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Extending SocialProtection in Health

Developing Countries’ Experiences,Lessons Learnt and Recommendations

ISBN 978-3-88864-425-2

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International Labour OfficeDeutsche Gesellschaft für Technische Zusammenarbeit (GTZ) GmbH

World Health Organization

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

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

International Conference on Social Health Insurance in Developing Countries in Berlin in December

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.

SHI_Umschlag.pmd 29.03.2007, 14:451

Extending Social Protection in Health


© 2007 VAS – Verlag für Akademische Schriften

Cover-Design: VAS, Wielandstr. 10, 60318 Frankfurt am MainLayout: Jens Holst GTZ/versionProduction: VAS, Wielandstr. 10, 60318 Frankfurt am MainDistribution: Südost Verlags Service GmbH, Am Steinfeld 4,

94065 Waldkirchen

ISBN 978-3-88864-425-2

Bibliographic information published by the Deutsche Nationalbibliothek

The Deutsche Nationalbibliothek lists this publication in the Deutsche Nationalbibliografie; detailed bibliographic data areavailable in the Internet at http://dnb.d-nb.de.

This conference reader was compiled and edited by Jens Holst and Assia Brandrup-Lukanow on behalf of the GermanAgency 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: GuyCarrin, Ole Doetinchem, David Evans and Timothy Evans from the World Health Organization; Xenia Scheil-Adlung andMichael Cichon from the International Labour Office; Bernd Schramm, Rüdiger Krech, Nicola Wiebe, Katja Bender, JensHolst, 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 ManiqueAbayasekara, 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 DavidEvans.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 theDivision of European and International Health Policy of the Federal Ministry for Health and Social Security (BMGS) for theircontribution to the conference preparations; to Ms. Simone König and the team from the Foreign Office for their advice andsupport; 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 participantsfor their contributions to the conference and to the publication, and especially Mr. Anver Versi for his excellent work onlanguage editing.

Rights and Permissions

The findings, interpretations, and conclusions expressed here are those of the author(s) and do not necessarily reflect theviews 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 otherinformation shown on any map in this work do not imply on the part of the GTZ any judgment of the legal status of anyterritory 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 anymeans, electronic or mechanical, including photocopying, recording, or inclusion in any information storage and retrievalsystem, without the prior written permission of the GTZ. However, GTZ and the co-editing organisations encouragedissemination 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, pleasesend 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) GmbHDivision 43 – Health, Education, Social ProtectionDag Hammerskjöld Weg 1-565760 ESCHBORNGermanyTelephone: +49 6196 79-1445Internet: www.gtz.deE-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, 173174 and cover (6); H. Sachs, pp. 90 151,171 and cover (1)).

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 chal-lenge for every country and every government. Resource-poor nations are in a par-ticularly 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 ad-ditional strain on health care systems. Many countries, along with their development partners, have worked on different na-tional or regional models of sustainable health care financing. The International Con-ference on Social Health Insurance in Developing Countries, held in Berlin 5-7 De-cember 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-WHO-Consortium, 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 KrechHead of Section Social Protection


Table of contents

1. Setting the Scene 1.1. Social Health Insurance in Development Cooperation

Heidemarie Wieczorek-Zeul 1

1.2. ILO’s Decent Work Agenda: Goal for Fair Globalisation Assane Diop

3

1.3. Universal coverage: from concept to implementation Timothy Evans

7

1.4. The Role of Social Protection in Health in achieving the Millennium Develop-ment Goals Stefan Helming

13

1.5. Social health insurance: Economic development and poverty reduction David Fuentes-Montero

16

1.6. Poverty, health and social protection Julio Frenk, Felicia Knaul, Eduardo González-Pier, Mariana Barraza-Lloréns

22

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 Tang, Xiaoming Cheng, Ling Xu

32

2.2. From Universal Coverage of Healthcare in Thailand to SHI in China: What Les-sons can be drawn? Pongpisut Jongudomsuk

42

2.3. Equity and solidarity in social health insurance: Chances and risks of the Costa Rican way towards universal coverage Alberto Sáenz Pacheco, Jens Holst

45

2.4. Advances in Implementing Social Security: Lessons from Tunisia Hedi Achouri

52

2.5. Social health insurance in French-speaking sub-Saharan Africa: situation and current reform Oumar Ouattara, Werner Soors

57

2.6. The Inclusion of the Poor in a Social Health Insurance Framework: The Strate-gies Applied in Viet Nam Tran Van Tien

63

2.7. Insuring the Very Poor against Health Risks in the Philippines Claude Bodart, Matthew Jowett

71

2.8. Reaching the Poor in Ghana with National Health Insurance – An Experience from the Districts of the Eastern Region of Ghana Ebenezer Appiah-Denkyira, Alex Preker

73

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 Joseph Kutzin

87

3.2. Implications of Enrolment Criteria for Social Health Insurance William D. Savedoff, Jens Holst

96

3.3. The Importance of Social Dialogue in the Extension of Coverage Youssoufa Wade

100

3.4. The German perspective on the Importance of social dialogue in the extension of coverage: Lessons learnt from Senegal Ursula Engelen-Kefer

104

3.5. Working with Community-based Groups: The Experience of the Philippine Health Insurance Corporation Ruben John Basa

106

3.6. Health Coverage for All: Strategies and Choices for India Indrani Gupta

111

3.7. Universal Coverage in Thailand: the Respective Roles of Social Health Insurance and Tax-Based Financing Viroj Tangcharoensathien, Phusit Prakongsai, Walaiporn Patcharanarumol, Pongpisut Jongudomsuk

121

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 Xenia Scheil-Adlung,Guy Carrin, Johannes Jütting, Ke Xu

132

4.2. Social Health Insurance Development as an Integral Part of the National Health Policy: Recent Reform in the Indonesian Health Insurance System Adang Setiana

146

4.3. Achieving Universal Coverage through Social Health Insurance in Asia Dorsjuren Bayarsaikhan

155

4.4. Implementation of Health Insurance in Developing Countries: Experience from Selected Asian Countries Bong-min Yang, Jens Holst

158

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


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 develop-ing 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 medi-cal care. They are at increased risk. That is why the high levels of child and maternal mortal-ity 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 poor-est 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.

H. Wieczorek-Zeul: Social Health Insurance in Development Co-operation

2

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 in-surance. 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 eco-nomic 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 over-view 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 de-veloping 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.


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 en-hance 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 ac-cess 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 busi-ness 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 ad-vance 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 develop-ing 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 com-bating poverty. These include halving extreme poverty worldwide, reducing child mortality by

two-thirds, reducing maternal mortality by three-quarters, and combating the spread of HIV/ AIDS, malaria and other diseases. Progress has been made, and in many countries, social health insur-ance is providing the much-needed safety net. But we also know that for many developing countries achieving the MDGs remains a distant goal. There is much to be done. This Conference is an important opportunity to examine how social health insurance can contri-bute towards paving the way - if not ac-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 for-midable challenge for developing coun-tries is providing universal access to basic health care, which is of good qual-ity and, at the same time, affordable. But as the vast majority of the population in many developing countries, including in

A New York Times article entitled "Neglected Poor in Africa Make Their Own Safety Nets", which was published on August 28th of 2005, recounts the story of Nogaye Sow, a 40-year-old grandmother, who struggles daily as a street vendor in Dakar. She recently became a member of the community health insurance plan, which means that when she, her seven children, her granddaughter and two other relatives become ill, they receive free consultations at a clinic down the road, cut-rate medicine and peace of mind. The chances are lower now that a bout of illness will bring the family to total ruin. Ms. Sow struggles to pay the 200 francs a month - less than half a dollar - that she must come up with for 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 pre-mium 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.

2 Executive Director, International Labour Office, Geneva, [email protected].

A. Diop: Decent Work: Goal for Fair Globalisation

4

formal economy wage earners and self-employed persons, have no social protection whatso-ever, a major focus must be on the extension of social protection.Workers in small- and mi-cro-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 pro-tection schemes.

