Transcript Improving Targeting of the Poor and Ensuring Equity Ghana

Improving Targeting of the Poor and Ensuring
Equity: Emerging Systems and Approaches
Dr. Nishant Jain
07.07.2015
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Introduction
 Providing Protection from catastrophic health related
expenditure is critical not only for poor but also to ensure that
people do not fall below poverty line
 In an study by Bales and Lu alongwith Equitap team it was
found that 67.3 million people, equivalent to 3.6% of the
population were pushed below the $1.25 poverty line due to outof-pocket health payments. (18 territories)
 In an study in India it was found that 21% of poorest get
indebted due to Outpatient and 64% due to Inpatient
 Therefore it is very important to provide cover from health
related shocks to poor and vulnerable families
 However, it is easier said than done and it is one of the biggest
challenges being faced by countries in moving towards UHC
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Estimated % point increase in poverty estimates after
deducting OOP health payments (PPP $1.25 Poverty Line)
consumption (PPP$1.25 poverty line)
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Who is poor and vulnerable?
 There are different definitions of defining poor and based on the
definition families can be called poor (innovative definitions)
 However, irrespective of the definition families with lower and/
or unsteady income are vulnerable
 Defining poor is important from the perspective of the
Government support as subsidy comes into play
 In addition to income there are many other criteria to determine
who is poor and a large number of countries are using a version
of means testing method
 Informal sector workers in most of the developing countries are
very large in number and are also very vulnerable to health
expenditure related shocks
 Most of the informal sector workers are poor
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Why it is Important to Reach Poor?
 Resources are limited with the Government and it should be
used effectively for the ones who are poor and vulnerable
 If the money is routed through a demand side system then it is
important that targeting is correct
 It is important to reach families that are near poor so that they
do not have catastrophic shocks and fall below poverty line
 Protect families that are already poor from catastrophic out of
pocket expenditure on health that will put them in a debt trap as
they have borrow money or sell assets
 Many times poor do not take health services at all as they do
not have money to pay for it
 Positive effect on the economic productivity of the country
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What is meant by targeting Poor and
Vulnerable and Improving equity?
 This means that extremely poor and vulnerable families are:
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Identified
Listed
Enrolled in the programme
Financed through Government/ self/ other funds
Aware about the benefits
Aware about the process to get the benefits of the programme
Able to approach the Government in case of any issue in enrolment or
access of benefits
 This also means that Government is able to execute above
through a planned strategy and monitor closely the above
through a robust system
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Country Examples
THAILAND
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Introduction
 Thailand is one of the very few Asian countries that has
reached almost 100% universal health coverage through
demand side mechanism
 In addition to the two existing schemes that cover formal
sector employees another scheme was introduced in 2001
 The Universal Coverage Scheme covers everyone who is
working in the informal sector, whether rich or poor.
 The co-payment of Baht 30 per visit was abolished at the end of 2006.
 Though this scheme focuses not only on poor but almost 80%
of the population including poor are covered by this scheme
 Non-Poor vulnerable population including informal sector
workers are also protected through this scheme
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Challenges
 Since coverage is almost universal, the challenge is less on
targeting
 Covering of left over small groups is a big challenge now
 Main challenges at present are
 Availability of adequate number of health care facilities
 Enlarging the benefit package
 Improving the quality of health care
 Costing and revising capitation rates
 Human resource availability
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Country Examples
COLUMBIA
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Introduction
 Mobilize resources from Treasury and payroll taxes for
mandatory insurance
 An Equity (equalization) fund was created
 Introduced SISBEN (BPL Surveys) to target public subsidies to
the poor
 Identify health priorities and change budget allocation rules
overtime
 Choice of insurer & provider for all insured whether in
Contributory or Subsidised regime
 Two Categories of Beneficiaries
 Contributory Regime
 Subsidised Regime
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Targeting of Public Subsidies in Colombia
Targeting proved
essential to reduce
health inequality
through public
subsidies
Distribution of social subsidies by income
group, 2003
100
93
90
80
72
Targeting is not
perfect
62
Housing subsidies
60
47
50
40
Public subsidies
for health are one
of the best targeted
in Colombia
Public services
70
33
50,6
Education subsidies
Nutrition and child care
programs
33,2
Subsidized health insurance
30
17
20
11
10
2
0
40% poorest
40% richest
Source: Lasso F. et al. Incidencia del Gasto Público. 2005.
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Source: Slide from Maria Luisa Escobar presentation “Colombia’s Health System Financing; Presented on November
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Country Examples
MEXICO
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Mexico
 Mexico’s Seguro Popular (Popular Health Insurance) aims to reach the poor
and tries to provide adequate coverage to people working outside the formal
sector
 The purpose of this voluntary program is to provide poor and informal
workers with subsidized insurance coverage comparable to that available to
formal sector workers
 The program initially focused on the poorest families first. Premium payments
by the families are subsidized on a sliding scale by the Government, and
poorest 20% of the population do not pay.
 The gap between income from premium payments and the program’s total
cost is covered by government subsidies.
