other indicators is very
low as can be seen from Appendix 1.
With a relatively low prevalence of HIV/AIDS
(1.0% in 2001), malaria is the principal cause of
morbidity and death in the country. It is prevalent throughout the country and accounts for
30% of all outpatient attendance (AED, n.d).
The government has initiated a countrywide
malaria-controlling program and treated bed
nets have been taken as a key prevention strategy (Asfaw 2004, p. 5).
101
Prior to the elaboration of the PRSP, Senegal already had a series of experiences
with social protection through mutual health
organisations, the Health Welfare Institutions (Institutions de Prévoyance Maladie,
IPM) and other specific insurance schemes
like those for public and state employees
and local communities. In this area, the
State through the Ministries of Labour and
Health and in close co-operation with the
ILO-STEP-programme, USAID and GTZ
has strongly supported the implementation
of mutual health insurance structures in rural and urban surroundings.
In order to promote social dialogue and social protection, Senegal adopted a National
Tripartite Charter on Social Dialogue in November 2002. The new social regulation instrument is a framework for reflection and
action. It allows the State and other stakeholders to promote social protection
through social dialogue. Therefore, a series
of different mechanisms of consultation,
negotiation and information exchange are
in place. The National Social Dialogue
Committee brings together Ministry departments as well as workers’ and employers’ organisations and is the main organ to
execute the national Charter. One of the
main goals of the National Committee is extending social protection through social dialogue.
State of the Art of Health Insurance in Senegal
The existing health insurance system in Senegal offers coverage only to formally contracted
and formally employed people and their families, retirees and their families, students and
their families, and indigent people. In addition, several voluntary health insurance systems
exist for the other non-salaried layers of the population, namely private insurance, mutual
health organisations, and micro health insurance schemes.
Senegal has several health insurance schemes, non-contributory regimes, voluntary contributory schemes, and compulsory contributory health insurance. Non-contributory schemes
give coverage to public employees on central and local levels, students and the very poor.
Voluntary contributory schemes are reaching the population groups who are able to join mutual health organisations or to sign a health insurance policy offered by private insurance
companies. And for private sector employees affiliated as individually paying members (IPM),
contributory health insurance is mandatory.
Despite the described options to enrol in health insurance, only about 10 % of the entire
Senegalese population are currently covered. The far-reaching social exclusion creates major problems regarding social coherence and equity in access to health care. Low revenues
and the weakness of formal solidarity mechanisms are two important reasons for this situation. Senegal faces the problem of insufficient human resources with acceptable qualification
needed for a development policy towards health insurance.
102
Y. Wade: The Importance of Social Dialogue in the Extension of Coverage
The country is in the middle of a health reform process affecting various areas of health care
delivery. New health care infrastructure is being built in order to improve geographic accessibility. Hospital management is being reformed in order to give health care providers more
autonomy. And alternative health financing systems are being developed to encourage the
participation of the population in decisions about health care expenditure in order to improve
financial accessibility.
The extension of social protection against the financial risk of ill health has nowadays become a priority objective at the centre of several stakes. However, the implementation of effective mechanisms of social protection in health faces a series of relevant challenges that
have to be tackled in order to improve social security of the citizens. The main question
seems to be how to increase the currently low level of health insurance coverage existing in
a given country. Extending coverage beyond the formal sector and the better-off remains a
major task for most developing countries. No blueprint can be applied; each society has to
look for the best ways to implement broader social protection according to historical experience, given conditions and existing priorities. Social dialogue, however, appears to be a
powerful tool to bring different stakeholders and interests together and to negotiate widely
accepted and socially viable pathways towards universal health insurance coverage.
Therefore, people’s awareness about the opportunities and challenges of social health protection has to increase while the health protection mechanisms and options have to be
adapted to the priority needs of the population. Last, not least, adequate training and capacity building of essential human resources is an indispensable condition for the planning and
management of health insurance schemes.
Reform Measures and Perspectives
Senegal has undertaken a vast reform of its health system by elaborating a national strategy
of social protection within the PSRP framework. The objective of the strategy is to achieve a
noticeable reduction of poverty through a new approach based on social protection. Senegal
will take in account all internationally available elements like the relevant ILO conventions
related to the social security and the Millennium Development Goals (MDG). The national
strategy aims to realise short, mid and long-term objectives. In the middle term, Senegal
wants to achieve health insurance coverage of all economically active sectors of the Senegalese society, extending the reach-out of social protection in health to about 40 % of the
whole population. In the long run, the goal is to achieve universal coverage.
Table 3.6.1: Trend of Sources of Finance in Senegal between 1997 and 2001
1998
1999
2000
5.1
4.9
4.7
4.6
4.8
-0.0182
Government expenditure on health as % of
total government expenditure
14.4
15.0
13.0
13.6
12.9
-0.0313
External resources for health as % of total
expenditure on health
11.7
11.1
12.4
14.1
20.2
0.1939
Private expenditure on health as % of total
expenditure on health
45.2
42.5
43.9
43.4
41.2
-0.0163
Out-of-pocket expenditure on health as % of
private expenditure
91.3
90.6
91.2
91.3
91.6
0.0014
25
24
22
22
-0.0336
Total expenditure on health as % of GDP
Per capita total expenditure on health at
average exchange rate (US$)
Prepaid plans as % of private health expend.
Source: Asfaw 2004
2001
Av. growth
rate*
1997
8.4
Extending Social Protection in Health
103
Along this path, the Senegalese strategy comprises numerous areas of action within the
overall operational goals. A certain number of pilot activities to be developed under guidance
or in close co-operation with the National Social Dialogue Committee are mentioned in the
strategy paper, e.g. the implementation of a health protection system for truck drivers and for
rural workers. This aspect of extending social protection will be developed in concert with the
stakeholders directly involved, namely transportation workers’ and haulage contractors’
trade-unions, rural workers’ and peasants’ organisations, etc.
All these activities developed under the guidance of the National Committee with the support
of the Sub Regional Office of the ILO in Dakar through the STEP programme have shown
significant and measurable progress due to the involvement of the stakeholders involved.
The STEP-programme has supported a pre-feasibility and a feasibility study about the social
protection scheme for workers in the transportation sector and contributed to the road-map
prior to the implementation of the scheme.
Conclusions
The lesson to be learned from the Senegalese experience with social protection in health is
that Social Dialogue based on a strong and credible structure like the National Social Dialogue Committee (CNDS) may produce satisfactory results within a reasonable time framework. The advantage of this approach is that it facilitates a consensus about major societal
problems, a shared comprehension of goals and policies and a stronger collaboration between public and other stakeholders in the health care sector.
References
Asfaw, Abay (2004). The Impact of Social Health protection Mechanisms on Access to Health Care,
Health Expenditure and Impoverishment: A Case Study of Senegal. Centre for Development Research
(ZEF) (http://www.gtz.de/de/dokumente/en-final-report-sn.pdf).
ILO (n.y.). Good Practices in Labour Administration. Social security / Informal sector. The case of
Senegal. ILO, Geneva (http://www.ilo.org/public/english/dialogue/ifpdial/gp/senegal.htm).
International Monetary Fund (2006). Senegal: Poverty Reduction Strategy Paper—Second Annual
Progress Report— Joint Staff Advisory Note. IM Country Report No. 06/69, Washington DC
(http://www.imf.org/external/pubs/ft/scr/2006/cr0669.pdf#search=%22Senegal%20%22social%20prote
ction%22%22).
Jütting, Johannes (2001). The Impact of Health Insurance on the Access to Health Care and Financial
Protection in Rural Developing Countries. The Example of Senegal. HNP Discussion Paper, World
Bank, Washington DC
(http://siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Resources/2816271095698140167/Jutting-TheImpactofwhole.pdf#search=%22Senegal%20%22social%20protection%22%20%22health%20insurance%22%
22).
Jutting, Johannes (2003). Health Insurance for the Poor? Determinants of Participation in CommunityBased Health Insurance Schemes in Rural Senegal. OECD Development Centre, DEV/DOC(2003)02,
Working Paper No. 204, Paris (http://www.oecd.org/dataoecd/39/62/2492297.pdf).
Tabor, Stephen (2005). Community-Based Health Insurance and Social Protection Policy. Social Protection Discussion Paper Series No. 0503, Social Protection Unit, Human Development Network,
World Bank, Washington DC
(http://siteresources.worldbank.org/SOCIALPROTECTION/Resources/0503.pdf#search=%22Senegal
%20%22social%20protection%22%20%22health%20insurance%22%22).
World Bank (2004). Operations Evaluation Department Approach Paper Senegal: Country Assistance
Evaluation. World Bank, Washington DC
(http://lnweb18.worldbank.org/oed/oeddoclib.nsf/DocUNIDViewForJavaSearch/9A78584264041A1A85
256F5C00030078/$file/senegal_cae_approach_paper.pdf#search=%22Senegal%20%22social%20pr
otection%22%22).
104
U. Engelen-Kefer: German view on social dialogue for the extension of coverage
3.4. The German perspective on the Importance of social dialogue in the extension of coverage: Lessons learnt from Senegal
Ursula Engelen-Kefer51
Surprising as it may sound, there are similarities between the situation in Senegal and the
development of social welfare systems in Germany. For instance, in Germany it was only the
political movements that emerged from discussions on the social question, particularly the
labour movement that brought about the introduction of a universal system of social protection. This happened early on, however, at about the same time as Senegal was made a
French colony, in the second half of the 19th century. Initially it began as a voluntary social
security system, in the form of assistance and support funds run on a co-operative or municipal basis. So there are parallels with the development of community-based health insurance
in Senegal, the so-called Mutuelles de Santé that were much discussed at the beginning of
the decade.
Then the imperial German state responded to the social question and the growing labour
movement. Bismarck, the imperial chancellor at the time, enacted social legislation to organise wide-ranging social insurance against life’s most serious risks. These laws on health insurance in 1883, accident insurance in 1884, and invalidity and pensions in 1889 marked the
beginnings of state-driven social policy. Whereas in those days only one-fifth of the labour
force and one-tenth of the total population were covered by social legislation, today almost
90 % of the German population is protected by the social security system. That social protection system – along with one other key element, unemployment insurance, added in 1927 –
has endured to the present day. It was not until 1995 that it was expanded with the addition
of a fifth pillar - compulsory long-term care insurance.
The second parallel with the present situation in Senegal is the problem of financing social
protection. Since the 1990s, social security has run into financial difficulties in many countries
of the European Union. However, the different welfare state systems have come up with different answers to their financing problems – or are still trying to work them out. In Germany,
we are still at the stage of looking for solutions. We have a highly articulated system – both in
terms of the different federal levels and the spheres of social security – so processes of
change take much longer than in a centralised state that operates its social welfare system
directly.
Social dialogue plays an important role in solving these problems. This is particularly true of
statutory health insurance, which provides coverage to some 71 million people in Germany.
Statutory health insurance in Germany is not a responsibility of the state administration. Instead, the legislator opted to set up independent administrative bodies, in the legal form of
corporations under public law. The responsibility for administration of these bodies was delegated to the workers and employers concerned. This decision was justified on the basis that,
by the time statutory health insurance was introduced, there were pre-existing insurance
funds that had proven their managerial capacity. The legislator therefore had reason to believe that these co-operative bodies, under state protection and support, were more appropriate than direct state authority for resolving the difficult challenges they faced.
To this day, Germany does not have one standard health insurance scheme but a large
number of legally independent insurance funds. These agencies are not run directly by the
state, nor do they pursue private commercial gain. Instead, as public law corporations, they
are obliged to fulfil a legally defined, public mission. The state lays down the framework in
which they operate and they conduct their business on their own responsibility. The role of
the state is to check compliance.
The social dialogue between employees and employers in statutory health insurance takes
place primarily within the organs of social self-administration. The self-administration organs
(representatives’ assemblies and boards) are composed of representatives of employers and
51
Former Deputy Chairperson, German Confederation of Trade Unions, Berlin, [email protected].
Extending Social Protection in Health
105
insured persons – which are mainly employees – on a parity basis. They need to be in close
contact with one another and with the administration of the particular health insurance fund,
in order to organise the necessary procedures as smoothly as possible. At the same time,
they are expected to provide the administration with realistic information about the basic risks
covered by social insurance, in order to assure effective provision of services. This close
contact ensures that the administration’s work stays in touch with real life and social reality.
The insured persons’ representatives are voted onto the representatives' assembly in what
are known as social elections. A self-administration body has independent decision-making
competence over significant matters of principle, organisational issues, the granting of benefits going beyond the statutory framework, and the rate of contributions for the particular
health insurance fund. These tasks make high demands upon the people elected to the selfadministrative body. This system also fulfils another important function: leaving aside disputes between employers’ organisations and trade unions, it forces their functionaries to engage in dialogue and reach a consensus about social security.
This is not the only form of social dialogue in the German health care system. The law establishes that the scope of benefits covered under statutory health insurance is defined in permanent dialogue with service providers, i.e. doctors, therapists and hospitals. Funding agencies, i.e. insurance funds, as well as health care providers and patients are all represented
on the Federal Joint Committee. This body also defines quality standards for out-patient, inpatient and inter-sectoral care.
Health policy actors are also in constant discussion with governments and parliaments at the
federal level. This takes place principally within the legislative process, so this is another
area in which social dialogue is institutionalised. Furthermore, Germany has two ongoing
evidence-gathering processes, which ensure that social dialogue and political decisionmaking are based on empirical evidence. One is the Federal Health Monitoring system,
which explicitly aims to promote co-operation among all actors in the health system and the
self-administration bodies. The other is the German Federal Government's Poverty and
Wealth Reporting system, which has an advisory group including representatives from sections of society such as employers' organisations and trade unions. The purpose of both initiatives is not only to supply empirical evidence for social dialogue in Germany, but also to
evaluate the effectiveness of interventions. These reporting systems are also a fertile source
of broad public debate, not least because of the media interest they create.
The ILO defines social dialogue as “all types of negotiation, consultation or simply exchange
of information between, or among, representatives of governments, employers and workers,
on issues of common interest relating to economic and social policy.” For the most part,
statutory health insurance funds fulfil the ILO’s requirements for social dialogue in Germany
on health insurance.
Naturally such an articulated system also has drawbacks; insured persons may find it unduly
complex, for instance, and it poses regulatory problems for the legislature and the social
partners. Nevertheless, the principle of social self-administration in health insurance has
proven successful. It gives those concerned a direct means of influencing the detailed form
of their health insurance. The large number of directly involved representatives raises the
level of acceptance. This contributes to social partnership and social peace. However, it also
relies heavily on the motivations of the various parties to reach a consensus.
The German Confederation of Trade Unions (DGB) is ready and willing to make German
experience available to others through the framework of the ILO. All Europeans have a particular duty of responsibility towards former European colonies. Lessons learned in Germany
can certainly contribute towards extending social health insurance to wider sections of the
population.
106
R. J. Basa: Working with Community-based Groups: Philippine Health Insurance Corporation
3.5. Working with Community-based Groups: The Experience of the Philippine
Health Insurance Corporation
Ruben John Basa52
Background
Building on the gains of the Medicare Program implemented for two and a half decades but
covering only the employed sector, the National Health Insurance Program (NHIP) was
launched in 1995. The Philippine Health Insurance Corporation (PhilHealth) was charged
with administering the program designed to provide all Filipinos with financial access to
health services within 15 years. PhilHealth is a government corporation attached to the Department of Health for policy coordination.
PhilHealth has five major membership categories and they are as follows: For formally employed workers in the government as well as in the private sector, enrolment is compulsory.
Contributions are paid through payroll deductions and currently set at 2.5 % of the salary
(although the law allows deductions of up to 3 % of the salary) and equally shared by the
employer and the employee. Currently, PhilHealth covers all government workers and 5.2
million out of an estimated total number of 9.0 million workers in the private sector.
Another group of affiliates are overseas workers who became entitled to health benefits since
March 1st of 2005. PhilHealth assumed Medicare functions for this sector although it was
already covered by a program albeit administered by another government agency. The very
poor are covered through the Sponsored Program (also called the Indigent Program)
launched in 1997. The program for the country’s poor was substantially boosted during the
past three years through heavy government support. To date, the Sponsored Program covers approximately 3.2 million families. The annual contribution of 1,200 Philippine Pesos (or
€ 18) is shared by the national and local governments.
In 1999, the Individually Paying Program (IPP) was launched in order to provide social protection in health to the extended informal sector. Retirees and pensioners become lifetime
non-contributing enrolees when they reach the age of retirement (usually 60 years) and after
having paid a minimum of 120 monthly contributions. In addition to the principal members,
the spouse, children below 21 years of age (and longer for persons with congenital health
problems) and also the enrolee’s parents above 60 years are entitled to PhilHealth benefits.
Altogether, PhilHealth is currently covering about two-thirds of the Philippine population.
PhilHealth provides a set of inpatient benefits and several outpatient packages including minor and ambulatory surgeries, normal deliveries, treatment of tuberculosis through direct observation therapy system (DOTS), dialysis, cataract extraction, among others. For inpatient
care, PhilHealth reimburses expenses for medicines, professional fees of doctors, room and
board, and x-ray and laboratory costs. There are more than 1,500 hospitals accredited by
PhilHealth, representing more than 90 % of the country’s health facilities.
The Individually Paying Program: The Challenges
The informal sector in the Philippines is extremely extended and heterogeneous because it
includes professionals, small entrepreneurs as well as street vendors. Covering the informal
sector is generally a major challenge for health care systems, and not surprisingly the PhilHealth Individually Paying Program (IPP) is currently facing a series of problems. First of all,
affiliation is developing slower than expected and only 2.7 million of the 16.3 million potential
target group have enrolled in the program. Thus, coverage is still limited to only 17 % of potential affiliates, and a high percentage of the informal sector remains uncovered in spite of
the existing PhilHealth program.
52
Head of Corporate Planning, PhilHealth, Philippines, [email protected].
Extending Social Protection in Health
107
Secondly, the IPP is confronted with adverse selection. In 2005, the utilisation rate for the
IPP was 3.9 % while wat is one percent point lower for all other affiliates. Moreover, utilisation for elective surgical procedures is higher for the IPP than the rest of the membership
groupings and a substantial portion of those enrolled who availed of the PhilHealth benefits
opted out of the system after utilisation.
Another major problem PhilHealth has to deal with is the low persistency rate that can be
observed among enrolees. While 2.7 million are registered IPP members, the estimated active membership is less than half. This is so even with the relatively relaxed qualification for
benefit availment - members can claim benefits even if contributions are paid at least for
three months.
Several reasons are responsible Figure 3.1.1: PhilHealth Program
for the low population coverage of
the IPP. One is the lack of information of the target groups. While
PhilHealth has managed to increase substantially its presence
in the provinces, it remains insufficient to reach potential informal
sector enrolees. The diversity of
the target market especially presents a challenge to the organisation. Although the target segment perceives a contribution of
PHP 1,200 per family a year as
reasonable, the nature and sometimes seasonality of income make
it difficult for many affiliates to
comply with the prescribed annual, semestral or quarterly payment
conditions. However, considering the increasing health care costs due mainly to medicines
that are particularly expensive in the Philippines, enrolling in the National Health Insurance
Program might increasingly become an attractive option.
Another identified weakness of the program is the fact that marketing is currently oriented to
individual members and not to potential target groups. The applied strategy does not only
imply administrative difficulties and high expenses for PhilHealth; the scheme is also not harnessing and taking advantage of the inherent strengths of organised groups throughout the
country. Clearly, the PhilHealth strategy to reach out to individual members fails to really involve the informal sector, while organised groups, co-operatives and other types of organisations may hold the key.
Model 1 – The POGI
In 2003, the PhilHealth Organised Groups Initiative (POGI) was launched with the support of
the German Development Cooperation (GTZ). Working with the organised groups (OGs)
represents a major policy shift for PhilHealth that had targeted only individuals since the implementation of the IPP. It also provided PhilHealth the opportunity to make some enhancements in a series of processes particularly with regard to contribution collection and remittance, to administrative tasks, and others. The POGI was pilot tested in two regions (Regions
VIII and IV-A) with a total of 11 organisational groups joining the pilot program.
Under this scheme, co-operatives act either as marketing agents or contribution collectors or
both depending on the assessment of PhilHealth of their organisational and financial capacity. An assessment tool called COOP PESOS was developed for this purpose. To qualify,
each cooperative must enrol at least 50 members into the program. The incentives provided
to co-operatives depended on the roles the OGs were playing. A group deputised as collec-
R. J. Basa: Working with Community-based Groups: Philippine Health Insurance Corporation
108
tion and marketing agent receives an incentive of 3 % of the total premium collected and P10
for every new affiliation. The annual contribution per member remains at PHP 1,200.
Regardless of the type of membership, enrolees of the POGI scheme are entitled to all benefits available for PhilHealth beneficiaries. Thus, they can claim inpatient and selected outpatient benefits including ambulatory surgeries in any accredited hospital. Affiliates who pay the
full annual contribution are entitled to receive an additional outpatient package including diagnostic services and basic consultations in rural health units (RHUs).
Figure 3.1.2: PhilHealth Affiliation: Actual versus Potential
35%
31,0%
30%
24,0%
25%
20%
16,3%
15%
9,0%
10%
5,2%
5%
2,7%
1,8% 1,6%
0%
Government
Poor
Private
Informal
Actual
Potential
After the pilot implementation of POGI, PhilHealth formed a team composed by GTZ, World
Health Organization (WHO) and the International Labour Office (ILO) for assessing and
evaluating the progress of the program and making recommendations on how to further improve the collaboration.
The evaluation showed that 6 % of the potential members in Cavite (IV A) and 8.5 % in
Southern Leyte (VIII) eventually enrolled in the program. The relatively low membership rate
is attributable to various factors including the low education and awareness of the target
group on the one hand and the low availability of quality health services on the other hand. In
addition, however, the campaign for POGI coincided with PhilHealth’s massive enrolment in
the Sponsored Program in 2004 that was very successful in enrolling a high proportion of the
target group.
Generally, potential enrolees are interested in joining the program and they perceive the contribution fee as basically acceptable. While a number of co-operatives have offered loans to
members in order to pay for health insurance, the repayment by the member of these loans
has resulted in high delinquency rates. Many members encounter the inflexibility of the payment schedule a great limiting factor.
For the period reviewed by the evaluation team, PhilHealth’s benefit payment covered about
40 % of the beneficiaries’ total medical expenses. The rather limited coverage of household
expenditure on health is largely attributed to the unavailability of medicines and facilities in
government health facilities. On the other hand, PhilHealth also applies the policy of reimbursing only drugs included in the National Drug Formulary. A major problem remains the
extremely high dropout rate of POGI enrolees that varies between 75 and 85 % and is only
slightly lower than the 91 % dropout of informal workers prior to the implementation of the
initiative.
Extending Social Protection in Health
109
Model 2: The KASAPI
While the POGI gave valuable insights and lessons on how to deal with organisations at the
societal level, the evaluation has proved that the model was not able to provide answers to
the key issues of informal sector coverage through IPP. One of the limiting factors arose from
the design itself because the selected OGs had only limited reach in terms of affiliation and
small financial capacity. One of the key lessons to be learned from this initiative is the finding
that OGs involved must be capable of administering the program. Based on the POGI experiences, PhilHealth developed a new model called Kalusugan Sigurado at Abot-Kaya sa
PhilHealth Insurance (KASAPI) roughly translated as: Health is ensured and within means
with PhilHealth.
The KASAPI is implementing a number of essential changes compared to the POGI scheme
regarding the selection of co-operating organisations (OGs). While the latter was limited to
small-scale organisations, the new scheme is focussing on larger organised groups with a
minimum of 1,000 members and at least 70 % willing to enrol in the program. While PhilHealth selected the geographic region first and afterwards the OGs to affiliate to the POGI
program, for KASAPI PhilHealth started to select OGs that were able to meet the required
membership preconditions.
Co-operatives, micro-finance institutions and other groups intending to participate in the
KASAPI are also evaluated based on their operational, managerial and financial capacities.
In addition, as a major policy shift, PhilHealth is granting a contribution discount between 6
and 10 % depending on the size of the group. The organised group however, has the prerogative to pass on this discount to the member or not. The following table 3.1.1 shows the
increasing incentives through discounts given to OGs according to an increase in the number
and percentage of enrolees covered by the program.
Table 3.1.1: Financial incentives given to Organised Groups
Group Size
Percent of
Enrolled
4,000 and up
85 %
8A
P 1,083
70 %
7A
P 1,089
85 %
6A
P 1,094
70 %
5A
P 1,100
85 %
4A
P 1,106
70 %
3A
P 1,112
85 %
2A
P 1,117
70 %
1A
P 1,123
3,000 to 3,999
2,000 to 2,999
1,000 to 1,999
Members Band
Group Premium
Source: PhilHealth Office Orders on the KASAPI
Together with GTZ, PhilHealth has developed a special data system for the KASAPI scheme
in order to support the information technology needs of the program. An individual member
data record will be established for each enrolee and member-cards are given containing their
unique PhilHealth Identification Number (PIN). Moreover, new information collaterals were
developed for the program.
Currently, PhilHealth has already signed Memoranda of Agreement (MOA) with two of the
largest micro-finance institutions in the country, namely CARD – MBA (Centre for Agriculture
and Rural Development – Mutual Benefit Association, Inc), the insurance arm of the CARD
established in 1986 with about 116,000 members nationwide, 99 % of whom are women; and
TSKI (Taytay sa Kauswagan or Bridge to Progress) – established in 1986 that has currently
about 200,000 enrolees nationwide. Another interesting development is the fact that most
110
R. J. Basa: Working with Community-based Groups: Philippine Health Insurance Corporation
OGs that participated in the POGI are nowadays considering agglomeration in order to fulfil
the requirements to affiliate to the KASAPI scheme.
Conclusions
The collaboration of PhilHealth with OGs offers a win-win situation for all parties involved. For
PhilHealth, it provides the opportunity to approach its target of universal coverage through
group enrolment with a membership base that will hopefully be able to stay on with the program and to pay more regularly. For the OGs, the scheme offers the palpable advantage of
providing health insurance for members in order to prevent fraud and delinquency in the repayment of loans and other financial obligations. Information suggests that hospitalisation is
one of the main causes of member’s infidelity to the organisation. At the same time, the
scheme offers the potential of generating additional resources through the premium discounts. Moreover, with social health insurance as part benefit portfolio of the OG’s, they even
have the potential to attract more members.
For enrolees, membership in the social health insurance program provides them with the
needed coverage at the time of need. For social health insurance to flourish, however, the
health delivery system has to be able to respond to the needs of beneficiaries. A PhilHealth
card is only as good as the services available for affiliates.
References
ILO-GTZ-WHO Consortium (2005). Evaluation Report PhilHealth Organized Group Interface (POGI).
Manila.
Jowett, Mathew (2004). The Philippine National Health Insurance Programme in the Autonomous Region of Muslim Mindanao. GTZ, Manila/Eschborn (http://wwwusers.york.ac.uk/~mj14/PhilHealthinARMM.pdf).
McCord, Michael; Buczkowski Grzegorz (2004). CARD MBA – The Philippines. CGAP Working Group
on Microinsurance. Good and Bad Practices, Case Study No. 4
(http://www.oit.org/public/english/employment/finance/download/goodbad.pdf).
Miñoza, Lourdes Irene (2005). KaSAPI Program launched. GTZ/PhilHealth, SHInet, pp. 3+7
(http://www.gtzhealth-philippines.org/Documents/Shinet_Dec05.pdf).
Novalez, Manolito A. (2004). The PhilHealth Organized Group Interface (POGI): Expanding Reach of
the National Health Insurance Program to the Informal Sector. GTZ/PhilHealth, SHInet, pp. 8f, Manila.
Palacio, Miramar (2003). Partnership with Organized Groups. SHInet, p. 8, Manila
Perion, Annaliza S. (2004). POGI Pilot Test in Cavite. GTZ/PhilHealth, SHInet, p. 9, Manila.
Philippine Health Insurance Corporation (2003). Pilot Test of the Integration of Organized Groups in
the Informal Sector to the National Health Insurance Program. PhilHealth Program Management
Group for Membership and Marketing, Circular 31, p. 1, Manila.
Philippine Health Insurance Corporation (2005). Group Premium for Enrolment and Premium Remittance Through PhilHealth’s Organized Groups Partners., PhilHealth Program Management Group for
Membership and Marketing, Circular 22, pp. 1f, Manila
(www.philhealth.gov.ph/circulars/2005/circ22_2005.pdf).
Philippine Health Insurance Corporation (2006). Recording of Premium Contributions from Informal
Sector (Organized Groups). PhilHealth Finance Department, Office Order No. 0060 (Series 2006): 1.
Manila.
Philippine Health Insurance Corporation (2006). Amendment to Office Order No. 0060, s-2006. PhilHealth Finance Department, Office Order No. 0062 (Series 2006): 1. Manila.
Schneider, Pia; Racelis, Rachel (2004). The Impact of PhilHealth Indigent Insurance on Utilization,
Cost, and Finances in Health Facilities in the Philippines. PRPlus, Bethesda
(www.phrplus.org/Pubs/Tech039_fin.pdf).
Gottret, Pablo; Schieber, George (2006). Health Financing Revisited. A Practitioner’s Guide. World
Bank, Washington DC. Chapter 3: Risk pooling mechanisms, pp. 73-121 (siteresources.worldbank.org/INTHSD/Resources/topics/Health-Financing/HFRChap3.pdf).
Extending Social Protection in Health
3.6.
111
Health Coverage for All: Strategies and Choices for India
Indrani Gupta53
Why health insurance?
Health care is characterised by risks and uncertainty, both of which affect the welfare of individuals. There are two important types of uncertainty associated with health care, one that
concerns the time of occurrence of illness and the other around the effectiveness of treatment. This results in a situation where individuals often undergo severe and unexpected
economic hardships to cover their medical expenditures, especially hospitalisation. It may
also result in one episode of illness leading to several rounds of care seeking. This situation
can be avoided if a system exists, like health insurance, that can smooth out these economic
shocks and compensate individuals for their economic losses.
Health insurance can go a long way in alleviating the economic hardships emanating from
the uncertainty around health expenditures of individuals and households. Health insurance
can help to defer, delay, reduce or altogether avoid payment for health care incurred by individuals and households. The idea is to get financial protection against cost of illness by
spreading the risks so that the patient does not bear all the risks. Any system that allows this
is in a way a health ‘insurance’ system, including subsidised care. Thus, in its broadest connotation, many systems can exist that cover individuals for their health care burdens.
An insurance system uses the concept of risk pooling, which reduces variations in risks by
averaging the risks over large numbers and heterogeneous members, and therefore lowers
the probability of an event occurring within a group. The risks can be borne totally by one
agency or spread among various agents like insurers, patients, and providers. Risks can be
pooled only when there are large numbers of individuals seeking insurance and when the
risk of any one individual suffering the loss is statistically independent of that of any other.
Risk pooling is, therefore, the most efficient way of running insurance programmes.
In the recent past, many developing countries in particular, have been discussing health insurance as a part of health sector reforms. There are various important reasons for this interest in health sector reforms and health insurance. Social protection in health can contribute to reduce inequities. Since the health care burden via out-of-pocket expenses falls more
on those least able to pay, health insurance is seen as way of meeting the equity objective of
a functioning health care system. It can also help to overcome uneven quality of medical care
depending on geographic location, physician and type of disease being treated, as well as
waste and inefficiencies in the health care system. The aim of many countries to move towards universal coverage is not only to reduce inequities in access to health care, but also to
find ways of covering all citizens for essential health services.
And, last but not least, health insurance is considered an alternative to tackling the difficulties
in financing health services through taxation. Countries that are spending significant public
resources on subsidising the set-up of a health care sector need to continuously find resources to run the system. This is seen as a major obstacle in resource-constrained settings,
and health insurance is essentially seen as a viable mode of health financing. Ultimately,
countries want the health and health insurance system to meet the overall objectives of a
well-functioning health care system, which are: affordability, accessibility, availability and
quality. These must be ensured and delivered - keeping in mind the principles of a good
health care system: equity and efficiency.
Health outcomes and financing in India
While the country has made rapid strides since Independence in bringing down infant, child
and maternal mortality rates and in increasing the life expectancy of the population, progress
has not been as fast as hoped. India remains a country that has not yet been able to reach
53
Professor, Head of Health Policy Research Unit, Institute of Economic Growth, Delhi, [email protected],
[email protected].
112
I. Gupta: Health Coverage for All: Strategies and Choices for India
much closer to the goal of ‘Health for All’ for its population. The scenario of health outcomes
in India is characterised by continued poor health of the majority, especially the poor, high
maternal and child mortality; the dual burden of communicable and non-communicable diseases, the emergence of newer diseases like HIV/AIDS as well as the re-emergence of
some diseases like dengue fever and plague.
In terms of access to health care, the following stylised facts and conditions are of interest in
the context of health insurance. The private sector accounts for 82 % of all out patient visits,
52 % of all hospitalisations and nearly all private spending in India is out-of-pocket at the
point of service use. Studies show that the poor are much less likely to get hospitalised than
the rich, mainly because of the inability to pay and for lack of insurance; those above the
poverty line have more than double the hospitalisation rates of the worst-off. Those hospitalised spend 58 % of their total annual expenditure on health care, and more than 40 % of
hospitalised people borrow money or sell assets to cover expenses. Altogether, one quarter
of hospitalised individuals fall below the poverty line because of hospital expenses.
India continues to face scarce public financing of the health sector. The proportion of development expenditure in the combined budget for the central and state governments has gone
down from 65 % between 1980 and 2001 to less than 50 % in 2004-2005. The share of public health, primary care and family welfare in total expenditure is very low, and has experi54
enced a decline in the recent past. The ability of states to raise more revenue seems to be
limited, and in many states, expenditure on health has decreased in real terms. Finally, only
10 % of individuals have some form of health coverage. The section below discusses the
health insurance scenario in India in more detail.
Health Insurance in India
India’s health system offers various ways of health care coverage for individuals. In principle,
all citizens are entitled to receive health care in public facilities, while formal sector workers
and employees are covered through mandatory or social health insurance schemes, namely
the Central Government Health Scheme (CGHS) and the Employees State Insurance
Scheme (ESIS). Some workers have access to employer-managed facilities that might be
linked to an insurance company. In addition, voluntary public and private sector insurance
companies, NGO/voluntary sector schemes and community financing offer protection from
the financial burden of health.
Public health facilities
India has a large government-funded health care system for primary, secondary and tertiary
care. Despite an elaborate primary health care system, which was supposed to function as
the gatekeeper for referrals, most of the curative treatment is sought at tertiary care hospitals. Further, in spite of an extensive government network of hospitals, evidence indicates
that a large percentage of individuals visit private facilities both for outpatient care and hospitalisation. This is due to major quality issues in public sector health facilities like the lack of
availability of doctors, inadequacy of medicines and drugs, facilities not being open at the
designated hours, unfriendly services etc. Thus, despite a substantial cost difference, individuals prefer visiting private physicians and hospitals.
Social Health Insurance55
Employees State Insurance Scheme (ESIS)
The promulgation of the Employees’ State Insurance Act in 1948 envisaged an integrated
need-based social insurance scheme that would protect the interest of workers and their
54
In 2005-2006, it was 1.1% for the central government and 4.2 % for the state governments. Overall health
budget of centre and state combined has declined slightly and remains less than 1% of GDP. States contribute 80
% of the total health budget, and spend mostly on non-plan salary expenses.