Of course, there is no universal approach to expanding social security coverage. Each coun-try 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 govern-ance 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 pro-tection could aggravate poverty. They realise that poverty is expensive as it impedes devel-opment, 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 manage-ment 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 participa-tion 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 rea-son is the lack of social security as it is provided in developed countries and guarantees fi-nancial 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 develop-ment. 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 cre-ate 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 so-cial security systems and extend coverage in health. Other countries will need a more plural-


5

istic approach, devising complementary measures that embrace those not covered. This in-cludes working closely with community schemes and groups of workers that have estab-lished 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 reco-gnised that different mech-anisms 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 poo-ling) and for social health insu-rance 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 ‘natu-ral’ contribution systems linked to payrolls and the scope for workers to participate in dia-logue and governance mechanisms through trade unions contributes to a sense of owner-ship 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 re-conceptualise 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 re-percussions 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 ex-cluded.

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 interna-tional debate about health and protection is the implications of an ageing population. In many

A. Diop: Decent Work: Goal for Fair Globalisation

6

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 grand-children 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 contrib-uted to capacity building, exchange of experience and research in order to support the de-velopment of social health insurance. Our goal is to provide countries with a crucial contribu-tion 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 tripar-tite 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 connec-tions 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 pro-vided an excellent forum to share experiences of how different interventions are improving the lives of many.


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 pro-vided 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 reduc-ing 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 rehabili-tative 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 ser-vices is shared by all and not borne by each person who is sick; and to use these contribu-tions to provide or purchase effective health interventions. The way in which countries com-bine these functions determines the efficiency and equity of their health-financing systems.

Health financing for universal coverage A great deal is spent on health globally, but this amount is unevenly dis-tributed and shows a high reliance on out-of-pocket payments in many coun-tries. Financial contribu-tions to the health system are raised in most coun-tries from households and businesses, although external flows such as official assistance are an important source in many settings. Recent increa-ses in the availability of external funding for health have the potential to stimu

Figure 1.3.1: In 2003, the World spent $ 4.4 trillion on health (International dollars)

Tax funded 32%

OtherPrivate 4%

Social Insurance 24%

Private Insurance 17%

Out of pocket 23% Source: National Health Accounts

EIP/HSF/CEP, World Health Organization

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 spe-cific programmes, more or less independent of efforts under way to build long-term sustain-able 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

Figure 1.3.2: Inequality in health spending and income by WHO Region* 2003 (international dollars)

0

10

20

30

40

50

60

70

80

AFR AMR* EMR EUR* SEAR WPR* OECD

%

PopulationGDPHealth expenditure

* AMR, EUR and WPR do not contain OECD countriesSource: National Health Accounts, EIP/HSF/CEP, World Health Organization

the broader objective of developing sustainable financing systems and institutions and mov-ing towards universal coverage.

Although various organisational options exist for achieving universal coverage, a key com-mon 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 pre-payment 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. So-cial health insurance may be managed in various ways, including through a single govern-ment 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 cov-ered 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 pro-tection: 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


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 Figure 1.3.3: Impact of health expenditure

- 30 60 90

WPR

AMR

SEA

EUR

AFR

EMR

Number of people (million)

impoverishmentcatastrophic

to care and fails to pro-vide protection against the financial risks associ-ated with high individual health-care costs. It is es-timated that as many as 178 million people could suffer financial catastro-phe as a result of out-of-pocket health payments each year, and that 104 million could be forced in-to poverty simply becau-se of health payments.4

The tendency of govern-ments to take the lead in ensuring that funds are raised and pooled to pro-

vide 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 appropri-ate 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 ser-vices that are required, at a high level of quality.

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 cover-age 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 instan-ce, both Japan and the United Kingdom took 36 years bet-ween the first law related to universal health protection and the final law to implement it. Ko-rea, 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 coun-

4 Preliminary global estimates on the population subjected to catastrophic expenditure and impoverishment. WHO, November 2004.


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 con-tinue 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 coun-tries, a variable part of the population is entitled to health care benefits financed by tax reve-nues 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.

3 24

13

7

10

2

4

6

8

10

12

14

Num

ber o

f cou

ntrie

s

40-50% 50-60% 60-70% 70-80% 80-90% > 90%

Prepayment ratio

Figure 1.3.4: Prepayment in OECD countries

The transition to universal coverage may take several years, even several decades. A num-ber of factors determine the speed of transition. Essential elements are the relative accep-tance of the value and concept of solidarity in society, the effectiveness of government stew-ardship 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 eco-nomic 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 sys-tem to assess incomes and draw contributions from households (i.e. to collect taxes or insur-ance 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. In-deed, 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 co-payments 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.


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 pro-viders – 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 na-ture 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 politi-cal 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 em-ployment; 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 num-bers to undertake all the financing functions.

Ultimately, a country’s decision on how to modify its health-fi-nancing system should be gui-ded by decisions on collection, pooling, and purchasing, and the associated organisational arran-gements 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 stew-ardship role in order to steer implementation while maintaining a certain degree of pragma-tism, 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 pre-vent households as well as the system as such from serious financial constraints and col-


12

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 poli-cies 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 imple-menting 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 in-fluence 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. Interna-tional 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 Re-source 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 Soli-darity. 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 Perform-ance. 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, Ge-neva (http://www.who.int/whr/2006/whr06_en.pdf). Xu, Ke (2005). Distribution of health payments and catastrophic expenditures Methodology. Discus-sion Paper No. 2 – 2005, Department "Health System Financing" (HSF), Cluster "Evidence and Infor-mation for Policy" (EIP), WHO, Geneva (http://www.who.int/about/iag2005/distribution_of_health_pay_dp_05_2.pdf).


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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 de-veloping 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 par-ticular 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 safe-guarded 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 con-ference 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 correspon-ding vaccine. But there is some-thing else which not so many people know of: he was also very concerned about the social causes of tuberculosis and strongly supported the introduc-tion 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].

St. Helming: The Role of Social Protection in Health Towards Achieving the MDG

14

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 popu-lation groups have some say in the framing of necessary reforms, and in their implementa-tion. 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 conse-quence, 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 sell-ing 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 coun-tries should always be gender-specific. This would bring considerably more progress towards Millennium Development Goals 4 and 5, reducing child and maternal mortality by three-quarters 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 dis-eases, 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 cover-age 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 struc-tures tend to be unstable and are not sustainably financed. As a result of inadequate financ-ing, 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


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 dev-elop within the clearly defined framework.

Promoting international technical co-operation from a single source – the GTZ-WHO-ILO 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 Halv-ing 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).

D. Fuentes M.: Social health insurance: Economic development and poverty reduction

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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 popula-tion are younger than 15, and 5.65 % older than 64 years (WHO 2006). The official unem-ployment 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 pri-mary 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 agri-cultural sector which was the driver of economic and social development. The agrarian sec-tor 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 integra-tion 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 condi-tions 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 Elec-tions Court and the establishment of the Civil Service in 1953 are examples of political insti-tutionalisation 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).


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 vulner-ability 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. Be-tween 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 Ri-can Government obtained from international organisations. Through several loans and dona-tions, the country obtained the resources required for fulfilling its external commitments and maintain its balance of payments equilibrium. The measures applied from 1982 were inti-mately 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 dec-ades ago were not affected – unlike the case in other places and they are in place until to-day.

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 nego-tiations 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 2.7

Social security expenditure on health as % of general government health expenditure 88.6

Out-of-pocket expenditure as percentage of private expenditure on health 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.


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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 trav-elling 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 estab-lished in 1914 that would beco-me 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 Universi-dad Autónoma de Centro Améri-ca 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 uni-versity education.

In 1958, the Fundamental Education Law was enacted, and starting from the analyses car-ried out in 1967 to identify the problems of the educational sector, the National Plan of Edu-cational 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 socio-economic 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 un-changed 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 cov-erage from preschool to higher education.


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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, compli-cated by an unfavourable fiscal situation. In Costa Rica, this period ended in the promulga-tion 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 liberal-ism. The new model tried to reconcile elements of the previous model with state intervention-ism and the social doctrine of the Catholic Church. As a result of the Calderón Guardia ad-ministration, 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 be-came core pillars of the current social security and protection system.

