24.09.2015 seite 1 improving targeting of the poor and ensuring equity: emerging systems and...
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Improving Targeting of the Poor and Ensuring Equity: Emerging Systems and Approaches
Dr. Nishant Jain
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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 out-of-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: 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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Thailand
Country Examples
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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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columbia
Country Examples
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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 is not perfect
Public subsidies for health are one
of the best targeted in Colombia
Distribution of social subsidies by income group, 2003
Source: Lasso F. et al. Incidencia del Gasto Público. 2005.
2
93
33
50,647
33,2
62
17
72
11
0
10
20
30
40
50
60
70
80
90
100
40% poorest 40% richest
Public services
Housing subsidies
Education subsidies
Nutrition and child careprograms
Subsidized health insurance
Targeting proved essential to reduce
health inequality through public
subsidies
Source: Slide from Maria Luisa Escobar presentation “Colombia’s Health System Financing; Presented on November 13, 2008
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mexico
Country Examples
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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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india
Country Examples
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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 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