55
This part is based mostly on Gupta/Trivedi 2005.
Extending Social Protection in Health
113
families in contingencies such as sickness, maternity, temporary or permanent physical disablement, and death due to employment injury resulting in loss of wages or earning capacity.
Following the promulgation of the ESI Act, the central government set up the ESI Corporation
to administer the Scheme. The ESI Act 1948, applies in the first instance to non-seasonal
factories using power and employing 10 or more persons and non-power using non-seasonal
factories and establishments employing 20 or more persons. The Act contains an enabling
provision under which the ‘Appropriate Government’ is empowered to extend the provisions
of the Act to other classes of establishments – industrial, commercial, agricultural or otherwise. Under these provisions, most of the state governments have extended the ESI Act to
certain specific classes of establishments such as shops, hotels, restaurants, cinemas etc
employing 20 or more persons (Ministry of Labour 1999). The ceiling wage for coverage is
Rs. 7,500 (= € 140) per month.
The Act extends to the whole of India and the administration of the ESI scheme is by an
autonomous body – the ESI Corporation. The Ministry of Labour oversees the operation of
the corporation. The ESIS covers about 7.9 million insured persons and about 30.7 million
beneficiaries. Employers and employees contribute 4.75 and 1.75 % respectively of their
wages.
The pre-payment set up, compulsory employer-employee contributions and ear-marked deductions on the one hand, and the fact that this scheme has been set up as part of the social
security net, makes this a typical social health insurance scheme, and the only one that fully
qualifies as one in India. However, many analyses have revealed that the ESIS system suffers from numerous quality issues including non-availability of drugs, waiting time and poor
services.
The Central Government Health Scheme (CGHS)
The CGHS was started in 1954 in Delhi with the objective of providing comprehensive medical care facilities to the central government employees (including pensioners) and their family
members. Beside central government employees, the scheme also provides services to (i)
members and ex-members of Parliament, (ii) judges of the Supreme Court and High Court
(both sitting and retired), (iii) freedom fighters, (iv) central government pensioners, employees of semi-autonomous bodies/semi-government organisations, (v) accredited journalists
and (vi) Ex-Governors and Ex-Vice Presidents of India. In addition, employees of the Accountant General of India are being provided these services in a few cities.
Contributions for becoming a cardholder range from Rs. 5 to Rs.150 (€ 0.10-2.80) per month.
The number of cardholders currently is about 1 million with the total number of beneficiaries
around 4.3 million. Facilities are provided to the beneficiaries through dispensaries, polyclinics and government-recognised hospitals and cover out patients facilities under all systems
of medicine, emergency services in allopathic system, free supply of necessary drugs, laboratory and radiological investigations, domiciliary visits to seriously ill patients and specialist
consultations both at the dispensary and hospital level.
The scheme, initially started in Delhi, was subsequently extended to 23 cities. This scheme
has all the important features of SHI, except three: individuals can opt out of the scheme,
though in reality, such attrition is low. But more importantly, the contributions are low and not
proportionate to earnings. Also, an autonomous body as in the case of ESIS does not perform the management of CHGS. As in the case of ESIS, the CGHS has also been plagued
by numerous quality issues and is not very popular among its beneficiaries, except for hospitalisation.
Employer managed facilities
Many corporate and public sector companies have comprehensive health schemes and
health facilities for their employees. Depending on the nature of the organisation, there are
either own health facilities, or tie-ups with insurance companies for coverage. Workers in the
plantation and mining industries, railways, defence, etc have their own health facilities,
whereas many others have comprehensive social protection through health insurance. In the
114
I. Gupta: Health Coverage for All: Strategies and Choices for India
private sector again, many of the factory set-ups have their own health facilities. However,
the coverage is restricted to the organised sector workers only, and most of the informal and
unorganised sector workers do not have these benefits.
Voluntary (commercial) health insurance
While the private health insurance market in India is still relatively untapped, there has been
a significant expansion in private insurance since the Privatisation Bill on the insurance sector was passed. To give a brief background: the Insurance Regulatory and Development Bill,
which was passed in Parliament in January 2000, allowed the insurance sector to open up to
private players. The Insurance Regulatory and Development Authority (IRDA) is the apex
body that has been created to ensure that the insurance sector operates in a fashion that is
consistent with the interest of the consumers. The General Insurance Company (GIC) was
converted into India's national re-insurer from December 2000, and all the four subsidiaries
working under the GIC umbrella were restructured as independent insurance companies.
The Indian Parliament has cleared a Bill on July 30, 2002 de-linking the four subsidiaries
from GIC. A separate Bill has been approved by Parliament to allow brokers, cooperatives
and intermediaries in the sector.
In addition to the four public sector general insurance companies and the Life Insurance
Corporation, India now has 16 life and 15 non-life insurers in the private sector. In addition,
Third Party Administrators (TPAs) have been allowed to operate in the health insurance market to facilitate cashless transactions and smooth administrative functioning of the insurance
market. The gross contribution has increased from around Rs. 95,220 million (€ 1.785 billion)
in 1999-2000 to about Rs. 161,280 million (€ 3.024 billion) in 2003-04 (IRDA 2004) and to
more than Rs. 180,000 million (€ 3.385 billion) in 2004-05 (IRDA 2005). The health premium
has shown an impressive eight-fold growth in the last five years reaching Rs. 17,322 million
(€ 325 million) in 2004-2005. These figures clearly reflect the contribution of the health segment to the overall growth of the insurance sector; while the latter is growing as a whole, the
health segment is contributing to this growth to a great extent.
The major share of the health insurance market is Mediclaim, the standardised product offered by the four public sector companies, National Insurance, New India Assurance, Oriental Insurance and United India Insurance. Mediclaim was until recently a reimbursement policy covering hospitalisation and domiciliary hospitalisation for a pre-specified period. There
are additional features like reimbursement of costs of medical check, claim free bonus, family
discount etc, but it excludes pre-existing diseases, HIV/AIDS, dental problems, pregnancy
related expenses etc. The private insurance companies are at present only 10-15 % of the
total health insurance market. The products that they offer are similar to Mediclaim, and a
few companies offer comprehensive products lumping life and health insurance.
In addition to Mediclaim and the private health insurance products, another policy that is offered by National Insurance Company and Life Insurance Corporation (LIC) of India is the
Critical Illness Policy. For example, the Critical Illness Policy offered by the National Insurance Company is an exclusive benefit policy for individuals in the age group 20-65 years
covering the following critical ailments: coronary artery surgery, cancer, renal failure, stroke,
multiple sclerosis, major organ transplants like kidney, lung, pancreas or bone marrow. A
similar policy, Asha Deep, is offered by LIC. Among the private sector companies also, several companies offer either stand alone or composite critical illness policies.
Finally, in an effort to offer low-priced insurance products to rural residents and vulnerable
sections, the public sector insurance companies were asked to introduce a Communitybased Universal Health Scheme with elements of subsidy for the below-poverty-line (BPL)
population. Under this scheme, the premium of Re 1 per day per individual and Rs. 1.50 for a
family of five, and Rs. 2 for a family of 7 was fixed. This scheme allowed reimbursement of
medical expenses up to Rs. 30,000 towards hospitalisation (b) cover for death due to accident for Rs. 25,000 and (c) compensation due to loss of earnings at the rate of Rs. 50 per
day up to a maximum of 15 days. However, this scheme did not take off in any significant
fashion, and remains more or less a scheme on paper.
Extending Social Protection in Health
115
Table 3.2.1: CHI with insurance company: some examples
Scheme/Cha
racteristics
Services covered
Beneficiary
Premium structure
Health/
Insurance
Composite company
Vimo SEWA, Hospitalisation expenses with an
Ahmedabad upper limit (Additional benefits of
Maternity cover, Denture and Hearing
Aid at subsidised rate for Fixed Deposit members)
SEWA union members - Urban and
Rural, their husband
and children
Vimo SEWA has 3 schemes
under the integrated package
1st
2nd
3rd
Member: Rs.85 Rs.200 Rs.400
Spouse: Rs.55 Ra.150 Rs. 325
Children: Rs. 100 Rs. 100 Rs. 100
Composite
ICICI
Lombard
and National Insurance
BAIF, Pune
Members of Self Help
groups of BAJF,
Individuals coming
from a family having
annual income considered as BPL, or
marginally above it.
Rs. 225 for SHG member and
Rs. 260 for others. (The additional benefits like, concession
at the health facilities and loan
for hospitalisation, can not be
extended to non-SHG members)
Composite
UIIC
Rag Picker’s. Hospitalisation, Standard jan Arogya
policy coverage with an upper cap
Insurance
and life cover
scheme,
Pune
Rag Pickers, kabadiwalaha, Dabbabatliwalahs
Membership fees - Rs. 25 and
LIC premium Rs. 25,
Age
below 45 - Rs. 70
46-55 - Rs. 100
56-65 -Rs. 120
66-70 Rs. 140, Paid by Municipal Corporation
Family floater: Same premium
for spouse and 50% for a child.
Composite
New India
Insurance
Co. Ltd.
CASP, Pune
Hospitalisation (Up w Rs. 16000),
Domiciliary treatment (Up to Rs.
4000)
Needy and school
going children and
their families
Rs. 330 per family of a child,
parents and two siblings
Health
New India
Assurance
Co. Ltd.
Seba
Seba hospital is general hospital with
36 beds (6 ICU beds), OPD, specialty
clinics, pathology, X-ray. USG, ECG,
Echocardiography, Dental, GP clinic,
Emergency, Ambulance and domiciliary services at night
Middle – High-income
group of people both
rural and urban Mediclaim scheme.
Also open to patient
not under Mediclaim
Mediclaim and group Mediclaim - prescribed premium,
UTI - One time payment depending on the age of enrolment
Health
GIC group
(National)
Standard cover - Jan Arogya policy
Poor marginalised
women self help
group members and
their family members
Age
below 45-Rs. 70
46-55 - Rs. 100
56-65 - Rs. 120
66-70 - Rs. 140.
Family floater: Same premium
for spouse, Rs. 50 for a child
Health
Oriental
Insurance
Co. Ltd.
Population of (lie T.
Narasipura taluk in
Mysore district and
Rs. 30 per person per annum
for general population
For SC/ST and BPL population, the premium is fully subsidised.
For BPL and non-SC/ST population, the premium is subsidised to the extent of Rs.10
from the project funds and the
insured have to pay the balance amount
Health
National
Cooperative
Health Society Ltd,
Kolkata
Sri Mayapur
Vikas
Sangha,
Mayapur
Hospitalisation (Inclusive of maternity
extension) UP TO Rs. 5,000
Natural death Rs. 20,000
Death due to accident Rs. 50.000
Partial permanent disability Rs.
25,000
Total permanent disability Rs. 50,000
Annual health examination
Karuna Trust, lnsured amount for Hospitalisation
Mysore
Rs.2500/'- per year
Rs.50/ per day as wage loss Rs.50/per day for hospital for all services no prescriptions to be given (The
public health facilities should be
used. Private health services are not
covered). Ambulance services and
referrals (to district hospitals / state
level tertiary centre) included.
Baihongal tatuk in
Belgaum district,
focussing mainly on
BPL and SC/ST
population
BUCCS
(Buldhana
Urban Cooperative
Credit Society) Health
Insurance
Scheme,
Accidental death of member Rs.
Rural population of
25,000. If member is hospitalised for Buldana district,
more than 3 days al a time Rs. 50/mostly farmers
per day up to Rs. 750/-(i.e. 15 days).
Hospitalisation for member and
family (for one illness maximum limit
Rs 15,000 with internal sub limits on
various expenses) Rs. 30,000
Individual: INRs 365/-
Sri Mayapur
Vikas
Sangha,
Mayapur
Standard cover - Jan Arogya policy
Age
below 45-Rs. 70
46-55 - Rs. 100
56-65 - Rs. 120
66-70 - Rs. 140.
Family floater: Same premium
for spouse, Rs. 50 for a child
Poor marginalised
women self help
group members and
their family members
Insurance
Co. Ltd
Composite
United
India
Insurance
Co. Ltd
Health
Oriental
Insurance
Co. Ltd.
Family of 5 (husband, wife,
three children): INRs 548/Family of 7 (husband, wife, 3
children and insured’s parents): Rs 730
I. Gupta: Health Coverage for All: Strategies and Choices for India
116
A recent analysis of the voluntary commercial insurance sector, and in particular the penetration of Mediclaim, indicate that while health insurance is growing significantly, it is still much
below the potential market it can capture and there is still no spontaneous demand for the
product. There are hardly any incentives built into the current product that will make it attractive to younger people, the elderly or women. It is clear that individual householders do not
see much merit in buying health insurance and do so only when they perceive tangible health
risks. Other research and results indicate that those with lower ability to pay have a significant willingness to buy insurance, and those with some coverage through employment – the
middle class – have the least interest in purchasing additional insurance. Individual insurance
has remained relatively small compared to group insurance (corporate coverage) and current
products are not very flexible and customer-friendly. Furthermore, marketing and distribution
of such products are poor. The spread of voluntary insurance is still very low in spite of some
innovative partnerships that have been able to use the voluntary insurance sector.
Table 3.2.2: CHI without insurance company
Scheme/ Characteristics
Services covered
Beneficiary
Premium structure
Health/
Composite
AKHS, Ahmedabad
Registration and Consultation for any diseases any time, Yearly check up - Diabetes,
Hypertension
Members of Dairy
co-operative
No direct premium. 6 paisa per
litre of the milk is being calculated.
Health
Tribhuvandas
Foundation,
Anand
Members of TF are covered for primary care
and secondary care at their sub-centres,
hospitalisation at any of the eight empanelled
trust hospitals.
All families that
are pouring milk at
dairy cooperatives, irrespective of the
amount of the
milk.
Rs. 25/year/family for the membership of TF and pouring of
minimum 300-liter milk/year for
SPAM membership. The services
of TF sub-centres can be availed
by non-members at Rs.
10/year/family.
Health
Comm. Assisted Complete eye examination & Cataract surgi& Financial Eye cal service and other secondary level eye
Care – Pilot
care and minor surgical services.
Proect, L.V.
Prasad Eye
Institute Hyderabad
All individuals
Rs. 1/persons/month on yearly
pertaining, to rural basis.
areas of selected
villages in the
adopted areas.
Health
Sludtnt Health
Hcnw, Kalkita
Students
Health
Free consultation across all the specialties
medicine @ Rs. 2 per day
All
diagnostic tests @ subsidised rate
Hospital facilities:
Universal subscription @ Rs. 4
per year/student
Individual membership @-Rs.
60/year
Admission charges for medical investigation
Rs. 25
Adm. Charges for surgical
Maintenance charges per dav
Rs. 75
Rs. 10
Surul Health co- Primary health care and minor surgeries
operative,
Shantiniketan
Poor people of
surrounding villages in Biribhum
district, West
Bengal
Membership Rs. 30 per year
Health
The insurance companies clearly stand to gain by expanding the market, and can offer even
lower premiums if they are able to attract more households and individuals. Tailor made
schemes with specific incentives to attract various segments of the population is clearly indicated as a business strategy, with benefits that can be distributed to the policyholders
through lower premiums. This strategy is also useful viewed from the perspective of the
country, where lack of sufficient health coverage seems to be hindering the achievement of
the Health for All objective. The way to utilise the growing private insurance sector in India is
to forge productive partnerships among insurance companies, community based organisations and different government levels. A new development in the recent past has been an
increasing number of 2 or 3-ways partnerships among the government, NGO/CBO and insurance companies. These are examples of both community health insurance as well as
commercial insurance, and in the cases where the government sector is included, of public
Extending Social Protection in Health
117
sector involvement as well. It is increasingly felt that to meet the requirements of the uncovered rural, informal and other vulnerable population, such partnerships and collaborations
may be the only option, with government being an active counterpart for financing as well as
provision. There are currently several such instances of partnerships, where the main beneficiaries are communities which get low cost health insurance. However, such partnerships
need to be studied carefully, from the perspective of costing and subsidies involved, as well
as from the operational and financial feasibility angle.
Community health insurance (CHI)
The insurance companies clearly stand to gain by expanding the market, and can offer even
lower premiums if they are able to attract more households and individuals to the market.
Tailor made schemes with specific incentives to attract various segments of the population is
clearly indicated as a business strategy, with benefits that can be distributed to the policyholders by way of lower premiums. This strategy is also useful viewed from the perspective
of the country, where lack of sufficient health coverage seems to be hindering the achievement of the Health for All objective.
Figure 1: The three models of community health insurance in India
Type 1
Type 3
NGO
(ACCORD, JRHIS, SHH, VHS)
Premium
INSURANCE
COMPANY
Health care
Group
Premium
Reimbursement
COMMUNITY
NGO
(SEWA, BAIF,
Navsarjan and Karuna)
Type 2
NGO
Reimbursement
(RAHA)
Reimbursement
Premium
(Karuna Trust, Navsarjan Trust)
PROVIDERS
(KKVS, RAHA)
Premium
PROVIDERS
Reimbursement
(KKVS)
COMMUNITY
Reimbursement
(SEWA, BAIF)
Health care
Health care
COMMUNITY
Source: Devadasan 2005
Looking ahead
What is the extent of social protection in health in India if all these various arrangements of
social protection in health are counted? Table 3.2.3 gives an overview of the existing schemes and their estimated coverage in India. These are best guesses, since no firm numbers are
I. Gupta: Health Coverage for All: Strategies and Choices for India
118
Table 3.2.3: Health insurance coverage in India56
Schemes
Beneficiaries (in mill.)
25.3
4.3
The Employees State Insurance Scheme (ESIS)57
Central Government Health Scheme (CGHS)58
Railways Health Scheme
Defence employees59
8
6.6
Ex-servicemen
Mining and plantations (public sector)60
7.5
4
Health insurance (Public sector non-life companies)61
10
Health insurance (Private sector non-life companies)
0.8
62
Health segment of Life insurance companies (public + private sector)
State sponsored schemes
63
0.23
<0.5
Employer run facilities/reimbursement schemes of private sector64
6
Employer run facilities/reimbursement schemes of public sector65
<8
Community health schemes
Total
3
~85
Source: Gupta/Trivedi 2004b
available. These estimates, and many other analyses on the health insurance scenario in
India, indicate that any form of health coverage reaches only about 10 % of the population,
and those outside the formal/organised sector are the least and last covered. While the public health facilities are open to all, there are serious problems regarding quality and accessibility to be solved. The current system of health coverage caters to only a small percentage
of the population and has a tilt towards non-rural and formal sectors. Also, schemes like the
CGHS, Railways, Defence etc raise equity concerns. For example, 14 % of total expenditure
is spent on less than 0.3 % of the workforce (CGHS). Social health insurance and employment based health benefit schemes are constrained by the small extent of organised sector
employment (about 7 %). In addition, community-based health insurance has narrow limits
56
Coverage includes family members of the employees.
ESIS coverage as on March 2003.
58
CGHS coverage figures for 2003-2004.
59
Figures for the Railways and Defence as per the officials in the respected ministry
60
These figures are based on data from Director General Employment and Training, Ministry of Labour. Approximately 10 million employees work in these two sectors of the government, as of March 2002.
61
The number of policies for Mediclaim is about 2 million, which would yield roughly 10 million lives covered. No
firm estimates of this are as yet available in India.
62
The total number of lives covered has been calculated based on market share of private companies in the
health business (premiums), since there is no other reliable estimate.
63
All riders related to critical illness benefit, hospitalisation benefit and medical treatment.
64
Estimates are not available for this; private organized sector covered about 8.4 million employees in 2002.
Using a factor of 4, roughly 35 million individuals and their families can potentially be covered. ESI covers about
25 million, and a gap of 10 million remains, of which many are covered under group medical insurance. Insurance
companies cover about 11 million, and of these rough data indicate that about 40% is group policies (i.e. corporate sector); this implies about 4.4 million may be covered through insurance out of these 10 million individuals.
Plantation and mining workers and their families in the private sector are covered by government regulations and
amount to about 4 million individuals. This gives us a gap of 1.6 million. In the column, therefore, we have put a
figure of 6 million, which is under the assumption that all of these 1.6 million people may be covered and adding
the 4 million plantations and mining in private sector, and rounding off.
65
Public sector companies employ 2 million workers; if a family size of 4 is assumed, at most 8 million workers
and their dependents can be covered. However, not all PSUs offer health benefits/coverage.
57
Extending Social Protection in Health
119
due to organisational and technical constraints. The potential of private or voluntary insurance is currently limited due to both demand and supply side issues.
It is proposed that for achieving Health for
All, India must think of extending ‘Health
Coverage to All’. It has to find ways of covering the unorganised and self-employed
workers, those not employed: elderly, unemployed, students, and other vulnerable
groups like women and backward classes.
Moreover, the rural population will have to
be brought under the umbrella of social
protection in health as well. Essentially, any
way of including different income and risk
categories in the same pool has to be considered and analysed. In the recent past,
several studies have discussed and debated various experiments for extending
health coverage and recommended micro
and macro solutions to achieve greater
coverage There has been a multisectoral
approach not only to research studies, but
also in discussions, meetings, conferences
on health insurance with most of the major
stakeholders participating in the debate in a
productive fashion. Both the government central as well as state – and the supervisory commission IRDA have shown keenness and resolve to tackle the gap between
current coverage and the targeted coverage necessary to ensure better health care
options for the population.
What are the challenges and questions India
faces in thinking of the objective of Coverage for All?
o Should SHI be expanded?
o Payroll tax?
o Compulsory?
o How many schemes?
o Subsidies involved?
o Should CHI be encouraged and
scaled up to the extent possible?
o Feasibility and sustainability:
reinsurance possibility
o Collaboration with insurance
companies, government
o Subsidies involved
o Scaling up
o Should voluntary commercial insurance be used for the benefit of the
population?
o Product development
o Partnerships
o Regulation
o Role of the government
o Provider, insurer, finance
o How to increase budget allocations for the health sector?
Earmarked tax?
User fees?
Centre-state sharing?
Recently, the central government and a few
state governments have initiated schemes
for the uncovered population, especially the vulnerable sections of the society, under the net
of social security. For example, the Unorganised Sector Workers’ Social Security Act 2005,
Coverage for Handloom Weavers, Textile Ministry, a drug benefit plan from the Ministry of
Chemicals and Fertilisers, revamping of the CGHS scheme initiated by the Health Ministry
are some examples of different initiatives on health insurance. There are also instances of
several state level initiatives that have been undertaken with a view to cover the vulnerable
sections of society
However, it is argued that such a piecemeal approach to health coverage is unlikely to
achieve the objective of coverage for all, beside being a very inefficient and costly way of
going about extending coverage to the population. The way forward is to go back to the
drawing board, with experts, to chart out for the entire country: (a) who needs to be covered,
(b) how they can be covered, (c) what should be covered and (d) where they should go to
seek services. The discussion could go occupation-wise (formal/informal), or economic
status-wise (below or above the poverty line), or based on any other classification. At the
outset, a separate body for planning, implementing and monitoring health insurance should
be set up either within the Insurance Regulatory and Development Authority (IRDA) or outside it. The IRDA regulations can also be suitably altered so that regulation of health insurance is done separately from non-health products. It is also important to have serious and
immediate involvement of the many bodies that are directly or indirectly concerned with
health and health insurance, like the Planning Commission, Ministry of Health, Ministry of
Finance, IRDA, Ministry of Labour and the State governments. The recent partnerships
among government, NGOs, hospitals and insurance companies are very encouraging in-
120
I. Gupta: Health Coverage for All: Strategies and Choices for India
stances of what is possible if all this energy is harnessed properly by a systematic and wellthought out approach to health coverage for all.
Selected bibliography
Acharya, Akash; Ranson, Kent (2005). Health Care Financing for the Poor: Community-Based Health
Insurance Schemes in Gujarat. Economic and Political Weekly 40 (38), pp..4141-4150.
Ahuja, Rajeev (2004). Health Insurance for the Poor in India. Working Paper No. 123, Indian Council
for Research on International Economic Relations (http://www.icrier.org/wp123.pdf).
Ahuja, Rajeev; Narang, Alka (2005). Emerging Trends in Health Insurance for Low-Income Groups.
Economic and Political Weekly 40 (38), pp. 4151-4158.
Devadasan, Narayanan; Ranson, Kent; van Damme, Wim; Criel, Bart (2004a). ‘Community Health
Insurance in India: An Overview’, Economic and Political Weekly 39 (28) (July 10), pp. 3184-3188.
Devadasan, Narayanan; Manoharan, S.; Menon, Nandakumar; Menon, Shylajadevi; Thekaekara,
Mari; Thekaekara, Stan (2004b). ACCORD Community Health Insurance: Increasing Access to Hospital Care. Munnetra Sangham (AMS) Team Economic and Political Weekly 39 (28) (July 10), pp. 31793183.
Devadasan, Narayanan (2006). Health Insurance in India – current status and some suggestions for
the future. Presented at the Health Secretaries meeting New Delhi, Government of India, April 2006.
Ellis, Randall; Moneer, Alam; Gupta. Indrani (2000). Health Insurance in India: Prognosis and Prospectus. Economic and Political Weekly 35 (4), p. 207-217
(http://adfdell.pstc.brown.edu/classes/readings/ellala00.pdf#search=%22Worldbank%20Shaw%20Ains
worth%20financing%20health%20care%20user%20fees%20insurance%22).
Gupta, Indrani; Trivedi, Mayur (2004). Voluntary Insurance Sector in India. Partnering To Achieve
Greater Coverage For Health. Institute of Economic Growth, Delhi (http://iegindia.org/dis_95.pdf).
Health Cover for All: The State of Voluntary Health Insurance in India. IRDA Journal III (9), pp. 11-15
(http://www.irdaonline.org/irdacontent/journals/irda_aug05.pdf).
Gupta, Indrani; Trivedi, Mayur (2005b). Social Health Insurance: India. In Social Health Insurance:
Selected Case Studies from Asia and the Pacific. SEARO Regional Publication No. 42, WHO. New
Delhi.
Gupta, Indrani; Trivedi, Mayur (2005c). Social Health Insurance Redefined: Health for All through
Coverage for All. Economic and Political Weekly 40 (38), pp. 4132–4140 (Paper also available at:
http://iegindia.org/dis_ind_90.pdf, and
http://iegindia.org/dis_ind_90.pdf#search=%22Gupta%20Trivedi%20%22Social%20Health%20Insuran
ce%22%20India%20%22).
Gupta, Indrani; Trivedi, Mayur (2005d). A Few Ways Forward: The State of Voluntary Health Insurance in India. IRDA Journal III (9), pp. 36-41
(http://www.irdaonline.org/irdacontent/journals/irda_oct05.pdf).
Gupta, Indrani; Trivedi, Mayur (2006). Health Insurance: Beyond a piecemeal approach. Economic
and Political Weekly 41 (25), pp. 2525-2528.
Mahal, Ajay, Janmejay Singh, Farzana Afridi, Vikram Lamba, Selvaraju, V.; Gumber, Anil (2000). Who
Benefits from Public Health Spending in India? Results of a Benefit-Incidence Analysis for India. New
Delhi: National Council of Applied Economic Research, New Delhi. 2000 (sitemaker.umich.edu/fafridi/files/cv_afridi_.pdf).
Shariff, Abusaleh (1994). Employees State Scheme in Gujarat; Key Results of a Survey. Report prepared by the Gujarat Institute of Development Research, Ahmedabad.
Extending Social Protection in Health
121
3.7. Universal Coverage in Thailand: the Respective Roles of Social Health Insurance and Tax-Based Financing
Viroj Tangcharoensathien66, Phusit Prakongsai66, Walaiporn Patcharanarumol66,
Pongpisut Jongudomsuk67
Financing healthcare and insurance coverage prior to UC
This paper briefly describes the long journey in the process of extending social protection for
health and health insurance coverage in Thailand, until the goal of universal access (Universal Coverage - UC) to healthcare by all citizens was achieved in early 2002. It also describes
how the design and experiences in implementing Social Health Insurance contributes to the
design of the current UC scheme.
Reviews of financing healthcare
Total health expenditure (THE) in Thailand in 1994 was 127,655 million baht at current price
including capital formation. The THE had gradually increased during 1995-1997 and sharply
decreased in 1998 due to the 1997 economic crisis. However, in 2000 and 2001 the total
expenditure for health had slightly increased to 167,147 and 170,203 million Baht respectively (see figure 3.4.1).
Figure 3.4.1: Amount of Total Health Expenditure (THE) and the
ratio of Total Health Expenditure to Gross Domestic Product
(GDP), constant price (1994- 2001)
Amount of THE and ratio of THE to GDP, constant prices, 19942001
250.000
6,0%
200.000
150.000
100.000
4,0%
2,0%
GDP
Million bath
The ratio of THE to
Gross Domestic Product (GDP) at constant price was 3.2 %
in 1994 and peaked
at 3.9 % in 1997, the
year which Thailand
faced the economic
crisis. After that period the ratios of THE
to GDP had decreased continuously to
3.2 % in 2001.
The ratio between
50.000
government and nongovernment financing
0
0,0%
(mostly households
1994 1995 1996 1997 1998 1999 2000 2001
and
a
negligible
investment
Ratio of THE to GDP (%)
amount of donor resources in financing
healthcare) had gradSource Thai working group on NHA (2003)
ually changed over
the period between
1994 and 2001. The formerly dominant non-government role (56 %) in 1994 has reversed,
as in 2001 the government was responsible for 57 % of health expenditure (see Figure 2).
Population coverage
Prior to the achievement of UC in early 2002, successive governments employed a piecemeal approach of gradual extension of target population (targeting approaches) without
much effort to harmonise different insurance schemes (Tangcharoensathien et al. 2005). The
result was a fragmented insurance landscape. As shown in table 1, more than 2/3 of the
66
67
International Health Policy Program, Ministry of Public Health, Thailand, [email protected].
National Health Security Office, Thailand.
122 V. Tangcharoensathien, P. Prakongsai, W. Patcharanarumol, P. Jongudomsuk: Universal Coverage in Thailand
population were uninsured in 1991; this was reduced to more than half in 1996, and to
around 30 % in 2001 despite government efforts to extend coverage. The best performing
scheme, in terms of coverage extension is the social welfare scheme for the poor, which later
extended to cover the elderly (more than 60 years old), and children less than 12 years old.
The population coverage by various insurance schemes is shown in Figure 3.4.3.
Figure 3.4.2: Ratio of government and non-government source of healthcare financing (19942001)
M io . B a h t
1 8 0 ,0 0 0
1 6 0 ,0 0 0
1 4 0 ,0 0 0
1 2 0 ,0 0 0
1 0 0 ,0 0 0
8 0 ,0 0 0
6 0 ,0 0 0
55%
51%
48%
45%
52%
55%
1998
1999
43%
43%
56%
56%
4 0 ,0 0 0
2 0 ,0 0 0
44%
44%
45%
1995
1996
49%
57%
57%
0
1994
1997
G o v e rn m e n t
2000
2001
N o n -g o v e rn m e n t
Source: Thai Working Group on NHA (2003)
Figure 3.4.3: Insurance coverage extension 1991-2000
100%
28
21.6
19.7
20.3
1995
1997
1998
2000
% coverage
80%
60%
67.1
40%
20%
0%
1991
Social Welfare Scheme
Compulsory Social Security Scheme
Private Health Insurance
Civil Servant Medical Benefit Scheme
MOPH Voluntary Health Card
Uninsured people
Extending Social Protection in Health
123
Table 3.4.1: Population covered by various insurance schemes
Insurance Schemes
1991
1996
2001
Social Welfare
12.7
12.6
32.4
Civil Servants
15.3
10.2
8.5
Social Security
-
5.6
7.2
Voluntary H Card
1.4
15.3
20.8
Private HI
4.0
1.8
2.1
Total insured %
33.4
45.5
71.0
Total uninsured %
66.6
54.5
29.0
Sources: NSO Health and Welfare Surveys 1991, 1996 and 2001
Voluntary healthcare also performed well, increasing population
coverage from 1.4 % in 1991 to
20.8 % in 2001. The rapid increase
of coverage between 1996 to 2001
is due to the 50 % government
subsidy on the contributions to
households. As a result of downsizing, the population coverage of
CSMBS actually shrank, from 15.3
% in 1991 to 8.5 % in 2001. SHI
had limited capacity to extend its
coverage, as the formal employment sector was still small since
the vast majority of labour engaged
in the agriculture sector.
Main characteristics of health insurances
Table 2 is self-explanatory, describing the main feature of four public insurance schemes. A
large gap was observed in term of per capita budget subsidy, in favour of the CSMBS (1778
Baht per capita in 1996 (exchange rate: US$ 1 equal to 25 Baht) and against the Low Income Scheme (around 280 Baht). This table was produced and monitored on a regular basis
by the reformists. The table sends a strong signal to reformists that there is a need to minimise the gap of inequity through future harmonisation of different schemes.
Table 3.4.2: Salient Features of Health Insurance Schemes prior to UC
Scheme
CSMBS
SSS
LIC
VHC
Target beneficiaries
Government employees & dependents, retirees
Formal sector employees:
Poor, elderly,
children under 12
years
Non-poor and marginal poor household in rural areas
Population Coverage
7.62 millions
6.9 millions
17.7 millions
7.92 millions
Health Benefit
Ambulatory service & Inpatient
service (Public)
Ambulatory service
& Inpatient service
(Public & Private)
Ambulatory service & Inpatient
service (Public
designated)
Ambulatory service
& Inpatient service
(MOPH)
Payment to health
facilities
Fee-for-service,
reimbursement
Capitation
Budgeting
Budgeting
Contribution from
beneficiaries
None if using
public, Copayment for IP in
private hospital
Tripartite 1.5% (1650
-15000 Baht/month);
co-payment for maternity and emergency services if beyond
ceiling
Non contributory
scheme, full
funded by government
HH 500 Baht/yr
Financing Body
Ministry of Finance
SSO
Ministry of Public
Health
Ministry of Public
Health
Expenditure per
capita, 1996 (Baht)
1778
1428
>280 + cross
subsidy by public
hospital
534 + cross subsidy
by public hospital
Budget subsidy per
capita
1778
476
280
125
Source: Tangcharoensathien et al. 2003.
Gov. 500B/yr, almost no co pay
124 V. Tangcharoensathien, P. Prakongsai, W. Patcharanarumol, P. Jongudomsuk: Universal Coverage in Thailand
Reform contents and UC systems design
Reform contents: main objectives
There are several policy statements that reflect the reform objectives. Efficiency has to be
improved through a more rational use of healthcare by level, starting with primary care and
ensuring a proper referral system. A capitation contract model should contribute to containing
health care costs in the long term. Equally important is to ensure equity across schemes
standardising benefit packages, equal access to care by beneficiaries covered by the three
public insurance schemes, and enhance convergence and standardisation of the level of
resource use. Good governance has to be guaranteed, and conflicts of interest minimised
through implementing a clear purchaser provider split of functions,68 and the National Health
Security Broad. Board members are representatives from all key stakeholders, for example
governmental institutions, non-governmental organisations, and experts have to ensure that
the concerns from all stakeholders are taken in account. And, last not least, the quality of
care has to improve through an adequate accreditation system and utilisation reviews.