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 de-velopment of a Welfare State model. As a very first statement of politics, a series of autono-

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) 17,01

Gross mortality rate (per 1000 inhabitants) 3,75

Vaccination coverage for children Measles (1 year) 88% Poliomyelitis (younger than 1 year) 90%

Rate of Diseases with mandatory reporting HIV/AIDS (per 100.000 inhabitants) 4,6 Measles (per 100.000 inhabitants) 0,0 Hepatitis (per 100.000 inhabitants) 22,1 Diarrhoea (per 100.000 inhabitants) (NOT SO GOOD) 2813,6

Coverage of Labour Risks Insurance 71.5%

Consultations to Health Insurance Services Emergency + outpatient consultations (per 100 inhab.) 3,7 Specialised outpatient care (per 100 inhabitants) 63,7 Total Consultations to Health Insurance Services 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

Source: CCSS 2006

In 1948, the wining side of the civil war took over power and constituted the provisional Government of the Eighteen Months pre-sided by José Figueres. The interim legislation ex-panded the Constitution of 1949 and a series of inter-ventionist economic meas-ures 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 wor-kers and part of public employees; to transform the Mixed Committee of Minimum Wages into the nationwide National Coun-cil of Wages (CNS); and to establish a charity tax.

Although the social demo cratic constitutional project


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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 Con-gress 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 cov-erage 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 Se-curity 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 compul-sory 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 im-plemented 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 re-sources 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 Se-curity Board, and 10.5 % to the Fund for Social Development and Family Provisions (FODE-SAF). 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 Assis-tance, the Board for Social Protection in San José, the National Authority for Childhood, and others.


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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, educa-tion, social mobility and poverty reduction. Therefore, the country has oriented its limited re-sources 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 micro-processor manufacturing or specialised software development. Headquarter offices estab-lished 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://www-wds.worldbank.org/external/default/WDSContentServer/IW3P/IB/2003/06/18/000112742_20030618174647/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,,contentMDK: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

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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 there-fore 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 secu-rity, 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 operat-ing 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, im-proving 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 im-portant 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 ill-nesses; 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 “pov-

8 Minister of Health of Mexico 2000-2006, [email protected]. 9 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].


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erty traps”. Poverty traps that are created by an adverse health shock not only expose nu-merous people to poverty, but also exclude them from contributing productively to the econ-omy. 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 mecha-nism that individuals can use to protect themselves from pos-sible adverse health events. Individuals can protect themsel-ves by acquiring private medi-cal insurance or accessing sta-te-sponsored insurance. Never-theless, access to formal priva-te insurance mechanisms is limited by insufficient informa-tion as well as by practices in which certain private providers of insurance get the most profit-able part of the market. And access to state-sponsored in-surance is often restricted to workers in the so-called formal sectors of the economy.

When people cannot insure themselves in the formal mar-ket, they can resort to informal mechanisms. Thus, when ex-posed 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 ex-penses 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 appropri-ate 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


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cost. Health insurance is also an instrument to subsidise health care financing between in-come 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 health-related 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, non-salaried 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 over-reliance 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 Sys-tem 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 Insur-ance 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 inclu-sion, 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 guaran-teeing 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 ‘democra-tisation of health’, meaning the effort to extend democracy to social as well as political and


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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 finan-cial 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 possi-

ble 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 in-cluding Brazil, Chile, Colombia and Costa Rica. Third, the distribution of public funds be-tween population groups and states was also inefficient and inequitable. Although the unin-sured 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 mecha-

nism to increase public expenditures in health so as to correct existing disequilibria;


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b. Stimulate greater allocative efficiency by protecting expenditure for public health interven-tions 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 sub-sidies 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 compo-nents: the stewardship role of the Ministry of Health; community health services; non-catastrophic, 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 exclu-sively 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 pur-poses, personal health services are divided between an essential package of primary and secondary interventions in ambulatory settings and general hospitals, and a package of high-cost tertiary-level care financed through the Fund for Protection Against Catastrophic Expen-ditures.

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 priority-setting 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 in-jury, long-term rehabilitation, HIV/AIDS, neonatal intensive care, organ transplants and dialy-sis. The criteria to select specific interventions are based on the burden of disease, cost-effectiveness, 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 unin-sured families; IMSS for private sector workers and their families; ISSSTE for public-sector workers and their families.


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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 solidar-ity within each population group and redistribution between states. For IMSS, this is the pri-vate 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 in-creased 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 re-mainder 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 affilia-tion, 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 provid-ers. Funding for the states will be largely determined by affiliation to the PHI. Thus, the re-form 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 effi-ciency of health service delivery. In order to convince families to enrol the states must pro-


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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 clin-ics, 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 cov-erage 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 con-tribute financially. Based on data from the affiliation rosters of the Ministry of Health, over 90 % beneficiaries are from the poor-est quintile of the income distri-bution. Further, an important res-ult in promoting equity is that more than 70 % of the affiliated families are female-headed. This reflects the over-representation of single mothers among non-salaried 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 finan-cially.

Additional public funding is required for the reform to achieve universal coverage. Initial esti-mates 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, pre-reform 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 unin-sured. In 2001, 33.3 % of all public funds for health were allocated to the uninsured popula-tion 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


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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 govern-ment 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 con-vinced 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 de-mand side, while also strengthening and making more competitive the supply side, consti-tutes 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 improv-ing drug procurement. This work is part of a national programme launched in 2001 to im-prove technical quality and interpersonal responsiveness throughout the system. The pro-gram 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 sugges-tions.

Evidence and information are important tools for successfully meeting the challenges of im-plementation. Rigorous analysis has been part of the reform since the design phase and a comprehensive regime of monitoring and evaluation accompanies the implementation proc-ess. 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 institu-tional improvement as they are used for the budgeting formula for states and as public refer-ence 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 agen-cies 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 fund-ing 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 cost-effectiveness and social acceptability. The allocation of funds to the states is based on a re-distributive formula to transform budgeting from an inertial, bureaucratic supply-side logic to a performance-based, demand-side subsidy.


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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 cli-mate. 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 coun-tries. 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 simul-taneously 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 delibera-tion 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 meth-ods (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 stimulat-ing a process of shared learning among countries that face the common challenge of improv-ing health through equity, quality and financial protection.

References Barraza-Lloréns, Mariana; Bertozzi, Stefano; González-Pier, Eduardo; Gutiérrez, Juan Pablo (2002). Addressing Inequity in Health and Health Care in Mexico. Health Affairs 21 (3), pp. 47-56 (http://content.healthaffairs.org/cgi/reprint/21/3/47). Commission on Macroeconomics and Health (CMH) (2001). Macroeconomics and Health: Investing in Health for Economic Development, Report of the Commission on Macroeconomics and Health, WHO, Gene-va (http://www3.who.int/whosis/cmh/cmh_report/report.cfm?path=whosis,cmh,cmh_report&language=english). Frenk, Julio; Lozano, R; González-Block, Miguel et al. (eds.) (1994). Economía y Salud: Propuestas


