The potential for social mobilisation in Bangladesh: the organisation and functioning of two health insurance schemes

Health insurance schemes are usually assessed according to technical indicators. This approach, however, neglects the dynamic perspective of insurance schemes as an element of people's mobilisation for participation in organising and managing health care delivery and financing. The first part of this paper describes the technical performance and the level of community involvement in management of the two largest health insurance schemes in Bangladesh, both in the rural areas and in the non-government sector. Part two discusses these achievements in light of the schemes' potential role as a mechanism for people's management of health care. A review of documents and key-informant interviews were conducted. Key findings include that (1) subscribers currently are not actively participating in scheme management. However, existing family groups, involved in credit programmes may serve as entry-points for interaction. This is sustained by the 'natural link' between health insurance as a means of spreading the risks of treatment costs and credit programmes as a means of decreasing the relative impact of illness on household income. (2) The schemes' role could be further enhanced, by improving their technical performance and applying health care systems elements with the input of all partners involved. These issues are avoidance of service duplication with other providers; better protection of the poorer households; inclusion of hospital care in the coverage package; simplification of scheme administration by introduction of episode-based co-payments instead of the current itemised ones and concentrating the schemes at the level of community-based services, which may be self-financed and also self-managed by the community, given available sensitisation, training and interaction. A shift to episode-based co-payments would also introduce solidarity among patients and among individuals at higher risk, such as pregnant women and under-fives. Finally, action-research is needed to document the process of increased community involvement.     

Strengthening institutional and organizational capacity for social health protection of the informal sector in lesser-developed countries: A study of policy barriers and opportunities in Cambodia

Reaching out to the poor and the informal sector is a major challenge for achieving universal coverage in lesser-developed countries. In Cambodia, extensive coverage by health equity funds for the poor has created the opportunity to consolidate various non-government health financing schemes under the government's proposed social health protection structure. This paper identifies the main policy and operational challenges to strengthening existing arrangements for the poor and the informal sector, and considers policy options to address these barriers. Conducted in conjunction with the Cambodian Ministry of Health in 2011–12, the study reviewed policy documents and collected qualitative data through 18 semi-structured key informant interviews with government, non-government and donor officials. Data were analysed using the Organizational Assessment for Improving and Strengthening Health Financing conceptual framework. We found that a significant shortfall related to institutional, organisational and health financing issues resulted in fragmentation and constrained the implementation of social health protection schemes, including health equity funds, community-based health insurance, vouchers and others. Key documents proposed the establishment of a national structure for the unification of the informal-sector schemes but left unresolved issues related to structure, institutional capacity and the third-party status of the national agency. This study adds to the evidence base on appropriate and effective institutional and organizational arrangements for social health protection in the informal sector in developing countries. Among the key lessons are: the need to expand the fiscal space for health care; a commitment to equity; specific measures to protect the poor; building national capacity for administration of universal coverage; and working within the specific national context.     

Indigenous social insurance as an alternative financing mechanism for health care in Ethiopia (the case of eders)

With increasing demand for services further propagated by population growth and by people's response to newly emerging pathologies, nations in sub-Saharan Africa are faced with insurmountable problems in sustaining their health systems. Realizing the inadequacy of solely relying on the public sector, these countries are seeking alternative mechanisms for health financing. Among the alternatives suggested are risk-sharing mechanisms that include community-based schemes that tap the potential of indigenous social arrangements.In Ethiopia, eders are major forms of indigenous arrangements utilized mainly for assisting victims in bereavement and executing funeral-related activities. These associations are also called upon in various self-help activities and sometimes provide health insurance, even though mostly in an informal manner. Therefore, they have the potential to serve as social financing mechanisms. Since these are already functioning groups, the administrative cost for the extra health-related activity will not be as high as in the case of forming a new insurance entity. In addition, the fact that eders are based on mutual understanding among members minimizes the possibility of adverse selection.Based on the above background, an exploratory study was conducted in 40 villages distributed in various parts of Ethiopia to assess the possible roles eders might play in providing insurance for health financing. Both qualitative and quantitative (household and health facility exit interview surveys) methods of data collection were utilized.The study concludes that eder-based schemes are, indeed, options for experimentation as mechanisms for financing health care in rural Ethiopia. It was also found that 21.5% of respondents in the household and 16% of those in the exit surveys were already utilizing eders to finance part of their health expenditure. In addition, 86% of the respondents in the household and 90% of those in the exit survey were willing to participate in eder-based health insurance schemes.     