The Hospital Accreditation Institute has been functioning for the last six years, though the
accreditation is still on a voluntary basis, and not yet adopted as a condition for contracting.
The Contractual Unit for Primary Care (CUP) may require a new accreditation scheme, not a
conventional hospital accreditation system. In addition, due to geographical monopoly of the
District Health System (DHS), as the sole contractor in the district, there is no way to apply
quality as a condition for contract. The National Health Security Office (NHSO has got to
have a new mechanism of quality improvement for (DHS).
UC systems: harmonisation with SHI
The same group of reformists and researchers had a hands-on involvement in the systems
design of SHI in 1990s. In addition, they were involved in the subsequent evaluations of the
SHI. Evidence from these researches provide invaluable lessons for the systems design for
the UC scheme. SHI is the predecessor of the UC. For example, the contract model through
contractual arrangement with competitive public and private provider contractor hospitals
split the role of purchaser (Social Security Office) and health care
provision (public and private). However, the contract model for UC
scheme is only feasible in the context of comprehensive
geographical coverage of the Ministry of Public Health (MoPH)
healthcare infrastructure. The Closed-ended provider payment
method is one of the main features of the UC Scheme in Thailand.
Among a few developing countries, Thailand pioneers capitation
payment method for SHI and UC scheme. Not only capitation,
there is an additional payment for accident and emergency (A&E)
based on fee scheme, payment for high cost care based on fee
schedule.
Purchaser Provide split is another key feature of the UC scheme
design. The National Health Security Office serves as the
healthcare purchasers, designs the benefit packages and payment
methods, while the MOPH, other public and private medical institutions are major providers.
Comprehensive coverage is influenced by historical experiences that the Low Income
Scheme also provided a comprehensive service package including OPC, IPC, prevention
and Promotion. In order to minimise barriers to access care, neither deductibles nor copayment at point of services were introduced. The UC scheme has a nominal payment of
US$ 0.75 per visit or admission for UC members who are not previously low income card
holders.
68
NHSO serves as purchasers and scheme governance, while the MOPH and other public and private sectors
serve as healthcare providers.
Extending Social Protection in Health
125
Advanced features of UC Scheme
Learning from the systems design of SHI (Tangcharoensathien et al. 1999, Mills et al. 2000),
UC applied a better and more advanced design than the SHI. This is described in Table 3.
While SHI contracts with 100-bed public and private hospitals, the UC scheme contracts with
Primary Care Network, notably District Health Systems (including health centres and the district hospital). The UC scheme thus advocates primary care contact and enforces referral
lines, which support the use of close-to-client services and makes optimum use of tertiary
care provincial hospitals.
While SHI employs capitation inclusive for OP and IP services, there is a tendency of dumping IPC into OPC and limited admission to general margin especially by private for profit contractor hospitals. The payment methods designed for UC scheme has a separate method,
capitation for OPC and global budge plus DRG for IPC. The reformists do not apply a conventional DRG, due to empirical evidence of DRG creeping and false diagnosis. The global
budget would prevent the cost escalation. A separate payment for IP does not send a wrong
signal toward not admitting patients as clinically indicated.
Maternity and dental packages were historically separated out from the capitation in the SHI.
There is no point for the UC scheme to follow this precedent. The dental and maternity packages were integrated into the curative services. Historically, the SHI law only covers the employee, excluding their non-working spouse and children. This precedent does not help extend coverage of SHI. The UC scheme avoids repeating the same mistake by covering all
members in the household.
Table 3.4.3: Comparison of systems design between UC scheme and SHI
Service contractor
Referral
Payment
method
Dental, maternity
Coverage
UC Scheme
Primary Care Network, typical model:
health centres and district hospital, as
mostly rural population
Ensure better referral
Capitation for outpatient care, global
budget and case-based payment (DRG)
for inpatient care. This is to prevent under-admission of inclusive capitation
Integrated into curative package
All family members, individual member
card issued (not a family card)
SHI
100 bed-hospital, as mostly urban population
No referral, covered within the
contractor provider
Capitation inclusive of outpatient
and inpatient care
Separate packages
Maternity: flat-rate payment
Dental: fee-for-service + ceiling.
Higher administration costs
Employee, exclude non-working
spouse and non-adult children
Main features of UC scheme
Bear in mind that, prior to the UC era, there were gaps of inequity across different schemes,
in favour of the CSMBS and SHI and against the Low Income Scheme. In this reform, the
reformists and researchers strictly follow the principle of harmonisation across three public
insurance scheme and try to apply it as far as possible.
Regarding the existing benefit packages, standardisation between UC and SHI has to be
achieved for curative services regarding the comprehensive SHI package including surgery,
inpatient treatment, accident and emergency services, and high cost care. Drug coverage
needs to be adapted according to the National List of Essential Drugs in its various versions
126 V. Tangcharoensathien, P. Prakongsai, W. Patcharanarumol, P. Jongudomsuk: Universal Coverage in Thailand
from 1999, 2002, and 2004. In addition, personal preventive and promotion services have to
be established in order to fulfil the MOPH standards.
The exclusion lists were set at a minimum
level and affects, for example, aesthetic
surgical and curative services. Chronic
psychotic patients are not covered by the
insurance benefit package as a national
program for mental health is in place and
gives universal access to all citizens
suffering from psychopathic disorders.
Initially, anti-retroviral therapy (ART) for
HIV patients was suspended, pending
more evidence of government fiscal
capacity and cost effectiveness. Note that
the Prevention of Mother to Child
Transmission was covered in the package, as it was the government policy prior to the UC
scheme. Note also that by 2003, universal ART for all people living with HIV/AIDS (PLWA)
was adopted by the government. Renal Replacement Therapy for End Stage Renal Diseases
(ESDR) was also excluded from the package, as there is a long term cost implication and
poor health outcome.
There is a need to build up capacity on Health Technology Assessment (HTA) in Thailand in
order to generate evidence on Cost Effectiveness of new interventions as well as long-term
budget impact analysis. HTA will guide policy decision on adopting new technologies and
registration of preferred public or private Contract Units of Primary Care (CUP). The requirement of contract model is registration with a provider. In the UC scheme, the typical CUP is a
District Health System in rural areas (district hospital + 5-10 health centres). The total number of CUP is 700 throughout the country, each responsible for ca. 70,000 people.
Table 3.4.4: Capitation rate and its components:
Baht per capita, 2002-2005
2002
2003
2004
2005
OP
574
574
488
533
IP
303
303
418
435
P&P
175
175
206
210
A&E
25
25
20
25
High cost
32
32
66
99
-
10
10
10
93
83
85
77
Adj remote areas
-
-
10
7
No fault liability
-
-
5
0
1202
1202
1309
1396
Pre hosp care
Capital replacement
Beneficiaries are entitled to individual
prevention and promotion services
and to free curative care at the registered CUP. For hospital admissions
and operations, a flat-rate co-payment
of 30 Baht (€ 0.62) is charged, but the
previous Low Income Card holders
are exempted. The CUP ensures
proper referral to upper levels of care
if needed, then the CUP serves as a
fund holding for OP services, the CUP
pays for referral OP services. Persons
who bypass the registered CUP are
liable to pay full charges. Beneficiaries
have the freedom to access any
healthcare providers, if not registered,
at their own cost.
Provider payment is based on a capitation method for outpatient services, prevention and health promoUSD
30
30
33
35
tion. Accidents and emergencies outside registered providers is paid on a fee schedule set and centrally managed by NHSO.
Inpatient services are paid by global budgets plus fees per case (DRG) at provincial level.
Currently, the global budget is set at the provincial level, but in the future it will be regulated
at national level.
Capitation Baht
Extending Social Protection in Health
127
The International Health Policy Program (IHPP) has estimated capitation rate based on actuarial estimations for the government in Fiscal Years 2001-2006. The capitation rate was peer
reviewed by national partners and the steering committee; and the Fiscal Year 2002 underwent an external peer review by the ILO headquarters (see table 3.4.4).
Achievements
By early 2002, there were three public insurance schemes covering 96 % of the population, though 4 % are still uninsured. As
a result, by early 2002, there were three public insurance
schemes. Government employees and their dependants, covered by the Civil Servant Medical Benefit Scheme form 10% of
the population. The Social Health Insurance covers the private
sector employee who form 13 % of the population. Unfortunately it fails to cover spouses and other dependants. The UC
Scheme covers the rest of the population, 74 % in total,
though 4 % are still uninsured. Payment of healthcare providers is dominated by the close-end method in SHI and UC
Scheme; the exception is CSMBS which applies a fee-forservice reimbursement model.
Table 3.4.5: Health insurance schemes, early 2002
Scheme
Target Population
Coverage
Source of fund
Payment method
Civil Servant
Medical Benefit
Scheme
Since 1963
Government employee, retiree and
dependants
6 million, 10%
General tax, non
contributory
Fee for service
reimbursement
model
Social Health
Insurance*
Since 1990
Private sector employee
8 million, 13%
Payroll tax tripartite
contribution
Capitation inclusive
OP, IP
UC Scheme
Since 2002
Rest of population
47 million, 74%
General tax, non
contributory
Capitation OP and
P&P. global budget
and DRG for IP
Lessons learned: a long march towards UC
It has really been a long march towards the UC Scheme. Thailand took 27 years of gradual
coverage extension to formal and informal sectors, since a formal government policy on propoor financing policy (Low Income Scheme) began in 1975. Universal Coverage was completely achieved in April 2002. The new UC Scheme is a general tax financed, noncontributory, public mandatory scheme. The Scheme replaces the previous two public insurance schemes – the tax financed free care for the poor, the elderly and children under 12
operating since 1975 and the subsidised public voluntary insurance (the Health Card
Scheme) for the non-poor operating since 1983, and includes the previously uninsured 30%
of total population.
Achievements of UC Scheme 2002-2005
Population coverage
Evidence from the Health and Welfare Survey conducted by the National Statistical Office
indicated that the beneficiaries of the UC Scheme are mostly the poor – 25 % belong to the
poorest quintile and 25 % belong to the poor quintiles (see Figure 3.4.4). In contrast, CSMBS
covers mostly the rich group; 52 % belong to the richest quintile. Among SHI members, 49 %
belong to the richest quintiles. This confirms the findings by Suraratdecha et al. (2005).
128 V. Tangcharoensathien, P. Prakongsai, W. Patcharanarumol, P. Jongudomsuk: Universal Coverage in Thailand
Figure 3.4.4: Scheme beneficiaries by income quintiles, 2004
100%
10%
17%
80%
49%
52%
23%
60%
40%
26%
20%
11%
31%
25%
14%
25%
7%
4%
5%
1%
CSMBS
SSS
0%
Q1 (poorest)
Q2
Q3
Q4
UC
Q5 (the richest)
Source: NSO Health and Welfare Survey 2004
Financing of UC scheme
Figure 3.4.5: Discrepancy of the proposed & approved capitation rate FY2002-2006
2.000
Baht per capita
1.500
1.447
1.202
1.512
1.788
1.670
1.202
1.309
1.901
1.659
1.396
1.000
500
2002
2003
Proposed
2004
2005
2006
Approved
The IHPP calculates capitation rates based on utilisation rate and unit cost of services at
different levels of institutional care for 2002 to 2006. See Figure 5. Due to fiscal constraints, it
results in a discrepancy between the proposed and approved figures. At hospital levels, the
fiscal constraint is cross-subsidised by other schemes such as CSMBS and the balances
from the past years of operations.
Extending Social Protection in Health
129
Table 3.4.6: Utilisation by UC members
Evidence from the National Statistical Office
(NSO) Health and WelOP million visits
IP million admission
Level of care
fare Survey (HWS),
2001
2003
2004
2001
2003
2004
prior to UC scheme in
Primary Care
29.7
43.7
63.8
2001, and after the
Unit
scheme in 2003 and
2004 indicated a sigDistrict hosp.
19
36.7
46.2
1.1
2.1
2.2
nificant increase in
Provincial Hosp.
24.5
14.8
20.1
2.1
1.4
1.8
utilisation of OP and IP
and significant reorienAnnual changes
tation of service utilisaPrimary Care
47%
46%
tion by beneficiaries
Unit
towards the use of serDistrict hosp.
93%
26%
91%
5%
vices at district health
systems (DHS). PriProvincial Hosp.
-40%
36%
-33%
29%
mary care units and
Source: NSO HWS2001, 2003 and 2004
district hospitals are the
major providers especially in ambulatory care. This is a good message. There was a major shift of utilisation from
tertiary provincial hospital to primary care unit and district hospital both for outpatients and
inpatients. The system design of the reform is very important for efficiency improvement. In
view of the under-funding, and significant increase in utilisation among UC members, there is
a danger of financial collapse among some public hospitals.
Utilisation and profiles
Who benefits from public subsidies?
A Benefit Incidence Analysis was conducted by IHPP in
order to compare pre-UC 2001 and post-UC 2004
using NSO HWS 2001 and 2004 (Limwattananon et al.
2005). For OP care, in the post UC 2004 phase, the
pro-poor subsidy was very pronounced at DHS. The
Concentration Index was - 0.3326 and - 0.2921 for
Health Centre and District Hospital respectively. It is
less progressive at provincial hospitals (PH) as the CI
is - 0.1496.
For inpatient care, there is more progress in favour of
the poor at DH, the CI is - 0.3130 in 2001 and - 0.2666
in 2004. However, we observe less progress in favour
of the poor at PH, the CI is - 0.1104 in 2001 and 0.1221 in 2004. In conclusion, the pro-poor subsidy
was strongest for DHS. DHS plays a key role in fostering the pro-poor nature of public subsidy; as it is a
close-to-client-service and better accessed by the rural
poor population.
Impact of UC: Catastrophic illnesses, impoverishment
IHPP conducted an assessment of catastrophic illness and impoverishment caused by medical bills by using national representative household survey dataset from NSO SES 2000
(24,747 households for pre-UC), compared with SES 2002 (34,785 households) and 2004
(34,843 households) as post-UC phase (Limwattananon et al. 2005). An exciting finding indicates that the incidence of catastrophic health expenditure (as measured by more than 10%
of total household consumption expenditure) has reduced from 5.4 % in pre-UC 2000 to 3.32.8 % in post-UC 2002-2004. On impoverishment, the increase in the poverty headcounts
130 V. Tangcharoensathien, P. Prakongsai, W. Patcharanarumol, P. Jongudomsuk: Universal Coverage in Thailand
due to OOP payments dropped from 2.1 % in pre-UC to 0.8-0.5 % in post-UC phases. In
conclusion, the reduction in the catastrophic illness and impoverishment due to OOP is evident after the UC reform. As the UC scheme provides a comprehensive coverage of health
care (OP, IP, A&E, dental services and high cost care) with a very small nominal fee at point
of service.
Why general-tax-financed UC Scheme?
An EU funded EQUITAP study (O’Donnell et al. 2005) estimates a Concentration Index of
various sources of healthcare finance in Thailand for 2002, using NSO SES data and National Health Account. CI, an index of the distribution of payments, ranges (-1 to 1), a positive
(negative) value indicates the rich (poor) contributes a larger share than the poor (rich), a value of zero is when everyone
pays the same irrespective of
Table 3.4.7: Various sources of financing healthcare
ability to pay. Based on macro
financing using the National
Concentration Index
Weight
Health Account, and microDirect tax
0.9057
0.1868
level household survey by the
National
Statistical
Office
Indirect tax
0.5776
0.3155
Socio-Economic Survey (SES);
Social insurance
0.5760
0.0582
empipirical evidence indicates
Private insurance
0.3995
0.0668
the total health financing in
Thailand is quite progressive,
Direct payments
0.4864
0.3728
the CI-index equals to 0.5929.
Total Health Financing
0.5929
Direct tax is the most progressive source for financing health
care achieving the largest CI of
0.9057. Indirect tax and social insurance contributions are similarly less progressive than
direct taxes, the CI is 0.57. Social health insurance contribution should be more progressive, but it cannot achieve a strong progressive effect as the maximum payroll was constraint
at 5 times the minimum wage. The CI for general tax (direct and indirect) at 0.6996, estimated by the consultant is quite satisfactory, as it is more progressive than the income related SHI contribution. If Thailand would go for the contributory scheme for the informal sector (similar to that applied by Phil Health), the best option is income-related contribution
(more complex than a few bands of fixed contribution), the progressive effect of SHI contribution would be less than using general taxes.
General Tax
0.6996
Future challenges
Taking into account the increasing prevalence of chronic non-communicable diseases in
Thailand, the poor performance in term of effective coverage of essential interventions, efforts should be made to improve early detection, increase treatment coverage and effective
control of, for example, diabetes, hypertension, hypercholesterolemia and obesity. Effective
prevention of injuries is currently the government policy. Renal Replacement Therapy (RRT)
for chronic kidney disease patients is not covered by UC Scheme, while SHI and CSMBS
provide full coverage. RRT results in catastrophic health expenditure by UC households. In
such a context, evidence based policy decision is vital as it has huge long-term financial implications for the government.
IHPP contributes to this policy analysis. The cost per life year saved (Teerawatananon et al.
2005) for peritoneal and haemodialysis is estimated at € 8,135 and 8,392 respectively. When
compared to the cost per life year saved (Lertiendumrong et al. 2005) by anti-retroviral therapy, € 5, RRT is 18 times as expensive as the current national universal ART program.
Compared to Thailand’s GNI of € 2,032 per capita (WDR 2006), the cost per life year saved
for RRT is 4 times of GNI per capita, which is beyond the benchmark of not more than 3
times of GNI as recommended by the Commission of Macro-Economic and Health, and not
more than 1 time of GNI as recommended by UK NHS. In term of cost effectiveness, RRT is
Extending Social Protection in Health
131
not recommended; however, IHPP recommends the government to include RRT in the UC
Scheme package, on the grounds of catastrophic expenditure to the households, as well as
ethical considerations of not extening RRT to UC members. In such cases, universal access
to RRT consumes a huge proportion of UC resources and since it is not possible for the government to provide RRT for all ESRD patients rationing is unavoidable. IHPP is working with
its partners to conduct public consultation of their perspective of selective access to RRT.
References
Lertiendumrong, Jongkol; Yenjitr, C., Tangcharoensathien, Viroj (2005). Cost and consequence of
ART policy in Thailand, Background paper: Economic evaluation of Anti-retroviral policy. Jointly
funded by IHPP and World Bank, Nonthaburi, International Health Policy Program, Ministry of Public
Health, Bangkok.
Limwattananon, Supon; Tangcharoensathien, Viroj; Prakongsai, Phusit (2005). Equity in health care
utilisation and public subsidy in Thailand – a transition to the universal access to health care. Nonthaburi, International Health Policy Program, Ministry of Public Health.
Mills, Anne; Bennett, Sarah; Siriwanarangsun, Porntep; Tangcharoensathien, Viroj (2000). The response of providers to capitation payment: a case-study from Thailand. Health Pol 51 (3), pp. 163-180.
National Statistical Office. Health and Welfare Surveys (various years). Bangkok, Office of the Prime
Minister.
O’Donnell, Owen; van Doorslaer, Eddy; Rannan-Eliya, Ravi; Somanathan, Aparnaa (2005). Explaining
the incidence of catastrophic expenditures on health care: Comparative evidence from Asia. EQUITAP
Project, Working Paper No. 5 (http://www.equitap.org/publications/wps/EquitapWP5.pdf).
Suraratdecha, Chutima, Saithanu, Somying, Tangcharoensathien, Viroj (2005). Is universal coverage
a solution for disparities in health care? Findings from three low-income provinces of Thailand. Health
Policy 73 (3), pp. 272-84.
Tangcharoensathien Viroj; Supachutikul, Anuwat, Lertiendumrong, Jongkol (1999). The social security
scheme in Thailand: what lessons can be drawn? Soc Sci & Med 48 (7), pp. 913-923.
Tangcharoensathien Viroj; Pitayarangsarit, Siriwan, Srithamrongswad, Siriwan (2003). Mapping health
insurance in Thailand-directions for reform. Global forum for health research, pp. 109-135.
Tangcharoensathien Viroj; Teokul, Waranya, Chanwongpaisarn, Lalita (2005). Challenges of implementing universal health care in Thailand. In: Kwon, Huck-Ju (ed.). Transforming the Developmental
Welfare State in East Asia. UNRISD publication, Palgrave Macmillan.
Teerawattananon, Yot; Mugford, Miranda, Tangcharoensathien, Viroj (2006). Economic evaluation of
palliative management vs. peritoneal and hemodialysis for end-stage renal disease: evidence for making coverage decision in Thailand. Value in Health.
Thai working group on NHA (2003). National Health Account 1994- 2001, Final report. Nonthaburi:
International Health Policy Program Thailand/Health Systems Research Institute. ISBN 974 465 625 5.
Acknowledgements
We wish to acknowledge the contributions by various partners, notably, international partners including ILO for peer reviews of capitation rate in 2002 and long term financing forecast for 20052020; WHO HQ and the Harvard University Professor Dan Wikler and Dan Block for studies in the
ethical dimension of RRT extension to UC members, and EU funded Equity in financing, health
utilisation and public subsidies in Asia Pacific (EQUITAP)
Our national partners are recognised, for example Thailand Research Fund for institutional grants
to IHPP, NSO for their national household surveys for UC program evaluations, National Health
Security Office (NHSO) and other partners who initiate, design and steer the UC scheme, and finally the MOPH who is the major healthcare provider in Thailand.
Finally, we wish to thank for the invitation by GTZ-ILO-WHO to Berlin Conference. It provokes the
writing up of this short report.
132
4.
X. Scheil-Adlung,G. Carrin, J. Jütting, K. Xu: Impact of social health protection in three African countries
Implementing Social Health Insurance: Learning from Evidence
4.1. Impact of social protection on access to health care, health expenditure
and impoverishment - A comparative analysis of three African countries69
Xenia Scheil-Adlung70, Guy Carrin71, Johannes Jütting72, Ke Xu71
Introduction
Despite progress, the achievement of the Millennium Development Goals (MDGs) will not be
easy and remains an important challenge. A better protection of the poor against health risks
is crucial in this endeavour. Obviously, poor health drastically impedes the social and economic development of a country: beyond directly affecting people’s well-being (reduced life
expectancy, high infant mortality, spread of infectious diseases etc.) poor health also lowers
the productivity of labour and menaces the entire economy.
Access to health services typically requires out-of-pocket payments. According to WHO
(2003) data, out-of-pocket payments (OOP) account for 1/3 of total health care spending in
2/3 of all low-income countries. In most African countries the amount of OOP is well above
this average (Drechsler/Jütting 2005). Such payments can lead individuals or households to
reduce their expenditures for basic needs such as for food, housing and clothing, to borrow
money and to sell household and production assets. As a result, some families are pushed
into poverty. Furthermore, out-of-pocket payments may lead to denied access to needed
services or prevent the receiving of a full course of needed treatment. This might result in a
vicious cycle of poverty from which it is difficult to escape in an already impoverished environment. Providing access to affordable health services can alleviate the financial burden of
households and improve their ability to generate income.
Recently, there has been an increasing focus on social health protection via health insurance
as a potentially promising way to better deal with health risks in developing countries. However, the empirical basis for a profound analysis of the effects of health insurance is still very
thin. Against this background the ILO, WHO, and the OECD Development Centre sponsored
by GTZ have undertaken a collaborative research project in this field. This paper summarises
the results of three individual research projects (Asfaw 2005; Lamiraud et al. 2005; Xu et al.
2005) measuring the impact of membership in a health insurance scheme in three African
countries, namely Kenya, Senegal and South Africa.
The structure of the paper is as follows. The first section briefly outlines the health care systems in Kenya, Senegal and South Africa followed by a short description of the methodology
and data used. The later sections focus on empirical results and policy implications.
Brief overview of organisation and financing of the health systems in Kenya, Senegal
and South Africa
The three countries selected vary substantially in economic development and health conditions (Table 1). South Africa is the richest country in sub-Saharan Africa; in 2001 its gross
domestic product (GDP) was 7,538 in terms of international dollar. In Kenya it amounted to
69
Original complete paper available at http://www.who.int/health_financing/DP.06.2.pdf.
International Labour Office. Geneva, [email protected].
71
World Health Organization, Geneva, [email protected]; [email protected].
72
Organisation for Economic Development and Co-operation Development Centre, Paris,
[email protected].
The author(s) write in their individual capacities and responsibility. They are indebted to Frikkie Booysen (University of Bloemfontein, South Africa), Karine Lamiraud (University of Lausanne), Abay Asfaw (currently IFPRI,
Washington), Stephen Muchiri (Ministry of Health, Kenya), Chris James, Somnath Chaterji and David Evans
(WHO).
We wish to acknowledge the financial support of the Deutsche Gesellschaft für Technische Zusammenarbeit
(GTZ) for this study.
70
Extending Social Protection in Health
133
1,452, and 1,323 for Senegal. Between 1990 and 2002, the percentage of the population
living below one dollar per day ranged between 26.3 %, the highest, in Senegal and 7.1 %
the lowest in South Africa. Kenya, with 23 %, lies close to Senegal.
Table 4.1.1: Kenya, Senegal and South Africa: Basic data
GDP in 100
million $
Population living
below 1 $ /day
1990–2002 in %*
Life expectancy
Child mortality
under 5 years
(Boys/Girls)
HIV/AIDS
Prevalence**
Kenya
1452
23
50.9
119/113
6.7
Senegal
1323
26.3
55.8
139/129
1
South Africa
7538
7.1
50.7
86/81
15.2
Sources:
* Human Development Report
2003 and 2004 (www.undp.org)
** Adult population; HIV/AIDS and work, global estimates, impacts and responses; ILO,
2004; All other data from the WHO-website
For life expectancy, Senegal has the highest rate among the three countries at 55.8 years. It
is followed by Kenya (50.9 years) and South Africa (50.7 years). Child mortality under 5 is
much lower in South Africa (86 per thousand for boys and 81 for girls) than in Kenya (119 for
boys and 113 for girls) and Senegal (139 for boys and 129 for girls).
Many African countries face the challenge of improving access to health care while struggling
with the burdens of the recent HIV/AIDS pandemic, other persistent infectious diseases and
severe overall economic constraints on financing of health services. Among the three countries, HIV/AIDS prevalence at 15.2 % among the adult population is highest in South Africa,
followed by Kenya, 6.7 % and Senegal with 1 %.
The organisational and financial arrangements of health systems play a critical role in improving health service access and protecting households from severe financial loss. All three
countries have an important tax-based component in their health financing system. In addition, various forms of compulsory and voluntary insurance schemes have been introduced in
a supplementary way. For example, in Kenya, we find a compulsory hospital insurance (organised by the National Hospital Insurance Fund - NHIF) that covers government and formal
sector employees and their family members, or 7 % of the population.
Other social health protection mechanisms include health maintenance organisations (HMO),
private health insurance, community-based health insurance and various mutual help groups
(Harambee). Children under 5 years old are entitled to free primary health services from public facilities. The poor are also entitled to free health care from public facilities in principle, but
there is no uniform standard on who, how much and what services are exempted. Kenya
passed a law on National Social Health Insurance in December 2004 which is an extension
of the current NHIS and with an attempt to cover the whole population.
In Senegal, company and inter-company health insurance institutions (IPMs) run the statutory social health protection scheme. Accordingly, formal sector workers and their families
are covered. Beside the statutory scheme, community based health insurance schemes have
emerged, particularly mutual health organisations (MHOs). In 2001 the coverage of IPMs
amounted to some 700,000 people and the number of persons covered in MHOs is around
422,000 persons in a total population of 9.8 Million (Fall 2002).
Social health protection in South Africa is split into public and private sectors. The large public sector covering 83.7 % of the population is financed by the state and offers basic care
depending on income testing. Government spending is used to provide service through public facilities to all people with various user fees for different services and at different administrative regions. The private sector consists of medical schemes, which often operate on a
community-rating environment based on risk profiles. Although social health insurance has
134
X. Scheil-Adlung,G. Carrin, J. Jütting, K. Xu: Impact of social health protection in three African countries
been under serious discussion in recent years, employment-based private insurance is still
the main type of scheme in the country.
Total health spending in the three countries includes prepayment through general tax, social
health insurance, private health insurance, and out-of-pocket payment. External resources
are also an important component for Senegal (16.9 % of total health expenditure) and Kenya
(16.4 %). Although both prepayment and out-of-pocket payment are expenditures made
eventually by households, they are fundamentally different in financing health care. Prepayment mechanisms improve equal access to services and protect households from financial
loss while out-of-pocket payments can be a barrier for accessing health services and a heavy
financial burden of ill health to a household.
Table 4.1.2: Organisation and financing of health care systems in Kenya, Senegal and South
Africa: Basic data
Total expenditure as %
of GDP
Kenya
Senegal
South Africa
Government
spending as
% of total
expenditure
Out-of-pocket
payments as
% of total expenditure
Private prepayments
as % of total
expenditure
4.9
44
44.8
11.2
5.1
45.2
43.6
11.2
8.7
40.6
12.4
47
Population
share covered
(%)
7 (NHIF)
11.4 (IMPs
and MOHs)
17 (all health
care plans)
Data and Methodology
Framework of the analysis
The definition of social health protection in this study is viewed broadly. It includes all kinds of
health financing protection mechanisms, from tax-based financing, statutory social health
insurance to private health insurance, community-based health insurance, and various fee
exemptions for health services. In this particular study, however, we focus on the net impact
of insurance mechanisms, including statutory schemes, various types of private non-profit
and for-profit health insurance, mutual benefit organisations and micro-insurance. This is not
to say, however, that all schemes stand alone and are able to protect against 'all' health care
costs. In fact, in quite a number of cases members receive indirect protection from government that may pay for health infrastructure, staff salaries, drug kits, etc. In other words, in
those cases the financial protection given to patients is ensured through a combination of
government funding and insurance revenues.
The analysis aims at highlighting the poverty implications related to ill health on all population
segments, including the poor, by evaluating the quantitative impact of health care costs on
households covered by health insurance schemes as compared to those without any health
insurance coverage. As tax-based funding normally benefits the entire population, it will not
be specified as one of the social health protection schemes in this study.
Out-of-pocket payments are part of a household's total health care expenditure that also includes health insurance contributions/premiums and even the imputed taxes allocated to
health through the government budget. However, in this study we concentrate on out-ofpocket payments. As previous studies have consistently indicated they are responsible for
triggering financial catastrophe for households. The analysis focuses on linkages between
the use of health services and households' financial risk on the one hand, and income and
health insurance status on the other. The key indicators in this study include: extent of coverage of social health protection, health service utilisation, catastrophic health expenditure,
financial sources for paying for health services and poverty impact.
Extending Social Protection in Health
135
These key indicators are estimated from cross-section household surveys. The comparison
focuses on the distribution across different socio-economic groups rather than the average
level of each indicator. The impact of social protection schemes on the use of services and
financial risk protection is identified after controlling other socio-economic indicators using
appropriate econometric methods. It also highlights the characteristics of vulnerable groups,
which need greater protection.
Variables defined
Coverage of social health protection: Coverage refers to the percentage of the population
covered by any health insurance scheme, including statutory schemes, various types of private health insurance, mutual benefit organisations and micro-insurance schemes.
Health service utilisation: Health service utilisation is measured by a ratio of the individuals
using services to those who reported illness (or need) in a certain period of time. The time
frame for utilisation varies from country to country depending on different survey instruments.
Catastrophic health expenditure: Catastrophic expenditure is defined as out-of-pocket payments for one or more household members equal to or above 40% of a household’s capacity
to pay. The capacity to pay relates to the constraint of reducing expenditure on other necessities for a period of time. It is measured as a household’s total expenditure minus its subsistence needs. The subsistence need is estimated using the food expenditure of the household
with the median food share in total household expenditure, which is then adjusted for household size. This subsistence need is used as the poverty line in the poverty impact analysis.
Out-of-pocket health payment refers to payments made by households at the time of receiving health services. Out-of-pocket payments typically include doctors’ consultation fees, purchases of medication and hospital bills. Although spending on alternative and/or traditional
medicine is included in out-of-pocket payments, expenditure on health-related transportation
and special nutrition are excluded. It is also important to note that out-of-pocket payments
are net of any insurance reimbursement.
Financial sources for health services payments: Financial sources used to pay for health services reflect the burden of ill health to a household. In addition to a reduction of funds available for other basic expenditure categories, borrowing money and selling of assets have
been reported in all three countries.
Poverty impact: Poverty impact includes the incidence and intensity of poverty due to out-ofpocket health payments. The incidence of poverty is measured by the percentage of households who were not poor before but become poor after paying for health services. This is
also referred to as impoverishment. The impact of intensity of poverty is measured by the
difference in the normalized poverty gap before and after health payments. The poverty gap
indicates the average amount per household that would be needed to bring all the poor
above the poverty line. As the currencies used by each country are different the normalized
poverty gap (the poverty gap divided by the poverty line) allows across country comparison.
Econometric models
A multiple logistic regression is used in exploring the socio-economic characteristics associated with the coverage of social protection. The same regression model is also applied to
testing the impact of social protection on health service utilisation, catastrophic expenditures,
financial burden and poverty impact by controlling all the other social economic indicators,
such as income, age, sex, education and so on.
Being aware that there could be unobservable characteristics which influence health insurance coverage, as well as health service utilisation and out-of-pocket payments, an endogeneity test is performed (using the Hausman test or the bivariate probit model) when the impact of health insurance membership was found to be statistically significant in the equations
for health service utilisation and out-of-pocket expenditure. In the three case studies the hypothesis of endogeneity could be rejected, however.
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X. Scheil-Adlung,G. Carrin, J. Jütting, K. Xu: Impact of social health protection in three African countries
Data
Data used in the research project are from 2003 household surveys. All the three surveys are
national representative. Data for both South Africa and Senegal are from the World Health
Surveys (WHS) using the same survey instrument. Data for Kenya are from the Household
Expenditure and Utilisation Survey (HEU). The instrument used in this survey is different
from the WHS. All the surveys include information on the coverage of social health protection, health service utilisation, household consumption expenditures, out-of-pocket health
payments, and general socio-economic indicators.73
Experience shows that in a household survey the more detailed the items on expenditures
the higher the number obtained. The different instruments used in these two types of survey
will compromise the comparability on the average level of catastrophic expenditure across
countries. However, the distribution across socio-economic groups among the three countries is still comparable. This also relates to the fact that the comparison is more focused on
the distribution rather than the level.
Furthermore, questions on health service needs were framed differently in the two types of
surveys. In the WHS the question asks when was the last time the respondent needed health
service with multiple choices on the duration of time, from last 30 days, to 1, 2, 3, 4, 5 years
ago. Obviously people are more likely to remember the occasions when they actually went to
see a doctor. In HEU, the question begins with whether the person was ill or not in the last
four weeks, which is a common approach to this question in many surveys. This difference
will make the utilisation rate less comparable across countries.
The impact of social health protection coverage: comparative empirical analysis
Coverage of social health protection
Although the level of coverage varies substantially in the three countries, the distribution
across income groups is fairly similar. The lower income groups have fewer people covered
by social health protection schemes compared to the higher income groups (figure1). In Kenya, for example, 2.3 % of the poorest
quintile are covered while the richest
Figure 4.1.1: Percentage of population
quintile has coverage of 24.7 %.
with social health protection
Results also show that higher popu30%
lation coverage at the national level
does not necessarily reduce the difference in coverage among income
20%
groups. Table 3 lists the results from
the multiple logistic regression. A
10%
positive sign indicates that the individual with that characteristic is more
likely to be covered by a social pro0%
tection scheme than those without
1
2
3
4
5
this characteristic given that all other
Senegal Kenya South Africa Quintile (poor to rich)
conditions are the same. A negative
sign indicates the opposite direction.