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para el avance del sistema de salud en México; Informe final. FUNSALUD, Mexico City (http://www.funsalud.org.mx/casesalud/economia/economia%20y%20salud.htm). Frenk, Julio; Sepúlveda, Jaime, Gómez-Dantés, Octavio, Knaul, Felicia (2003). Evidence-based Health Policy: Three Generations of Reform in Mexico. Lancet 362 (9396): 1667–1671. Frenk, Julio; Knaul, Felicia; Gómez, Octavio (2004). Closing the Relevance-Excellence Gap in Health Research: The Use of Evidence in Mexican Health Reform. In: Matlin, Stephen (ed.). Global Forum Update on Research for Health 2005. Pro-Brook Publishing, London (http://www.globalforumhealth.org/filesupld/global_update1/GlobalUpdate3.pdf). Frenk, Julio et al. (2004). Fair Financing and Universal Social Protection: The Structural Reform of the Mexican Health System. Working Paper Ministry of Health, Mexico City. Frenk, Julio (2006). Bridging the divide: global lessons from evidence-based health policy in Mexico. Lancet 368 (9539), pp. 954-961. Frenk, Julio, Horton, Richard (2006). Evidence for health-system reform: a call to action. Lancet 368 (9529), pp. 3-4. Knaul, Felicia; Frenk, Julio (2005). Health Insurance in Mexico: Achieving Universal Coverage through Structural Reform. Health Affairs 24 (6): 1467-1476 (http://content.healthaffairs.org/cgi/reprint/24/6/1467). Knaul, Felicia; (2005). Research Matters Discussion Note/Policy Brief: The Role of Evidence on Fi-nancial Protection in the Mexican Health Reform of 2003. Mimeo/Draft for comments: policy note summarizing a longer paper being prepared for the IDRC. Knaul, Felicia; et al. (2005). Research Matters Background Paper: The Role of Evidence on Financial Protection in the Mexican Health Reform of 2003. Mimeo/Draft for comments. Knaul, Felicia; Arreola-Ornelas, Héctor; Méndez-Carniado, Oscar; Miranda-Muñoz, Martha (2005). Preventing Impoverishment, Promoting Equity and Protecting Households From Financial Crisis: Uni-versal Health Insurance through institutional Reform in Mexico. Mimeo: draft proposal for submission at the Global Development Network (http://ctool.gdnet.org/conf_docs/Knaul_Paper_Parallel1_Session3.pdf). Mexican Commission on Macroeconomics and Health (MCMH) (2004). Investing in Health for Eco-nomic Development, Executive Summary. Universidad de las Américas, Puebla. Ministry of Health (2005). Comisión Nacional de Protección Social en Salud: Informe de resultados, Segundo semestre de 2005. Ministry of Health, Mexico City (http://www.seguro-popular.gob.mx/files/1.Informe2osemestre2005.pdf) Ministry of Health (2005). Salud: México 2004: Información para la rendición de cuentas. Ministry of Health, Mexico City (http://www.salud.gob.mx/unidades/evaluacion/publicaciones/publicaciones.htm) Ministry of Health (2004). Salud: México 2003: Información para la rendición de cuentas. Ministry of Health, Mexico City (http://www.salud.gob.mx/unidades/evaluacion/publicaciones/publicaciones.htm) Ministry of Health (2003). Salud: México 2002: Información para la rendición de cuentas. Ministry of Health, Mexico City (http://www.salud.gob.mx/unidades/evaluacion/publicaciones/publicaciones.htm). Ministry of Health (2002). Salud: México 2001: Información para la rendición de cuentas. Ministry of Health, Mexico City (http://www.salud.gob.mx/unidades/evaluacion/publicaciones/publicaciones.htm). Ministry of Health (2001). Programa Nacional de Salud 2001–2006: La democratización de la salud en México, hacia un sistema universal de salud. Ministry of Health, Mexico City (http://www.salud.gob.mx/unidades/evaluacion/publicaciones/publicaciones.htm). Organisation for Economic Cooperation and Development (OECD) (2005). Reviews of Health Sys-tems: Mexico. OECD, Paris. Executive Summary provided at background material prior to the confer-ence: check conference website, permission granted by the OECD (http://www1.oecd.org/scripts/publications/bookshop/redirect.asp?pub=812005081P1). Torres, Ana (2001). Análisis del gasto de bolsillo en salud en México. Tesis de licenciatura (doctorial thesis), Instituto Tecnológico Autónomo de México (ITAM), Mexico City. World Health Organization (2000). Health Systems: Improving Performance. World Health Report 2000, WHO, Geneva (http://www.who.int/whr/2000/en/index.html).

Sh. Tang, X. Cheng, L. Xu: Urban Social Health Insurance in China

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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 Econ-omy 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 ur-ban 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 in-creased 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 un-changed in 2003. The decrease in urban health insurance coverage in the 1990s can be at-tributed 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 build-ing 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 estab-lished 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 experi-ences with reforming urban social health insurance schemes, identify main achievements and problems of the reformed urban social health insurance schemes, and discuss chal-lenges 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]. 13 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).


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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 found-ing 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 enter-prises and factories allocated around 11-14 % of the gross salaries/wages from their bene-fit/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 profit-able enterprises, on the other hand, received superfluous services from their service provid-ers. 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 enter-prises 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, afford-able 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 ar-rangements 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 ur-ban employees introduced in the late 1990s.


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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, Sip-ing, 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 de-velop 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 be-gan 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 co-ordinating funds (Box 2.1.1).

The personal accounts and co-payment mechanisms were expected to encourage modera-tion 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 dis-cussed 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 unwill-ingness of managers to join.

While Zhengjiang and Jiujiang were experimenting with new health insurance schemes un-der 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 de-veloped 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.


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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 employ-ees’ 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 medi-cal care. The amount deposited into their personal accounts depended on their wage/salary and age. Approximately 5-7 % of the wage/salary was deposited peri-odically 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 ac-count, medical care was paid out-of-pocket until the payments reached 5 % of an-nual 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 medi-cal 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 co-payment 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 La-bour. 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 per-centage 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 in-surance 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.


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Sources of finance Official national regulations on BMI development stipulate that all employers have to contrib-ute at least 6 % of the wages/salaries paid to their employees to the BMI fund, while employ-ees 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 municipali-ties, 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 pool-ing 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 in-dividual saving account, while the employer’s contribution is split between the individual sav-ing 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 in-dividual 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 emer-gency services

Eligible for the use of the fund

Eligible for the use of the fund in some cities under certain conditions

Special treatments at outpatient department

Eligible for the use of the fund

Eligible for the use of the fund in some cities under certain conditions

Inpatient services Eligible for the use of the fund in some cities

Eligible for the use of the fund, but 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 ser-vices or co-insurance payment for inpatient services, or buy drugs from designated pharma-cies.


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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 pro-vider payment was fee-for-service (FFS), however an increasing number of BMI fund man-agement 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 mea-sures to control the rapid increa-se of medical costs and expendi-ture. 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 out-of-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 ac-tively 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 prob-lems 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 individ-ual 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 ill-ness are now cross-subsidised by those organisations who have a younger working force.


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 reimburse-ment 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 sys-tem. In the meanwhile, profitable enterprises are making higher wage-related financial con-tributions 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 negoti-ate 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 expendi-ture. 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, pri-vate 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

2003 1998 Insurance status Income

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

SHI

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

No insurance

Very high 1902 19.91 3586 40.37 Source: National household health surveys conducted by the Centre for Health Statistics and Informa-tion, MoH, China.

governments should take a major responsibility in tackling the financial difficulties of money-losing 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


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 them-selves 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 % Non-use of inpatient service rate %

Income level

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 refe-reed 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 pool-ing 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. About two thirds of the patients re-ferred to inpatient treatment without being hospitalised in 2002 came from the very low in-come group, while only one out of five referred patients from the high income group was not hospitalised. Apparently, the applied cost controlling measures (i.e. deductible and co-


40

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 beneficiar-ies do not need to be referred by their GPs or family physicians to a specialist or to an outpa-tient 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 contribution-free insured retirees with greater health care needs than the active and contributing employ-ees has risen significantly. It is vital for the central and local governments in China to mobi-lise 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 cer-tain 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 en-terprises/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 sus-tainable 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


41

the BMI managers in developing adequate cost-containment strategies in service purchas-ing. 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 bene-ficiaries 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 devel-oped 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/equip-ment) is also vitally important to ensure that the vast majority of Chinese living in urban set-tings 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, Mal-colm. 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 out-of-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). Fi-nancing 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/502734-1129734318233/China-Inequity-Health-Access.pdf). Wang, Y.Q.; Wang, J.H. (1999). Practice and Thoughts on Zhengjiang Health Insurance Reform. Chi-nese Journal of Health Service Administration 12, pp. 629-630 (in Chinese).

P. Jongudomsuk: From Universal Coverage in Thailand to SHI in China: What Lessons can be drawn?

42

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 conclu-sions 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 indica-tors of the two countries in focus, China and Thailand. At the same time, some critical differ-ences 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.

