Transcript Politiques de couverture maladie en Afrique de l’Ouest

Social Health Protection
in Low Income Countries
Building up from the evidence
Marame NDOUR
AfGH Seminar on UHC – Madrid - 25 October 2012
Oxfam France • 104 rue Oberkampf, 75011 Paris • 01 56 98 24 40 • [email protected] • www.oxfamfrance.org
Social Health Protection in LICS : a
global social challenge

Huge inequalities in access to health services which
reflect inequalities in wealth & power

HC spending inversely proportional to global burden of
disease

80’s : healthcare reform in LICs politically driven by
influential institutions (WB, Usaid, OECD…), pro-market
approach influencing research & policy making

2000’: UHC push by WHO “the single most important
concept in public health today” : new Alma Ata?
Exit from a market style blueprint for
healthcare protection in LICs ?
 Previous assumptions: LICs lack the tax base to
develop publicly funded healthcare
 Solution : out of pocket spending/user fees
• inefficient in HSS ; failed to increase revenue
• failed to adress inequalities in access to health care
 Recent paradigm shift and attempts to reshape
healthcare systems to widen access
• Abolish user fees , subsidize free healthcare initiatives
• Risk pooling social health insurance…
The situation in LICs

« Inverse care law » : those most subject to ill-health are least
able to pay for it

Low levels state and private HC spending

High level of diseases of poverty, preventable mortality //
beginning of an epidemiological transition (NCDs burden)

Poor infrastructure of 1ary & 2ndary HC; shortages of skilled health
staff; high cost of modern medicines and medical equipment

Inequalities in access : rich/poor; rural/urban; preferential access
for the elite and formal sector

Lack of local and democratic control over health policies
What doesn’t work?

Charging even small user fees: financial barrier, complex, costly,
inefficient

Two-tier systems with services targeting the poorest & general
attempts to target and exempt poor people in LICs
• difficulty to identify those qualified
• inclusion/exclusion problems

Private health insurance: still no evidence that it can benefit more
than a limited group of people

Profit driven private actors involved in delivery of services
intended to benefit poor people
• Private sector of its own can nowhere deliver a comprehensive health care
system
• Needs to be combined to public subsidy and provision for most demanding &
unprofitable cases
What does work for the most vulnerable?

Universal, free or extremely low priced services are
more effective to achieve equity & widen access

2% of GDP Govt spending on a UHC system would allow to
reduce or eliminate user fees with a huge benefit for the
poorest (2005 Equitap research health equity in Asia)

Well organized, upgraded and adequately funded universal
public services

Supportive actions to ensure most vulnerable have access to
& use these services
NEPAL
26.6 million
83% of the population live on less than US$2/day
 Enormous health challenges, wide inequalities, e.g in
maternal and child care
• 1 in 80 women will die in pregnancy or childbirth
• Skilled birth attendance: richest 20% of women benefit 12 times
more than the poorest 20%;
• 1 in 19 children will die before their fifth birthday: twice likely to
affect children in rural areas
 Strong political will for UHC backed by donors
- Right to health enshrined in 2007 constitution
- Move from 7% to 10% of national budget on health
Key Social Security Programmes

Maternal health programmes
• Safe Delivery Incentive” in 2005
•  transport; user fees abolition in 25 poorest districts; financial
incentive for health workers attending deliveries
• “Aama”in 2009
•  free hospital deliveries, antenatal & post natal & family
planning services for all women in public health facilities

Free essential health care services
•
2008 : user fees removal in public health facilities throughout
Nepal (for PHC; free essential medicine, targeted free 2ndary care
for senior, disabled, minorities...)
Positive impact
 General increase in utilization of healthcare
• outpatient care doubled
• inpatient care increase by 6-10 folds in 2 years of user fees removal
 < 50% increase : number of women giving birth in
health facilities
• remarkable increase : 6% to 20% in most poor districts
• significant reductions in the cost of care for women
 Improved equity in access to services
• the poor, senior citizens, women and marginalized people are
benefiting more than other groups
Nepal Free healthcare initiatives challenges
 Low awareness about the free healthcare
initiative
 Low funding in 2010/11
• government spending around 7%
• per capita health gvt allocation US$7.60 (far lower than the
WHO recommended US$60)
 Health systems shortfalls
• Inadequate health infrastructure; poor referral system,
Inadequate human resources (trained health workers
shortages go abroad/private), 1:30 000 doctor ratio
Gvt plans: introduce mandatory health
insurance

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Pilote scheme in selected districts in 2012 
nationwide in 5 years
Mandatory enrolment + premium
Extension of covered health services
Concerns: risk of scraping the free healthcare
policies, high premiums, inefficient exemptions for
targeted groups
Evidence from Ghana and Tanzania shows that
health insurance is often inefficient and exclude the
poorest and most vulnerable
Evidence from African countries
 RWANDA : 60% of population live with less than 1$/day

Mutual health insurance schemes
•
•
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Pilot scale in 1999
Rural/informal sector coverage
2$ (enrollment + 10% co-payment of cost of services)
Laws enforcement requiring Mutuelle enrollment
Scale up to more than 91% coverage in 2010 where most
community insurance are far below 10% of coverage
Cited questionably as an example of how community
health insurance can scale up to achieve large coverage
Rwanda achievements … can not be only
attributed to Mutuelles !