The results suggest some common socio-economic characteristics associated with the coverage of social protection in all three countries:
73
It should be noted that household consumption expenditures were collected differently in the two types of surveys. In the HEU, household expenditures were recorded in 38 items (excluding health expenditures) for one
month on frequent spending and one year on less frequent spending, such as purchasing of durable goods.
Health spending in HEU came from the health section. In the WHS, household expenditures were recorded in 5
items excluding health expenditure and all for one month. Health spending in the WHS is collected in the expenditure section in 8 items for a one-month period.
Extending Social Protection in Health
137
Income is the factor that has a positive relationship with social health protection coverage. The higher the income the greater the likelihood of being covered by a scheme.
This also confirms the descriptive results and the result holds in all three countries.
Education is another variable that shows the positive link to social health protection coverage across all three countries.
There is no significant difference in coverage between male and female, or by different
health conditions in all three countries. This implies that females and people with poor
health who need more health care services are not given special attention in the current
schemes.
Being employed is associated with social health protection in South Africa and Kenya as
in both countries main health insurances are employment-based. There is no significant
difference regarding the employment status in Senegal meaning that here employment
related health protection schemes do not cover significantly more or less persons than
other schemes.
People living in urban areas are more likely to be covered by a social health protection
scheme in Kenya and Senegal; the difference is not statistically significant in South Africa.
Ethnic groups, specifically the high-income English speaking population in South Africa,
are more likely to be protected than other groups.
Seniors in South Africa are more likely to be covered by social health protection
schemes, but not in Senegal and Kenya. In Kenya, this is due to the exclusion of people
over 65 years, who are not even eligible for membership in the National Hospital Insurance Funds, the biggest health insurance scheme in Kenya.
Table 4.1.3: Effects of indicators on social health
protection coverage
Indicators
South Africa
Kenya
Senegal
Income
+
+
+
Education
+
+
+
Sex
Ns
ns
ns
Health condition
Ns
ns
ns
+
+
ns
Ns
+
+
Ethnic group
+
ns
NA
Senior person
+
ns
ns
Employment
Urban
Note: Significance level is set at 5% level.
ns: not significant;
+: positive effect
NA, the variable is not available.
-: negative effect
Given the characteristics of the
insured population outlined
above, it can be concluded that
in all three countries the current social health protection
schemes are lacking coverage
of specific, most likely vulnerable, groups of the population.
The social protection deficit
concerns particularly households with low or no income,
persons without formal employment, women and rural
households. In Kenya and
Senegal, the elderly are particularly neglected. These excluded groups should be given
more attention when implementing and reforming social
health protection schemes.
Impact of social health protection on utilisation
Social health protection aims at ensuring access to services without causing financial catastrophe for the individual or the household, e.g. those who could otherwise not afford the
needed services. Therefore, in general, it is a desired result of social health protection that
the insured are more likely to use health services than the uninsured whose access is only
supported via the tax-based funding. Utilisation of health care services will probably increase
after implementation of social protection schemes if one considers currently prevailing underutilisation in developing countries (Dor/van der Gaag 1993, Müller et al. 1996). At the same
138
X. Scheil-Adlung,G. Carrin, J. Jütting, K. Xu: Impact of social health protection in three African countries
time the insured might use more services than necessary (moral hazard). The surveys used
in this study do not provide sufficient information to separate the moral hazard effect.
Results from all three countries in the univariate analysis show that the insured use more
outpatient services than the non-insured with perceived illness (figure 2). Concerning the reasons for not seeking care in Senegal, 85 % of respondents in the
Figure 4.1.2: Utilisation of outpatient
poorest income quintile cited "could
services
100%
not afford" as the principal reason,
whereas availability of services
80%
("could not get health care") seems
60%
to be a minor problem. Comparable
results were observed regarding
40%
the affordability of medicines pre20%
scribed (figure 4.1.3).
0%
What is the impact of health insurance on seeking care if needed?
uninsured
insured
In Senegal, among the group of the
non-insured, affordability of health
services is a major barrier for two
thirds of the non-insured as compared to one third of the insured. As regards affordability of
medicines prescribed, more than 63 % of the non-insured mentioned this reason, whereas
no insured person raised this issue (figure 4.1.4).
South Africa
Kenya
Senegal
Accordingly, financial barriers to access health services are conceived to be more important
than e.g. geographical barriers. The results of univariate analysis reveal further that the insured are more likely to get health care given need than the non-insured and less likely to not
seek care due to affordability issues.
Figure 4.1.3: Health Care Utilisation Indicators in Senegal
100
1st quintile
3rd quintile
5th quintile %
80
60
40
20
0
Need health Could not get Could not affordCould not get Could not afford
care
health care health care
most of the
to get the
medicine
medicine
Health Utilisation Indicators
The impact of social health protection on the use of health services is further examined using
a multiple logistic regression model. The regression is applied to the sample that reported
illness in a month previous to the interview. Results suggest that controlling the income, education, age, sex, employment status, urban/rural location, health condition and ethnic groups,
the insured uses more health services than the uninsured in South Africa and Senegal. In
Kenya, the impact of social protection on outpatient services is not statistically significant, as
the main insurance, the NHIF, does not cover outpatient services. For inpatient services, the
NHIF coverage has a positive effect at 20 % statistical significant level (table 4).
Extending Social Protection in Health
139
Figure 4.1.4: Health Care Utilisation by Insurance Status in Senegal
100
80
N o n -in s u re d
In s u re d
%
60
40
20
0
N e e d h e a lth C o u ld n o t g e t
c a re
h e a lth c a re
C o u ld n o t
C o u ld n o t g e t
C o u ld n o t
a ffo rd h e a lth
m o s t o f th e
a ffo rd to g e t
c a re
m e d ic in e
th e m e d ic in e
Other
socio-economic
indicators also influence
the use of health serviIndicators
South Africa
Kenya
Senegal
ces. Income and educa*
tion are found to have a
Insurance
+
ns (+ for inpat.)
+
positive effect on utilisaIncome
Ns
+
+
tion in both Kenya and
Education
Ns
+
+
Senegal but not in South
Africa. Urban location
Male
Ns
Ns
does not have a signifiHealth condition
Ns
NA
cant impact on utilisation
Employment
Ns
Ns
NA
controlling all the other
variables. Sex makes no
Urban
Ns
Ns
ns
difference on service
Ethnic group
Ns
Ns
NA
utilisation in South Africa
Senior person
+
ns
and Kenya, but females
are more likely to use
Note: Significance level is set at 10% level except * which indicate 20% level.
services controlling all the
ns: not significant;
NA: the variable is not available.
other indicators in Sene+: positive;
-: negative
gal. Use of health services by older persons varies among these three countries. Given all the other indicators the
same, in South Africa the senior population are more likely to use health services than other
age groups. An opposite situation is found in Kenya while in Senegal there is no significant
difference in the use of health service by the senior and non-senior population.
Table 4.1.4: Effects of indicators on health service utilisation
Impact of social health protection on poverty
Health services are essential to improve people's health and health is a necessary prerequisite to generate income. Payments required to access health services and illness-related
inability to carry out paid work affect greatly the financial situation of a household. In order to
cope with the financial loss some households reduce their basic needs spending, such as
expenditures for food, housing and clothing others sell their assets, fall into poverty or
deepen their current state of poverty.
Social health protection and catastrophic expenditure
In the following we analyse the impact of social health protection on catastrophic expenditure, income generation, households' strategies to finance health care costs and poverty alleviation. Catastrophic expenditure occurs when the required payments for health services
are equal to or exceed 40 % of a household's non-subsistence spending. Results show that
140
X. Scheil-Adlung,G. Carrin, J. Jütting, K. Xu: Impact of social health protection in three African countries
being covered by a social
protection program reduces
a household's financial loss
to a certain extent, but it
does not fully ensure that
the household is protected
from facing catastrophic
health expenditure. A simple tabulation result shows
that the percentage of
households with catastrophic expenditure is lower
among the insured than the
uninsured in all three countries while the magnitude of
the difference varies across
countries (figure 5).
Figure 4.1.5: Percentage of households facing
catastrophic expenditure
25%
20%
15%
10%
5%
0%
South Africa
uninsured
Kenya
Senegal
insured
The multiple logit regression results confirm that the insured households are less likely to
face catastrophic expenditure than the uninsured in Senegal (table 5). However, in South Africa
it only works for the richest
Table 4.1.5: Socio-economic characteristics associated quintile and in Kenya no significant impact emerges. This
with catastrophic health expenditures
result may not be surprising
Indicators
South Africa
Kenya
Senegal
given the fact that in South Africa, the rich enjoy a better
Insurance ns (first 3 quintiles)
ns
benefit package through different insurance schemes than
+ (4th quintile)
the poor who are only entitled
- (5th quintile)
to very limited benefit from
st
public program or low cost inIncome (1 quintile as control group)
surance schemes.
2nd quintile
Ns
ns
In Kenya the insurance cover3rd quintile
Ns
ns
age is mostly based on emth
ployment status and the main
4 quintile
+
insurance program, NHIF, only
5th quintile
covers inpatient service with a
high cost-sharing rate by paEducation
NA
tients. Two important results
Urban
NA
emerge from the analysis:
First, social health protection
Children < 5
NA
+
can help to better shield
Senior person
NA
ns
ns
households against financial
shocks. Secondly, however,
Note: Significance level is set at 10% level.
the current forms of health inns: not significant; NA: the variable is not available.
surance are far from being
+: positive;
-: negative
complete or perfect.
Other socio-economic indicators, such as rural locations are associated with a higher probability of facing catastrophic expenditure in all three countries. Further, households with
members under five years old are more likely to face catastrophic expenditure in Senegal
while the opposite result is obtained in Kenya. The policy of free services to children under
five years old in Kenya could contribute to this result.
Having senior members in a household who need more health services often is a risk factor
for facing catastrophic expenditure. However, the empirical results do not show a positive
correlation between senior member and incidence of catastrophic expenditures in any of the
Extending Social Protection in Health
141
three countries. Several reasons could contribute to this result: the population above 60
years is relatively small in Kenya (4.9 %) and Senegal (4.2 %); and the senior person may
use less service when needed due to both financial and geographical barriers.
Social health protection and households' strategies to finance health care
In order to cope with the financial burden of ill health, households use various strategies to
draw on all kinds of financial sources, such as using up savings, reducing other expenses
including basic needs, borrowing money from relatives, friends or financial institutions and
selling assets such as livestock and land if cash savings are not sufficient. All strategies have
an impact on current and future welfare of households. Borrowing money and the sale of
assets particularly have long-term impact on households' financial situation and income generation capacity. Both strategies are not rare in all these three countries.
Health insurance coverage seems to reduce the need to sell assets in case of financial difficulty in both Kenya and Senegal, but not South Africa. In Senegal, 15.4 % of non-insured
households sold assets so as to finance health care services compared to 4.4 % of insured
households (table 6). In addition, health insurance coverage reduces the probability of borrowing, except in Kenya.
Table 4.1.6: Household financial mechanisms to cope with health care expenses (%)
South Africa
Sales of assets
Borrowing from
family or friends
Borrowing from
outside
Kenya
Senegal
Uninsured
Insured
Uninsured
Insured
Uninsured
Insured
5.9%
10.6%
1.0%
0.2%
15.4%
4.4%
10.5%
7.0%
27.9%
12.3%
13.2%
6.1%
4.1%
11.5%
4.3%
3.0%
Social health protection and depth of poverty
Figure 4.1.6: Impact of health payments
on poverty gap
before payment
increased
80%
Poverty gap
Poor health triggers poverty.
Households just above the
poverty line are easily pushed
into poverty for even a small
amount of health expenses.
Further, within poor households poverty might be deepened by health expenditure.
These facts have been confirmed in numerous research
findings and led to special
attention and conclusions of
the international community
e.g. in establishing healthrelated MDGs, the WHO
Commission on Macroeconomics and Health and ILO
resolutions and conclusions
on a new consensus in social
security.
10%
60%
4%
40%
37%
20%
0%
54%
2%
South Africa
25%
Kenya
Senegal
The impoverishment due to health expenditures ranges between 1.5 % and 5.4 % of households across the three countries. This translates to over 100,000 households in Kenya and
Senegal and about 290,000 households in South Africa being pushed under the poverty line
by paying for health services. Furthermore, in all three countries, out-of-pocket health pay-
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X. Scheil-Adlung,G. Carrin, J. Jütting, K. Xu: Impact of social health protection in three African countries
ments deepened the level of poverty of the already poor. Figure 6 illustrates the poverty gap
before and after health payments that tended to enlarge the gap in all three countries.
It can be concluded that besides impoverishing non-poor households, health expenditure
enlarges the poverty gap among the poor. The results reveal also that social health protection can help to reduce impoverishment. However, under the current health financing system
in all three countries, the poor have very limited social protection coverage, therefore, the
impact of coverage on the intensity of poverty is not expected at an observable level from the
cross-section sampled surveys.
Summary of findings and policy implications
In Kenya, Senegal and South Africa, the level of coverage of any form of health insurance is
very low ranging from 7 to 17 %. At the same time, out-of-pocket payments are very high in
Senegal and Kenya and account to about 45 % of total health expenditure in both countries.
This implies that the majority of the population working in both the formal and informal economy is not benefiting from social health protection programs. Further, it could be shown that
the social health protection deficit concerns particularly vulnerable groups in the three countries, such as people living close to or in poverty, persons living in rural regions, women and
the elderly.
The analysis of the financial impact of (lacking) social health protection on access to health
services, expenditure and poverty revealed that health care cost constitute a very high barrier to access health services for households in need. Under the condition of insufficient taxbased funding, social health protection schemes can reduce this barrier. The results of the
study showed that the insured are more likely to get health care if needed. Further, social
health protection has the potential to reduce lacking income generation due to sickness and
protect households from hazardous, wealth threatening health financing strategies such as
borrowing money or selling assets to cover health care cost. Against this background, social
health protection can play an important role in reducing impoverishment.
These results confirm the importance of political strategies setting priorities in extending coverage of social protection schemes to the poor and investing in social health protection development. Three policy recommendations are put forward to improve access to social health
protection, reduce the financial burden and impoverishment due to health expenditure,
namely extending coverage to the poor and vulnerable, providing benefit packages and adjusting cost sharing, and policy considerations beyond the health sector.
Extending social health insurance coverage to the poor and vulnerable
Currently in all three studied countries, the limited social health protection coverage principally benefits persons in the formal economy. The poor who have low capacity to pay and
the vulnerable that need more services are not given even the same attention as the rest of
the population. Specific programs, e.g. targeting children under 5 years old and the poor, fall
short of expectations. This situation is also common among other developing countries.
Therefore, extending social health protection to the poor should be a priority.
While social health protection schemes generally have the potential to mitigate the worst financial effects of ill health on poor households, it is not possible to develop a single right
model for all countries or even for all types of vulnerability and poverty within one country.
There are different strategies to enhance effectiveness of social health protection in changing
social and economic environments. Whereas improving performance and coverage of statutory social health protection schemes seems to be straightforward for formal sector workers if
principles of good governance, solid financing and administration are applied, it is very complex to reach the often vulnerable and poor people living and working in the informal sector.
Therefore, social protection strategies need to take into account specific approaches regarding identification of persons, adjusting to reduced capacities to pay for contributions, arranging for specific needs and health risks. Even these modifications of the protection scheme
will not ensure that regulations can be enforced. To reach the majority of the population
Extending Social Protection in Health
143
working in the informal sector in African countries will require, beside improvement of publicly
provided health, to better integrate schemes that are based on collective risk sharing at the
community level. The emerging movement of mutual health organisations and microinsurance schemes in African countries is very interesting in this respect. Programs have
either been initiated by health care providers (e.g. hospitals), non-governmentalorganisations, or local associations. Schemes are generally limited to a specific region or
community and thus only reach a small number of people.
Moreover, health insurance packages are not comprehensive. Despite these limitations, micro health insurance is a promising approach to extend health care coverage to traditionally
excluded individuals. Specifically, it has the potential to integrate a large part of the rural
population in Africa that would otherwise be left with no or very little health care coverage.
Although the scope of each individual scheme is very restricted, there are different ways to
scale up coverage. They include building federations between schemes and using community institutions, such as co-operatives, to disseminate the insurance product and link community efforts with public efforts, e.g. through subsidies. This requires creating ‘attractive’
schemes with low transaction costs. The challenge ahead for policymakers lies in the need to
encourage scaling up of schemes and linking them to public policies. This requires a careful
balancing for regulation in order to leave sufficient space for insurance schemes to develop.
Providing adequate benefit packages and adjusting cost sharing
Health services covered by social protection programs are essential for preventing people
from severe financial loss. Households may still experience devastating financial consequences even when covered by insurance if the benefit package is not comprehensive
(Himmelstein et al. 2001). There is no gold standard on the benefit package, but its overall
objective should be protecting the poor and vulnerable against catastrophic health costs.
There is experience in practice suggesting that restricted benefit packages would be less
successful in protecting against catastrophic expenditure. In Kenya, where the NHIF covers
only inpatient services (specifically the hospital bed expense) there is evidence that catastrophic expenditure due to outpatient services is not rare (country reports).
It is not, however true that the larger the benefit-package, the better it is. The comprehensiveness of the benefit package involves a balance between cost and risk protection. Given
scarce resources, it is necessary to set priorities in benefit packages and other components
of the scheme design in order to cover the needs of the poor. Priority setting should be
based on medical guidelines, evidence based medicine, epidemiological needs and all kinds
of certification or quality assurance.
Policy considerations and research needs beyond the health sector
South Africa, Kenya and Senegal are facing great challenges on their way to reach universal
health coverage. People impoverished by health payments or unable to access services due
to financial barriers are numerous in all three countries. Meanwhile great efforts are being
made to expand social protection programs in order to allow widespread access to needed
services, minimize households' severe financial loss and break the vicious cycle of illness
and poverty. It is obvious from the above discussion that there is no one-fits-all solution.
Policy interventions in the area of social protection have concentrated in the past largely on
the supply side, e.g. via subsidising public health care facilities, providers and MoH. Recently, a change can be observed and the demand side of the health care system comes
increasingly into the focus of policy makers. Patients are more and more considered as economic agents instead of purely as beneficiaries or target groups and are seen as actors who
interplay with other stakeholders such as providers, government authorities, etc. This is an
important step forward, though not sufficient. As households face several risks at the same
time – beside health risks, production risks etc. – only a holistic strategy to deal with risk and
vulnerability will have a long lasting impact.
144
X. Scheil-Adlung,G. Carrin, J. Jütting, K. Xu: Impact of social health protection in three African countries
The topic of risk and vulnerability is gaining more and more attention in the international arenas. In their current work on pro-poor growth, the donor community (DAC member countries)
has set up a specific task force analysing the relationship between risk and vulnerability on
the one hand and poverty, inequality and growth on the other hand. Over the last years important knowledge has been accumulated in estimating the costs of being unprotected
against shocks. However, one major conclusion of this study is that far less progress has
been made in discussing what kind of policies and instruments are appropriate in a given
context to improve existing risk sharing arrangements. Much more work is needed in this
area. An important step forward would be to include systematically risk analysis in the PRSP
process as well as to do further research to identify policies and instruments that help people
to deal with risks more effectively. Progress in health protection would be particularly welcome as labour is often the only asset of the poor. Increasing worker productivity is a cornerstone of any pro-poor growth strategy that aims to achieve the MDGs.
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A. Setiana: Social Health Insurance Development as an Integral Part of National Health Policy
4.2. Social Health Insurance Development as an Integral Part of National Policy: Recent Reform in the Indonesian Health Insurance System
Adang Setiana74
Abstract
Social Health Insurance (SHI), as a concept, has the potential to achieve universal coverage
to ensure that every body will get access to the medical care they need In accordance with
Indonesia’s National Health Policy, the right to health care has been included in the Constitution amended in 2002. The Indonesian government has reformed the National Social Security Law and on October 19th, 2004, passed a bill providing for the foundation for a National
Health Insurance Program (NHIP). The concept of social health insurance has been poorly
understood in Indonesia. Most people consider social health insurance as a program for the
poor. This misunderstanding has caused difficulties in introducing social protection in Indonesia; even though a social health insurance program for the government employees was
implemented in 1968, and a social health insurance program for private employees in 1992.
Several International organisations, such as GTZ, EU, ILO, and WHO provided technical
assistance to expand health insurance coverage through social security reform. The Cabinet,
chaired by President Susilo Bambang Yudoyono has a strong commitment to providing access to health care for every body, a policy that is in line with the concept of social health
insurance. As a start, the Ministry of Health has insured about 60 million of the poorest Indonesians by paying their contributions to Askes, the insurance scheme for civil servants.
This paper will discuss the existing implementation of SHI in Indonesia, the expansion of
coverage to 60 million poorest Indonesians and the political and economic implications of
extending social health insurance coverage to 220 million people. A qualitative analysis, including discussions on the political processes involved, conflicts of interests, opposition to
the concept, and the prolonged debates on the expansion of coverage as a National Health
Policy, will be presented. There will also be an evaluation of the existing policy.
Introduction
Indonesia is located between Asia and Australia, comprising more than 17,000 islands
spread over an area about 5,000 km long
and 3,500 km wide across the Equator.
More than half of the population lives below
€ 1.6 a day, the standard poverty line defined by the World Bank. Successful family
planning programs implemented in the last
30 years have controlled population growth
and Indonesia now has an annual population growth rate of 1.3 %. However, due to
low educational levels, the unemployment
rate remains high and the wage level is low.
GDP per capita in 2005 was at € 850 (US$
1,050).
Table 4.2.1: Basic Indicators of Indonesia
Indictors
Land area
Value
(km2)
1,890,754
Population (2004)
220 million
Pop. below poverty line
50 %
Crude birth rate (2002)
21.87/1,000 pop
Crude death rate (2002)
6.28/1,000 pop
Infant mortality rate (2005)
30/1,000 live births
Unemployment rate
9.1%
GDP per capita
$ 2,800 Int. US$
Indonesia had achieved a GDP per capita
Sources: BPS 2005; WHO 2006, pp. 170ff
of more than US$ 1,200 in 1996. However,
the Asian financial crisis of 1997 hit the Indonesian economy and led to a political crises resulting in a sharp fall of the country’s GDP and economic competitiveness. Currently, political
and economic stability have improved significantly. Despite small-scale political unrest in
some areas, the commitment of the current government to improve Indonesia’s political envi74
Deputy Coordination for Social Welfare, Coordinating Ministry for People’s Welfare the Republic of Indonesia,
Jakarta, [email protected]; [email protected].
Extending Social Protection in Health
147
ronment, its economy, investment climate and the welfare of its people has been gaining the
trust of the international community. At the same time, social security - including social health
insurance - has received significant attention.
Indonesia’s traditional provision of health services includes public health centres, sub-health
centres (both stationary and mobile) and public hospitals. User fees, determined by local
governments according to a fee-for-service payment system, hinder access to care where
expensive and multiple medical procedures are needed. In addition, services by public health
providers are perceived by people to be of poor quality. The well-off, who demand better
quality services may pay visits to private clinics run by the same doctors who work in the
public centres and pay much higher fees.
One important factor for equitable access to primary health services is their proximity to the
population. The Indonesian health policy mandates local governments to build one health
centre for every 30,000 inhabitants, and one sub-health centre for every 10,000 inhabitants.
A public health centre has a staff of at least one physician (general practitioner), several
nurses and midwives, other health related personnel and administrative staff. A sub-health
centre has at least one nurse or a midwife plus a few administrative staff to provide very basic health services to the community. There are currently more than 7,000 health centres and
more than 21,000 sub-health centres throughout Indonesia (MoH 2001). In addition, there
are about 50,000 doctors who offer private medical services in their clinics at various rates. It
has to be pointed out that there is no regulation on private medical fees in Indonesia.
There are four types of public hospitals providing secondary and tertiary care: (1) small district hospitals (less than 50 beds with four specialists - internist, obstetric-gynaecologist, surgeon, and paediatrician) provide basic secondary care at district level; (2) municipality hospitals (50-100 beds with more than four specialists) deliver secondary and tertiary care for a
larger district; (3) provincial hospital (100-400 beds with a variety of specialists) providing
more specialised referral care at provincial level, and (4) regional and national hospitals (up
to 1,500 beds) designed to provide top (national) referral care.
Public hospital patients are charged according to the number and type of services received
(regulated and subsidised fees-for-service system in public facilities). User charges at health
centres and third-class rooms of public hospitals cover about 50-80 % of the unit costs, depending on the type of facility. Currently, Indonesia has about 700 public hospitals across the
country and there are about 600 private hospitals owned by various organisations and companies. The growing numbers of privately owned and foreign investor hospitals are competing to sell higher quality services to the richest quintile of the population.
Until recently, there has been great inequity in access across income groups, even in public
hospital services, not to mention in private hospitals. Additional problems, such as geographical (distance) and cultural (education and beliefs) barriers remain significant factors for
low access to hospital services. A study by Thabrany (2005) indicates that in 2001 the richest
10 % of the population consumed more than 400 hospital days per 1,000 people, while
members of Askes and Jamsostek (insured) had more than 500 and thus more than the noninsured. On the other hand, hospital days were less than 100 per 1,000 people for the poorest 10 % of the population and the uninsured.
Physicians working at health centres and public hospitals are public servants receiving low
basic salaries. To supplement their income, every medical staff working with the government
is allowed to work in private clinics after office hours. Nurses and midwives are officially not
given this kind of privileges; however in practice they also have private practices (especially
in small towns or districts). The charges in private clinics run by the same physicians working
in public facilities in the mornings are three to 10 times higher than the public sector fees.
Social Health Insurance Systems before Reform
The socioeconomic survey of 2004 indicated that 20.6 % of the 220 million Indonesians are
covered by some kind of health insurance (BPS 2005). The most comprehensive scheme in
148
A. Setiana: Social Health Insurance Development as an Integral Part of National Health Policy
the country, the civil-servant social health insurance scheme Askes, reached about seven
percent of the population. Currently there are various health insurance schemes in place,
including Askes, social health insurance for private employees (Jamsostek), community
health insurance, private commercial health insurance and employer-covered health insurance. The benefits of those insurance schemes are not comparable one to another, and one
should not assume that the fifth part of the population covered by health insurance are completely free from financial risks once they incur severe or catastrophic illness.
Government Regulations No 69/1991, No 6/1992, and No 28/2003 provide the legal bases
for the Askes scheme. The scheme covers about 13.8 million beneficiaries comprising about
4.5 million affiliated employees and 9.3 million dependents. All civil servants and civil service
pensioners, personnel of the armed forces and veterans are mandated to contribute 2 % of
their basic monthly salary, regardless of their marital status. In the past, the government did
not contribute as employer but from 2004 it started contributing 0.25 % to top up the 2 %
employee contribution. The government contribution is to be increased annually by 0.25 % of
the employee’s salary to reach contribution parity by 2007 matching the 2 % employee payment. Regardless of an employee’s wage level, all beneficiaries are entitled to comprehensive health benefits considered medically necessary. With regard to non-medical services,
however, benefits are differentiated in two different levels. Highest ranking civil servants are
entitled to first class wards and board in public hospitals, while low and middle ranking employees and their dependents have access to second-class rooms only. All other health
benefits, deemed medically necessary, are not discriminated by rank. The Askes scheme
covers benefits delivered in contracted provider networks consisting mainly of public health
centres and public hospitals. Services rendered outside the network are not covered. Contracted providers are paid prospectively by capitation, per case or per diem. The Ministry of
Health and the Ministry of Internal Affairs determine the level of provider payment in order to
ensure Askes’ financial solvency.
Private employees are covered under the Jamsostek scheme. The legislative structure for
Jamsostek are Social Security Law No 3/1992 and Government Regulation No 14/1993. All
employers having 10 or more employees are obliged to insure their employees through Jamsostek. However, the Law prescribes that (1) employers that prefer better health benefits
may opt out from the scheme; (2) only employers are mandated to pay contributions of 3 %
(for single) and 6 % (for married employees) of their wages; (3) the scheme set a wage ceiling that has not been changed since 1993 at one million Rupiah (€ 80) salary per month,
freezing revenues for SHI contributions while costs of medical care continue to rise; (4) the
benefits are provided to employees and family members up to a maximum of three children;
(5) some expensive medical procedures, such as cancer treatment and haemodialysis, are
not covered fully; and (6) coverage terminates when employees are retired or lose their jobs.
Membership has grown very slowly, from 199,000 members in 1991 to 2.74 million (1.26 million employees) in 2005. Due to the opt-out option, only a few employers, mostly small and
medium sized enterprises, enrol their employees to Jamsostek while larger employers tend
to buy private health insurance or provide their employees other types of health benefits. By
2005, Jamsostek covered less than 5 % of eligible employees. On the other hand, 19.8 million employees have been enrolled in the other three Jamsostek programs (occupational
accident scheme, death benefit scheme and provident fund scheme) since the Jamsostek
Law was implemented, but only about 8 million members were actively paying contributions
in 2004 (Jamsostek 2005). Even if all employees had been enrolled, it would still form a relatively small number of workers covered by social security; a national labour survey in 2000
estimated that there were 56.2 million workers in Indonesia (ILO 2005). Data from commercial insurance companies shows that total membership of the private health insurance market in 1999 was only about 4 million people (Djaelani 2002). In addition to the two SHI
schemes (Askes and Jamsostek), about 2 million people are insured by the military health
services system covering all armed forces, civil servants of the Ministry of Defence, and their
families.
Extending Social Protection in Health
149
The New National Agenda of Askeskin: The Most Expansive Initiative
After the monetary crisis that hit Indonesia severely in 1997, a series of political, economic,
and social reforms have been undertaken. Decentralisation of authority to local governments
to run various public services, including health care and health financing, has been the main
focus of the reform. The Indonesian Constitution has been amended three times between
1999 and 2002, something that had never before occurred during the first 55 years after the
country’s independence. One of the most important political measures was the reform of social security, including health insurance. The constitutional amendment of 2002 obliged the
government to establish social security for all citizens. This amendment was followed by the
passing of a law on the National Social Security System (Sistem Jaminan Sosial Nasional SJSN) on October 19th, 2004.
The National Social Security System Law mandates employers, including the government, to
provide social health insurance (SHI) through Askes or Jamsostek. In addition, for the first
time, this law mandates the government formally to pay contributions to the SJSN for low
income populations. Once their incomes rise above the poverty line, they are required to contribute to the system to access health benefits.
One day after the law was passed, the new cabinet, headed by
President Susilo Bambang Yudoyono came into power. In the
General Five Year Plan, the new cabinet placed high priority on
improving access to the Indonesian health care system. The new
cabinet is willing to relieve the financial burden of the low income
groups to meet their health care needs. The initial new agenda
was the provision of free hospital services in third class wards
and board in public hospitals. The Ministry of Health then designated Askes to administer the initiative and paid contributions on
behalf of the poor to Askes. This is part of the policy requiring
everybody to contribute. The only difference is that the
government subsidises the contributions of those who are
temporarily or constantly unable to contribute.
Although the details on how and how much the government
should contribute are still being worked on, the Ministry of Health has taken a bold initiative,
called Askeskin, to start health insurance for those on low incomes. Since 2005, the new
initiative (Askeskin) has extended health insurance coverage to an additional of 60 million
people (27 % of the population).
Askeskin: The Health Insurance Program for Low Income People
In early 2005, the Bureau of Census declared that Indonesia had about 36 million poor people as defined by the national poverty line. Before 2005, to compensate for rising prices and
cost of living due to high oil prices, the government had provided the poor with a health card
that entitled holders to free health care in public health facilities. The fund for the compensation program was distributed directly to public health centres and public hospitals according
to the number of the poor individuals within the catchment’s area of each facility. The distribution of funds was similar to that of capitation payment. Health centres provided primary
health care, maternal and child health services and childbirth; while public hospitals provided
outpatient and inpatient care. Evaluation of this program revealed several access and equity
problems. The utilisation of health centres was low while the demand for public hospital care
was much higher than expected. However, the funds allocated to a health facility could not
be transferred to other facilities – resulting in inequity across facilities and populations.
As a pilot project, Askes had initiated a program to provide health care for the poor to which
the local government contributed monthly on per capita basis in the Musi Banyuasin district
in South Sumatra. The program started in 2002 when Askes was contracted by the Musi
Banyuasin government to cover 20,000 poor individuals, mostly in remote areas. The district
government paid a monthly contribution of Rp. 5,000 per person (€ 0.40) per capita, but this
150
A. Setiana: Social Health Insurance Development as an Integral Part of National Health Policy
amount was adequate to cover already heavily subsidized user charges in public health facilities). In 2003, the number of poor covered by this program was expanded to 167,000 people (about one-third of the district population) at the same level of contribution. Based on this
experience, the Ministry of Health then set out to expand the scheme to the national level.
This was in accordance with the SJSN regulation prescribing mandatory government contribution to insure the poor through a designated social security implementing agency (known
as Badan Penyelenggara Jaminan Sosial or BPJS).
In November 2004, following discussions, the Ministry of Health asked Askes to administer
the scheme, scheduled to begin in January 2005. The official designation of Askes was issued by the Ministerial Decree No. 1241 of the Minister of Health in December 2004. At the
beginning, 36,146,700 individuals were covered and the monthly contribution was fixed at Rp
5,000 (€ 0.40) per capita. In January 2005, the program was started and all basic principles
of SJSN were implemented. The fund has been managed by Askes on a not-for-profit basis
to cover comprehensive health services equivalent to the health benefits for the government
employees. The only difference from the government employee’s scheme is that for inpatient
care, the poor are only entitled to admission in third class public hospital wards. The program
was implemented nationwide in order to ensure portability of health care benefits all over the
country. This is very important because the availability and the range of services across districts vary widely. The portability principle ensures the poor can obtain tertiary care in public
hospitals across districts or provinces.
Six months after the implementation, the number of people covered has been increased to
60 million to accommodate those who are ‘nearly’ poor but who cannot afford to pay for
health care needs. The delivery of health benefits has been changed slightly to accommodate previous health card schemes. However, at the beginning of 2006, the whole program
reverted to the original concept of providing comprehensive benefits through Askes.