Table 2.2.1: Some Basic Indicators in 2003

China Thailand

Total population in million 1,311 62.8

GDP in US$ 1.6 trillion 143 billion

GNI/capita in US$ 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

Private health exp. as % of THE (2002) 66.3 30.3

Government expenditure on health (% total government exp.) in 2002 10 17.1

Health insurance coverage as % of total population (year) 22 (2003) 96 (2005)

Number of main public health insurance schemes

2 (SHI, CMS)

3 (SSS, CSMBS, UCS)

Social security exp. on health (% total government exp on health) in 2002 50.8 21.8

A crucial difference bet-ween the two countries is the higher share of GDP that China is spending on health, including a high proportion of private ex-penditure, while Thailand had higher government health expenditures (17 % compared to 10 % in China).

Thailand has already achieved universal cover-age in health through the three most important pub-lic health insurance sche-mes. However, the social security expenditure on health accounted only for 21.8 % of total govern-ment expenditure on health. This is because the biggest scheme in Thailand, the 30 Baht or UC Scheme, is financed by general tax revenue.

Table 2.2.2 on the follow-ing page provides an overview on some coun-try- and scheme-specific facts and characteristics

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)

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 fi-

17 National Health Security Office (NHSO), Thailand, [email protected].


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 facili-ties.

Table 2.2.2: Social policy and protection in China and Thailand

China (SHI) Thailand (SSS) Thailand (UC)

Driving forces 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 (em-

ployer+ employee+ gov-ernment 1.5 % each

General tax revenue

Risk pooling City National National

Financing agency SIB (local government) SSO NHSO

Cost sharing Co-payment & deductible(approx. 40 % of med.

expenditure)

None Minimal co-payment (0.75US$/visit)

Provider payment A fixed budget for the provision of services

(global budget?)

Capitation Capitation for OP & PP and case based pay-

ment (DRG)

Choice of provider Any of contracted provid-ers

Contracted hospital and its network both public &

private

Contracted primary care unit both public &

private

Per capita budget/ expenditure 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 so-cial protection reform comprises some outstanding systemic approaches that make the Chi-nese experiences relevant for many other countries. The four wing elements might be char-acterised 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 chang-ing 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 in-creasing 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 im-plemented 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 sys-tem like Thailand, we are facing the problem of limited system capacity, including the ade-quate number of competent and trained human resources to maintain and improve the sys-tem. 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

P. Jongudomsuk: From Universal Coverage in Thailand to SHI in China: What Lessons can be drawn?

44

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, finan-cial protection should focus on catastrophic health expenditures to prevent impoverishment of households due to medical spending. In many cases this demands reconsidering cover-age 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. Effec-tive socio-political interventions should rather focus on the supply side and on provider pay-ment mechanisms that send positive signal towards the efficient and equitable use of re-sources. 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 govern-ment 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 contribu-tion rate of employer and employees and to make the system more attractive for stake-holders; sharing the risk among cities (national risk pooling) by establishing risk equalisation mechanisms and standardising provider payment and fee schedules for referral cases be-yond 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 learn-ing 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 Fi-nancing Schemes in Thailand: A Review of Country Experience. Working paper series no. 2004-9, World Bank, Washington DC (http://www-wds.worldbank.org/external/default/WDSContentServer/IW3P/IB/2004/12/27/000090341_20041227095123/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/).


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 coun-

Costa Rica Territory: 51,100 km2 Population: 4.211.692 Inhabitants/ km2: 77 Immigrants: 7,8 % of total populationIndigenous: 1,7 % of total population

try’s biodiversity, national parks and protected ar-eas representing about one quarter of the national territory. But Costa Rica is also a shining example for successful social policy that has achieved very important results in social development. The aboli-tion of the army in 1948 has permitted the country to invest in health and education to pursue the peo-ple’s social progress and the reduction of poverty that has remained around 20 % during the last few years with approximately 5 % of the population being extremely poor. With regard to social expenditure in the region, the last report of the Eco-nomic 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 Gini-Coefficient 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 Na-tions 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) Fertility rate General mortality rate Infant mortality rate (1000 L.B.) Gross National Product (per capita)

0.834 4

47 79.0

76.52 81.54 21.4 2.5 4.0

9.25 $ 4028

Unemployment rate (%) Inflation rate Minimum wage Poor households Investment in Health (% of GNP)

per capita Investment in Soc. Sec. as % of

GNP of Public Expenditure of Social Expenditure

6.5 10.2

$ 226 21.1 %

9.5 € 185

8 %

36 % 57 %

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

0% 20% 40% 60% 80% 100%

Cuba

Venezuela

Dom. Republic

Costa Rica

Brazil

Colombia

Panama

Mexico

Latin America

Paraguay

El Salvador

Nicaragua

Peru

Ecuador

Honduras

Bolivia

Guatemala

Table 2.5.2: Years of Potential Life Lost in Costa Rica 1980 - 2000

Source: Bortman 2002, pp. 14ff. *: Group of districts (cantons) according to social development index. GII: Gradi-ent 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 Devel-opment Index (SDI) as a synthesis of seven indicators related to the education infrastructure

1980 1985 1990 1995 2000

Total 1,070.5 911.5 773.4 729.6 625.4

1st group* 996.9 778.4 627.4 624.5 605.5

2nd group* 993.0 876.0 733.9 724.3 632.2

3rd group* 1045.7 875.8 750.2 676.0 574.5

4th group* 1132.5 986.7 824.7 744.5 649.7

5th 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


47

Figure 2.5.2: Regional distribution according to the SDI in Costa Rica

N

5th Group 4th Group 3rd Group 2nd Group 1st Group

Source: Bortman 2002, p. 11

and special education programs, infant mortal-ity, child mortality im-pact, growth retardation, electricity consumption, and single mothers. Ac-cording to these criteria, the Central American country started to as-sess and catalogue the communities called can-tons (cantones) all over the country. According to the SDI, the cantons were ranked in five groups reflecting the living conditions and standards of the popula-tion.

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 relation-ship between life years

Figure 2.5.3: Population share according to socio-economic standard of living conditions

3rd group21%

4th group18%

5th group14%

2nd group32%

1st group15%

Source: Bortman 2002, p. 10

lost and social groups remained evi-dent since this indicator was clearly lower in the better-off cantons com-pared 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 dif-ferent social groups showed a ten-dency towards flattening (Bortman 2002, p. 14f).

One may think that it is easier to im-plement widespread health services under the responsibility of Social Se-curity in countries where public ex-penditure in health represents the lar-ger 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 in-troduction 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 priva-tise 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

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

Reduction of non-institutional deliveries

Change of Mater-nal mortality

1st group* 36,6 % 65 % - 48,8 %

2nd group* 49,8 % 83 % - 31,1 %

3rd group* 44,7 % 79 % - 28,5 %

4th group* 43,6 % 77 % + 69,5 %

5th group* 46,2 % 85 % + 184,3 %

Total 44,5 % + 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 ur-ban low-wage workers. Health insurance coverage has progressively been extended to al-most 90 % of the population. A series of political steps were needed in order to make palpa-ble 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 cover-

Relevant steps towards universality

• 1945 Family benefits • 1959 Pensioners, contributory • 1974 Pensioners, non contributory • 1975 Voluntary insurance • 1984 Self employed • 1985 Collective insurance agreements • 2000 Law for the protection of workers

age. Access to Primary Health care and attention to emergencies is universal. About 96 % of deliveries are attended by specialised personnel. Access to good quality medicines is universal and ex-ceeds the WHO recommendations for a basic drug list. This list in our system in-cludes 460 active substances in 608 presentations. Costa Ricans have access to pharmaceutical products for all types of pathologies, including antiretroviral 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 wide-spread network of services that has developed in over 60 years of performance. This net-


49

work is organised by hierarchical levels of health care in regions, areas and sectors in which the whole country is divided and covered.

Number of Public Health Care Facilities at the 1st, 2nd and 3rd Health Care Level 7 Regional Managing Offices 29 Hospitals 104 Health Areas 893 Primary Care Facilities 1800 Temporary Health Care De-

livery Facilities 7 Mobil Health Care Facilities 2837 Health Care Facilities

In primary health care, a very strong empha-sis has been placed on the Basic Integrated Health Teams (Equipos de Salud Básicos In-tegrados). These teams comprise a medical doctor, a nurse, a pharmaceutical and a pri-mary health technician. They provide integra-ted health services to a population of 4,500 to 5,000 people. For pharmacy, laboratory, ima-ging, dental care and administrative services they depend on a Health Area that supports several basic teams. An important comple-ment to the network has been the inclusion of 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

• Aging population • Changes in population distribution • Strong immigration • Increase in non-traditional family

settings • Changes in nupciality patterns • Longevity • Reduction in family size • Reduction in dependency

urbanisation change the epidemiological pat-terns and thus tend to increase costs. A well known phenomenon is the change from acute infectious and environment-related diseases to chronic and high cost illnesses like cardiovascu-lar diseases and cancer.