 Most of the funding for this programme comes from the federal government,
through payments to the state governments
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Ensuring Participation by Poor
 Subsidized Premium for the Poor
 The premium varies according to the economic status. Families pay up
to 5% of disposable income
 For poorer families lower percentage of income is to be paid and for
poorest 20% there is no premium payment
 Identification of the Poor – Different Options
 Use existing programme called Progresa/Oportunidades for data OR
 Use data created by SP through means testing method OR
 States are free to use approach of any federal subsidy programs
 Incentive for Enrolling the Poor
 The federal SP programme support to States depends on the number of
people State serve
 The result is an incentives for States to enroll as many people in
programme as possible and since there is no premium for poor it is
comparatively easier to enrol them
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Country Examples
INDIA
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Introduction
The National Health Insurance Programme of India called
Rashtriya Swasthya Bima Yojana started targeting only
Poor and informal workers
Since the target was only poor in the beginning the
experience from this experience has interesting insights
The implementation model involved hiring of Private
Insurance Companies by the Government to implement the
scheme
The premium for poor families was subsidised 100% by the
Federal and State Governments together
However, families are mandated to pay a small amount
(US$ 0.5) as registration fee
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Process
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A list of poor families is provided by the Government to the
Insurance Companies
The model incentivise Insurance Companies to enroll as
many families as they get premium per family enrolled
To ensure that people do not have to make extra effort for
enrolment, the enrolment process is done at the village level
and biometric photo Smart Cards are issued on the spot
To ensure that fake enrolment do not happen a local
Government officer verifies the identity of each family getting
enrolled through his/ her smart card
The Insurance Company is paid based on the data
automatically collected in the smart card of Government
officer at the enrolment station
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Enrollment Station
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Challenges
 Quality of List of Below Poverty Line families prepared by
the Government needs not good due to various reasons
 Reaching with the message to people about enrolment in
the scheme and enrolling the family is critical
 Duplication amongst different lists as there is no National
ID available for all citizens of the country
 People in hard to reach geographical areas are still being
left at many places as incentive is not enough
 Poor families who are not able to get into the List were
excluded – An Employment Guarantee Scheme has
started and people working there are not eligible for RSBY
 Even if families are enrolled they are not many times
aware about utilising the scheme
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Strategies in Terms of Funding
 Poor are Fully Subsidised –The poor are ensured without
paying any premium as either it is exempted or fully subsidised
 This can work better if targeting is good and people are aware
 However, there are opportunity costs involved from people e.g. loss of
wages when they go for enrolment
 Premium is Partially Subsidised – The poor pay a part of the
premium and rest is paid/ exempted/ subsidised by Government
 Paying even a subsidised premium is often very difficult for very poor
 Income Based Premium – Premium varies based on income of
the family
 Very difficult to determine income and also to collect premium
 Premium paid in kind – People can pay premium through work
or food grains etc.
 This can work for pilots for difficult for large scale initiatives
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Challenges and Suggestions
 How to effectively Identify poor and vulnerable is one of the
biggest challenge for any programme
 Start with any reasonable list/ method available as a perfect list/ method
will never be available.
 Improving the system for identification of Poor is necessary
 Once the transparency is increased in terms of families that are getting
subsidy for health insurance then slowly the list improves
 Getting de-duplicated lists and removing ghost names
 If there is National ID programme then it is best to link with that. In its
absence a unique ID shall be provided centrally. Biometric data can also
help in removing duplicates and ghost names
 Whether the premium should be partially or fully subsidised
 For the poorest it is advisable to fully subsidise the premium as it is very
difficult for them to pay. For near poor also some subsidy should be
there so as to encourage them in joining the programme
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Challenges and Suggestions
 Enrolment of Poor and Vulnerable in the programme is quite low
 There should be incentive mechanisms built for the agency that has a
mandate to enroll them and their performance should also be measured
on their ability to reach poor and enroll them in the programme
 Additional incentives for enrolment in hard to reach areas to be given
 In countries incentives have been built in different ways like third party
agencies (e.g. India), through State Governments (e.g. Mexico) or
through field level Government functionaries
 Involvement of Civil Society Organisations and/ or field level existing
Government functionaries is also beneficial in the process
 Enrolment at/ near the doorstep can remove barriers to access due to
distance, opportunity cost loss and recall value
 Using technology in enrolment can improve the efficiency of the process
and minimise frauds
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Challenges and Suggestions
 Utilisation of Services after Enrolment by the beneficiaries
 Improve the awareness about the programme through media channels
suited to the target segment. If the literacy is not very high then visual
media, local folk media, Inter personal communication etc. is more
important
 Government should involve local functionaries, local CSOs, opinion
makers etc. to inform people
 Local guidance by designated persons to utilise services in the villages
and also at the hospital help in improving the utilisation
 Partnering with the providers through health camps etc. however, this
has potential of provider induced moral hazard if monitoring is weak
 Improving the supply side through adequate number of both private and
public providers empanelment so that people are empowered through
choice and they need not travel far to get the benefits
 Including Primary Care in the benefit package will make the product
more attractive to the beneficiaries and they will use it
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Thank You
[email protected]
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