Table 4.2.2: Description of Askeskin Program in 2005
Description
First Semester 2005 + 2006
Second Semester 2005
Scheme
Health insurance, government pays contributions for
the poor for comprehensive
services to Askes
Direct provision of primary care in
public health centres. Health insurance scheme covers inpatient only,
in third class ward of public hospitals
and participating private hospitals
Number of beneficiar- Poor population: 36,146,700 The poor and nearly poor: about
ies
60,000,000 persons
Appointment of Askes To cover comprehensive
health care
Outpatient referral and inpatient
hospital care
Budget
Rp. 1.323 trillion (€110 million)
Rp. 1 Trillion (€80 million) in
the first semester of 2005
Rp 3.7 Trillion (about € 300
million)
Description
First Semester 2005 and in
2006
Second Semester 2005
Scheme
Health insurance, government pays contributions for
the poor for comprehensive
services to Askes
Direct provision of primary care in
public health centres. Health insurance scheme covers inpatient only,
in third class ward of public hospitals
and participating private hospitals
Extending Social Protection in Health
151
Registration of the Insured
Based on census data collected by the Central Bureau of Statistics in December 2004,
36,146,700 poor people were eligible for health insurance by the Ministry of Health by paying
a premium) of Rp 5,000 per person per month (BPS 2005). While this data provided the MoH
with the number of poor people in each district, it did not give names and address of those
people. The district government then identified the persons to be insured and sent the names
and address to Askes who issued Askeskin cards with which the holders are eligible for
comprehensive health benefits. In practice, the identification of beneficiaries was made by
the head of a village often with the support of midwives, village’s women organisations and
health centres. At the beginning, it was not easy for the district government to select the
number of poor as allocated by the MoH. Some districts already had similar programs or
other poverty alleviation programs based on the district poverty line criteria; the result was a
much higher number of poor. The difference in the numbers of poor between those insured
by the MoH and the number of the poor identified by the districts
sparked protests by the poor and NGOs in some districts. Later,
the number of poor insured by the MoH via Askes was increased
to 60 million to accommodate the difference.
Benefits and Procedures
Benefits for the Askeskin program comprise of various levels of
health care. Primary health care is provided at health centres and
sub-health centres with midwifery services in smaller villages. To
be eligible for secondary care benefits provided in district
hospitals, a referral from a primary health care provider is
required. In case of emergency, however, a patient may visit a
public hospital without referral from health centre. A district
hospital can also refer a patient to a provincial hospital if the
medical equipment is insufficient or a specialist is required. Birth
delivery services are provided by accredited midwives at village
level or by general practicing physicians working in health centres, hospitals or clinics. Drugs
are covered only if doctors prescribe drugs listed on the formulary developed by Askes,
known in Indonesia as DPHO (Daftar Plafon Harga Obat). Finally, the Askes scheme also
covers other supplies deemed medically necessary.
Due to geographic difficulties in providing basic maternal and child health, (other than those
delivered by a freshly graduated general practitioner providing mandatory services in health
centres) a midwife is appointed to provide primary maternity care (antenatal care and delivery) in a village. By assigning a midwife to each village access to maternity care was made
easier. In addition, the midwife can also provide treatment for simple medical problems and
deliver very basic drugs such as anti-diarrhoeals or pain killers or when no physician is available. The midwife works under the supervision of a physician in health centres.
Problems and Constraints
Askeskin has been the largest extension of the system, insuring 60 million people in about a
year. In the field many technical problems were certainly encountered. The first difficulty was
identifying poor households among the poor and near-poor who were eligible for receiving
financial assistance in paying contributions to the SHI scheme. Before Askeskin was implemented, local governments were provided with seed money to create some kind of medical
aid where local governments matched the funds and created local systems. Overall, local
governments claimed that they already covered more than 54 million people (however, the
benefits were not comprehensive and varied across districts) whereas Askeskin started with
only 34 million people. Of course, even with far less comprehensive benefits, people who
had been covered before and then were not eligible for Askeskin were very disappointed and
felt discriminated against. This problem was finally overcome by adding MoH commitments to
cover up to 60 million people in the second semester of 2005.
A. Setiana: Social Health Insurance Development as an Integral Part of National Health Policy
152
To avoid the misuse of Askeskin, the photograph of each beneficiary was attached to each
membership card. This ambitious project, attaching photographs of each individual for more
than 36 million people within six months caused serious administrative difficulties. The process of taking photographs, attaching the appropriate photo to the name and address of each
person and distributing the cards was a nightmare. It was finally decided to distribute the
cards without photographs and to cover all people who claimed they are unable to pay user
charges as long as they were willing to be confined in third class wards in public hospitals,
even if they had no Askeskin card. Thus, this decision eliminated the administrative problems
in identifying each individual eligible for the government program and if a person was actually
poor, a card was issued for him/her and their family members.
Due to the sprawling nature of Indonesia, many hospitals and even health centres in small
districts are geographically difficult to reach. The coverage of health care only, though it relieves the financial burden of obtaining health care, does not solve health problems of the
poor. Problems of transportation, sometimes requiring the use of an airplane in remote areas
to reach health facilities prevents the sick from receiving treatment provided through Askeskin. As the MoH budget is insufficient to cover transportation costs, local governments were
urged to support the program by providing transportation costs or by bringing mobile clinics,
including personnel and medical supplies, to remote areas.
The Progress
Regardless of geographical, technical, and administrative problems, the Askeskin program
has brought a reasonable degree of relief to low-income groups. The registration of the indigent people has been completed and the cards have been distributed to eligible individuals.
The data submitted by health care providers indicates that the distribution of cards has been
effective, health care providers understood their function and that the poor used their entitlements of health care. In the first semester of 2006, 2.9 million hospital outpatient referral visits and 800,000 inpatient care have been recorded to Askes (Marisi 2006). 2005 data indicated that about 15 % of the beneficiaries utilised health care in public health centres and
hospitals. The following tables show the total utilisation numbers (Table 4.2.4), the corresponding claim expenditures (Table 4.2.3) and the epidemiological profile of enrolees (Table
4.2.5) (Sutadji 2006).
Table 4.2.3: Distribution of Health Care Costs Incurred (Claimed) for Various Medical Procedures, in Indonesian Currency (Rp) as of September 2005
No
Medical Procedures
Costs incurred
1
Heart surgery
2
Haemodialysis
643,264,255
3
Cardiac catheterisation
580,000,000
4
Caesarean section
458,831,000
5
Congenital diseases
172,000,000
6
Craniotomy
142,064,000
7
Explorative laparoscopy
119,817,000
8
Radical mastectomy
64,755,000
9
Appendectomy
53,349,724
10
Hysterectomy
15,650,000
Total
3,134,600,000
5,384,330,979
Extending Social Protection in Health
153
Table 4.2.4: Reported Health Care Utilisation for the Askeskin Program by September 2005
Description
Utilisation
Total visits
50,517,586
15.02
Referral visits
4,051,512
8.02
Secondary health care visits
3,277,438
6.48
429,223
0.84
Number of admissions
Number of haemodialysis cases
Ratios to Population
437
Table 4.2.5: Distribution of Medical Diagnoses among Askesin Beneficiaries Reported by
Health Care Providers as of September 2005
No
Diagnosis
Number of Cases
%
1
Unidentified causes of fever
90,045
34.41
2
Acute diarrhoea
39,985
15.28
3
Upper respiratory tract infections
37,577
14.36
4
Typhoid and paratyphoid fever
25,488
9.74
5
Birth problems/complicated delivery
20,542
7.85
6
Tuberculosis
11,226
4.29
7
Dyspepsia
10,703
4.09
8
Injuries
10,389
3.97
9
Dengue hemorrhagic fever
8,557
3.27
Bronchial asthma
7,170
2.74
261,681
100.00
10
Total
Conclusion
Coverage by social health insurance is dominated by formal sector employees and beneficiaries of government subsidised contribution (Askeskin). In the formal sector, coverage extends to all civil servants, military personnel, police personnel, veterans, and less than 5 % of
private sector employees. In 2005, the government underpinned its strong commitment to
increase access to health care by paying social health insurance contributions for the poor as
prescribed by the SJSN Law of 2004. This program, known as Askeskin, is the largest expansion of health insurance in Indonesian history, may be in the world. Within two years, the
Askeskin program extended coverage to about 60 million low-income people across Indonesia and improved access to health care significantly. The program is expected to accelerate
the reduction of maternal and infant mortality, thereby speeding up the attainment of Millennium Development Goals.
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Pradhan, Menno; Prescott, Nicholas (2002). Social Risk Management Options for Medical Care in
Indonesia. Health Economics 11 (5), S. 431-446 (http://www3.interscience.wiley.com/cgibin/fulltext/93515125/PDFSTART).
Newby, Liza; Kolehmainen-Aitken, Riitta-Liisa; Supriadi, Chandrawila; Wasisto, Broto (2004). The
Content and Uses of Health Laws: An Overview of Selected International Models and Lessons
Learned for Possible Application in Indonesia. Management Sciences for Health, Management and
Leadership Program/USAID/ Ministry of Health, Jakarta
(http://www2.cdc.gov/phlp/docs/IndonesiaLawReport.pdf#search=%22Carrin%20health%22).
Sutadji, Andari (2006). Progress Report of the Askeskin Program. National Planning Workshop on
Health. Medan, March 2006.
Scheil-Adlung, Xenia (2004): Sharpening the Focus on the Poor: Policy Options for Advancing Social
Health Protection in Indonesia, ESS Paper no 19, ILO Social Security Policy and Development
Branch, Geneva (http://papers.ssrn.com/sol3/papers.cfm?abstract_id=675663#PaperDownload;
http://www-ilomirror.cornell.edu/public/english/protection/socsec/download/esspaper19.pdf#search=%22ScheilAdlung%20Implementing%20social%20security%20health%20care%3A%20Social%20security%20and
%20HIV%2FAIDS%22;).
Tambunan, Tulus T.H.; Purwoko, Bambang (2002). Social Protection in Indonesia. In: Adam, Erfried.
Social protection in Southeast and East Asia. Friedrich Ebert Stiftung, (http://library.fes.de/pdffiles/iez/01443003.pdf; http://library.fes.de/pdf-files/iez/01443.pdf).
Thabrany, Hasbullah; Gani, Ascobat; Pujianto; Mayanda, Laura; Mahlil; Satria Budi, Bagus (2004).
Social Health Insurance in Indonesia: Current Status and the Plan for National Health Insurance. In:
World Health Organization –South East Asia Region (ed.). Regional Overview of Social Health Insurance in South-East Asia. New Delhi, Annex 3, pp. 101-161
(http://w3.whosea.org/LinkFiles/Social_Health_Insurance_an3.pdf).
Thabrany, Hasbullah (2005). The 36 Years Experience of Health Insurance in Indonesia. Paper presented in IHEA Conference, Barcelona, July 10-13, 2005.
Extending Social Protection in Health
4.3.
155
Achieving Universal Coverage through Social Health Insurance in Asia
Dorsjuren Bayarsaikhan75
Today, most developing countries need additional financial resources to meet their increasing health service demands and population health needs. Countries in Asia and the Pacific
are struggling to introduce alternative financing mechanisms to ensure access and coverage
for their population. Social health insurance is one of the options to increase financial resources for health through equitable and affordable contributions. In recent years, there has
been growing interest and expectation from social health insurance financing mechanism.
Policy and decision makers are becoming aware that social health insurance does not
merely generate additional revenues, but it also increases access and equity, and provides
financial protection. This is a very important factor since policy objectives on improving health
and reaching universal access require equitable and effective health financing arrangements
affordable by all population segments.
Growing interest and expectations from Social Health Insurance (SHI) in developing
countries
SHI generates additional revenue from stable
sources
SHI increases access to needed health services
SHI promotes equity in financing
SHI provides financial protection
Health care costs are increasing rapidly because of many factors associated with the epidemiological shift due
to ageing populations, the burden of
diseases and new medical technologies. Mostly sick people pay for health
services at the point of delivery. If there
is inadequate financial protection, the
cost of illness pushes low income and
vulnerable people into deep poverty.
Even health services incurring modest
charge can lead to catastrophic expenses if the frequency of their use is
sufficiently high.
High out-of-pocket payments
Recent national health accounts statistics
estimate that health systems in most developing and low-income countries rely heavily
on out-of-pocket payments. In countries
where financial health protection is limited,
direct out of pocket payments account for
almost 60 - 80 % of total health expenditure.
As a result, the highest prevalence of catastrophic health spending with a large poverty
impact can be found in countries where outof-pocket payment dominates in health care
financing.
Table 4.3.1: Health Expenditure in Asia
Private HE %
Public HE (%)
India
Viet Nam
78.7
70.8
21.3
29.2
China
66.3
33.7
Indonesia
64.0
36.0
Philippines
60.9
39.1
Sri Lanka
51.3
48.7
Thailand
30.3
69.7
In Asia and the Pacific, coverage by prepayment schemes including social health insurSource: World Health Report 2005
ance, is relatively low except for a few coun
tries such as Australia, Japan and the Republic of Korea that have achieved universal coverage. However, some regional experiences show that social health insurance is an attractive
and feasible option for low and middle-income countries if it is appropriately designed. Many
experts agree that social health insurance has the considerable potential of translating outof-pocket payments into prepayment. Strong political commitment and government support is
75
Regional Adviser in Health Care Financing, WHO Regional Office for Western Pacific, Manila, Philippines,
[email protected].
D. Bayarsaikhan: Achieving Universal Coverage through Social Health Insurance in Asia
156
necessary for successful social health insurance. But there are some challenges that countries face in the process of developing and delivering effective social health insurance
mechanisms. Lack of political will and commitment due to low awareness about social health
insurance, poor regulatory and coordinating mechanisms, limited knowledge, skills, evidence, information and experience sharing are common issues that need to be addressed
effectively.
Graph 4.3.1: Health care costs lead to poverty: Income Distribution in Viet Nam
25
Percent of Population
20
Health Expenditure
Poverty Line
15
10
5
0
0
1000
2000
3000
4000
5000
6000
Annual Income Per Capita (in 1,000 dong)
Source: World Health Report, 2005
Experiences and challenges for Indonesia
Indonesia represents some of the challenges that we are facing in Asia and the Pacific. The
country has been practicing a national compulsory social health insurance scheme for civil
servants and private sector employees for many years. But it is still struggling to achieve
adequate coverage and social health protection for the entire 212 million population. Before
the recent measures to extend social protection ion health, about 20 % of Indonesians were
covered by some form of health insurance such as Askes, Jamesostek and others. A socially-oriented scheme to provide comprehensive health care benefits and universal coverage through various types of health insurance seems to be a very attractive policy for Indonesia. But the country needs innovative solutions and approaches to implement this policy in
order to reach the largest population segment excluded from social health insurance coverage, and to benefit particularly rural and self-employed people.
The Indonesian experience represents several important issues that can be discussed further. For example, good political commitment and support is needed especially for the poor.
Poor people have greater health care needs but they demand less because of many barriers
and limitations. Therefore, the formal commitment by government to support the poor and
other vulnerable populations is critical. It will ensure that all population segments are covered
and protected and no sick and poor person is neglected due to their income status or ability
to pay for health care services when they need them. Another important point is that health
insurance contributions should be affordable to the majority of the population. Relatively affordable levels of pre-payment under Askes and Jamesostek insurance scheme seem to be
an important factor of success in enrolment – both in the public and private sectors.
Extending Social Protection in Health
157
The Indonesian experience shows that comprehensive health care benefits delivered by a
defined provider network are an important factor in the operation of a health insurance
scheme. The next important issue is whether specific provider payment methods have any
impact on increasing the potential for extending coverage. Currently, fee-for-service seems
to be the main method for provider payment in Indonesia. But experiences in some other
countries show that other payment methods, such as fee-per-case or capitation payment
tend to ensure greater opportunities to control costs and to share financial risks between insurers and providers. The capitation method also requires a less complex and costly billing
system and that is why it has been adopted by several social health insurance schemes.
Lastly, Indonesia and other country experiences show that having a separate social health
administration that operates with close links to the Ministry of Health is another important
condition to ensure broad population coverage under a national social health insurance policy and administration. The Indonesian social health insurance reform to integrate public and
private employee insurance into a single national scheme under a National Social Security
System seems to be a crucial step in achieving broad coverage and benefits for all.
The future development of social health insurance in Indonesia may help us to answer the
most frequently debated questions whether social health insurance is feasible in developing
countries and whether universal coverage is achievable if the labour force comprises a large
informal sector. It is expected that in Indonesia, the informal sector will continue to play a
major role in the country's economic and social development. Thus, the national social protection policy has to focus intensively on this population share in order to be successful in
achieving universal coverage. This situation presents a great challenge and, at the same
time, offers enormous opportunities to develop and apply innovative strategies and techniques that might become valuable experiences for other developing countries.
References
Bayarsaikhan, Dorjsuren (2006). Current challenges in delivering social security health insurance.
Innovation: The key to social security progress, Social Security Documentation, Asia and Pacific Series No. 29, International Social Security Association, Geneva
(http://www.issa.int/pdf/seoul05/2bayarsaikhan.pdf).
van Doorslaer, Eddy; O'Donnell, Owen; Rannan-Eliya, Ravi; Somanathan, Aparnaa et al. (2005). Paying out of pocket for health care in Asia: catastrophic and poverty impact, EQUITAP Project Working
Paper No.2 (http://www.equitap.org/publications/wps/EquitapWP2.pdf).
World Bank (1998). Viet Nam living standard measurement survey (VLSS), Washington/Hanoi
(http://surveynetwork.org/surveys/index.php?request=SURVEY_VIEW&ihsn=704-1997-002).
World Health Organization (2005). Social Health Insurance: Selected case studies from Asia and the
Pacific. WHO Regional Offices for Western Pacific and South East Asia, New Delhi
(http://www.searo.who.int/LinkFiles/RD_speeches_M0305.pdf#search=%22World%20Health%20Organisation%20Social%20Health%20Insurance%3A%20
Selected%20case%20studies%20from%20Asia%20and%20the%20Pacific.%20WHO%20Regional%20O
ffices%20for%20Western%20Pacific%20and%20South%20East%20Asia%22).
World Health Organization (2005). World Health Assembly Resolution, WHA58.33, Geneva
(http://www.who.int/gb/ebwha/pdf_files/WHA58-REC1/A58_2005_REC1en.pdf#search=%22World%20Health%20Organisation%20World%20Health%20Assembly%20Resolut
ion%20WHA58.33%22).
World Health Organization (2005). Make every mother and child count. World Health Report 2005,
Annex Table, WHO, Geneva (www.who.int/whr/2005/en/).
World Health Organization (2005). Strategy on health care financing for countries of the South East
Asia and Western Pacific, WHO Regional Office for Western Pacific and South East Asia Manila(http://www.wpro.who.int/sites/hcf/documents/hcf_strategy.htm).
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B.-M. Yang, J. Holst: Health Insurance in Developing Countries: Experience from Asia
4.4. Implementation of Health Insurance in Developing Countries: Experience
from Selected Asian Countries
Bong-min Yang76, Jens Holst77
Introduction
Global evidence (Xu et al. 2003; van Doorslaer et al. 2005) suggests that high out-of-pocket
payments (OOP) for health care are positively related to catastrophic household payments,
and can often lead to impoverishment of households. In some countries, catastrophic payment explain a good portion of the cause of impoverishment. This in turn indicates that poverty can be prevented by reducing the burden of catastrophic payment, whose primary determinant is OOP payment in total health expenditure. The linkages among high OOP payment in health care, catastrophic payment, and poverty is more evident among developing
countries, which do not have advanced social protection mechanisms such as social insurance or tax-funded health systems. Protecting people from catastrophic payment is therefore
widely accepted as a key objective of health policy (Kawabata et al. 2002).
It is well known that prepayment and risk pooling through social insurance and taxation prevent households from facing catastrophic spending in health. Nevertheless, many countries
fail to develop social mechanisms to pool financial risks, even with rising income. Experiences in different countries tell us that social insurance has been functioning effectively in
achieving a nation’s health objective, namely, protecting people’s health from financial risks.
Social insurance is a form of social protection that provides people with access to needed
and effective health services, and with financial protection through a health financing system
based on the solidarity principle. The adoption of social insurance for pooling financial risks
in a country depends on its financial capacity, which in turn is influenced by the number of
workers employed, proportion of households below poverty line, and tax base. The process
of developing social insurance as a mechanism for risk pooling depends also on political will
and public trust on government stewardship.
During the 1980s and 1990s, two East Asian countries, South Korea and Taiwan, achieved
universal coverage through implementing National Health Insurance (NHI), in relatively short
time periods. Both countries’ social insurance schemes are based on the solidarity principle
and cover the whole population. Although the two countries encountered some difficulties
with the delivery and performance of their systems after NHI implementation, Koreans and
Taiwanese now have much-improved access to needed health care, and their financial risks
caused by ill-health are undoubtedly better protected than before.
Expansion of SHI Programms towards NHI in Korea
A blueprint for the Korean health insurance system was initiated by the Health Insurance Act
of December 1963, when Korea’s real per capita GDP (RPCG) was still under US$ 1,600. At
that time, Korea’s RPCG was only two-thirds of that of the Philippines, and was about the
same level of Mozambique, Niger, Sri Lanka, and Cameroon (Penn Table, various years).
The first social insurance program (Employee Scheme) started in 1977 with a strong stewardship by President Park Jung-hee. Social health insurance in Korea started with enterprises that had more than 500 employees and extended coverage stepwise for smaller sized
firms. Social health insurance schemes for civil servants and school employees started in
1981 and became important promoters of extending social protection because the then uncovered population was eager and highly motivated to join the SHI when they became aware
of the substantial financial protection benefits by the Employee and Civil Servant Schemes.
Civic societies and non-governmental organisations demanded expansion of insurance coverage for the self-employed and made a strong advocacy to extend SHI coverage towards
the excluded sectors of Korean society.
76
77
Dean of the School of Public Health, Seoul National University, South Korea, [email protected].
Senior Health Advisor, Berlin, Germany, [email protected].
Extending Social Protection in Health
159
During the 1988 presidential election campaign, the then ruling party candidate Mr. Noh Taewoo promised to cover the self-employed who were scheduled to be included in the SHI
scheme by 1991 already two years earlier. Unsurprisingly, a major hurdle was the contribution collection from those beneficiaries who did not have formal contracts and especially for
those with an irregular income base. After Mr. Noh was elected, he pushed actively towards
extending SHI coverage to the self-employed who achieved social protection in health from
1989 on. When a countrywide NHI scheme was effectively born in July of 1989, South Korea
achieved formally universal coverage of the population, including the rural and informal labour force.
Expansion of SHI Schemes to Get to NHI Taiwan
The Republic of Taiwan started the implementation of social protection in health by establishing SHI schemes modelled after the German and Japanese systems. In 1994, 13 SHI funds78
covered 58 % of the population before the implementation of the universal National Health
Insurance (NHI) started. To go for NHI, LIS (Labour Insurance Scheme) extended its coverage to smaller-sized firms, other existing funds extended coverage for dependents, and the
rest of the population (self-employed) was covered through community enrolment. Finally in
1995, the National Health Insurance scheme was born.
Implementation of universal social protection in health occurred in the political context of NHI
inception in Taiwan, motivated by the advocacy of an opposition party in favour of the Farmers’ Insurance during a county governor election. Most candidates in presidential, parliamentary and regional governor elections put the creation of a NHI on their political agendas in
their election campaigns. The democratisation process brought about the political decision to
implement NHI earlier than initially planned. The pathway towards universal coverage was
rescheduled several times by the prime ministers in charge and finally advanced from 2000
to 1994. With the support of the then ruling party (KMT) and strong political will possessed by
then President Li (Deng-hui), the NHI-Act was approved in 1994, and one year later, in
March 1995, a single-payer NHI was launched.
Taiwan had considered several alternatives to the single-payer system. They had discussed
leaving the GEI (government employee insurance) and LIS (labour fund) schemes independent and to establish a new, additional scheme to cover the rest of the population. Other proposals tended to maintain the Indigent Health Insurance, or to merge all SHI programs to one
unitary fund. Today, Taiwan is proud for having taken the right final decision to merge all
funds into a single-payer NHI. This mechanism guarantees both a high level of equity
through universal risk pooling and good efficiency due to a single and condensed administration.
The process of implementing universal social health insurance in Korea and Taiwan illustrates that political will is decisive for advocating SHI as a means to social stability, making it
even possible to achieve universal coverage ahead of the original political schedule. South
Korea managed to bring forward the successful implementation of NHI from 1991 to 1989,
and Taiwan, even more impressively from 2000 to 1995 (Chiang 2005). It is important to
stress that in both cases the process of democratisation and the public’s demand functioned
as a basis, while the political leaders understood the value of universal coverage, recognised
the opportunity and seized it boldly. Another decisive factor was the strong governmental
commitment in Korea and Taiwan where the authorities assume organisational responsibility,
pay half of the contributions of civil servants (in Taiwan even more) and about half of the contributions of the self-employed (also a higher share in Taiwan), are responsible for paying
contributions for the poor who cannot afford regular and sufficient payments and take action
on financial deficits in case of emergency.
78
The Government Employee Insurance (GEI), the Labour Fund (LI), the Public and Private School Teachers
Fund, the Farmers Insurance Fund, the Indigent Health Insurance Fund (by government general revenues),
among others.
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B.-M. Yang, J. Holst: Health Insurance in Developing Countries: Experience from Asia
Establishing NHI - is it the End? The case of Korea
Although achieving universal coverage is undoubtedly a considerable success, it does not at
all mean that that the process ends with establishing health insurance. Ongoing health sector
reforms in practically all countries of the planet show rather that implementing social protection is rather like a never-ending story. Many insufficiencies, problems and perverse effects
can only be detected and encountered when the system is working; thus continuous health
insurance reforms are necessary and even unavoidable to improve the quality of care, equity
and efficiency and other relevant aspects of health systems.
The Korean SHI system was encumbered with many problems, mainly around equity and the
efficiency of financing because beneficiaries had to afford high co-payments and coinsurance rates and many benefits were expressively excluded from SHI coverage. The
share of out-of-pocket payments was an important cause of the low level of equity in insurance financing and proved to be highly regressive (Yang et al. 2004). The diversified structure, with many small sickness funds, made administration inefficient and risk-pooling was
rather low. With regard to the resource allocation or service delivery modality, open-ended
fee-for-service provider payment (FFS) induced a continuous cost escalation. The lack of
separation between the roles of physicians and pharmacists, the lack of gate-keepers at the
primary care stage and the extensive application and utilisation of new medical technologies
were some of the main reasons for increasing health expenditures and called for health insurance reforms aimed at containing the increasing cost.
All problems were tackled one by one over time, and some are still on the reform agenda.
The expansion of coverage and changes in financing modalities towards lower co-payments
is a continuously pursued challenge for the Korean NHI system; and co-payment rates have
been declining since 1989. In order to improve risk pooling and to achieve greater efficiency,
the administration structure changed in 2000 from a multiple fund to a single-payer system.
In 2001, the Korean government implemented a policy of separate functions regarding the
delivery of drugs: prescription relies on physicians and dispensing on pharmacists. Since
2002, the revision of claims and auditing of providers has significantly strengthened, and in
2004, health insurance extended its domain on health promotion, education, and case management.
Additional NHI structural reforms were discussed by the Health Insurance Reform Committee
and a number of NHI reforms were recommended to the government in 2004. On the macro
level, the provider-payment method needs to be changed from the current FFSreimbursement to a form of prospective payment system, such as the global budgeting system. A separate long-term care system for the growing number of elderly citizens has to be
designed. Regarding the referral system, ongoing reforms strive at strengthening the role of
the government in health care delivery. On the micro level, an adequate management of the
utilisation of new medical technologies will be implemented through the introduction of economic evaluation criteria into provider-payment and reimbursement decisions.79
The principal implementation approach taken by Korea was to start universal coverage first,
to identify the gaps and problems in achieving equity and efficiency and to fill the gaps and
solve the problems through reforms. The Korean experience draws an important conclusion:
If the country had waited to meet all pre-requisites for broad social protection in advance, it
would neither have achieved universal coverage nor the various reforms that followed.
In terms of the politics and economics of universal coverage, it has to be pointed out that
health sector reforms are often very difficult to realise, mainly due to the vested interests of
provider groups and other influential stakeholders. However, universal coverage works as
79
On May 3, 2006, the South Korean government officially announced a new pharmaceutical reimbursement
system. The new system stipulates the enhanced use of economic evaluation data for reimbursement decisions.
Under the new system, evidences of costs and effectiveness will be considered - on top of safety, efficacy, and
quality of drugs - in (positively) selecting what is to be covered by social health insurance system and how much
is to be paid. The newly announced fourth-hurdle policy in pharmaceuticals is aimed at boosting rationality of
rapidly rising drug expenditures within Korea.
Extending Social Protection in Health
161
leverage in bringing about desirable changes in a health care system. With a substantial
amount of resources being poured into NHI, the health insurance authority, as a single payer,
gains relevant bargaining power. This provides the NHI system today with a reasonable bargaining position against monopolistic medical and other professional organisations, and even
against other health care providers like the pharmaceutical and medical equipment industry.
This relative power of social health insurance institutions enables the overall health care system to move forward towards further health system reforms. Without universal coverage having been achieved, the successive reform step undertaken after implementing NHI would not
have been feasible.
Establishing NHI - was it enough? The case of Taiwan
Comparable to the Korean experience, implementing NHI and universal coverage in Taiwan
was only a first step and induced a series of adaptations and reforms in the following years.
Problems and incompatibilities were encountered in the financing and contribution aspects.
The need for adequate, stable and elastic contributions is closely related to ensuring the system’s financial accountability. In order to improve the quality, effectiveness and efficiency of
service – a key issue if the major part of the financial risk is taken by payers and enrolees –
correctly designed payment incentives for providers is essential.
As in Korea and in most industrialised countries, a sustainable long-term care model is urgently needed in order to face the challenges of an aging society characterised by an increasing prevalence of chronic diseases and need for home-care. At the same time, welldesigned and affordable cost containment mechanisms are necessary for controlling not only
demand but also mainly supply-side induced cost escalation. The comprehensive NHI benefits package turned out to be unsustainable due to allocative inefficiencies, coverage of many
cost-ineffective benefits and the provision of care not based on evidence. Thus, continuous
micro-reforms are unavoidable for keeping the NHI running. Financing reforms included obtaining additional resources by increasing revenue through taxes on tobacco and charging
rebates on automobile insurance. The comprehensive benefits package was relieved by a
kind of ‘de-insurance’ when the Ministry of Health started to pay for preventive care, AIDS
treatment, teaching costs, infection control programmes, and other benefits from general tax
revenue.
The co-payment system underwent seven different reforms, starting from an increase of copayment for hospital outpatient care, levying co-payment for prescription drugs (> NT$ 100,
equivalent to € 2.5), and reached its climax when, in 2005, a referral system for hospital outpatient care was implemented, charging high costs to those who went to a hospital for ambulatory care without having first visited a physician. The drug payment mechanism has also
been adjusted seven times, achieving total cumulative savings of NT$ 25.4 billion (equivalent
to € 641.4 Million) between 1996 and 2003.
The payment reforms between 1998 and 2002 comprised global budgets in order to enforce
providers to share the financial risk, create the right incentives to providers for improving
quality and outcome as well as effectiveness of care. Since October 2001, quality-based
payment initiatives have accomplished the set of new methods applied in the Taiwanese
health care system; and since 2004, the first pilot projects with family physicians acting as
guides through the system are in place.
Additional NHI reforms foresee, in the main, strategies for enhancing the responsibility of
both beneficiaries and providers. First of all, instead of wage-related contributions, all types
of income will be considered as basis for social security payments in order to increase NHI
resources and to adapt financing to ongoing changes in income distribution. At the same
time, the replacement of the global budget fee-for-service by the global budget DRG payment system is intended to enhance providers’ responsibility and improve the efficiency of
the health care system. Introducing quality-based payment according to proven effectiveness, expanding the currently piloted Family Physician Initiatives, and strengthening a well
162
B.-M. Yang, J. Holst: Health Insurance in Developing Countries: Experience from Asia
designed referral system are three major tasks to be followed through by the ongoing health
sector reform.
One principal implementation approach taken by Taiwan was to carry out research in order
to prepare for many years. The conceptual bases for structure design were ‘equity’ and ‘cost
containment’, both applied with a view to reach universal coverage. Like in other countries,
Taiwan has continuously identified existing gaps and insufficiencies in service quality, equity
and efficiency, and has tried to overcome the problems detected through successive reforms.
The timing of implementation was important. “Had the plan not been implemented then
(1995), the plan of NHI would have been postponed, perhaps indefinitely” (Cheng 2003). Like
Korea, Taiwan would not have achieved even universal coverage leave alone the various
reforms that followed if it had tried to meet all pre-requisites for universal coverage in advance.
The NHI plan was designed to incorporate the mechanism of collective bargaining with provider groups through a single payer system. The global budget was established in the NHI
Act of 1994, and the corresponding payment reform was initiated four years after the establishment of NHI (1999) and achieved three years later (2002). The successful implementation
and performance of NHI has convinced the general public of the importance of the philosophy of ‘solidarity’ in health care. The necessity of NHI as a social mechanism has received
strong public support, with 70-80 % of the population supporting the redistribution mechanisms institutionalised by the solidarity principle. The ideas of mutual help and social coherence manifest in social health insurance are deeply embedded in the Taiwanese population.
This is why the system could be successfully defended against attacks by privatisation lobbies, market mechanisms and options of choice according to the basic concepts of neoliberalism and enhanced by the consequences of globalisation.
Experiences from other Asian countries reviewed in the context of universal coverage
The case of Thailand80
Thailand has implemented three different social insurance systems. Since 1978, the Civil
Servant Medical Benefit Scheme (CSMBS) for public employees, pensioners, and their dependents, financed through general tax revenue covers 11 % of the total population (2003),
and applies a FFS provider payment mechanism. The Social Security Organisation Scheme
(SSOS) was initiated in 1990 for private sector salaried workers (full coverage) and their dependents (limited coverage). It is financed through contributions shared equally between employer and employee, with additional resources from general revenue, covering 13 % of the
total population (2003); and pays providers according to a capitation method. The Universal
Coverage Scheme (UCS, generally called ‘30 Baht Scheme’) implemented in 2001 represents a decisive step towards universal coverage by merging the pre-existing VHC (rural
population) and SWS schemes (poor and indigent). The current ruling party of Prime Minister
Mr. Thaksin took universal coverage as an important issue of its political agenda, and
pushed forward with a strong political will. Financing relies mainly on general revenue; beneficiaries have to pay 30 Bahts (equivalent to € 0.6) out-of-pocket for any service (outpatient
benefits and inpatient admission). In 2003, three out of every four Thais (76 % of total population) were covered by the 30-Baht-scheme; provider payment is realised through capitation.
Government commitment was a decisive factor in the implementation of the UCS, as it was
the generous capitation payment for health care utilisation from the country’s general tax
revenue, not only for the 30-Baht-scheme but also for the CSMSB and partially for the SSOS
that made it possible. The Health System Research Institute of Thailand is providing technical support, while International organisations and foreign donors including WHO, ILO and
others are promoting health insurance reforms aimed at universal coverage. All previous efforts had been oriented towards universal coverage so that there is not much room left for
80
Please compare V. Tangcharoensathien et al., Universal Coverage in Thailand: the Respective Roles of Social
Health Insurance and Tax-Based Financing, Chapter 3.4, pp. 121-131.
Extending Social Protection in Health
163
additional reforms. However, a payment reform with the CSMBS has been suggested in order to substitute FFS by capitation for outpatient care and from the global budget to DRG for
inpatient care. In addition, SSOS coverage will be expanded to beneficiaries’ spouses and
other dependents currently under the UCS scheme.