Rising operational costs are especially attribut-able to increasing expenditures for pharmaceu-tical products and medical supplies, the intro-duction of new technologies and rising salaries. In the case of drugs, the Costa Rican Social Insurance Fund has been able to continue the 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 impor-tant population segment currently excluded from social protection. The indigenous population accounts for 1.7 % of Costa Rican citizens and represent another group with inequitable ac-cess 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.


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for those who cannot afford them. Immigration in a country with a low fertility rate has a posi-tive 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 le-galise 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 phenome-non 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 ac-tive 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 care-fully 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 contri-bution 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 coun-tries 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 ap-plied 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.


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 Sec-retary General, who said: “I believe that Social Security is the only way to guarantee the so-cial 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 consoli-dated 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/2carrin-james.pdf). Economic Commission for Latin America and the Caribbean (2005). Social Panorama of Latin America 2005. ECLAC/CEPAL, Santiago (http://www.eclac.cl/cgi-bin/getProd.asp?xml=/publicaciones/xml/4/24054/P24054.xml&xsl=/dds/tpl-i/p9f.xsl&base=/dds/tpl/top-bottom.xsl). Miranda-Gutierrez, Guido (2003). La seguridad socialy el desarrollo en Costa Rica. 3rd Edition, EU-NED, 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, San-tiago (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

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Private Insurance

Mutual profes sional bodies

Free of charges forsocio-professionals

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 em-ployees, covering the same package as the public insurance.

Health care is free of charge for the poorest population as well as for some socio-professio-nal 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 diffi-culties regarding efficiency, quality, equity, and satisfaction of stakeholders and users. In-creasing inequities were appearing between people enrolled in the two social health insurance Figure 2.6.1: Health insurance coverage: Current Situation

Source: Estimations of the Ministry of Public Health

institutions. These invol-ved the burden of contri-butions on employers and employees; and at the same time, in terms of benefits, direct care delivery in the MoH facili-ties for CNSS beneficiar-ies and limited access to the private providers for some of the CNRPS’s in-sured. On the other hand, among the benefi-ciaries of each social se-curity institution contribu-tion payment was inequi-table between the eco-nomically active and 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 organisa-tions 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].


53

A very small share of the population (1 % or less) is not covered by the social health insur-ance 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 insur-ance 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”23 Public providers of MoH The CNSS’s polyclinics

The particular conventions24 Public & Private Providers CNRPS

Mandatory Regime25

Option 1- The refund regime26 Public & Private Providers

Option 2 - The “health care booklet”23 Public providers of MoH

Optional Regime (Refund)27 Public & Private Providers

The particular conventions24 Public & Private Providers

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 in-creasing 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 pro-vider 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 ex-pansion 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 finan-cial 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. 24 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 provid-ers 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 manda-tory 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.


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Figure 2.6.2: Health Financing in Tunisia

0%

10%

20%

30%

40%

50%

60%

1985 1990 1995 2002

Government Social Security 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, epi-demiological, 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 complemen-tary 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 de-livery, mechanisms of cost containment, tariffs and provider payment methods.

In more specific terms, the Tunisian reform process is battling with a series of technical chal-lenges 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 Nation-ale 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 re-sources 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 regard-ing the necessary procedures and technical infrastructure (computerisation, data collection


55

and processing, human resources training, etc.), to define tariffs and modes of provider pay-ment 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 appro-priate information system (CNAM and providers) will be required; this must include the defini-tion 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 profes-sional 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 accom-plish 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 informa-tion 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 manage-ment capacities and the public-private mix of the healthcare supply and financing.

From 1996 until the end of 2005, several commissions have discussed the strategic ap-proaches 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 ne-gotiation 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 fi-nancing 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 ser-vices 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 im-plemented, 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

higher proximity of insured people and providers for delivering benefits in time. Additional technical and ad-ministrative 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 provi-ders 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 dému-nie 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 so-ins. Tunis. Achouri, Hédi; Khaled, M. Kheireddine (2001). Assurance maladie: les défis de la réforme. Communi-cation 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 Tuni-sie 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-ilo-mirror.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. Tu-nis. 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 sec-teur 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. Ri-yadh, 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 Re-form (PHR). Bethesda (http://www.phrplus.org/Pubs/pps1f.pdf).


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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 alterna-tive 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 ineq-uity – 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, Mar-tine/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 kilome-tres 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 politi-cal 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 Como-ros), presented at the symposium L’amélioration de l’accès aux services de santé en Af-rique francophone: le rôle de l’assurance (Improving access of health services in French-speaking 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 développe-ment 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 docu-ments 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]. 29 Research assistant at the Public Health Department of the Institute of Tropical Medicine, Antwerp, [email protected].

O. Ouattara, W. Soors: Social health insurance in French-speaking sub-Saharan Africa

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Very soon the young African states faced their first and massive financial problems. Hospi-tals and other health care structures ran short of all basic requirements: drugs, medical con-sumables 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 ex-plored 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 opera-tional 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?


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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 pro-viders in a convention, whereby fee-for-service reimbursement is the standard, fee-for-episode 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 insur-ance 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 na-tional 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 spe-cific 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 in-surance 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 French-speaking sub-Saharan Africa looks promising. In our opinion, however, none of these re-forms will solve the continent-wide problem of access to health care without a series of addi-tional 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 sub-Saharan 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 so-cial 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 sub- Saharan 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


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Table 2.7.2: Overview of health insurance mechanisms in francophone sub-Saharan Africa

Country Public sector Private sector Other sectors Ongoing reforms

Benin Non-contributory scheme, related to the Code of Civil Service

Contributory scheme accord-ing to the Labour Code. Covers work-related injuries and illnesses, maternity and daily allowances

CHIs and private-for-profit insurance com-panies

Burkina Faso

Non-contributory scheme, related to the Code of Civil Service



Creation of a com-pulsory health insur-ance scheme for the formal sector

Burundi Compulsory contribu-tory scheme (Mutuel-le de la Fonction Pub-lique), since 1980, in theory for 600,000 beneficiaries, in prac-tice only 10 %.

Compulsory scheme created in 2000, but not functional. Application presently de-pendent on the goodwill of the employers

Medical Assistance Card for independents and farmers. Should cover 20% of the popu-lation but faces major operational difficulties

Chad Contributory compul-sory scheme. Covers 75% of ambulatory care, hospitalisation and referral

Contributory scheme accord-ing to the Social Security Code. Covers work-related injuries and illnesses, mater-nity and daily allowances. Some non-occupational schemes exist


Planning of the crea-tion of a broader compulsory scheme, a pilot committee has been installed

Gabon Non-contributory scheme, about 160,000 beneficiaries. Ambulatory care is fully covered, 10% co-payment applies for hospitalisation, 20% for referral

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, co-payment applies for hospi-talisation and referral

National Fund of So-cial Guarantee for gov-ernment contractors, independents and the very poor; based on a budgetary contribution, about 300,000 benefi-ciaries. Supplementary private insurance scheme, 65,000 bene-ficiaries

Creation of universal health insurance, provided by a sover-eign Gabonese public institution: contributory and compulsory for all workers, non-contributory for the very poor

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

CHIs, MURIGA (Mu-tuele pour la prise en charge des Risques associés à la Grossesse et aux Accouchements) for obstetrical risks and private-for-profit insu-rance companies

Ivory Coast

Semi-contributory compulsory scheme (Mutuelle Générale des Fonctionnaires et Agents de l´État). Civil servants have the option to withdraw from the scheme

Well developed occupational medicine, with insurance contracts in some cases


Creation of universal health insurance (Fonds National), based on two sche-mes (Caisse Sociale Agricole and Caisse Nationale d’Assuran-ce Maladie)

Mali Non-contributory sche-me, related to the Co-de of Civil Service. Similar schemes for the elderly and war orphans.