Experiences in paying for health care in India's voluntary sector

This article summarizes the results of four in-depth case studies on the financing and costs of the health care programmes of well-known non-government organizations (NGOs) in India. These organizations have shown a high degree of creativity and innovation in developing varied sources of financing to reduce dependency and enable them to sustain their programmes. Government funds play a major role in supporting these voluntary health activities, with less significant roles played by foreign donations, user charges, pre-paid memberships, and public fund raising. Some effective methods of assuring access for poor clients while developing self financing are described. Cost studies of the NGOs' health schemes indicate that they operate at least as efficiently as public services and primarily supplement rather than substitute for such services. Suggestions for further development of voluntary sector financing are put forward.     

Willingness to pay for rural health insurance through community participation in India

The main objective of this article is to examine the willingness to pay for a viable rural health insurance scheme through community participation in India, and the policy concerns it engenders. The willingness to pay for a rural health insurance scheme through community participation is estimated through a contingent valuation approach (logit model), by using the rural household survey on health from Karnataka State in India. The results show that insurance/saving schemes are popular in rural areas. In fact, people have relatively good knowledge of insurance schemes (especially life insurance) rather than saving schemes. Most of the people stated they are willing to join and pay for the proposed rural health insurance scheme. However, the probability of willingness to join was found to be greater than the probability of willingness to pay. Indeed, socio-economic factors and physical accessibility to quality health services appeared to be significant determinants of willingness to join and pay for such a scheme. The main justification for the willingness to pay for a proposed rural health insurance scheme are attributed from household survey results: (a) the existing government health care provider's services is not quality oriented; (b) is not easily accessible; and, (c) is not cost effective. The discussion suggests that policy makers in India should take serious note of the growing influence of the private sector and people's willingness to pay for organizing a rural health insurance scheme to provide quality and efficient health care in India. Policy interventions in health should not ignore private sector existence and people's willingness to pay for such a scheme and these two factors should be explicitly involved in the health management process. It is also argued that regulatory and supportive policy interventions are inevitable to promote this sector's viable and appropriate development in organizing a health insurance scheme.     

The desirability and feasibility of scaling up community health insurance in low-income settings--lessons from Armenia

There is growing evidence that community financing mechanisms can raise additional revenue, increase equitable access to primary health care (PHC), and improve social protection. More recently there has been interest in scaling up community financing as a step towards universal coverage either via tax-based systems or social health insurance. Using key informant interviews and focus group discussions, this study sought to assess the desirability and feasibility of scaling-up community health insurance in Armenia. The results suggest that there is broad-based political support for scaling up the schemes and that community financing is synergistic with major health sector reforms. High levels of social capital within the rural communities should facilitate scaling up. Existing schemes have increased access and quality of care, but expansion of coverage is constrained by affordability, poor infrastructure, and weak linkages with the broader health system. Long-term subsidies and system-building will be essential if the expanded schemes are to be financially viable and pro-poor. Overall, successfully scaling up community financing in Armenia would depend on addressing a range of obstacles related to legislation, institutional capacity, human resources and resistance to change among certain stakeholders.     

Constraints on the retreat from a welfare-orientated approach to public health care in Malaysia.

Both in its articulation of values and through incremental changes, the Malaysian government has signalled a change in attitude towards the welfare approach which had hitherto characterized public health care policy. This change envisions an end to reliance upon the state for the provision and financing of health services and the fostering of a system of family-based welfare. In the future citizens should finance their own health care through savings, insurance or as part of their terms of employment. While the state will still accept a degree of responsibility for those unable to pay for their health care, it wishes to share this burden with the corporate sector and non-government organizations as part of a national policy of the 'Caring Society'. In this article the retreat from a commitment to a welfare model of public health care is documented and some of the serious obstacles to such a policy are discussed. It is concluded that the government's aspirations for reforming the welfare model will need to be tempered by both practical and political considerations. Moreover, the socio-economic consequences of the Asian currency crisis of 1997 are likely to increase the need for government welfare action.     

Primary health care in the Philippines: banking on the barangays?

Primary health care has been hailed by some countries as the only practical means of providing any form of health care for expanding populations in poor economies. This is particularly true in Third World countries where the cost explosion of technology-oriented health care has been a major problem in extending services. Therefore, the PHC package of education, nutrition, preventive medicine and treatment of the most common diseases and injuries is sometimes regarded as the most beneficial application of scarce resources. The Philippines claims to be one of the first (perhaps the first) countries to have adopted PHC as a national strategy for health care and, since 1981, impressive achievements have been attained in this sector by contrast with reversals in many other sectors of the economy. PHC has not challenged the pre-eminence of Metro-Manila in the provision of hospital and specialist facilities but it has extended some basic care particularly to rural regions of the country. This paper reviews the background to health care in the Philippines and it then examines the implementation of PHC in Negros Oriental, where PHC has taken on the additional feature of special use of indigenous materials and resources. The administrative, financial and legal bases and some geographical facets of PHC are highlighted in this province. The campaign relies heavily on local (barangay) initiatives and community participation, in part to minimise resources which have to be devoted to health in a very troubled national economy. In spite of local skills and enthusiasm, this arguably still involves the abrogation of a degree of government responsibility for health care. As a result, the Philippines strategy may be said to be "banking on the barangays."     