The case of Mongolia
The Mongolian Citizens’ Health Insurance Program (CHIP) started in 1994 on an individual,
not family basis and has not achieved universal coverage yet. The scheme is partly financed
through contributions paid by the employees, while 62 % comes from government general
revenues and are dedicated to provide cover for seven well-defined vulnerable population
groups. Benefits are restricted to inpatient care and provider payment relies on a fee-forservice mechanism (a perverse result of this incentive nearly doubled the length of hospital
stay) (WHO 2004b, p. 199f). The policy of exclusively covering inpatient care led to a palpable increase of hospital admission rates. Both factors make the CHIP scheme rely on high
subsidisation by the government and severely threaten the viability and sustainability of the
insurance program.
The current reform in Mongolia aims at expanding the CHIP in order to respond to primary
care needs. The new Family General Practitioners Programme (FGPP) added on to the Citizens’ Insurance Program foresees a capitation payment to providers. The government is
deeply concerned about the vulnerability of the population in the transition period to a market
economy. In order to maintain equity and access to health care and to protect the population
from high and impoverishing health spending, universal coverage was set as a target and
occupies an important place on the political agenda.
When the government started to reduce subsidies, high drop-out rates from insurance were
observed. In order to not loose the goal of achieving universal coverage, the Citizens’ Health
Insurance (CHI) Law was amended in 2003. According to the amended CHI Law, the Mongolian government plans to extend the unit of coverage from individuals to families, to
strengthen the accreditation of providers, and to change provider payment from FFS to capitation for hospital care. The process of developing health insurance in Mongolia started with
strong political commitment, an ambitious program, and a government subsidy for vulnerable
population groups. However, the Mongolian health care system is facing challenges by the
growing private sector and insufficient government funding. Additional reforms are required
because, despite the legislative basis for universal coverage, the de facto coverage of the
entire population is yet unachieved. One important step will be the improvement of the management capacity to register and collect contributions from the self-employed, the cattle
herdsmen, and other informal sector workers. In parallel, the capacity to negotiate with providers and ensure quality has to be further developed, and a provider payment reform is
needed.
The case of the Philippines
Very early, compared to other Asian countries, the Philippines started their Medicare Program (MP) in 1969. It was compulsory for public and private sector salaried workers and dependents, and voluntary for self-employed and informal sector workers. The MP covered only
inpatient benefits, but enrolees had to make high out-of-pocket payments of more than 50%
of the treatment costs. Provider payment was realised through the fee-for-service method.
The attempt to include ambulatory care in the benefit package was not achieved. Altogether,
the Medicare Program failed due to low compliance with the legislation, namely, a low level
of registration. Accreditation of providers was inappropriate, and the fee-for-service reimbursement for hospital care provoked a high number of fraudulent claims and private HMO
developed for high income employees and professionals in parallel.
In 1995, the National Health Insurance Program (NHIP), managed by PhilHealth, started as a
compulsory social health insurance scheme replacing the previous Medicare Programme.
NHIP is mandatory for the employed of both the government and private sectors, and independent workers and professionals in the private sector (physicians, lawyers, etc.), Overseas
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Filipino workers and their dependents, as well as some pensioners and retirees can enrol on
a voluntary basis. Indigent beneficiaries have the right to be enrolled for subsidised contributions. The NHIP scheme includes both inpatient and ambulatory care benefits and coverage
of indigent population is priority. The insurance scheme has established standards and regulations for the accreditation of health facilities.
A major problem derives from the inadequacy of available funds, and until 2002, coverage
was about 53 % of the Philippines’ population. Universal coverage is yet to be achieved and
planned for the year 2010. PhilHealth emphasises the complementary role of community
based health insurance schemes in reaching universal coverage. What is lacking in achieving universal coverage in Philippines, compared to other countries that have achieved NHI, is
strong political commitment by political decision makers. Lack of political commitment could
well be due to the existence of private HMOs as well as the early (1992) devolution of health
care services to local government units.
With regard to the implementation of social protection in
Elements of Universal Coverage:
health, a series of lessons can
Political will toward universal coverage
be drawn for developing counGovernment financing commitment for vulnerable
tries. Once a society realises
population groups
that societal health goals – better health status, financial risk
Technical support in planning and implementaprotection, health equity – can
tion, plus effective administrative capacity
be achieved through social
Followed by amendment of the system for exhealth insurance, the concept
pansion of coverage and refinement of the syshas to be shared among the
tem for improved performance
public and has to be expressed
As health care becomes costly under universal
in the political agenda. Certaincoverage, various structure reforms for long-run
ly, social security has to start
sustainability are required
with a firm political will, but political commitment may not be
sufficient. Government commitment in terms of financing is a prerequisite, particularly for
vulnerable population groups. As firms and citizens pay their share of contributions, government must shoulder the responsibility of protecting the health of the disadvantaged members
of the society.
Strong political will is essential in order to overcome various obstacles during the implementation period. With government financing for vulnerable population groups, even low-income
countries can get to universal coverage. Effective administrative capacity is needed to extend
coverage in a steady and continuous manner.. Therefore, it is of utmost importance to have
technical support in planning and implementation, and sufficiently educated and specialised
government bureaucrats, academic researchers and foreign experts. Technical experts have
to examine the financing context, the income distribution, the tax base, the share of the poor,
the household distribution of employment status, and the government’s ability to collect taxes
or contributions. Technical experts are also needed for designing the financing model, the
service delivery model, and the administrative structure. However, the determination of financing mechanisms, service delivery modality, organisational structure and other key elements of health care financing are hardly the same in two different countries and rely on
every country’s own and independent decision.
It is also recommendable to establish clear strategies from the very beginning of the implementation process. In most cases, a gradual approach, starting with the formally employed
sector, followed by including civil servants and then the self-employed and other informal
workers might be a viable and feasible approach to implement social health insurance. It is
imperative to motivate people to join and to make people willing to pay regularly for health
insurance, and to use general or earmarked tax revenue as a reserve for introducing desired
incentives and promoting equity.
Extending Social Protection in Health
165
One important lesson learned from the implementation of social health insurance in Korea
and elsewhere is that universal coverage should be achieved before private health insurance
companies emerge. Private insurance often looks very attractive to decision-makers, stakeholders and also the better-off members of society. It certainly provides more choices especially for the better off and is more appealing when government funding is scarce and insufficient to cover people’s needs. As private health insurance is strongly advocated by important
developing agencies (Worldbank 1993 & 2004; comp. Arhin-Tenkorang 2000), international
insurance companies, and some health economists (Pauly et al. 2006), their de facto increasingly important role in most developing countries is even enhanced through development co-operation. However, international evidence shows that neither private for-profit nor
informal insurance schemes have ever managed to contribute a relevant portion to universal
coverage. The experiences from South Korea, Taiwan and elsewhere calls for a degree of
reluctance with regard to private health insurance, because once it takes root and grows
strongly, universal coverage might become unachievable.
Health care policy is the science of reality, and any policy design should be evidence-based.
International evidence clearly shows that the strong existence of private health insurance
functions as a barrier to achieving universal coverage. If providing average people with reasonable access to needed health care is the goal of a country’s health policy, then, most of
us agree that universal coverage is the answer. With its several advantages, private health
insurance could be an option for some societies but only if a stable universal coverage program already exists. Private health insurance cannot be the answer for developing countries,
in this regard. Changes in service delivery and/or financing modality should not be introduced
prematurely. Reforms should wait until the time is ripe, sufficient experience on the implemented mechanisms available and SHI possesses reasonable bargaining power against professional provider groups who are used to being strong stakeholders in every health care
system. Countries often begin the implementation of social health insurance on the basis of
existing structures like fee-for-service and weak referral systems that tend to hamper achieving universal coverage in the long-term and require further reforms.
Basic questions
The experiences from Taiwan and Korea raise two interesting for developing countries currently without social health insurance; these are: ‘What made the two systems implement
NHI?’ and ‘How did the process proceed?’ Many think money (or income growth) is a core
asset or at least a pre-condition. However, it is well-known that even countries of high economic status, like the United States of America, lack universal coverage and social health
insurance. The experiences of the two East Asian countries indicate that it takes more than
strength of income to achieve universal coverage. Their experiences point to a framework
that a developing country may consider in implementing NHI. It is certainly an experiencebased framework, rather than a concept-based theoretical framework. Contributing factors
for NHI, common to both countries, were; sustained economic growth, strong consumer demand for insurance coverage, public trust in bureaucratic leadership, democratisation process81 and firm political will at the top (TM Cheng 2003; Yang 2005). The most conspicuous
among these was the strong political commitment towards achieving universal NHI, in which
the political will was based on the confluence of other factors.82
81
South Korea started its first social insurance program in 1977, under the environment of a dictatorship. The fact
that health care was provided free in confronting North Korea worked as one of the stimulants to start such a
program by the then political leader (Yang, 1991). However, successive expansion of programs towards universal
coverage became possible by peoples’ power, during the democratisation process.
82
Strong political will was heavily influenced by the level of people’s demand for financial protection from health
risks, namely, health insurance. The transition to democracy in South Korea and in Taiwan during the 1980s
forced the political leaders (both in the leading and opposition parties) to advocate the establishment of universal
health insurance coverage. Their decisions were based, in addition to the philosophy of solidarity, upon data and
information on health care costs, health budgets, financial plans for resource allocation, and efficient administration structure.
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The political leadership in both countries understood the value of NHI in the first place, recognised the opportunity of achieving it, and seized it boldly. During the implementation process of NHI, there were various conflicts among stakeholders, resistance from vested interest
groups, political struggle, bureaucratic misunderstanding, and financial impediments. Overcoming all these obstacles was possible, in both countries, only by strong government leadership, particularly by the well-manifested will of a political leader. In both countries, universal
coverage was achieved well ahead of schedule; two years earlier (in 1989 rather than in
1991) in the case of South Korea (BM Yang, 2003) and five years earlier (in 1995 rather than
in 2000) in Taiwan (Chiang 2005). Once again, political leaders’ decisions were critical in
expediting the implementation of NHI.
Once a system of universal health insurance coverage is launched, a critical challenge to be
faced in most cases is its financial sustainability over time. On financial sustainability, two
purely experienced-based lessons can be drawn from the two countries. In developing a social health insurance framework, it was found imperative to institutionalise a prepayment
health care financing mechanism or to strengthen existing prepayment schemes. The way
providers are paid is a key determinant of the efficiency of a health insurance system. With
unregulated fee-for-service payments of providers, as empirically seen in both systems, financial insolvency would endanger the system in the long run.
Another lesson for sustainable SHI is that there needs to be a strong primary care base and
an efficient referral system for extended care. Without such a structure, both allocative and
technical inefficiency result. However, conflicting interests among stakeholders involved in
the resource allocation process may make a change in structure very difficult. Both South
Korea and Taiwan are struggling to improve this situation, with little progress. It can be noted
from this experience that if one needs to have such a structure, it is better to establish one in
the early stages, before additional resources are poured in for universal coverage. Nevertheless, the two countries are exerting efforts to improve the equity, efficiency, and quality of
service aspects of NHI even after achieving universal coverage.
Various forms of health insurance reforms have been tried, are currently under way, or are
planned in both countries. Examples include consolidation of insurance funds, changes in
payment-reimbursement methods, payment based on clinical outcomes (fee-for-outcome
approach), separation of pharmaceutical prescription and dispensing, drug utilization review,
setting up an efficient referral channel, introduction of health care IC-Cards and use of economic evaluation information in decision making. The prospect of desirable changes is promising, though not totally optimistic.
Universal coverage, with much additional resources pumped into the system, is being used
as a leverage to bring about desirable changes in health care financing and delivery. One
could say that various reforms would not have been feasible, or even been attempted, in the
absence of universal coverage within the two nation’s systems.
In both countries, critics argued that universal coverage was implemented with inappropriate
planning and undue haste. However, had they not been implemented then, the plan of NHI
would have been postponed, perhaps indefinitely (Cheng 2003). The policy of separation of
pharmaceutical prescription and dispensing (SP: separation policy) in South Korea, for example, whose implementation in 2000 would not have been possible in the absence of NHI,
could not have been implemented at all if it had been delayed (Yang, 2005). Observing the
public’s need and listening to their demands for improved access to health care services, the
political leaders, convinced that universal coverage and the related reforms were good for
the people, seized the opportunity and pushed the plan forward. It is the political will that
made it a reality.
There are many different routes to achieving the health system goals of making people
healthy, satisfied, and financially protected (Hsiao 2000). Achieving universal coverage
through social health insurance and tax financing is one of them. In observing the recent implementation of universal health insurance and successive health insurance reforms in the
Extending Social Protection in Health
167
two East Asian systems, health policy makers in other countries may realize that social
health insurance could be a priority, with strong political will serving as a vehicle to fruition.
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Yang, Bong-Min (2005). National Health Insurance in South Korea: opportunities and challenges. Paper presented at the International Conference on Health Insurance, Taipei, Taiwan, March 2005.
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Conference Conclusions
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5.
Berlin Recommendations for Action83
In December 2005 the International Conference on Social Health Insurance in Developing
Countries was held in Berlin. The conference was convened by the Deutsche Gesellschaft
für Technische Zusammenarbeit (GTZ) GmbH together with the International Labour Office
(ILO) and the World Health Organization (WHO). It was held in the context of the Resolution
and Conclusions concerning social security of the International Labour Conference (ILC) in
2001 and the Global Campaign on “Social Security and Coverage for All”84; the World Health
Assembly (WHA) Resolution on “Sustainable Health Financing, Universal Coverage and Social Health Insurance 2005”85; and the GTZ initiatives on Social Health Insurance.
The international conference was a concrete contribution to the implementation of the recommendations made in the above-mentioned Resolutions. Both resolutions urge to work
towards universal coverage and sustainable health financing, and to share experiences on
different methods of health financing, including the development of social health insurance
schemes, and private, public, and mixed schemes.
The Berlin conference brought together 234 Ministers, Deputy Ministers, Heads of Department, Directors-General, Directors, Chief Executive Officers (e.g. in the field of health, finance, labour, planning, development) and national authorities from developing countries
and countries in transition, social partners and stakeholders of international co-operation.
The broad spectrum of participants enabled the consideration of a wide range of perspectives on accomplishments so far, challenges ahead and policies needed to address them.
These recommendations for action result from this conference.
Background
Problem Statement
Health and social security are human rights. Both health and social security are tools and
indispensable prerequisites for poverty reduction, economic growth and development. The
overwhelming importance of addressing health and poverty is also reflected by the Millennium Development Goals (MDG) adopted by the international community in 2000. They
range from halving extreme poverty (MDG 1) to reducing child mortality (MDG 4), improving
maternal health (MDG 5), and combating HIV/AIDS, malaria and other diseases (MDG 6), all
between 1990 and 2015. Still, the extent of premature deaths and ill health in developing
countries is staggering. Specifically for the poor, the risk of severe illness and earlier death
from disease is considerably higher than for those who are financially better off. Poor people
are more exposed to health risks as they often experience bad working environments, living
in inadequate sanitary conditions, have no access to clean water and suffer from malnutrition.
In addition, worldwide 1.3 billion people do not have access to effective and affordable health
care; including drugs, surgeries, and other medical interventions because people cannot afford to pay or governments cannot afford to provide them with the coverage necessary. This
is exacerbated by the fact that half of the world's population is without social security coverage at all. The poor are the most vulnerable as they are less able to recover from the financial consequences of out-of-pocket payments and loss of incomes associated with ill health.
In order to cope with illness related expenditures they often have to cut down expenditures
on necessities like food and clothing or take their children out of school as they cannot afford
to pay the school fees anymore. It is estimated, that every year, more than 150 million individuals in 44 million households face financial catastrophe as a direct result of having to pay
83
Recommendations elaborated by the organisers of the Berlin Conference and endorsed by comments from the
participants.
84
See: http://www.ilo.org/public/english/protection/socsec/download/aconsens.pdf
85
See: http://www.who.int/gb/ebwha/pdf_files/WHA58/WHA58_33-en.pdf
Extrending Social Protection in Health
169
for health care. About 25 million households or more than 100 million individuals are pushed
into poverty by the need to pay for services.
If trends continue, the majority of poor countries will not meet the MDGs for health. Especially in Sub-Saharan Africa many countries are lagging behind badly and face the additional
burden of HIV/AIDS.
A question that remains of utmost importance is therefore, how national health systems can
ensure universal coverage that is defined as access to essential health promotion, and, preventive, curative and rehabilitative health interventions for all. In this context, a country’s
health financing system is a key determinant of population health and well-being. In many
developing countries, the level of spending is still insufficient to ensure equitable access to
basic and essential health services and interventions. Despite the Abuja Commitment to allocate 15 % of total government expenditure to health, in most countries government spending
remains far below that target. There is also a growing international consensus that development assistance for health must be increased significantly if the MDGs for Health can be
met. However, in addition to the level of spending, the way how a health system is financed
is crucial for universal coverage.
Social Protection in Health
The conference acknowledged that the extension of social protection in health is the key
strategy to reduce financial barriers to access health care and move towards universal coverage (i.e. universal health protection). Social protection in health comprises a variety of financing mechanisms. Besides tax-funded health financing, social health insurance in a
broad sense is one important option for countries to ensure social protection in health
thereby contributing to universal coverage. Community-based and employer schemes are
complementing options. Within each of these broad categories identified in terms of financing
sources lies a range of options for organising arrangements for pooling funds and purchasing
services. Further options lie in mixed arrangements that use these different sources of funds
in an explicitly complementary manner.
Irrespective of the financing mechanisms employed, social protection in health involves a
shift towards enhanced risk-sharing and risk-pooling, i.e. increasing the share of prepayment
in total health expenditure and reducing the reliance on out-of-pocket-payments. The strategy also involves subsidies and cross subsidies within or between risk-pools.
Social protection in health is essentially a matter of shared societal values and procedures
towards an overall more equitable distribution of wealth and resources. Important underlying
values include equity and solidarity, which in turn can contribute to social justice. According
to the principle of solidarity everyone should have access to an adequate package of healthcare and no family should be catastrophically burdened by the cost of illness. The principle of
solidarity is directly related to equity in financing and financial risk-protection. The former
means that people should contribute on the basis of their ability to pay rather than according
to whether they fall ill. Achieving the latter ensures that the cost of care does not put people
at risk of financial catastrophe.
While progress towards increased social protection in health based on these principles and
values can be made in systems funded from general revenues, payroll tax revenues, or a
combination, social health insurance is generally based on the additional principle of responsibility and participatory governance by social partners and insured. In many systems, governance includes the delegation of functions from the state to public, non-state institutions,
such as independent or quasi-autonomous health insurance organisations, ruled by public
law and civil society groups (e.g. mutual health organisations, co-operatives), professional
associations (e.g. medical doctors), workers' and employers' organisations and the private
sector (e.g. private providers). It often involves a wide range of actors, thereby strengthening
participation and decentralization in social protection as well as reducing the burden on governments (though of course accountability relations between the insurance fund(s) and the
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Conference Conclusions
government with regard to the use of public funds must be clear). In this context regulations
based on social dialogue are crucial for defining policies, assigning roles and responsibilities.
Social Protection and Health Sector Reform
The extension of social protection in health needs to be embedded in a comprehensive strategy of health sector reform and enabling social and economic policies. In many developing
countries, this strategy could involve an increase in the level of health spending in developing
countries (in case clear accountability mechanisms are put in place), an improvement of human resources within the health sector and an ensured availability of a regular supply of
medicines and equipment. Furthermore, reliable data and information management systems
are needed to measure progress, target interventions and formulate policy objectives. Beyond the health sector, the broader determinants of ill-health such as social exclusion of specific groups (e.g. the rural population, ethnic minorities, migrants, and unemployed), low levels of education, unequal gender relations, high risk behaviour, malnutrition and an unhealthy
environment necessitate the inclusion of a health promotion strategy in any social protection
policy.
Socio-economic Impacts of Social Protection in Health
Social protection in health not only improves upon the health status of people, but also directly contributes to the ambitious goal of halving poverty by 2015 as it protects people from
the impoverishing effects of the direct and most of the indirect financial costs of illness. Better
health of the population increases the productivity of the labour force, thus protecting and
promoting their income generation. At a macroeconomic level social protection in health
bears a potential to foster economic growth via three channels: Firstly, by reducing inequalities and promoting a better overall health status, it enhances human capital formation,
thereby increasing overall economic productivity. According to estimates by the WHO Macroeconomic Commission on Health a 10% increase in life expectancy leads to an additional
0.3-0.4 percentage points increase in annual per capita income. This causes a difference of
1.6 % in annual growth rates between a typical high-income country with an average life expectancy of 77 years and a typical low-income country with an average life expectancy of 48
years. Secondly, by preventing sickness-related income variations, social protection in health
stabilises internal demand and may subsequently lead to higher consumption levels and accumulation of assets. Thirdly, it contributes to social cohesion and social peace, which are
prerequisites for sustainable economic growth.
Financing Social Protection in Health in Developing Countries
Some basic social protection in health is possible and affordable in any country, but it requires a strong political will. Combining contribution-based financing with tax-financed subsidies enables the coverage of population groups or specific epidemiological necessities. A
mix of financing methods could share the burden of health care expenditures among a
broader tax base while also promoting greater potential for cross-subsidy by having contributors and non-contributors in the same pool. Employing different financing mechanisms for
different groups demands a careful coordination. Potential difficulties which might arise (e.g.
different interests and solidarity attitudes between formal and informal sector workers) need
to be taken into consideration at an early stage.
However, specifically in low-income countries, domestic financial resources might not be sufficient to finance approaches to include the poor. Depending on country-specific needs, external funds can assist in financing measures of social protection in health. Innovative financing mechanisms like the proposed International Finance Facility or debt for health swaps can
provide additional financial resources. All external funds should be provided in a predictable
way and ensuring longer-term support. However, external inflows of funds must not substitute national funding. Moreover, transfer of funds must be made in such a way to ensure sustainability and that they still benefit the sector they were originally earmarked for. In the long
term, all schemes should become as financially independent of external funding as possible.
Extrending Social Protection in Health
171
Prerequisites for Implementation
Irrespective of the financing method applied, making progress towards universal coverage is
a long term process that can only be successful if progress is made on all necessary areas
required. Realistic options and scenarios have to be developed within the particular macroeconomic, socio-cultural and political context of a country. A number of factors determine the
speed and form of transition: the political will, the effectiveness of government stewardship,
the institutional and legal framework, the relative acceptance of the values and concepts of
equity and solidarity in society, the population’s confidence in government and its institutions,
the health care infrastructure as well as the availability of skilled administrative, medical and
nursing personnel to facilitate the effective implementation of a nationwide system of social
health protection.
Another critical factor is of
course the ability to collect
insurance contributions or
tax revenues, which in turn
is dependent on the structure of the economy, particularly on the relative size of
the informal and formal sector. The manner by which
countries coordinate mechanisms for revenue collection, pooling of prepaid
funds, and purchasing of
services has critical implications for the extent to which
financing systems contribute to health gain, financial
protection, and other performance objectives. Certainly, economic growth enhances governments' and people’s capacity to contribute to a health financing system, irrespective of
whether this is via general tax revenues, payroll or other forms of earmarked taxation, or voluntary contributions.
Areas of Action
For countries aiming to promote and expand universal health protection under their leadership, the conference recommends the following areas of actions:
Extension of coverage
In order for social protection in health to be an effective instrument to reduce poverty and to
contribute to the achievement of the MDGs, extending coverage to the poor and otherwise
excluded remains the foremost challenge to partners and donors. However, national governments assume the primary responsibility to initiate, promote and facilitate the extension of
coverage.
Although various options exist for achieving universal coverage, a common characteristic of
successful systems is that some part of the financial contributions of households is prepaid
and pooled. Solidarity-based social health insurance schemes offer, among others, an effective, fair and flexible contribution to the realization of universal coverage. When implementing
a social health insurance scheme, marketing the insurance principle is essential. Within the
basic principles of social health protection, including equity, dignity, and sustainability, each
country should determine a national strategy for working towards universal coverage. Indeed,
in accordance with the WHA and ILC Resolutions, when managing the transition to universal
coverage, each strategy will need to be developed within the particular macroeconomic,
socio-cultural and political context of each country. In this context, it is necessary to develop
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Conference Conclusions
scenarios that are politically acceptable and affordable by different income groups as well as
being economically feasible. Furthermore, any strategy must be linked to proposals for controlling the costs of health care and by linking it to preventative schemes.
Impact of HIV/AIDS
In many developing countries, particularly in sub-Saharan Africa, the HIV pandemic is having
a dramatic effect on every aspect of society. Strengthening national capacities to address
and effectively combat HIV/AIDS is of fundamental importance; otherwise the pandemic will
undermine the financial sustainability of national health systems in developing countries.
Recognizing that the fight against HIV/AIDS cannot be won without external resources, creating operative links between global health initiatives like the GFATM (Global Fund to Fight
Aids, TB and Malaria) and national health and HIV/AIDS financing mechanisms could provide new opportunities to strengthen countries’ national programmes. In this context, national
health financing systems, including social health insurance funds, can provide effective fund
management structures. On the other hand, resources from global financing mechanisms
could be used to expand the benefit package, complementing the benefits offered from domestic compulsory sources.
Good Governance
The introduction or expansion of solidarity-based health financing systems, and accordingly
the funding of systems through some form of compulsion, i.e. direct contributions or taxes, is
a complex task that involves broad changes in a country’s institutional (e.g. legislative and
regulatory requirements) and organisational frameworks (e.g. relationships between public
and private providers, health insurance organisations, and patients). The effectiveness of
Government stewardship as well as skilled administrative personnel, are crucial for successful reforms. Furthermore, public confidence in the health financing system is a key factor for
its success. For confidence to exist, good governance is essential. Therefore, all systems
should conform to certain basic principles: benefits should be secure and non-discriminatory;
funds should be managed in a sound and transparent manner, with administrative costs as
low as practicable, clear lines of accountability and a strong role for social partners.
Roles and Activities
The extension of social protection in health and the quest for universal coverage requires the
involvement and commitment of a variety of actors. National dialogue between policy makers, employers and workers’ organisations, key actors from the private sector and from various civil society groups, health care providers, and development partners is essential for the
overall sustainability of national health systems. Social dialogue can create social consensus
and the political will to act in favour of social protection in health.
Governments
State legislative and executive bodies have a priority role in facilitation, promotion and extension of health protection, including legislative decisions on its form. Overall government
stewardship and a strong political will to engage in health financing reform are essential for
steering the implementation of sustainable systems of social protection. Moreover, governments need to ensure that incentives are in place to encourage providers to supply only the
services that are required, at a high level of quality and low costs (efficiency).
Workers and Trade Unions
Trade unions are vital in advancing the principles of solidarity and social justice among their
members and in society at large. Workers and trade unions should be included in participatory forms of decision-making. In the case of social health insurance, this may include a direct vote in the governance of social health insurance schemes through deciding on the
board of these schemes. Further participatory decisions should include ensuring adequate
distribution of available funds and that benefits correspond to needs. Trade unions could also
Extrending Social Protection in Health
173
support governments in establishing measures to extend coverage to people not covered so
far (e.g. workers in the informal economy, rural populations) and in taking account of genderrelated aspects.
Employers and Employers' Organisations
Employers should be included in social dialogue and, where social health insurance
schemes are present, should be included in decisions with regard to the boards of such
schemes. Further, employers should respect national and international labour standards.
Supporting the establishment of social protection systems is also an element of corporate
social responsibility.
Voluntary Health Insurance
Voluntary health insurance
(e.g. private for profit or community-based) can offer supplementary insurance packages or
complement a basic benefit
package to that funded from
compulsory sources. In some
countries
privately
owned
health insurers are critical
agents in the implementation of
public compulsory health insurance. Community-based health
insurances might be important
organisational devices in extending coverage to the excluded
in particular in the informal economy. They can make the concept of insurance known to the
population and increase coverage in the medium term, though of course the potential for
such expansion of coverage is limited as with all forms of voluntary health insurance.
Social Security Institutions
Due to their institutional interest, social security institutions are a cornerstone in any coverage extension strategy. They need to be at the centre of capacity-building and training
strategies.
Civil Society Groups
Civil society groups (e.g. religious bodies, non-governmental organisations, cooperatives)
play a key role in promoting the principles of equity and solidarity in society. They should
participate in national dialogues to further the extension of coverage to excluded groups.
Health Care Providers
Private and public health care providers should be adequately equipped to provide quality
health care services, including the treatment of specific diseases (e.g. HIV/AIDS). Health
care providers also need to be acquainted with the principles of modern health care purchasing arrangements, including the procedures of accreditation, contracting and payment
mechanisms' advantages and limits within a third party payment agreement.
Development Partners
Development partners need to strengthen their efforts and commitments to enable countries
to develop fair financing health systems. This includes offering technical cooperation as well
as further knowledge and capacity development to partner countries. External funds should
be made available to partner countries on a predictable and longer term basis. In line with
Conference Conclusions
174
the Paris declaration on aid harmonisation, development partners should work together more
closely and harmonise their agendas.
National and international organisations and agencies sharing the values of equity, universality and solidarity in health are invited to join the global partnership and cooperate at the international, regional and country level. At this conference in Berlin, the international community
suggested to support countries and pursue advancements within the described priority areas
of actions by the following activities:
Technical Cooperation
A central problem in organizing health financing is that governments and other decisionmaking authorities often face limited capacities and experience to develop socially balanced
and pro-poor health care systems. In principle, technical
cooperation and collaboration at
regional, country and community
level to strengthen capacities
and expertise in the development of health financing systems should be demand driven
and originate from country level
as a result of broad consultation
between partners and donors. It
includes the following activities:
Providing comprehensive
policy advice to interested
partners
on
the
introduction and reform of social protection in low and middle-income countries,
thereby taking into account the legal and regulatory framework as well as the macroeconomic dimension of social protection and health care delivery.
Collaborating in analysing the benefits and costs of different methodologies in health
financing, covering collection of revenues, pooling, and purchasing of services (including contracting), extending protection to those at greater risk of non-use of needed services or impoverishment, health insurance coverage and registering members, designing the benefits package, costing of the benefits package, assuring the provision of
good quality health care, and setting up efficient fund management structures.
Intensifying efforts for financing health promotion and disease prevention including environmental issues.
Jointly applying tools in order to support the planning, implementation, evaluation and
monitoring of social health protection systems.86
Carrying out feasibility studies to analyse systematically the political and socioeconomic conditions, needs and expected costs related to the introduction of a health
insurance system or the expansion of a tax-based system and examining the potential
for linking up existing local, regional and national as well as public and private approaches to social protection.
Networking and Advocacy
86
Available tools comprise, for instance, of InfoSure, an Internet based information and evaluation tool for assessing health insurance systems; SimIns, a simulation tool used to forecast trends in an insurance scheme’s income
and costs over the medium term (up to 10 years), national health and social budget models, policy tools for designing, implementing and improving social protection mechanisms and governance such as social dialogue and
STEP tools to administer, monitor and evaluate micro insurance schemes.
Extrending Social Protection in Health
175
A high priority is placed on national and international collaboration and cooperation, including
donor harmonisation. Networking as well as activities to advocate and promote social health
protection will be pursued by the following activities:
Contributing to the creation and ongoing development of national and international
network structures encouraging the flow of information and dissemination of e.g. policy
papers, practical guidelines, studies and working papers.
Working closely with national and international partners to exploit synergies and develop coherent strategies.
Cooperating on the international level to position social protection, including social
health insurance, more prominently on the development agenda.
Establishing and strengthening partnerships between government authorities and academic institutions as well as non-governmental institutions to produce more relevant
evidence on the feasibility, costs and benefits of social protection systems.
Monitoring and Evaluation
Regular monitoring and evaluation is necessary to know what progress has been made, and
how performance can be improved in the future. Whereas monitoring should be part of any
country driven initiative, evaluation efforts could be part of a broader learning initiative. Activities should focus on:
Introducing mechanisms and developing indicators to monitor progress, evaluate impacts, and document the results of financing reforms aimed at improving social protection, including social health insurance.
Establishing national benchmarks, which clearly define targets of success (e.g. issues
such as increase of the level of health sector spending, reduction of the rate of out-of
pocket-payments, reduction of poverty arising due to health expenditures and increased equity in health care utilisation are to be specified).
Capacity Development and Exchange of Experience
The development of adequate arrangements for social protection, adapted to the country's
preferences and needs is a lengthy and complex process. Knowledge needs to be developed
in a process of continuous dialogue, fostered by the following activities. All activities should
be built on the existing.
Sharing experiences on different methods of health financing, including the development of social health insurance schemes, and private, public and mixed schemes as
well as other innovative approaches to extend financial protection and coverage to the
poor and those working in the informal economy.
Evaluating and documenting findings and results from national and regional-specific
experience, and using these findings for effective policy advice.
Analysing concepts of social health protection and impacts on poverty reduction.
Organising seminars and workshops on various issues in social protection and health
care financing for decision-makers, executives and social partners as well as training of
professionals (e.g. within the institutions ILO has set up).
Creating sustainable and continuing mechanisms, including international conferences,
subject to availability of resources, in order to facilitate the sharing of experiences and
lessons learnt with regard to health financing reforms aimed at promoting universal
health protection.
Contributors
176
6.
Annex
6.1. Contributors
Hédi Achouri, MD degree from the Faculty of Medicine of Tunis (1980), education in general medicine,
various short-term trainings in the fields of primary health care, health economics and hospital management. General practitioner and regional director of public health until 1986, since 1987 director of hospitals in the headquarter of the Tunisian Ministry of Public Health. Founding member and president of the
NGO "Maghreb Economics and Health Systems Network", work in the fields of health economics and
management of health systems in Algeria, Morocco and Tunisia. Currently President of the Board of
Habib Thameur Hospital (Tunis), Member of the Board of the National Health Insurance Fund, and General Director of Health Public Facilities.
Ebenezer Appiah Denkyira holds a BSc, MB, ChB (Kumasi, Ghana) (1984) and a MPH (Leeds, UK)
1990), Fellow of the Ghana College of Physicians and Surgeons. Project manager of a DANIDA sponsored program for Strengthening Primary Health Care in the Upper West Region of Ghana (1992-1998).
Facilitator of the Civil Servants Health Insurance scheme in the Ashanti Region and consultant to the
MOH in the review of Health Financing and Strategies in 2005. Director of Health Services in the Ministry
of Health for the past 10 years, currently Regional Director of Health Services in the Eastern Region of
Ghana.
Dorsjuren Bayarsaikhan studied engineering and economics in the former USSR and holds a Masters
of Public Health (MPH) from the Public Health School of Boston University (1998). Director General and
Vice Minister for Health in Mongolia (1990-1999) contributed to the development and implementation of
market-oriented government polices on various socioeconomic aspects. Member of Asia Pacific Health
Economics Network (APHEN) and Asia Pacific National Health Accounts Network (APNHAN). Currently
doctoral candidate at the School of Public Health at the Tokyo Medical and Dental University, and Regional Adviser in Health Financing at the WHO regional Office for the Western Pacific (Manila).
Mariana Barraza-Lloréns, BA in Economics from the Instituto Tecnológico Autonómo de México (1996),
MSc in Health Economics degree from the University of York (1997). Research Fellow at the York Health
Economics Consortium (1997-1999). Advisor in the Planning and Finance Directorate at the Mexican
Institute of Social Security (2000–2001). Area Director (2001-2003) and Joint Director-General in the
Economic Analysis Unit at Mexico’s Ministry of Health (2003-2006).