CHIs, emergency obstetrical funds and private-for-profit insur-ance companies

Creation of a compul-sory health insurance scheme for the formal sector and of a medi-cal assistance fund for the very poor

Maurita-nia

Non-contributory scheme, related to the Code of Civil Service. Similar schemes for the military, students


CHIs, obstetrical fund, private-for-profit insur-ance companies, fund for the very poor


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Country Public sector Private sector Other sectors Ongoing reforms and the very poor

Niger Non-contributory scheme, related to the Code of Civil Service. Similar schemes for the mili-tary, students and the very poor



Creation of an over-all HIs for the civil servants

Rwanda Contributory scheme of the Rwandaise d’Assurance Maladie, based on third-party payment + 15% co-payment on behalf of the insured

Contributory compulsory schemes, diverse benefit packages and service level coverage according to the different employers

National fund for ge-nocide victims (Fonds National pour l’Assis-tance aux Victimes les plus nécessiteuses du Génocide et des Mas-sacres), about 283,000 beneficiaries CHIs, 7,388,647 bene-ficiaries: probably the biggest African CHI network

Restructuring of the different schemes, with extension of the benefit package

Senegal Non-contributory scheme related to the Code of Civil Service. Similar schemes for the military, students and the very poor

Contributory compulsory schemes of the Health In-surance Institutions (Institu-tions de Prévoyance Mala-die) with defined benefit packages, co-payment per-centage according to the different schemes Compulsory scheme of the Social Insurance Institute (Institut de Prévoyance So-cial) for the retired


Planning of the crea-tion of a National HIs for the civil servants Planning of the crea-tion 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

Togo Coverage for civil ser-vants should be assu-red in the newly esta-blished Lomé hospital. Government shares the medical costs of expatriate civil ser-vants. Government assumes the medical costs of the military.

Contributory scheme accord-ing to the Social Security Code. Covers work-related injuries and illnesses and maternity

CHIs and private.for-profit insurance com-panies

Planning of the crea-tion of a compulsory scheme

Source: World Bank Institute/Institut Multilatéral d’Afrique 2004.

indebted social security institutions in our failing states, is vital for imple-menting sustainable health insurance mechanisms. Only if these condi-tions 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 san-té de premier niveau au Mali : Analyse de la situation et perspectives. Départe-ment du développement humain, Région Afrique, Banque Mondiale, Washing-ton (http://siteresources.worldbank.org/INTAFRICA/Resources/Mali_sante_final.pdf).


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ILO (2003). Working out of poverty: report of the Director-General. International Labour Conference, 91st session. International Labour Office, Geneva. Letourmy, Alain (2004). Premiers résultats de l’inventaire 2003 de la Concertation. Forum de la Con-certation, Bamako (http://www.concertation.org/atelier/forum2004/DocsForum2004.htm). Moens, Freddy (1990). Design, implementations, and evaluation of a community financing scheme for hospital care in developing countries: a pre-paid health plan in the Bwamanda health zone, Zaire. Soc Sc & Med 30 (12), pp. 1319-1327. OECD (2003). Poverty and health DAC guidelines and reference series. Organisation for Economic Co-operation and Development and World Health Organization, Paris. Ouattara, Omar; Colas, Jean-Pierre (2003). Senegal mission report (unpublished). République du Bénin, Ministère de la Santé Publique (2004). Couverture du risque maladie au Bénin. Paris (http://www.ces-asso.org/docs/WBI_IMA_Rapport_Benin.PDF). (No author) (2004). Présentation de l’assurance maladie au Burkina Faso. Paris (http://www.ces-asso.org/docs/WBI_IMA_Rapport_Burkina_Faso.pdf). (No author) (2004). Dispositif de financement de la santé et de couverture du risque maladie au Bu-rundi. Paris (http://www.ces-asso.org/docs/WBI_IMA_Rapport_Burundi.pdf). République de Côte d’Ivoire, Ministère de la Solidarité, de la Sécurité Sociale et des Handicapés, Co-mité de Pilotage de l’Assurance Maladie Universelle (2004). La couverture du risque maladie en Côte d’Ivoire. Paris (http://www.ces-asso.org/docs/WBI_IMA_Rapport_Cote_d_Ivoire.pdf). (No author) (2004). Colloque sur la couverture maladie en Afrique francophone WBI-IMA, Paris, 26-30 avril 2004: assurance maladie au Gabon. Paris (http://www.ces-asso.org/docs/WBI_IMA_Rapport_Gabon.pdf). République de Guinée, Ministère de la Santé Publique (2004). Colloque sur la couverture du risque maladie en Afrique francophone, Paris, 26-30 avril 2004: (no title). Paris (http://www.ces-asso.org/docs/WBI_IMA_Rapport_Guinee.pdf). (No author) (2004). Rapport Mali sur la couverture sociale de la maladie. Paris (http://www.ces-asso.org/docs/WBI_IMA_Rapport_Mali.pdf). République Islamique de Mauritanie, Ministère de la Santé et des Addaires Sociales (2004). La cou-verture du risque maladie en Mauritanie. Paris (http://www.ces-asso.org/docs/WBI_IMA_Rapport_Mauritanie.pdf). République du Niger, Ministère de la Santé Publique et de la Lutte contre les Endemies (2004). Le point sur la couverture du risque maladie au Niger. Paris (http://www.ces-asso.org/docs/WBI_IMA_Rapport_Niger.pdf). (No author) (2004). L’amélioration de l’accès aux services de santé au Rwanda: le role de l’assurance. Paris (http://www.ces-asso.org/docs/WBI_IMA_Rapport_Rwanda.pdf). République du Sénégal, Ministère de la Santé et de la Prévention médicale; Ministère de la Fonction publique, du Travail, de l’Emploi et des Organisations Professionnelles (2004). Document colloque sur la couverture du risque maladie en Afrique francophone, Paris, 26-30 avril 2004, Version II. Paris (http://www.ces-asso.org/docs/WBI_IMA_Rapport_Senegal.pdf). République du Tchad, Ministère de la Santé Publique (2004). Colloque sur l’évolution de la couverture risque-maladie dans les pays de l’Afrique francophone: document de la République du Tchad. Paris (http://www.ces-asso.org/docs/WBI_IMA_Rapport_Tchad.pdf). République Togolaise, Ministère de la Santé, Direction Générale de la Santé (2004). Colloque sur l’assurance maladie: presentation de l’équipe du Togo. Paris (http://www.ces-asso.org/docs/WBI_IMA_Rapport_Togo.pdf). Schultz, Paul; Aysit, Tansel (1997). Wage und labor supply effects of illness in Côte d’Ivoire and Ghana: instrumental variable estimates for days disabled. J Dev Econ 53, pp. 251-286. Waelkens, Maria-Pia; Soors, Werner; Criel, Bart (2005). The role of social health protection in reduc-ing 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.ces-asso.org/Pages/index.php?redir=http://www.ces-asso.org/Pages/ESPAD-ColloqueWBI-IMA-CES-actes.html).


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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 con-tributes 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).

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

Although Viet Nam has recently been consid-ered 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 de-velopment 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.

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 ap-propriate 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]. 31 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, includ-ing 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. Pro-gram 135 provided poor communes with a resource allocation that they most often use to invest in a local infra-structure project, including roads, health centres, schools, irrigation systems, water supply systems, etc.

T. Van Tien: The Inclusion of the Poor in Social Health Insurance Framework in Viet Nam

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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 prison-

ers, heroes, dioxin victims …) The poor (from 2003); Foreign students (having government fellowships).

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 cover-age 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 en-rolees of the compulsory scheme. Other affiliates of mandatory health insurance are the members of socially protected groups, such as revolution merit people, heroes, veteran inva-lids etc (see box 2.3.1).

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, par-ticularly 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 regis-tration 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 operat-ing since 1995 and covers more than 5 million persons or 25 % of all students and school-children 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.).