Spending and financing in health care: situation and trends]

Being knowledgeable about national health expenditures and sources of financing is essential for decision-making. This awareness also makes it possible to evaluate the equity of allocation and the efficiency of utilization of these resources. Changes in financing have been a substantial component of health sector reform in the Americas. The goal has shifted from merely one of financial sustainability to simultaneously seeking equitable access to quality services. In this article the Pan American Health Organization (PAHO) presents a proposal for analyzing and designing a policy on health financing. The aim of the policy is to identify the mix of financing mechanisms most likely to simultaneously produce financial sustainability, equity, access, and efficiency. The PAHO proposal combines traditional mechanisms for generating resources (public funds from taxes, as well as private health insurance, national health insurance, and user fees) with complementary subsidy mechanisms for vulnerable groups. Health financing strategies ought to explicitly consider the financing both of care for individuals and of health interventions for the general public good, for which public financing is the most equitable and efficient approach.     

Effectiveness of community health financing in meeting the cost of illness

How to finance and provide health care for the more than 1.3 billion rural poor and informal sector workers in low- and middle-income countries is one of the greatest challenges facing the international development community. This article presents the main findings from an extensive survey of the literature of community financing arrangements, and selected experiences from the Asia and Africa regions. Most community financing schemes have evolved in the context of severe economic constraints, political instability, and lack of good governance. Micro-level household data analysis indicates that community financing improves access by rural and informal sector workers to needed heath care and provides them with some financial protection against the cost of illness. Macro-level cross-country analysis gives empirical support to the hypothesis that risk-sharing in health financing matters in terms of its impact on both the level and distribution of health, financial fairness and responsiveness indicators. The background research done for this article points to five key policies available to governments to improve the effectiveness and sustainability of existing community financing schemes. This includes: (a) increased and well-targeted subsidies to pay for the premiums of low-income populations; (b) insurance to protect against expenditure fluctuations and re-insurance to enlarge the effective size of small risk pools; (c) effective prevention and case management techniques to limit expenditure fluctuations; (d) technical support to strengthen the management capacity of local schemes; and (e) establishment and strengthening of links with the formal financing and provider networks.     

Progressivity of health care financing and incidence of service benefits in Ghana

The National Health Insurance (NHI) scheme was introduced in Ghana in 2004 as a pro-poor financing strategy aimed at removing financial barriers to health care and protecting all citizens from catastrophic health expenditures, which currently arise due to user fees and other direct payments. A comprehensive assessment of the financing and benefit incidence of health services in Ghana was undertaken. These analyses drew on secondary data from the Ghana Living Standards Survey (2005/2006) and from an additional household survey which collected data in 2008 in six districts covering the three main ecological zones of Ghana. Findings show that Ghana's health care financing system is progressive, driven largely by the progressivity of taxes. The national health insurance levy (which is part of VAT) is mildly progressive while NHI contributions by the informal sector are regressive. The distribution of total benefits from both public and private health services is pro-rich. However, public sector district-level hospital inpatient care is pro-poor and benefits of primary-level health care services are relatively evenly distributed. For Ghana to attain an equitable health system and fully achieve universal coverage, it must ensure that the poor, most of whom are not currently covered by the NHI, are financially protected, and it must address the many access barriers to health care.     

Changing medical doctor productivity and its affecting factors in rural China

Using the data collected from the health facility-based survey, part of the national health service survey conducted in 1993 and 1998, this paper tries to examine changes in labour productivity among the county-level hospitals and township health centres in rural China, and to analyse factors affecting the changes. The results presented in the paper show that the average number of outpatient visits per doctor per day and the average number of inpatient days per doctor per day declined significantly over the period from 1986 to 1997. The main factors resulting in the reduction of productivity are associated with the increase of inappropriate staff recruitment in these health facilities, the significant decline of rural population covered by health insurance, particularly rural cooperative medical schemes (CMS), and the rapid rise of health care costs. The latter two factors also have brought about a reduction in the use of these health facilities by the rural population. The paper suggests that the government should tighten up the entrance of health and non-health staff into the rural health sector and develop effective measures aimed to avoid providing pervasive financial incentives to the over-provision of services and over-use of drugs. In addition, other measures that help to increase the demand for health services, such as the establishment of rural health insurance, should be considered seriously.     