Ruben John Basa holds a degree in Political Science from the Ateneo de Manila University (1992) and
a Master's Degree from De La Salle University in Manila (1995). Former head of the Technical Staff of
the Senate Committee on Health and Demography and 1st Deputy Secretary General of the Philippine
Social Security Association (PHILSSA). Currently manager of the Corporate Planning Department of the
Philippine Health Insurance Corporation (PhilHealth) and the concurrent Head Executive Assistant of its
President and CEO.
Maryam Bigdeli holds a Bachelor in Pharmaceutical Sciences (1987), a Master in Pharmaceutical Sciences (1990), and a Master in Public Health (1995), all from the University of Brussels. Responsible for
regional supply of essential drugs (Médecins Sans Frontières Belgique) in Nzérékoré (Guinea) (19931994), researcher at the School of Public Health, University of Brussels (1994-1997) and at the Health
Economics Unit in Brussels (1997-1998), Senior pharmaco-economist at UCB Pharma (Belgium) (19992001), and technical officer for health systems development for the World Health Organization, Western
Pacific Region, Lao PDR (2001-2004). Currently WHO Health Financing Advisor, West Pacific Region in
Cambodia.
Claude Bodart, MD degree from the State University Liège, Belgium (1981), a MPH from The University
of Michigan (1989), and an EMBA from the Asian Institute of Management, Philippines (2005). Two decades of field experience in public health and health financing in Latin America, Africa and Asia. Principal
GTZ advisor for social health insurance in Indonesia.and advisor of the Philippine Health Insurance Corporation (1996–2006). Since July 2006, working for the Asian development Bank in Manila, Philippines.
Guy Carrin holds a M.A. and Ph.D. in economics from the University of New Hampshire (USA) and the
University of Leuven (Belgium), respectively. Econometrician at the Ministry of Planning of Tunisia, researcher at the Center for Operations Research and Econometrics in Leuven, Takemi Fellow in international health at the Harvard School of Public Health (1985-86), and adviser to the Minister of Public
Health of Belgium (1987-88). Professor of economics (1979-90) and visiting professor of international
health economics since 1990 at the University of Antwerp (Belgium). Appointed adjunct professor of public health at Boston University in 1990. Currently coordinator of health financing policy within WHO's Department of Health Systems Financing in Geneva.
Extrending Social Protection in Health
177
Xiaoming Cheng, graduated from Shanghai Medical University in 1976. He is Professor at Health Economics Department of School of Public Health, Fudan University since 2000. His main research fields
include health sector reform and development, evaluation of health economics, health insurance, health
financing and expenditure, allocation and utilization of health resources, pricing of health service, cost–
benefit analysis.
Timothy Evans has a Bachelor of Social Sciences from the University of Ottawa, a PhD in Agricultural
Economics from the University of Oxford, and an MD from McMaster University in Canada. Training in
internal medicine (Brigham and Women’s Hospital at Harvard University). Assistant professor of international health economics at the Harvard School of Public Health, and Director of Health Equity at the
Rockefeller Foundation from 1997 to 2003. Currently Assistant Director-General at the World Health
Organization, Geneva, Switzerland.
Julio Frenk, MD degree in 1979 from the National Autonomous University of Mexico, Master of Public
Health (1981), Master of Arts in Sociology (1982), and Doctor of Philosophy in Medical Care Organization and Sociology (1983) at the University of Michigan. Founding Director of the Centre for Public Health
Research 1984 - 1987, and of the National Institute of Public Health of Mexico 1987 - 1992, Executive
Vice President of the Mexican Health Foundation 1995 - 1998, and President of the Mexican Society for
Quality in Health Care from 1994 to 1996. Executive Director in charge of Evidence and Information for
Policy at the World Health Organization 1998-2000. Mexican Secretary (Minister) of Health 2000-2006.
David Fuentes-Montero, holds a degree as Certified Public Accountant (1995). Former Chief executive
officer of the Cooperativa de Servicios Aeroindustriales (Aeroindustrial Services Co-operative) (19932001), Director of Administration and Finances of the Bolsa Nacional de Valores (Costa Rican Stock
Exchange) (2002-2004). Member of the board of directors of the Central Bank of Costa Rica, Costa Rican governor at the Inter-American Development Bank. Minister of Finance of the Republic of Costa Rica
2005–May 2006, Vice Minister of Expenditures at the Ministry of Finance since May 2006; currently also
postgraduate studies at the Yale World Fellows Program, Yale University.
Eduardo González-Pier, BS in Economics and Mathematics from Washington and Lee University
(1988), MA in Economics (1990) and PhD in Economics (1993) from the University of Chicago. Economist at the World Bank and the International Monetary Fund in Washington DC (1990-1992), consultant
at the Grupo de Economistas y Asociados in Mexico (1993-1994), Planning Co-ordinator at the Mexican
Institute of Social Security (1995-2000), and Head of Strategic Planning at the Mexican Ministry of Health
(2001-2003). Currently head of the Ministry’s Economic Analysis Unit (2003-2006).
Indrani Gupta holds a PhD in Economics from the University of Maryland. Teaching economics in India
and abroad, economist in the Indian Government, and consultant at the World Bank. Setting up a unit for
health economics and policy research in the Institute of Economic Growth in Delhi for policy-oriented
health sector research. Work on issues around demand for health care, insurance and financing, costing
and cost-effectiveness, poverty and health, and related areas. Currently professor and Head of the
Health Policy Research Unit of the Institute of Economic Growth in Delhi.
Jens Holst, MD degree at the Free University of Berlin (1990), MPH (2001) and DrPH (2003) from the
University of Bielefeld. Specialisation in internal medicine (1991-1998). Currently consultant for the German Technical Co-operation (GTZ) and other development agencies in the area of health financing,
health sector reform, social protection, insurance assessment and implementation (since 1999), lecturer
at the University of Applied Sciences Magdeburg-Stendal, and associated fellow of the Social Science
Research Centre Berlin (since 2005).
Pongpisut Jongudomsuk, MD degree at the Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Master of Public Health at the Institute of Tropical Medicine Antwerp, Certificate of Preventive
and Family Medicine of the Thai Medical Council. Currently Director of the Bureau of Policy and Planning
at the National Health Security Office (NHSO), National Project Director of the (EU-supported) Health
Care Reform Project, and Head of the Technical Support Team of the Thai Minister of Public Health,
Bangkok.
Matthew Jowett holds a BA in Geography from the University of Sheffield (1989), an MSc (Econ) in
Health Planning & Financing from the London School of Economics (1994), and a DPhil in Health Economics from the University of York (2003). Management of health projects in Africa with Save the Children Fund (1992-1995), Economic and Financial Advisor at the EC Health Sector Reform Project in India
(2000-2003). Currently advisor to Philippine Health Insurance Corporation (since 2003).
Johannes Jütting, Ph.D. in agricultural economics awarded by Humboldt-University of Berlin, habilitation from the University of Bonn. Research Fellow at the Centre for Development Research in Bonn
(ZEF) where he directed the Research Group on Poverty. Currently Senior Economist and Principal Administrator at the OECD Development Centre, team leader for the Centre's work programme on institu-
178
Contributors
tions, poverty and health, culture and gender. Scientific adviser of the World Bank, WHO and ILO in matters related to health care financing in developing.
Felicia Knaul, BA in Economics and International Development from the University of Toronto (1988),
Ph.D. in Economics from Harvard University (1995). Collaborator of the Ministry of Planning of Colombia
(1992-1994), Mexican Social Security Institute (1995-1996), and Mexican Ministry of Social Development
(2002-2003). General coordinator for Modernisation at the Ministry of Education of Mexico (2003-2006).
Activities for WHO, World Bank, Inter-American Development Bank and UNICEF. Working group member of the Commission on Macroeconomics and Health and commissioner in the corresponding Mexican
commission. Senior economist at the Mexican Health Foundation (2000-2006).
Joseph Kutzin holds an MA in Development Economics from Boston University (1984) and BAs in History and in Afro-American and African Studies from the State University of New York at Binghamton
(1982). Health Policy Analyst at Project HOPE Center for Health Affairs (1985-89), Health Economist at
the World Bank (1989-93), as independent consultant (1993-94) and at WHO Headquarters (1994-99).
Senior Resident Advisor (WHO) to the Ministry of Health of Kyrgyzstan (2000-03). Currently Regional
Advisor, Health Systems Financing, WHO Regional Office for Europe (since 2003).
Oumar Ouattara, MD degree from the National Medical and Pharmacological School Point G, Bamako
(1990), and a postgraduate diploma on Public Health from the Paris VI University (1998). Broad experience in community health services and community health insurance, in Mali and throughout Africa. Since
1998 to September 06 General Director of UTM (Union Technique de la Mutualité Malienne); Chair of
Institut Ophtalmologique tropical pour l’Afrique (IOTA) and Consultant of Health system and Health insurance; Member of the Board of Directors of the Canadian Coalition of Global Health Research.
Alberto Sáenz Pacheco, MD degree from the University of Costa Rica (1970) and a specialisation in
paediatrics from Johns Hopkins University, Baltimore (1974). Member of the Permanent Medical Staff of
the Costa Rican Social Security Fund (Caja Costarricense de Seguro Social de Costa Rica) since 1975
until today. Founder of the Medical Education Department at the National Children’s Hospital in San José
Costa Rica, and former professor of paediatrics and Dean of the Medical School of the Autonomous University of Central America. Executive President of the Caja Costarricense de Seguro Social (2004 –
2006). Currently Chief of the Newborn Intensive Care Unit at the National Children`s Hospital of Costa
Rica.
Walaiporn Patcharanarumol, B.Sc. in Pharmaceutical Science from Khon Kaen University, Thailand
(1992), MSc. in Health Development from Chulalongkorn University, Thailand (1998), Master degree in
Social Protection Financing from Maastricht University, Netherlands (2003). She is a full time health policy and systems researcher at International Health Policy Program, Ministry of Public Health, Thailand
(since 2001), specialised in the area of health financing systems and social protection, health insurance
expert for ILO Social Security Project in Lao PDR (2003-2004). Currently postgraduate studies at the
Health Policy Unit of London School of Hygiene and Tropical Medicine (Sep 2004-Mar 2008), doctoral
thesis on “Health Care Financing for the Poor in the Resource Constraint Setting, Lao PDR”.
Phusit Prakongsai, MD degree from Mahidol University, Thailand (1988), Certificate in Preventive
Medicine from Thai Medical Council (1993). Ten years of field experience in public health and health
service management at three district hospitals in rural areas of Thailand (1988–1998). Principal investigator of several research studies on health policy, health insurance, and health financing at the International Health Policy Program, Thailand (1999–2002). Currently, doing PhD in Public Health and Policy at
London School of Hygiene and Tropical Medicine with the thesis about “Equity in Health Care Financing
and Benefit Incidence Analysis before and after universal health care coverage in Thailand”.
Alexander Preker holds a Ph.D. in Economics from the London School of Economics and Political Science, a Fellowship in Medicine from University College London, a Diploma in Medical Law and Ethics
from King’s College London, and a MD from University of British Columbia/McGill. Member of the teaching faculty for the Harvard/World Bank Institute Flagship Course on Health Sector Reform and the Berkeley/Barcelona Leadership Forum, regular lecturer at Columbia University and McGill University. Seconded to the World Health Organization during 1999 to 2000, recently participation in preparing a Health
Financing Strategy for the Africa Region. Since 1990 at the World bank, currently Lead Economist at the
World Bank for West Africa.
William D. Savedoff, A.B. at Harvard University, M.A. and PhD in Economics from Boston University. 20
years experience of preparing, co-ordinating and advising development projects in Latin America, Africa
and Asia. Associate Researcher at the Instituto de Pesquisa de Economia Aplicada (Rio de Janeiro)
(from 1989 to 1991), Senior Economist at the Inter-American Development Bank (Washington DC (from
1991 to 2001), and Senior Economist at the World Health Organization (from 2001 to 2004). Currently
Senior Partner at Social Insight, an international consulting firm with expertise in economic and political
analysis of public policy.
Extrending Social Protection in Health
179
Xenia Scheil Adlung, Dr. rer. pol. (Ph.D) degree obtained the Free University of Berlin. Head of Division, Federal Government of Germany, Ministry of Youth, Family Affairs, Women and Health (19791991), Programme Manager and Research Officer at the International Social Security Association (19912003). Since 2003, Health Policy Coordinator in the Social Security Department of the International Labour Organization.
Adang Setiana holds a B.Sc. in Analytical Chemistry (1977) from Bogor College of Chemistry, M.Sc. in
Pollution & Environmental Control (1987) and Ph.D in Environmental Biology (1991) from University of
Manchester. Researcher at the Indonesian Agency for Assessment and Application of Technology,
(1980-1997), and former Deputy Secretary of the Indonesian Disaster Management Coordinating Board,
responsible for disaster mitigation and preparedness coordination policy (1998-2001). Currently Deputy
Minister of People’s Welfare responsible for coordination of social welfare including development and
implementation of National Social Security System.
Werner Soors, MD degree from the Antwerp University (1986), Tropical Medicine diploma from the Institute of Tropical Medicine, Antwerp (1987), and a MPH from the Institute of Tropical Medicine, Antwerp,
Belgium (2004). Sixteen years of field experience in health services and community organisations in
Latin America. Since 2004, research assistant on health services organisation and community health
insurance at the Public Health Department of the Institute of Tropical Medicine in Antwerp.
Shenglan Tang, MD degree in 1985 from Shanghai Medical University, MSc in Epidemiology in Shanghai in 1988, MPH in Seattle in 1992, and PhD in development studies at the Institute of Development
Studies at Sussex University in 1999. Senior Lecturer in International Health at Liverpool School of
Tropical Medicine, currently seconded to WHO China Office as Health and Poverty/Equity Advisor. Numerous research projects on health care financing, among others, in China and Vietnam, and technical
assistance services on health systems development to many international donors and governments of
developing countries.
Viroj Tangcharoensathien is MD from Mahidol University in 1979, served in several remote district
hospitals (1980-1987). Rockefeller fellowship for a Ph.D. in health policy, planning and financing at the
London School of Hygiene and Tropical Medicine in 1987 90. Employee in the Health Planning Division
of the Thai MoPH 1991 94, then full time secondment by MoPH to the International Health Policy Program, a research arm of the ministry. Pioneer of Thai National Health and Thai National AIDS Accounts.
Government advisor on the design of Social Health Insurance and the current Universal Health Care
Coverage Scheme in Thailand. WHO consultant on financing reform in China and Turkey, technical advisor of international agencies, e.g. the ILO project in Lao PDR on designing and reforming of public health
insurance scheme and financial protection for the poor. Currently director of International Health Policy
Program of the MoPH.
Tien Van Tran is MD graduated at the University of Palacky (Czechoslovakia) (1977) and holds a PhD
from the same university (1985). Head of Hematology Department, Thai Nguyen Hospital (1985-1992),
Director of the Department of Planning and Research and lecturer at the Thai Nguyen Medical College
(1987-1992). Head of the Medical Benefit Department of the Vietnam Health Insurance Agency (19931997), Director of the Vietnam Health Insurance Agency (1997–1998) and Director General of the Viet
Nam National Health Insurance (1998–2002), WHO short-term adviser on social health insurance in Lao
Democratic Republic (2000), Papua New Guinea and Fiji (2003/2004). Currently head of the research,
training and international co-operation department at the Health Strategy and Policy Institute and visiting
Lecturer to the Hanoi School of Public Health.
Heidemarie Wieczorek-Zeul, holds a PhD in English and History from the University of Frankfurt,
teacher in Rüsselsheim (1965-1974). Since 1965 member of the Social Democratic Party of Germany
(SPD), Deputy in the town council of Rüsselsheim (1968-1972), Federal President of the SPD junior organisation „Jungsozialisten“ (Young Socialists (1974-1979), Member of the European Parliament (Committee of international Commerce and Committee for women’s emancipation) (1979-1987). Member of
the German Parliament (Bundestag) since 1987, spokeswoman for European policy of the SPD-group in
the Bundestag (1987-1998), deputy chairwoman of the federal SPD (1993 – 2005), Federal Minister for
Economic Co-operation and Development since October of 1998.
Ke Xu holds a MD degree and a Ph.D in Health Economics. Before 1999, lecturer in the Department of
Health Economics of the Fudan University in China. Since 1999, health economist in the department of
Health Systems Financing at WHO headquarters, main focus on health financial protection, catastrophic
health payments and poverty.
Ling Xu has BA in management information system and Diploma in nursing. Ms Xu is now Division Chief
for Survey and Evaluation at the Centre for Health Statistics and Information, Ministry of Health China.
Prior to 1987, she was lecturer at the School of Nursing, Peking Union Medical College. Her main research interest focuses on health services and health insurance in China.
Conference Program
180
6.2. Program
International Conference on Social Health Insurance in Developing Countries Berlin
05 - 07 December 2005
DAY 1 (05 December 2005)
1200
1300
Registration
1300
1330
WELCOME ADDRESS: Ms Heidemarie WieczorekZeul, Minister of Economic Cooperation and Develop“Health, Solidarity and Social Protection: The Germent, Germany
man contribution to the Millennium Development
Introduced by Dr Assia Brandrup-Lukanow, GTZ
Goals”
1330
1415
Inaugural address:
H.E. David Fuentes Montero, Minister of Finance, Costa “Social health insurance and its role in economic
Rica
development and poverty reduction”
1415
1445
Break
1445
1510
Mr. Assane Diop, Executive Director General, Interna- “Decent work and Decent Health: A Goal for Fair
tional Labour Office
Globalization”
1510
1535
Dr. Stefan Helming, Director General for Planning and “Social Protection and Health Improvements”
Development, German Technical Cooperation (GTZ)
1535
1600
Dr Timothy Evans, Assistant Director General, World “Social Health Insurance and Poverty Reduction”
Health Organization
1600
1630
Break
1630
1730
Open Debate
MODERATOR: Michel Gabrysiak, CEO Finance Foundation / Television Producer
1930
2200
Evening reception at the GTZ-House
DAY 2 (06 December 2005)
0830
0915
CHAIRPERSON: Dr Assia Brandrup-Lukanov, Senior Advisor for Health,
Education and Social Protection, GTZ
Keynote address: H.E. Julio Frenk, Minister of Health, Mexico
0915
0945
Break
0945
1115
SESSION 1: Equity, solidarity and
poverty reduction
CHAIRPERSON: Dr Belgacem
Sabri, Director Health Systems,
WHO Regional Office for the Eastern
Mediterranean
PRESENTER: Dr Tran Van Tien
Health Policy and Strategy Institute,
Vietnam:
“The inclusion of the poor in social health insurance framework:
The strategies applied in Viet Nam”
DISCUSSANT: Dr. Claude Bodart,
GTZ Programme Manager, Philippines
PRESENTER: Dr Alberto Sáenz
Pacheco, Executive President, Caja
Costarricense de Seguro Social,
Costa Rica
“The role of equity and solidarity
within social health insurance:
Chances and risks of the Costa
Rican way towards universal coverage”
DISCUSSANT: Dr Rüdiger Krech,
Head of Social Protection, GTZ
SESSION 2: Advancing the socioeconomic development agenda
CHAIRPERSON: Dr Nata Menabde, Director of Division Country
Health, WHO Regional Office for
Europe
PRESENTER: Prof Shenglan
Tang, University of Liverpool
“Economic and social development: New challenges to social
protection and the health care system in China”
DISCUSSANT: Dr Jungudomsuk
Pongpisut, Director of Bureau of
Policy and Planning, Ministry of
Public Health, Thailand
PRESENTER: Dr Hedi Achouri,
Ministry of Health, Tunesia
“Advances in the implementation
of social security: Lessons from
Tunisia”
DISCUSSANT: Dr. Oumar Ouattara, Union Technique de la Mutualité Malienne, Mali
“Poverty, health and social protection”
SESSION 3: Social Protection and
Global Health Initiatives
CHAIRPERSON: Dr Alimata J. Diarra-Nama, Director Health Systems,
WHO Regional Office for Africa
(AFRO)
PRESENTER: Dr Bernhard
Schwartländer, GFATM, Director,
Strategic Information and Evaluation
“The Global Fund and solidaritybased health financing systems:
Challenges and opportunities for
collaboration”
DISCUSSANT: Dr Henri van den
Hombergh, Senior Health Advisor,
GTZ
PRESENTERS: Dr Appiah Denyira,
Ghana; Dr Alex Preker, Senior Health
Economist, Human Development
Department, The World Bank
“Extending health coverage to the
poor under the new National Health
Insurance system in Ghana”
DISCUSSANT: Ms Neva Maketla,
South African Trade Union
DISCUSSANT: Ms Maryam Bigdeli,
WHO Cambodia
Extrending Social Protection in Health
181
1115
1145
Break
1145
1245
CHAIRPERSON: Dr Timothy
Evans, Assistant Director General, WHO
1245
1415
Lunch
1415
1545
SESSION 4: Social health protection
- linking up in mixed health financing systems
SESSION 5: Current reforms in
the extension of health insurance coverage
SESSION 6: Implementation of
social health insurance: learning
from the evidence and setting of
policy objectives
CHAIRPERSON: Dr Mark Blecher,
Director, Ministry of Finance, South
Africa
CHAIRPERSON: Mr Assane
Diop, Executive Director, ILO
PRESENTER: Dr Indrani Gupta:
PRESENTER: Ms Lorna Fajardo,
Acting President, Philippine Health
Insurance Corporation (PhilHealth)
and Dr Ruben Basa, Head of
Corporate Planning, PhilHealth,
Philippines
“Creating linkages between
national social health insurance
and community groups in the
Philippines”
CHAIRPERSON: Mr Alejandro
Bonilla-Garcia, Acting Secretary
General, International Social Security Association
Ministerial Round Table on challenges to implementation: Discussion
among Ministers of finance, health and labour + keynote speaker and rapporteurs (Dr Ponmek Dalaloy, Minister of Health, Laos; Mr David Fuentes Montero, Minister of Finance, Costa Rica; Prof Amara Cisse, Minister of Health,
Guinea; Dr Sodnompil Tserendorj, Deputy Minister of Health, Mongolia )
“The challenge of universal coverage in mainly rural settings: New
approaches in India”
DISCUSSANT: Mr Joseph Kutzin,
Regional Advisor Health Financing,
WHO Office for Europe
PRESENTER: Dr Viroj Tangcharoensathien, Director, International Health
Policy Programme, Ministry of Public
Health, Thailand
“Universal coverage in Thailand: The
respective roles of social health insurance and tax-based financing”
DISCUSSANT: Dr William Savedoff,
Senior Partner, Social Insight (Consultant)
PRESENTER: Dr Ainura Ibraimova
Sultanovna, Deputy Minister of Health,
Director Mandatory Health Insurance
Fund, Kyrgyz Republic “Health Financing Reform in the Kyrgyz Republic: Addressing Equity, Access
and Efficiency”
DISCUSSANT: Dr Walter Seidel,
EuropeAID, European Commission
DISCUSSANT: Dr. Bergis
Schmidt-Ehry, GTZ Tanzania
PRESENTER: Dr Youssoufa
Wade, President, Comité du Dialogue Social, Sénégal
”The importance of social dialogue in the extension of coverage: Lessons learned in Senegal”
DISCUSSANT: Dr Ursula Engelen-Kefer, Deputy Chairperson,
German Confederation of Trade
Unions, Germany
PRESENTERS: Dr Xenia ScheilAdlung, Health Policy Coordinator,
Social Security Department, International Labour Office; Dr Ke Xu,
Health Economist, Department of
Health Systems Financing, WHO
and Dr Johannes Jütting, OECD
Development Centre “The impact of
social health insurance on access
to health care, health expenditure
and poverty reduction: Evidence
from Kenya, Senegal and South
Africa”
PRESENTER: Dr Adang Setiana,
Deputy Minister of People Welfare,
Indonesia
"Social Health Insurance Development as an Integral Part of the
National Health Policy: Recent
Reform in Indonesian Health Insurance System”
DISCUSSANT: Mr Dorsjuren
Bayarsaikhan, Regional Advisor
Health Financing, WHO Office for
the Western Pacific
PRESENTER: Mr Emmanual
Humba, Director General of NHIF
“Experience of Extending Health PRESENTER: Prof Dr Vlad Iliescu,
Insurance Coverage in TanzaSecretary of State, Ministry of
nia”
Health:
”Lessons Learned in the Health
DISCUSSANT: Dr Eduardo
Financing Reform in Romania”
Levcovitz, Regional Advisor
Health Financing, PAHO
DISCUSSANT: Sasa Cvetojevic,
Croatia
1545
1615
Break
1615
1715
CHAIRPERSON: Dr Michel
Cichon, Director Social Security
Department, ILO
Ministerial Round Table on sharing best practices:
among keynote speakers plus 3 panel members
drawn from the Presenters of the papers in the afternoon (Dr. Ainura Ibraimova Sultanova, Deputy Minister of Health, Kyrgyzstan; Mr Julio Frenk, Health
Minister of the United States of Mexico; Dr. Adang
Setiana, Deputy Minister of People’s Welfare, Indonesia; Mr. Abu Md. Maniruzzaman Khan, Secretary of
State, Ministry of Health and Family Welfare, Bangladesh )
Conference Program
182
DAY 3 (07 December 2005)
0900
0930
Conference Reporter
Feedback from the Working Sessions of Day 2
Michel Gabrysiak, CEO
Finance Foundation /
Television Producer
0930
1000
CHAIRPERSON: Dr David Evans, Director Health
Systems Financing, WHO
Keynote address: Prof Bong-min Yang, Dean
School of Public Health, Seoul National University,
Korea
1000
1100
Moderator: Ms Andrea
Fischer, Department of
Health, Institute for Organisational Communication, Germany
1100
1130
Break
1130
1215
Mr. Stefan Helming, Director General, GTZ
Ministerial Round table on ways forward: Prof Dr Vlad
Iliescu, Secretary of State, Ministry of Health, Romania; Mr
Neph Bunchin, Minister of Labour and Vocational Training,
Cambodia; Dr Sjafii Ahmad, State Secretary, Ministry of
Health, Indonesia; Dr Alex Kamugisha, Minster of State for
Primary Health Care, Uganda
Mr. Assane Diop, Executive Director, ILO
Dr. Timothy Evans, Assistant Director General,
WHO
1215
1230
Closure: GTZ
“Implementation of health insurance in developing countries:
lessons from international experience”
Conference Conclusion: Enhancing the responses to international
commitments on Social Health
Protection (WHA Resolution 2005,
New Consensus on Social Security
from ILC 2001)
Extrending Social Protection in Health
183
6.3. Participants
Bangladesh
Abu Md. Maniruzzaman Khan
Shamim Ara
Md. Jahangir
Günter Dietz
State Secretary, Ministry of Health and Family Welfare
Deputy Director, Ministry of Health and Family Welfare, Health Economics Unit
Joint Chief, Ministry of Health & Family Welfare, Health Economics Unit
German Technical Cooperation (GTZ), Office Bangladesh
Belgium
Alain Coheur
Pierre de Paepe
Werner Soors
Jean Hermesse
Dominique Evrard
Mutualités Socialistes
Institute for Tropical Medicine (ITG) Antwerp
Institute for Tropical Medicine (ITG) Antwerp, Public Health
Secrétaire National, Alliance Nationale des Mutualités Chrétiennes
Mutualités Chrétiennes
Cambodia
H.E. Mam Bun Heng
Ouk Samvithyea
Lo Veasnakiry
Olivia Nieveras
Deputy Minister of Health
Ministry of Health
German Technical Cooperation (GTZ), Support to the Health Sector
Reform
Cameroon
Saa
Theophile Moulong
Komi Alain Ahawo
Ministry of Public Health
Technical Director, La Citoyenne
Technical Consultant, German Technical Cooperation (GTZ), Office
Yaoundé
Chile
Michael Hagen
Fondo Nacional de Salud (FONASA)
China
Song Daping
Sheng-Lan Tang
Ministry of Health, China Health Economics Institute
Liverpool Institute of Tropical Medicine
Columbia
Beethoven Herrera Valencia
University of Bogota
Costa Rica
H.E. David Fuentes Montero
Alberto Pacheco Sáenz
Minister of the Treasury
Executive President, Caja Costarricense de Seguro Social
Croatia
Sasa Cvetojevic
General Manager, Insako
Finland
Risto Pomoell
Ministerial Counsellor, Ministry of Social Affairs and Health
France
Pascal Brouillet
Michel Gabrysiak
Alain Letourmy
Agnès Plassart
Kulmie Samantar
Agence Française de Développement, Dép. du Développement Humain
CEO, Finance Foundation
Centre de Recherche Médecines, Maladie et Sciences Sociales (CERMES)
Public Interest Group, Social Security
Mutualité Française, Direction Générale Groupe
Participants
184
Ghana
E. Appiah-Denyira
Eastern Regional Director, Ministry of Health
Guinea
H.E. Amara Cisse
El Hadj Aboubacar Dione
Alhassane Barry
Helga Piechulek
Minister of Health
Ambassador, Embassy of Guinea in Germany
Conseiller Technique/ RECAP, German Technical Cooperation (GTZ),
Office Guinea, Programme Santé et lutte contre le VIH/SIDA
Programme Santé et lutte contre le SIDA
Honduras
Richard Zablah
Director, Instituto Hondureño de Seguridad Social
India
Narayan Devadasan
Alok Kumar Gosh
Indrani Gupta
Subhash Sharma
N. K. Roy
Thomas Thampan
Johann Peter Steinmann
Institute of Tropical Medicine, Bangalore
Chief Technical Officer, Governm. of West Bengal, Basic Health Project
University Enclave, Institute of Economic Growth and Health Policy Research
Ministry of Finance
Deputy Director, Government of West Bengal, Basic Health Project
President, Hind Mazdoor Sabha (HMS)
Principal Advisor Health, German Technical Cooperation (GTZ), Office
New Delhi
Indonesia
H.E. Sjafii Ahmad
H.E. Adang Setiana
Ida Bagus Indra Gotama
Aditiarsih Destriani
Miroslaw W. Manicki
Bambang Purwoko
Asih Eka Putri
Orie Andari Sutadji
Hasbullah Thabrany
Claude Bodart
State Secretary, Ministry of Health
Deputy Minister for Social Security, Coordinating Ministry for People’s
Welfare
Director of Health Insurance, Ministry of Health, Directorate General of
Public Health
Team-Leader, Social Health Insurance Project, GTZ/GVG
National Advisor, Social Health Insurance Project, GTZ
President Director, PT ASKES
Dean, University of Indonesia, Faculty of Public Health
Program Director, German Technical Cooperation (GTZ), Support to
Health Sector Reform and Population Management Program, Indonesia
Israel
Dov Chernichovsky
Ben Gurion University of Negev, Dept. of Health Systems Administration
Jamaica
Raphael D. Barrett
Chief Executive Officer, National Health Fund
Kenya
Tom Mboya
Burkard Kömm
Inke Mathauer
Director, Ministry of Health, Dep. of Standards and Regulatory Services
German Technical Cooperation (GTZ), Office Nairobi, Kenya
German Technical Cooperation (GTZ), Office Nairobi, Kenya
Korea
Yang Bong-min
Dean, School of Public Health, Seoul National University
Kyrgyzstan
H.E. Ainura Ibraimova Sultanova
Ninel Kadyrova
Deputy Minister of Health, Ministry of Health, Social and Family Affairs
Deputy Director, Mandatory Health Insurance Fund, Ministry of Health
Extrending Social Protection in Health
185
Laos
H.E. Ponmek Dalaloy
Khouanta Phalivong
Khamphet Manivong
Vorasarn Somnuk
Jürgen Hohmann
Minister, Ministry for Health
Ambassador, Embassy of the Lao PDR in Germany
Head of Planning Division, Ministry of Health
President and General Director, ASSA
Belgian Technical Cooperation, Laos
Mali
Aissata Diallo
Oumar Ouattara
Advisor, Ministry of Health
Union Technique de la Mutualité Malienne
Mexico
H.E. Julio Frenk
Carlos Dittmann Fernández
Felicia Knaul
Minister of Health
Embassy of Mexico in Germany
Principal Economist, Fundacion Mexicana para la Salud (FUNSALUD)
Mongolia
H.E. Sodnompil Tserendorj
T. Galbaatar
Erdenesuvd Derem
D. Tegshargal
Amar Bazarragchaa
Surenchimeg Vanchinkhuu
State Secretary, Ministry of Health
Ambassador, Embassy of Mongolia in Germany
Ministry of Social Welfare and Labour
Embassy of Mongolia in Germany
Deputy Director, State Social Insurance General Office
Coordinator, ADB/TA, Support for Health Sector Reform
Netherlands
Anno H.Y.Galema
Senior Advisor in Health Systems, Netherlands Ministry of Foreign Affairs, Social and Institutional Development Department
Pakistan
Muhammad Mukhtiar
Muhammad Bashir
Muhammad Iqbal Afridi
Inayatullah
Zakirullah Khan
Paul Josef Rückert
Health Department NWFP Peshawar
Law Government of NWFP
Health Department
Health Department
Provincial Assembly
German Technical Cooperation (GTZ), Health Project NWFP
Philippines
Donabelle de Guzman
Eduardo Banzon
Ruben Basa
Tito Mendiola
Matthew Jowett
Department of Health
Vice President for Health Financing Policy, Philippines Health Insurance
Corporation
Head of Corporate Planning, PhilHealth
Philippinian Health Insurance Corporation
German Technical Cooperation (GTZ), Office Manila, Philippines
Romania
H.E. Vlad Iliescu
Catalin Victor Arjoca
Mihai Laurentiu
Deputy Minister of Health
Embassy of Romania in Germany
Ministry of Health
Rwanda
Laurent Musango
Andreas Kalk
Director of the Public Health School, National University of Rwanda
German Technical Cooperation (GTZ), Office Kigali, Rwanda
Senegal
Youssoufa Wade
Comité National du Dialogue Social, Dakar
Participants
186
South Africa
Mark Blecher
Michael Thiede
Neva Makgetla
Director, Ministry of Finance, Health Care Financing
Director, University of Cape Town, Health Economics Unit
Coordinator, South African Trade Union, Fiscal,
Monetary and Public Sector Policy
Sudan
Mustafa Salim Mustafa
Ministry of Health
Sweden
Lennart Bogg
Karolinska Institute
Switzerland
Franziska Freiburghaus
Alexander Schulze
Fritz Brugger
Advisor for Health, Swiss Development Agency, Social Development
Division
Manager Health Projects, Novartis Foundation for Sustainable Development
Brugger & Partner
Syria
Mahmoud Dashash
Director, Ministry of Health, Planning Department
Tanzania
Faustin Njau
Emmanuel Humba
Bergis Schmidt-Ehry
Head of Health Sector Reform Department, Ministry of Health
Director General, National Health Insurance Fund (NHIF)
German Technical Cooperation (GTZ), Health Sector Support Program
Thailand
Viroj Tangcharoensathien
Pongpisut Jungudomsuk
Samrit Srithamrongsawat
Kaemthong Indaratna
Ernst Tenambergen
Director, Ministry of Public Health, International Health Policy Program
Ministry of Public Health, National Health Security Office
National Health Security Office
Chulalongkorn University, Faculty of Economics
German Technical Cooperation (GTZ), Office Bangkok
Tunisia
Abdessalem Hichem
Hédi Achouri
Director, Ministry of Public Health
Directeur de la Tutelle des Hôpitaux, Ministère de la Santé Publique
Uganda
H.E. Alex Kamugisha
Rogers Enyaku
Robert K. Basaza
Francis M. Runumi
Minister of State for Primary Health Care
Ministry of Finance, Planning and Economic Development
Senior Health Planner, Ministry of Health
Commissioner of Health Services Planning, Ministry of Health
United Kingdom
Stephen Kidd
Team Leader, Department for International Development,
Governance & Social Development
United States of America
William Savedoff
Senior Partner, Social Insight
Viet Nam
Nghiem Tran Dung
Van Tien Tran
Deputy Director, Ministry of Health, Health Insurance Department
Health Policy and Strategy Institute
Yemen
Rashad Sheikh Bin Shujaa
Health Policy Unit, Public Health and Population
Extrending Social Protection in Health
187
Germany
— Ministry of Economic Cooperation and Development (BMZ)
Heidemarie Wieczorek-Zeul
Federal Minister of Economic Cooperation and Development
Uwe Gehlen
Director, Division 310 – Social Development, Ministry of Economic
Cooperation and Development,
Ute Möhring
Division 310 – Social Development, Ministry of Economic Cooperation
and Development
—Foreign Office (AA)
Simone Koring
Legationssekretärin, Foreign Office, Referat GF03
— Ministry of Health (BMG)
Thomas Renner
Ministry of Health, P22 – Finanzielle Grundsatzfragen der Sozialpolitik
— Deutscher Bundestag
Goran Mihaljevic
Deutscher Bundestag, Office Sibylle Pfeiffer
— KfW Entwicklungsbank
Wolfgang Bichmann
Ulrich Dorf
Katharina Anschütz
Joachim Schürmann
Astrid von Kutzleben
Vice President, KfW Entwicklungsbank, Sector and Policy Division
Health / Sub-Saharan Africa
Division Chief Health Asia, KfW Entwicklungsbank
Senior Sector Specialist, KfW Entwicklungsbank
Senior Public Health Expert, KfW Entwicklungsbank
KfW Entwicklungsbank
— German Technical Cooperation (GTZ)
Bernd Eisenblätter
Managing Director, German Technical Cooperation (GTZ)
Stefan Helming
Director General for Planning and Development, German Technical
Cooperation (GTZ)
Assia Brandrup-Lukanow
Director, German Technical Cooperation (GTZ), Division of Health,
Education and Social Protection
Rüdiger Krech
Head of Section, Sustainable Social Protection
Friedeger Stierle
Head of Health Section, German Technical Cooperation (GTZ)
Michael Adelhardt
Project Manager, German Technical Cooperation (GTZ), Division of
Health, Education and Social Protection
Thomas Kirsch-Woik
Senior Consultant HIV/Aids, German Technical Cooperation (GTZ),
Sektorprojekt "Aids-Bekämpfung in Entwicklungsländern"
Regine Meyer
Priority Area Manager AIV/AIDS, German Technical Cooperation
(GTZ)
Henri van den Hombergh
Senior Health Advisor, German Technical Cooperation (GTZ)
Carmen Pérez Samaniego
German Technical Cooperation (GTZ), Sektorprojekt "AidsBekämpfung in Entwicklungsländern"
Bernd Schramm
Coordinator Sector Project, Division of Health, Education and Social
Protection
Katja Bender
German Technical Cooperation (GTZ)
Johanna Claass
German Technical Cooperation (GTZ)
Marion Frank
German Technical Cooperation (GTZ)
Jens Holst
Senior Consultant, German Technical Cooperation (GTZ)
Christoph Lankers
Senior Consultant, German Technical Cooperation (GTZ)
Alfred Merkle
Senior Advisor, Health Asia, German Technical Cooperation (GTZ)
Christine Mialkas
German Technical Cooperation (GTZ)
Doris Seeger
International Services
Gabriele Ramm
Senior Consultant, German Technical Cooperation (GTZ)
Sabina Schnell
Division Health, Education and Social Protection
Katja Tielemann
German Technical Cooperation (GTZ)
Thorsten Wassermeyer
German Technical Cooperation (GTZ)
— InWent
Participants
188
Barbara Kloss-Quiroga
Claudia Kornahrens
— AOK
Alfred Heigl
Karin Dobberschütz
Klaus Jacobs
Michael Stahl
Jan van Lente
Thomas Uhlemann
Boris Velter
Christina Weinreich
Jürgen Borchardt
Stephan Burger
Joachim Gromotka
Jürgen Huppenbauer
Rolf Jordan
Harald Kröck
Helmuth H. Leuters
Frank Micheel
Michael Niechzial
Andreas Plate
Mathias Rompel
Cornelius Schmaltz
Hartmut Welscher
Barbara Schmidt-Eule
Martin Wrede
Stefan Zimmer
InWent – Capacity Building International gGmbH
Head of Health Section, InWent – Capacity Building International gGmbH
AOK-Bayern, Direktion Augsburg
AOK Consult GmbH
Leiter, Wissenschaftliches Institut der AOK (WIdO)
AOK-Bayern, AOK Systems
AOK Bundesverband
AOK Research Institute
AOK Bundesverband
AOK Berlin
German Development Service (DED)
Geschäftsführer, Wissenschaftlicher Beirat der Betrieblichen Krankenversicherung, BKK Bundesverband
GFA Consulting Group Hamburg
Gesamtverband der Deutschen Versicherungswirtschaft e.V.,
Abteilung Politik
Asienstiftung Essen
German Trade Union Confederation (DGB)
Consultant
Federal Institute for Population Research
EPOS Health Consultants GmbH
Techniker Krankenkasse
University of Giessen, Institute of Sociology
Volkswagen Stiftung
Institute of Asian Affairs
Arbeitsgemeinschaft für Entwicklungshilfe
Gesellschaft für Versicherungswissenschaft und –gestaltung e.V.