Insurance coverage
• 2003 to 2010 : 7% to 91%

Services utilization
• 0.31 to 0.95 outpatient visits per capita

Under 5 mortality decreased
• 2005 to 2010 : 12,5% to 7,6% (similar to South Africa, India)

Secret n°1 massive increase in gvt health spending
• 2002 to 2010 : 10US$ to 48US$ per capita on health
• 2006 : of all health spending 53% from donors, 28% private, (of which
5% Mutuelles), 19% public
N°2: Improved service delivery + subsidization

Upgraded comprehensive service delivery
• Increased health personnel; Reinforced drug supply
• New equipment and general infrastructure improvement
• Improved management (strong leadership and political will,
effective implementation…)

Combined to financial barrier reduction through
subsidization
• Utilization rates doubled/tripled only after (2$)/year Mutuelles
enrollment were subsidized & premium removed
• 37% of enrolled households sponsored by government
• 2011 study shows the impact of co-payment supression on
utilization of PHC facility in Mayange district
Annualized utilization rates for Mayange and 2 neighbouring health
centres Jan-2005 to September 2007 (Dhillon & al, 2011)
Gvt plan to raise premiums WHILE co-payments remain
an important barrier to access !

Co-payment: minimal contribution to local healthcare financing
while costly to levy & manage

Upgraded services alone did not generate a dramatic increase
in utilization + combination with fees removal

Point-of-service payments discriminate against the poor 
disproportionate use of healthcare by the wealthy


Lack of money = barrier to healthcare among 83% of the lowest wealth
quintile // 52% in highest wealth quintile (2005)
Other economic costs : geographic barrier; opportunity costs for
farmers…
“Higher coverage rates, often used to measure the
success of insurance programmes are not sufficient
to improve access (ILO, 2002)

Current cost of subsidising all mutuelle premiums and copayment = 25 million US$

Total cost of absorbing co-payments + complete subsidization of
Mutuelle = 75 million US$


Challenges : expand access without aid dependance
Possibilities :
• move to a centrally financed care free to the population (donor support)
• Middle ground: target lower utilization, provide timely access for the poor ?
• Examine ways of eliminating co-payments, increasing subisides for enrollment ,
expanding free services including curative care and free primary care to priority
populations (children, pregnant women…)
DIRECT PAYMENT EXEMPTION POLICIES
A critical component in promoting universal access
to social health protection ?

Gradually became prominent in a large number of low income
countries

First dedicated to increase success of HIB/TB patients with
international funding

Lately focus on maternal and child mortality & morbidity, PHC,
elderly...

Requirements : precise planification, broad quality services
coverage, adequate and sustainable funding

Potentially play a role in providing social health protection for
the most vulnerable
Coverage for indigent & priority population

Free coverage for women/Children under five
• Geographic  SENEGAL: delivery care costs totally subsidized
everywhere except in the capital Dakar
• Services  NIGER: free contraceptive services, antenatal care,
deliveries, c-sections, breast & uterus cancers treatment ;
consultations, surgery, medicines, and laboratory tests for children
under 5

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100% subsidization (except co-payments Burkina/Kenya)
Access in public and private facilities
• Niger, Senegal, Sierra Leone : childbirth free only on public hospitals
• Benin, Burkina, Burundi : also in private not for profit health centres
• Kenya: private for profit and private not for profit sector
Sustainability challenges of these policies

Difficulties in implementation: lack of planification, acute
funding shortfalls (unpaid healthcare bills, lack of external aid
support predictability if any)
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Targeting uneasy: complex definition of “poor” beneficiaries
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People uninformed of their rights
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Risk of non-compliance with free policies, informal fees
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Complexity to articulate different co-existing free policies
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Scaling up and transition to UHC?
Positive impacts
Evidence from West African Countries
(report to be published early 2013)
 On population
• promote access to essential care, remove financial barriers
• empower populations
• benefit all, including the disadvantaged

On health services
• opportunity to improve the quality of care (prescription, rational use)
and improve health services efficiency
• reinforce resources and strengthen community participation

If well prepared and funded remain a realistic intermediary
option for West-African countries striving to achieve UHC
• Strong political will needed + accountability to populations
• What about the Abuja promises?
Many thanks for your attention !
Marame NDOUR
[email protected]
Oxfam France • 104 rue Oberkampf, 75011 Paris • 01 56 98 24 40 • [email protected] • www.oxfamfrance.org