Who pays and who benefits from health care? An assessment of equity in health care financing and benefit distribution in Tanzania

Little is known about health system equity in Tanzania, whether in terms of distribution of the health care financing burden or distribution of health care benefits. This study undertook a combined analysis of both financing and benefit incidence to explore the distribution of health care benefits and financing burden across socio-economic groups. A system-wide analysis of benefits was undertaken, including benefits from all providers irrespective of ownership. The analysis used the household budget survey (HBS) from 2001, the most recent nationally representative survey data publicly available at the time, to analyse the distribution of health care payments through user fees, health insurance contributions [from the National Health Insurance Fund (NHIF) for the formal sector and the Community Health Fund (CHF), for the rural informal sector] and taxation. Due to lack of information on NHIF and CHF contributions in the HBS, a primary survey was administered to estimate CHF enrollment and contributions; assumptions were used to estimate NHIF contributions within the HBS. Data from the same household survey, administered to 2224 households in seven districts/councils, was used to analyse the distribution of health care benefits across socio-economic groups. The health financing system was mildly progressive overall, with income taxes and NHIF contributions being the most progressive financing sources. Out-of-pocket payments and contributions to the CHF were regressive. The health benefit distribution was fairly even but the poorest received a lower share of benefits relative to their share of need for health care. Public primary care facility use was pro-poor, whereas higher level and higher cost facility use was generally pro-rich. We conclude that health financing reforms can improve equity, so long as integration of health insurance schemes is promoted along with cross-subsidization and greater reliance on general taxation to finance health care for the poorest.     

Private health care in South Africa: should the unions intervene?

The South African state's policy of privatization of health services has led to deterioration of public-sector health care and increased costs of access to this sector. This has generated an increasing demand for private health insurance among the predominantly black organized working class. These demands pose a dilemma for the progressive trade unions; negotiation of private-sector health insurance will have deleterious consequences for the equity and efficiency of the health services in general. Current trends in the private health sector also indicate that rapid cost increases will make most regular insurance packages unaffordable to the majority of workers within a few years. On the other hand, trade unions are obliged to meet the material demands of their members, and to intervene to stem the flow of individual workers to the private health sector. This article describes these trends, and the authors argue the case for intervention in this process by trade unions, in the form of union-negotiated and union-controlled "managed care" schemes. Such schemes will allow for the delivery of an adequate and appropriate package of health services at affordable rates. Union control will also allow for such structures to become the building blocks of a future national health service, and for incorporation into that service. Finally, the political implications of such interventions are addressed. The authors argue that the potential for undermining broader political campaigns and for creating divisions within the working class are important problems, but that many of these may be overcome through appropriate interventions.     

Health care financing in Asia: key issues and challenges

This article examines the major elements of health care financing such as financial risk protection, resource generation, resource pooling, and purchasing and payment; provides key lessons; and discusses the challenges for health care financing systems of Asian countries. With the exception of Japan, Korea, Taiwan, and Thailand, most health care systems of Asia provide very limited financial risk protection. The role of public prepaid schemes such as tax and social health insurance is minimal, and out-of-pocket payment is a major source of financing. The large informal sector is a major challenge to the extension of population coverage in many low-income countries of Asia, which must seek the optimal mix of tax subsidy and health insurance for universal coverage. Implementation of effective payment systems to control the behavior of health care providers is also a key factor in the success of health care financing reform in Asia.     

贫困农村地区妇幼保健保偿制案例分析

妇幼保健保偿制是中国卫生部门的一项创举,已得到国内外学术界的好评。本文报告了在云南贫困农村地区进行的保偿制现场调查研究的部分结果:①保偿制保证了贫困农村地区最基本的妇幼保健服务。②贫困家庭的妇女较少利用保偿制提供的服务。本项研究表明,在农村社区应特别关注贫困妇女的健康服务,增加她们对现有保健服务的利用,以保证服务的公平性。     

Health insurance in Korea: opportunities and challenges

A substantial change has taken place in the Korean health sectorwith the introduction of a national health insurance system.Many issues raised by this new system are of interest to bothdeveloped and developing countries. Major questions of interestare: (i) how the government of Korea was able to move from thefirst step of health insurance schemes in 1977 to completionof the system in 1989; (ii) how a predominantly private-orientedhealth care delivery and financing system could support government-initiatedcompulsory health insurance schemes; and (iii) if there areany inherent problems with this health insurance system. Whilethere are some positive aspects, the study shows that many basicproblems remain unresolved. Unless basic reforms are implementedat system level, in the long-run neither efficiency nor equitywill be achieved. It is important, therefore, for both the governmentand the health sector to grasp the significance of the situationand actively pursue better formulated strategies.     