Executive Assistant to the Director General, Hauptverband der gewerblichen Berufsgenossenschaften
International Organisations
EU – European Union
Walter Seidel
GFATM
Rolf Korte
Bernhard Schwartländer
ILO
Assane Diop
Christine Bockstal
Michael Cichon
Wolfgang Heller
Frank Hoffer
Fiona Howell
Christian Jacquier
Xenia Scheil-Adlung
Carmen Solorio
Philippe Vanhuynegem
European Commission (EuropeAid E3), Operations Quality Support –
Health Sector
Chair, GFATM TERG
Director Monitoring & Evaluation, Global Fund to Fight AIDS, Malaria
and Tuberculosis
Executive Director, International Labour Office (ILO)
International Labour Office (ILO), STEP Regional Coordination
Director, International Labour Office (ILO), Social Security Department
Direktor, Internationale Arbeitsorganisation (ILO), Vertretung in
Deutschland
International Labour Office (ILO), ACTRAV
CTO ILOSSP, International Labour Office (ILO)
Coordinator, International Labour Office (ILO), STEP PROGRAM
Health Policy Coordinator, International Labour Office (ILO), Social
Security Policy and Development Branch
International Labour Office (ILO)
Advisor, International Labour Office (ILO), STEP PROGRAM
Extrending Social Protection in Health
John Woodall
Hiroshi Yamabana
ISSA
Alejandro Bonilla-Garcia
Jens Schremer
OECD
Johannes Jütting
189
International Labour Office (ILO)
Social Security Specialist, International Labour Office (ILO), Subregional Office
Acting Secretary General, International Social Security Association
(ISSA)
International Social Security Association (ISSA)
OECD Development Centre, Economic Analysis and Development
Policy Dialogue
UNAIDS
Denis Broun
UNAIDS India
UNDP
Dorothy Rosenberg
U.N. Development Programme (UNDP), Bureau of Development Policy
United Nations Foundation
David de Ferranti
United Nations Foundation
WHO
— WHO Headquarters, Geneva
Timothy Evans
Assistant-Director General, Evidence and Information for Policy Cluster (EIP)
David Evans
Director, Department of Health System Financing, Evidence and Information for Policy Cluster (EIP)
Guy Carrin
Coordinator Health Financing Policy, Department of Health Systems
Financing
Tessa Tan-Torres Edejer
Coordinator Costs, Effectiveness, Expenditure and Priority Setting –
Department of Health Systems Financing
Ke Xu
Health Economist, Health Financing Policy, Department of Health Systems Financing
Ole Doetinchem
Health Systems Analyst, Health Financing Policy, Department of
Health Systems Financing
Manique Abayasekara
Assistant, Health Financing Policy, Department of Health Systems
Financing
— Regional Office fort he Americas (AMRO/PAHO)
Eduardo Levcovitz
Unit Chief, The Pan American Health Organization, Health Systems
and Policies
— Regional Office for Africa (AFRO)
Alimata J. Diarra-Nama
Director Health Systems and Services Development (DSD)
Joses Kirigia
Regional Advisor for Health Economics
Saidou Pathe Barry
Regional Advisor for National Health Services
— Regional Office for Europe (EURO)
Nata Menabde
Director Division of Country Support
Joseph Kutzin
Regional Advisor, Health Systems Financing
Tamas Evetovits
Senior Health Financing Specialist, Health Systems Financing
— Regional Office for the Eastern Mediterranean (EMRO)
Belgacem Sabri
Director of Health Systems and Services Development,
Hossein Salehi
Regional Advisor, Health Economics
— Regional Office for Western Pacific (WPRO)
Dorjsuren Bayarsaikhan
Regional Advisor, Health Care Financing
— Country Offices
Henrik Axelson
Maryam Bigdeli
Hana Brixi
World Health Organization (WHO), Viet Nam
World Health Organization (WHO), Cambodia
World Health Organization (WHO), China
Participants
190
Stephanus Indradjaya
Dick Jonsson
Sunil Nandraj
Diosdado-Vicente
NsueMilang
Nguyen Kim Phuong
Ibrahim Mohamed Abdel Rahim
National Professional Officer, World Health Organization (WHO), Indonesia
Senior Advisor, World Health Organization (WHO), Uganda, Head of
Programme Coordination
National Professional Officer, World Health Organization (WHO), India
Representative, World Health Organization (WHO), Rwanda
Public Health Officer, World Health Organization (WHO), Viet Nam
Representative, World Health Organization (WHO), Tunisia
World Bank
Oscar Picazo
Alex Preker
Sr. Economist (Health), The World Bank, AFTHD Africa Region
Senior Health Economist, The World Bank
World Bank Institute
Gilles Dussault
Senior Health Specialist (Policy), The World Bank Institute
Extrending Social Protection in Health
191
6.4. Bibliography for further reading
Achouri, Hédi, Jarawan, Eva (2003). Autonomous Hospitals in Tunisia. In: World Bank (2003). Innovations in Health Service Delivery. Washington DC.
Achouri, Hédi (2003). L’assurance Maladie. Médicalis, santé et médecine en Tunisie. Tunis.
Mansouri Fethi, Khaled; Kheireddine, M.; Achouri, Hédi (2003). Les dépenses de santé (indicateurs et
approches analytiques). Médicalis, santé et médecine en Tunisie. Tunis.
Achouri, Hédi; Achouri, Noureddine (2002). Health Services in Tunisia in the Light of World Trade
Organisation Agreements. In: Trade in Health Services: Global, Regional and Country Perspectives.
Pan American Health Organization, Program on Public Policy and Health, Division of Health and Human Development. Washington DC.
Achouri, Hédi (2001). L’Assurance Maladie en Tunisie. Publié par l’Institut National de Santé Publique
de Tunisie dans un ouvrage collectif, Travail préparé pour la consultation OMS sur l’assurance maladie dans les pays du Maghreb : Défis et réformes planifiées. Tunis.
Adam, Erfried; von Hauff, Michael (Eds.) (2002). Social Protection in Southeast & East Asia. FriedrichEbert-Stiftung/Toennes Satz + Druck GmbH, Erkrath. ISBN 3-89892-122-0 (http://library.fes.de/pdffiles/iez/01443.pdf)
Adato, Michelle; Ahmed, Akhter; Lund, Francia (2004). Linking Safety Nets. Social Protection, and
Poverty Reduction – Directions for Africa. International Food Policy Research Institute, 2020 Africa
Conference Brief 12, Washington DC (www.ifpri.org/pubs/ib/ib28.pdf).
Advisory Council for the Concerted Action in Health Care (2001). Appropriateness and Efficiency.
Report 2000/2001. Federal Ministry of Health, Bonn (http://www.svrgesundheit.de/gutacht/sogu01/01engl/engl01.pdf).
Aguilar Rivera, Ana Mylena; Xu, Ke; Carrin, Guy (2006). The Bolivian Health System and its impact on
health care use and financial risk protection. Discussion Paper No. 7 – 2006, Dep. Health System
Financing (HSF), Cluster Evidence and Information for Policy (EIP), WHO, Geneva
(http://www.who.int/health_financing/Bolivian_health_system.pdf).
Agyemang-Gyau, Peter (1998). The Ability and Willingness of People to Pay for their Health Care The Case of Lushoto District, Tanzania. Dpt. of Tropical Hygiene and Public Health, University of
Heildelberg.
Ahmed, Mosleh; Isla, Syed Khairul; Quashem, Abdul; Ahmed, Nabil (2005). Health Microinsurance, A
comparative study of three schemes in Bangladesh, Good and Bad Practices. CGAP Working Group
on Microinsurance, Good and Bad Practices, Case Study No. 13
(http://microfinancegateway.org/files/27889_file_Bangldesh_Health_Good_and_Bad_Practices_No._1
3.pdf).
Ahuja, Rajeev; Jütting, Johannes (2004). Are the Poor Too Poor to Demand Health Insurance? Journal of Microfinance 6 (1), pp. 2-20 (http://www.oecd.org/dataoecd/37/0/33715556.pdf).
Ahuja, Rajeev; Jütting, Johannes (2004). Are the Poor Too Poor to Demand Health Insurance? Indian
Council for Research on International Economic Relations, Working Paper No. 118, NewDelhi(http://www.icrier.res.in/wp118.pdf; http://www.iaaeagecon.org/conf/durban_papers/papers/006.pdf).
Ahuja, Rajeev (2004). Health Insurance for the Poor. Indian. Council for Research on International
Economic Relations, Working Paper No. 123. Neu-Delhi (http://www.icrier.res.in/wp123.pdf).
Akal, Afsar; Harvey, Roy (2001). The Role of Health Insurance and Community Financing in Funding
Immunization in Developing Countries. WHO, Geneva
(http://www.who.int/immunization_financing/options/en/role_chf.pdf).
Akin, John; Dow, William; Lance, Peter; Loh, Chung-Ping (2005). Changes in access to health care in
China, 1989–1997. Health Pol & Plan 20 (2), pp. 80-89
(http://heapol.oupjournals.org/cgi/reprint/20/2/80).
Alber, Jens; Bernardi-Schenkluhn, Brigitte (1992). Westeuropäische Gesundheitssysteme im Vergleich. Bundesrepublik Deutschland, Schweiz, Frankreich, Italien, Großbritannien. Campus-Verlag
Frankfurt/New York.
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Abbreviations
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6.5. Abbreviations
Abbr.
Original full name
English translation
ADB
Asian Development Bank
Asian Development Bank
AFRO
African Regional Office
WHO Regional Office for Africa
AIDS
Acquired Immunodeficiency Syndrome
Acquired Immunodeficiency Syndrome
ART
Anti-retroviral therapy
Anti-retroviral therapy
BMI
Basic Medical Insurance
Basic Medical Insurance
BPJS
Badan Penyelenggara Jaminan Sosial
Social Security Corporation
BPL
Below-poverty-line
Below-poverty-line
BTC
Belgian Technical Co-operation
Belgian Technical Co-operation
CAFTA
Central American Free Trade Agreement
CARD
Centre for Agriculture and Rural Development
Centre for Agriculture and Rural Development
CBO
Community based organisation
Community based organisation
CCSS
Caja Costarricense de Seguro Social
Costa Rican Social Security Fund
CDC
Council for the Development of Cambodia
Council for the Development of Cambodia
CEPAL
Comisión Económica para América Latina y
el Caribe
Economic Commission for Latin America
and the Caribbean
CERMES
Centre de Recherche de Médecines, Maladie et Sciences Sociales
Research Centre for Medicine, Diseases
and Social Sciences
CGHS
Central Government Health Scheme
Central Government Health Scheme
CHI
Community Health Insurance
Community Health Insurance
CHI
Citizens’ Health Insurance
Citizens’ Health Insurance
CHIP
Citizens’ Health Insurance Program
Citizens’ Health Insurance Program
CHI
Community Health Insurance
Community Health Insurance
CHIS
Community Health Insurance Schemes
Community Health Insurance Schemes
CHN
Community Health Network
Community Health Network
CMH
Commission on Macro-Economics and
Health
Commission on Macro-Economics and
Health
CI
Index of the distribution of payments
Index of the distribution of payments
CMIE
Centre Médical Inter-Entreprise
Inter-Company Health Centres
CMS
Co-operative Medical Scheme
Co-operative Medical Scheme
CNAM
Caisse Nationale d’Assurance de Maladie
National Health Insurance Fund
CNDS
Comité National du Dialogue Social
National Social Dialogue Committee
CNRPS
Caisse Nationale de Retraite et de Prévoyance Sociale
National Pension and Social Prevision
Fund
CNSS
Caisse Nationale de Sécurité Sociale
Social Security Fund
CSMBS
Civil Servant Medical Benefit Scheme
Civil Servant Medical Benefit Scheme
CUP
Contractual Unit for Primary Care
Contractual Unit for Primary Care
DAC
Development Assistance Committee
Development Assistance Committee
DANIDA
Dansk Udviklingsistand
Danish International Development Agency
Extrending Social Protection in Health
219
DGB
Deutscher Gewerkschaftsbund
German Confederation of Trade Unions
DFID
Department for International Development
Department for International Development
DGB
Deutscher Gewerkschaftsbund
German Federation of Trade Unions
DHIS
District health insurance scheme
District health insurance scheme
DHS
District Health System
District Health System
DMHIS
District Mutual Health Insurance Scheme
District Mutual Health Insurance Scheme
DOTS
Direct Observation Therapy System
Direct Observation Therapy System
DPHI
Department of Planning and Health Information
Department of Planning and Health Information
DPHO
Daftar Plafon Harga Obat
List of Drugs and Prices
DRC
Zaïre
Democratic Republic of the Congo
DRG
Diagnosis Related Groups
Diagnosis Related Groups
EIP
Evidence and Information for Policy
Evidence and Information for Policy
EMRO
Eastern Mediterranean Regional Office
WHO Regional Office for the Eastern
Mediterranean
ESDR
End Stage Renal Diseases
End Stage Renal Diseases
ESI
Employees State Insurance
Employees State Insurance
ESIS
Employees State Insurance Scheme
Employees State Insurance Scheme
ESIS
Employees State Insurance Scheme
Employees State Insurance Scheme
EU
European Union
European Union
EURO
European Regional Office
WHO Regional Office for Europe
€
Euro
= 1.25 US$
FFS
Fee for service
Fee for service
FGPP
Family General Practitioners Programme
Family General Practitioners Programme
FODESAF
Fund for Social Development and Family
Provisions
FONASA
Fondo Nacional de Salud
National Health Fund
GAVI
Global Alliance for Vaccines and Immunization
Global Alliance for Vaccines and Immunization
GDP
Gross domestic product
Gross domestic product
GEI
Government employee insurance
Government employee insurance
GIC
General Insurance Company
General Insurance Company
GDP
Gross Domestic Product
Gross Domestic Product
GFATM
Global Fund to Fight AIDS, Tuberculosis
and Malaria
Global Fund to Fight AIDS, Tuberculosis
and Malaria
GIS
Government Insurance Scheme
Government Insurance Scheme
GNI
Gross National Income
Gross National Income
GTZ
Deutsche Gesellschaft für Technische Zusammenarbeit
German Technical Co-operation
HCFP
Health Care Fund for the Poor
Health Care Fund for the Poor
HEPR
Hunger Eradication and Poverty Reduction
Hunger Eradication and Poverty Reduction
Abbreviations
220
HEU
Household Expenditure & Utilisation Survey
Household Expenditure & Utilisation Survey
HI
Health Insurance
Health Insurance
HIV
Human Immunodeficiency Virus
Human Immunodeficiency Virus
HPIC
Highly Indebted Poor Country
Highly Indebted Poor Country
HSF
Health System Financing
Health System Financing
HSS
Health Systems Strengthening
Health Systems Strengthening
HTA
Health Technology Assessment
Health Technology Assessment
HWS
Health and Welfare Survey
Health and Welfare Survey
IHPP
International Health Policy Program
International Health Policy Program
ILC
International Labour Committee
International Labour Committee
ILO
International Labour Office
International Labour Office
IMSS
Instituto Mexicano del Seguro Social
Mexican Social Security Institute
IPM
Instituts de Prévoyance Maladie
(Inter-company) health insurance institutions
IPM
Individually paying members
Individually paying members
IPP
Individually Paying Program
Individually Paying Program
IRDA
Insurance Regulatory and Development
Authority
Insurance Regulatory and Development
Authority
ISSSTE
Instituto de Seguridad y Servicios Sociales
de los Trabajadores del Estado
Institute of Social Security and Services of
State workers
ITG
Institute voor Tropische Geneeskunde
Institute for Tropical Medicine
IPC
In-patient care
In-patient care
JICA
Japan International Cooperation Agency
KMT
Kuomintang
LIC
Life Insurance Corporation
Life Insurance Corporation
LIS
Labour Insurance Scheme
Labour Insurance Scheme
MBA
Mutual Benefit Association
Mutual Benefit Association
MCH
Mother Child Health
Mother Child Health
MDG
Millenium Development Goals
Millenium Development Goals
MHIF
Mandatory Health Insurance Fund
Mandatory Health Insurance Fund
MHO
Mutual Health Organisation
Mutual Health Organisation
MoEF
Ministry of Economy and Finance
Ministry of Economy and Finance
MoH
Ministry of Health
Ministry of Health
MOLISA
Ministry of Labour, War Invalids, and Social
Affairs
Ministry of Labour, War Invalids, and Social Affairs
MoLSS
Ministry of Labour and Social Security
Ministry of Labour and Social Security
MoPH
Ministry of Public Health
Ministry of Public Health
MP
Medicare Programme
Medicare Programme
MPNyPE
Ministerio de Planificación Nacional y Política Económica
Ministry of National Planning and Economic Policy
Extrending Social Protection in Health
221
MRI
Magnetic resonance imaging
Magnetic resonance imaging
MSA
Medical Saving Accounts
Medical Saving Accounts
MTEF
Medium Term Expenditure Framework
Medium Term Expenditure Framework
MSA
Medical Saving Accounts
Medical Saving Accounts
NDPC
National Development Planning Commission
National Development Planning Commission
NGO
Non-government organisation
Non-government organisation
NHA
National Health Account
National Health Account
NHI
National Health Insurance
National Health Insurance
NHIC
National Health Insurance Company
National Health Insurance Company
NHIF
National Hospital Insurance Fund
National Hospital Insurance Fund
NHIP
National Health Insurance Program
National Health Insurance Program
NHSO
National Health Security Office
National Health Security Office
NIS
National Institute of Statistics
National Institute of Statistics
NSO
National Statistical Office
National Statistical Office
OCDP
Outpatient Consultation and Diagnostic
Package
Outpatient Consultation and Diagnostic
Package
OECD
Organisation of Economic Co-operation and
Development
Organisation of Economic Co-operation
and Development
OG
Organised Groups
Organised Groups
OOP
Out-of-pocket payment
Out-of-pocket payment
OPC
Out-patient care
Out-patient care
PFMB
Provincial Fund Management Boards
Provincial Fund Management Boards
PAHO
Pan American Health Organization
WHO Regional Office for the Americas
PHI/SPS
Seguro Popular de Salud
Popular Health Insurance
PHR+
Partners for Health Reform Plus
Partners for Health Reform Plus
PIN
PhilHealth Identification Number
PhilHealth Identification Number
PLWA
People living with HIV/AIDS
People living with HIV/AIDS
POGI
PhilHealth Organised Groups Initiativ
PhilHealth Organised Groups Initiative
PP
Provider payment
Provider payment
PRS
Poverty Reduction Strategies
Poverty Reduction Strategies
PRSP
Poverty Reduction Strategy Process/Paper
Poverty Reduction Strategy Process/ Paper
RH
Reproductive Health
Reproductive Health
RHU
Rural Health Units
Rural Health Units
RRT
Renal Replacement Therapy
Renal Replacement Therapy
SDI
Social Development Index
Social Development Index
SEAR
South East Asia Region Office
WHO Regional Office for South East Asia
SES
Socio-Economic Survey
Socio-Economic Survey
SHI
Social Health Insurance
Social Health Insurance
SIB
Social Insurance Bureau
Social Insurance Bureau
Abbreviations
222
SJSN
Sistem Jaminan Sosial Nasional
National Social Security System
SP
Separation policy
Separation policy
SSNIT
Social Security and National Insurance
Trust
Social Security and National Insurance
Trust
SSO
Social Security Organisation
Social Security Organisation
SSOS
Social Security Organisation Scheme
Social Security Organisation Scheme
SSPH
System for Social Protection in Health
System for Social Protection in Health
SSS
Social Security Scheme
Social Security Scheme
STEP
Strategies and Tools against social Exclusion and Poverty
Strategies and Tools against social Exclusion and Poverty
SUS
Sistema Único de Saúde
Unified Health System
SWAp
Sector Wide Approach
Sector Wide Approach
SwiM
Sector Wide Management
Sector Wide Management
TD
Territorial Department
Territorial Department
THE
Total Health Expenditure
Total Health Expenditure
TPA
Third Party Administrators
Third Party Administrators
TSKI
Taytay sa Kauswagan
Bridge to Progress
UC
Universal coverage
Universal coverage
UCS
Universal Coverage Scheme
30 Baht Scheme
UNDP
United Nations Development Program
United Nations Development Program
UNFPA
United Nations Population Fund
United Nations Population Fund
UNICEF
United Nations Children’s Fund
UNRISD
United Nations Research Institute for Social
Development
USAID
United States
US CDC
United States Centres for Disease Control
and Prevention
United States Centres for Disease Control
and Prevention
USSR
Union of Socialistic Soviet Republics
Union of Socialistic Soviet Republics
VIP
Very Important Person
Very Important Person
VSS
Viet Nam Social Security Agency
Viet Nam Social Security Agency
WB
World Bank
World Bank
WHA
World Health Assembly
World Health Assembly
WHO
World Health Organization
World Health Organization
WHOSEA
WHO Regional Office for South-East Asia
WHO Regional Office for South-East Asia
WPRO
Western Pacific Regional Office
WHO Regional Office for the Western
Pacific
United Nations Research Institute for Social Development
Extrending Social Protection in Health
223
6.6. Social protection in health: Links to Important Websites
http://www.afdb.org/portal/page?_pageid=473,970
558&_dad=portal&_schema=PORTAL
African Development Bank, Social Protection
And Risk Management
http://www.alliance-hpsr.org
Alliance of Health Policy and Systems Research
http://www.adb.org/SocialProtection/default.asp
Asian Development Bank, Social Protection
http://www.ausaid.gov.au/hottopics/topic.cfm?ID=8
626_7911_7180_5880_5425
AUSAid HIV/AIDS
http://www.eclac.cl
UN-Economic Commission for Latin America
and the Caribbean (CEPAL)
http://www.socialhealthprotection.org;
http://www.shi-conference.de
Consortium GTZ-ILO-WHO
www.medicalschemes.com
Council for Medical Schemes, Statutory Body of
the South African Parliament
http://enrecahealth.ku.dk
Danish Health Research Network
http://www.dfid.gov.uk
Department of International Development
Eldis Health systems/Health Sector Financing
http://www.eldis.org/healthsystems/index.htm;
http://www.eldis.org/healthsystems/financing/index.
htm
http://www.diplomatie.gouv.fr/en/ministry_158/publi French International Cooperation Social protection
cations_2288/international-cooperation-anddevelopment_2289/reperes-serie_2290/attackingpoverty-inequality-and-exclusion_2722/socialprotection_3239.html#nb20
http://www.gavialliance.org/
Global Alliance for Vaccines and Immunization
(GAVI)
http://www.globalforumhealth.org/
Global Forum for Health Research
http://www.theglobalfund.org
Global Fund to Fight AIDS, Tuberculosis and
Malaria (GFATM)
http://www.gtz.de/social-protection;
http://www.gtz.de/en/themen/sozialeentwicklung/soziale-sicherheit/895.htm
GTZ, Social Protection Systems
http://www.healtheconomics.org
International Health Economics Association
http://www.healthfinancingtaskforce.org/
Health Financing Task Force
www.hst.org.za
Health System Trust, South Africa
http://www.healthsystemsrc.org
HSRC website (DFID Health Systems research)
http://www.ids.ac.uk/ids/
Institute of Development Studies (IDS), University of Sussex
http://www.iadb.org/topics/subtopics.cfm?subtopicI Inter American Development Bank (IADB, BID),
D=SEG&language=English&topicID=IS&parid=2&it Social Inclusion & Equality
em1id=10
http://www.ilo.org/public/english/protection/
International Labour Office Social Security Department
http://www.issa.int
International Social Security Association
http://www.jica.go.jp/english/global/soci/index.html
JICA, Social Security
http://www.kfwentwicklungs-
KfW Health Division
Weblinks
224
bank.de/DE_Home/Fachthemen/Gesundheit32/ind
ex.jsp
http://www.danida.dk;
http://www.who.int/healthmetrics/en/
Ministry of Foreign Affairs of Denmark
(DANIDA), Health Metrics Network
http://www.stm.fi/Resource.phx/eng/index.htx
Ministry of Social Affairs and Health of Finland
http://www.minbuza.nl/de/home;
Netherlands Ministry of Foreign Affairs;
http://www.minbuza.nl/en/ministry,organisational_st Social and Institutional Development Departructure/Policy-Theme-Departments.html#a8
ment Netherlands
http://www.novartisfoundation.com/en/health_coop
eration/index.htm
Novartis Foundation for Sustainable Development
http://www.norad.no/default.asp?V_ITEM_ID=1597 NORAD Health
http://www.oecd.
Organisation for Economic Co-operation and
Development (OECD)
http://www.sida.se/sida/jsp/sida.jsp?d=428&langua SIDA, Health and development
ge=en_US
http://www2.sdc-health.ch/
Swiss Development Agency, Social Development Division
http://www.worldbank.org/;
World Bank, Health, Nutrition & Population
http://web.worldbank.org/WBSITE/EXTERNAL/TO
PICS/EXTHEALTHNUTRITIONANDPOPULATION
/0,,menuPK:282516~pagePK:149018~piPK:14909
3~theSitePK:282511,00.html
http://www.who.int/healthsystems/topics/financing/
en/index.html
Health Systems Financing, WHO
http://www.who.int/health_financing
World Heath Organization, Health Financing
Policy
http://www.afro.who.int
WHO Regional Office for Africa
http://www.paho.org/
WHO Regional Office for the Americas / Pan
American Health Organization
http://www.afro.who.int/dpm/hec/index.html
Health Economics at the WHO Regional Office for Africa
http://www.euro.who.int
WHO Regional Office for Europe
http://www.euro.who.int/healthtopics/HT2ndLvlP
age?HTCode=health_economics
Health Economics at the WHO Regional Office for Europe
http://www.wpro.who.int
WHO Regional Office for the Western Pacific
http://www.wpro.who.int/health_topics/health_e
conomics_and_financing/
Health Economics and Financing at the WHO
Regional Office for the Western Pacific
http://w3.whosea.org
WHO Regional Office for South-East Asia
http://www.emro.who.int
Regional Office for the Eastern Mediterranean
http://www.euro.who.int/observatory
European Observatory on Health Systems
www.york.ac.uk/inst/che/intpub.htm
Centre for Health Economics University of York
Extrending Social Protection in Health
225
6.7. The Consortium
Scope
The GTZ-ILO-WHO Consortium is a joint effort to coordinate work of the participating organisations and collaborate at country, regional and global level. The Consortium strives for extending health protection coverage in developing countries. It is open to various options of
health financing and not limited to social health insurance.
Objectives
Increase quality and scope of sustainable and comprehensive health care financing in
partner countries
Strengthen technical support by joining resources
Create synergies and savings through complementary activities
Modus Operandi
The three founding organisations signed a letter of agreement in November 2004. The Consortium makes use of an informal, light and flexible organisational structure. The three organisations generally share incoming requests and pool resources. All activities are financed by
either regular bilateral or other available funds. Only in case the other organisations do not
want to join, one organisation proceeds on its own.
Added Value
The Consortium allows for creating of important synergies in order to enable a faster and
broader response to countries' requests as well as inducing a more significant impact. Therefore the Consortium provides a forum for improved coordination and harmonisation with donors in the spirit of the 2005 Paris declaration on Aid Effectiveness. And at country level the
Consortium offers a platform for sharing experience and strengthening co-operation. The
joint development and application of tools is another important source for synergies. Furthermore, the Consortium can support countries in consensus building around normative
aspects of social health protection.
Achievements
The Consortium has been focusing so far on conceptual work on policies and tools, technical
co-operation at country level, policy dialogue at regional and international level, and capacity
building through seminars, workshops and international conferences.
•
•
•
Example Technical Support to Cambodia: The government of Cambodia expressed interest regarding advice on extension of social health protection by the Consortium during the
Berlin Conference in December 2005. The 1st joint mission took place in May 2006 and
recommendations and conclusions presented to the MoH, MoF and MoE as well as to the
Cambodian Health Insurance Committee. A report was prepared and approved by the
Cambodian Government already in July 2006.
Example Joined Research Projects: A recent project analysed the impact of social health
insurance on poverty reduction.
Work In Progress: The Consortium intends to develop an option paper and guidelines on
social health insurance as well as a joint discussion paper.
More information under: www.socialhealthprotection.org
SERIES: „Higher
Education for
Sustainability“
Edited by Gerd Michelsen
T
higher education for sustainability
he book series „Higher Education for Sustainability“ provides information and experiences on the question of
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Maik Adomssent / Jasmin Godemann /
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E
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Maik Adomssent / Jasmin Godemann /
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Higher Education for Sustainability
New Challenges from a Global Perspective
different political, methodological, and didactical approaches is the visible expression of the diversity of
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ances that develop among stakeholders at all levels.
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VAS-Verlag
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People all over the world depend on having access to health services for maintaining their health
or for their survival. It is crucial therefore that they are able to afford the treatment they need.
Payments for health care push an estimated 100 million people into poverty every year. Functioning
social health protection systems could prevent this. They entitle people to access the health services
Extending Social Protection in Health
International Labour Office
Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ) GmbH
World Health Organization
Extending Social
Protection in Health
Developing Countries’ Experiences,
Lessons Learnt and Recommendations
needed, they ensure that no one is impoverished by health bills, and they set prices and contributions
according to what people are able to pay. This book represents the combined insight into social
health protection from over 200 academics, policy makers and politicians, who gathered at the
2005. The book tackles issues as diverse as universal coverage, social dialogue, poverty reduction
or mixed financing systems and draws on experiences spanning four continents.
GTZ / I LO / WHO
International Conference on Social Health Insurance in Developing Countries in Berlin in December
ISBN 978-3-88864-425-2
SHI_Umschlag.pmd
1
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