Social health insurance in a developing country: the case of the Philippines

Very little is known about the Philippine health care system, and in particular its experience with social health insurance (SHI). Having initiated an SHI programme 35 years ago, the Philippines hold many lessons for the development of such schemes in other low and middle-income countries. We analyse the challenges currently facing PhilHealth, the national health insurer. PhilHealth was formed in 1995 as a successor to the Medicare programme and was given a mandate to achieve universal coverage by 2010. To date, PhilHealth has been quite successful in some areas (e.g. enrollment), but lags behind in others (e.g. quality and price control). We conclude that SHI in the Philippines has been a success story so far and provides lessons for countries in a similar situation. For example: (i) SHI is based on value decisions and the clear statement of societal goals can give guidance in the technical execution, (ii) SHI is a financing institution and needs to be treated accordingly, (iii) SHI can be implemented independently of the current economic situation and might actually contribute to economic development, (iv) community-based health care financing schemes should be merged with the national SHI in the long run, and (v) there is a strong need to push for high quality care and improved physical access. No clear suggestions can be given with respect to the benefit catalogue and the balance between economies of scale and decentralisation. Although riddled with many inadequacies, PhilHealth was set up as a strong and largely politically independent institution for the development of SHI. SHI can act as a stabilizing institution in a politically and economically volatile environment.     

Household health expenditures in Nepal: implications for health care financing reform.

His Majesty's Government of Nepal has embarked on an ambitious social welfare programme of increasing the accessibility of primary education and health care services in rural communities. The implications on the financing of health care services are substantial, as the number of health posts has increased twelve-fold from 1992 to 1996, from 200 to 2597. To strengthen health care financing, government policy-makers are considering a number of financing strategies that are likely to have a substantial impact on household health care expenditures. However, more needs to be known about the role of households in the current structure of the health economy before the government designs and implements policies that affect household welfare. This paper uses the Nepal Living Standards Survey, a rich, nationally-representative sample of households from 1996, to investigate level and distribution of household out-of-pocket health expenditures. Utilization and expenditures for different types of providers are presented by urban/rural status and by socioeconomic status. In addition, the sources of health sector funds are analyzed by contrasting household out-of-pocket expenditures with expenditures by the government and donors. The results indicate that households spend about 5.5% of total household expenditures on health care and that households account for 74% of the total level of funds used to finance the health economy. In addition, rural households are found to spend more on health care than urban households, after controlling for income status. Distributing health care expenditures by type of care utilized indicates that the wealthy, as well as the poor, rely heavily on services provided by the public sector. The results of this analysis are used to discuss the feasibility of implementing alternative health care financing policies.     

Factors influencing the burden of health care financing and the distribution of health care benefits in Ghana, Tanzania and South Africa

In Ghana, Tanzania and South Africa, health care financing is progressive overall. However, out-of-pocket payments and health insurance for the informal sector are regressive. The distribution of health care benefits is generally pro-rich. This paper explores the factors influencing these distributions in the three countries. Qualitative data were collected through focus group discussions and in-depth interviews with insurance scheme members, the uninsured, health care providers and managers. Household surveys were also conducted in all countries. Flat-rate contributions contributed to the regressivity of informal sector voluntary schemes, either by design (in Tanzania) or due to difficulties in identifying household income levels (in Ghana). In all three countries, the regressivity of out-of-pocket payments is due to the incomplete enforcement of exemption and waiver policies, partial or no insurance cover among poorer segments of the population and limited understanding of entitlements among these groups. Generally, the pro-rich distribution of benefits is due to limited access to higher level facilities among poor and rural populations, who rely on public primary care facilities and private pharmacies. Barriers to accessing health care include medical and transport costs, exacerbated by the lack of comprehensive insurance coverage among poorer groups. Service availability problems, including frequent drug stock-outs, limited or no diagnostic equipment, unpredictable opening hours and insufficient skilled staff also limit service access. Poor staff attitudes and lack of confidence in the skills of health workers were found to be important barriers to access. Financing reforms should therefore not only consider how to generate funds for health care, but also explicitly address the full range of affordability, availability and acceptability barriers to access in order to achieve equitable financing and benefit incidence patterns.