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Figure 2.3.1: HI Membership in 2000- 2004 (x 1.000.000)

0,841 1,214 1,665 3,254 3,889

20

0

5

10

15

20

25

2000 2001 2002 2003 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 ex-ams, x–ray and other diagnostic imaging procedures, as well as drugs listed as reimburs-able. 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 av-erage 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 utilisa-tion by the poor might be attributable to a lack of awareness of the benefits of SHI at the be-ginning and/or to other barriers in access to health care for the poor, such as unofficial pay-ments 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.


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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 catego-ries: (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 na-tional 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, ena-bling 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 sta-tions) was implemented. There were 66 communes without health stations in 1993; however,


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‘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 work-ers 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 disad-vantaged 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 trans-portation for the neediest. The most significant direct support consists of different mecha-nisms 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 pro-vide 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 Gov-ernment 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, com-munity 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. Ac-cording 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 capac-ity. 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 re-mained 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 prob-lem 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.


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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 in-patient care. Public health facilities provided the holders of the health cards with health care services and requested provincial authorities to reimburse the expenses. Provincial govern-ments 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 im-plemented 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, dis-tance to public health facilities, convenience of private services, lack of money for transporta-tion 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 pro-gram. 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. Utilisa-tion 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 dif-ference 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 deci-sion 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.


69

The current per capita allocation to the HCFP is 70,000 VND (approximately € 3.5). The cen-tral 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, cen-tral).

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 % re-spectively (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 Mountain Provinces

Red River Delta

Provinces

North Central

Provinces

South Central

Provinces

Central Highland Provinces

East South

Provinces

Mekong Delta

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 con-sensus on moving from dual mechanisms (HI cards and health cards) to only one mecha-nism, 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 admini-stration 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 insur-

ance 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 en-abled 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

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 compul-sory SHI membership, adding to the current 18 million HI members. Currently, the govern-ment 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 hospi-tals and other components of the primary health care network. The reform of hospital man-agement 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 Min-istry 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 Insur-ance 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-9835-3281C799DEA0/0/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/7A81DB31-4899-42CA-9835-3281C799DEA0/0/vtn_hdb.pdf).


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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 identifi-cation. 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 par-ticipating 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 bene-fits 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 Pro-gram of PhilHealth started in 1997 and the number of participating local government has in-creased 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 lead-ing up to the 2004 Presidential elections (Plan 5M). In August 2005, almost 12 million benefi-ciaries were covered. The premium contribution for this massive enrolment was funded en-tirely by central government (through the charity sweepstakes office). Whilst controversial, the programme was successful in increasing coverage and in highlighting social health in-surance 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 indi-gent 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 gov-ernment 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]. 37 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.

Cl. Bodart, M. Jowett: Insuring the Very Poor against Health Risks in the Philippines

72

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 priori-tise other activities. Although the Indigent Program is gaining popularity amongst Local Governments, PhilHealth still devotes much time and resources to marketing and admin-istering 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, espe-cially 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-for-service 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 in-clude all the poor in the national health insurance programme. The Philippines has intro-duced 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 Depart-ment. 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).


73

2.8. Reaching the Poor in Ghana with National Health Insurance – An Experi-ence 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 sec-tor 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 ser-vices. The benefit package covers 95 % of the disease burden and takes on board both out-patient 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 be-longingness, 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 epidem-ics, 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 ine-qualities in health between regions. Though this facility was extended to six other regions in

40 Director of Health Services, Eastern Region, Ghana, [email protected]. 41 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$; CGH 10,720 = 1 €, and CGH 9,050 = 1 US$.

E. Appiah-Denkyira, A. Preker: Reaching the Poor in Ghana with National Health Insurance

74

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 prom-ise 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 sus-tainable. 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 Gon-

ja Districts which were for admis-sion only. The health programme for civil servants in the Ashanti Region for the formal sector and the Dangbe West district com-munity health insurance were the first to cover both out patient and in-patient services (Agya-pong 2003). By close of 2001, registered mutual health organis-ations (MHOs) have proliferated from two to 47 (barely two years ago) with many more, especially in the informal sector using tradi-tional systems such as welfare, Susu, etc being formed almost in

every community and evolving into a mutual health schemes (Atim et al. 2001). These re-ceived 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 In-surance 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


75

traditional mutual health organisation for the informal sector of the society. The mixed mem-bership 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 sub-scriber 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 en-able 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 Na-tional 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 % ru-ral; 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


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 dis-missal 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 popula-

tion

Dues per Adult

Paid up

adults

≤ 18 years

indi-gents

≥ 70 years

SSNIT Pensio-

ners

SSNIT Total mem'ship for Ben.

Total amount collected

(GHC)

Kwahu South 226,74 80,000 24,159 34,966 188 6,222 210 4,568 70,313 1,600,000,000

Afram Plains 148,412 72,000 7,595 17,057 127 1,301 1 1,108 27,189 547,000,000

Kwaebibirem 186,842 72,000 12,875 23,054 364 2,115 24 3,28 41,712 1,009,228,000

Asuogyaman 103,1 84,000 898 30,76 558 9,75 4,722 12,347 59,035 75,000,000Akuapem 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 127,41 77,000 5,89 11,497 31 886 39 1,389 19,732 382,000,000Akuapem South 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

Total 2,226,780 83,424 187,159 4,16 34,584 7,296 54,218 370,841 5,904,274,440

Percentage 22.495 50.468 1.122 9.325 1.967 14.62 Regional 16.64


77

Percentage of Various Categories of Members, Eastern Region

Nov. 2005

9,47

1,94 1,11

22.30

14.50

50.31

0

10

20

30

40

50

60

Under 18 Years Paid Up Adults SSNIT Contributors

70 and Above SSNIT Pensioners Indigents

Category

Perc

enta

ge

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.

Figure 2.8.1: District Population against Registered Members by each District, November 2005 Eastern Region

1984

54

1735

62

1607

83

1602

27

1484

12

1466

18

1274

10

1212

99

1092

15

8970

81031

00

8615

4

1845

76

1868

42

2267

48

9.08

123.0

50

12.3

70

18.9

57

7031

3

23.5

36 41.7

12

10.0

6729.7

27

20.7

63

19.7

32

13.1

16

16.3

57

59.0

35

7.13

1

0

50000

100000

150000

200000

250000

Kwahu S

outh/

Wes

t

East A

kim/ A

tiwa

Kwaebib

irem

Birim S

outh

S-K-C

Manya

Krob

o

Wes

t Akim

Afram P

lains

New Ju

aben

Birim N

orth

Akuap

em S

outh

Akuap

em N

orth

Asuog

yaman

Yilo K

robo

Fantea

kwa

DISTRICTS

DIS

TRIC

T PO

PULA

TIO

N

DISTRICT POPULATION POPULATION COVERED

Figure 2.8.2: Percentage of Various Categories of Registered Members


78

O.P.D ATTENDANCE (INSURED & NON-INSURED) AT THE VARIOUS HOSPITALS - SEPT. 2005 E/R

0

1.000

2.000

3.000

4.000

5.000

6.000

7.000

8.000

9.000

10.000

Region

al Hos

pital

Begoro

Hos

pital

Kibi H

ospit

al

Holy Fam

ily Hos

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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:

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 evolu-tion of health financing from the independence era. The current scheme is driven by the po-litical 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


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

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 motiva-tion 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 con-stitute 85 % of the Ghanaian population (2000 Population Census).

Financial sustainability is the biggest challenge, especially when all DMHIS are in full opera-tion with all the attendant risks This may call for adjusting certain ‘triggers’ such as the pre-mium, 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 pre-mium 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

INPATIENT ATTENDANCE (INSURED &NON-INSURED) AT THE VARIOUS HOSPITALS IN THE REGION -SEPT. 2005 E/R

554

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80

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 commit-ment, 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 com-mitment 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 Ex-ecutives 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 involve-ment 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 replac-ing out of pocket payment with health insurance, to making the NHIS the main purchaser of


81

services, whilst permitting the health providers to charge economic fees. This will imply phas-ing 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 sup-port for the poor and into public goods. To ensure sustainability, provider motivation, net-working within facilities and improving referral mechanisms among the health providing facili-ties 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 Re-gion 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 innova-tion. 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 Admini-stration 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).

M. Bigdeli: The Impact of Global Health Initiatives on Fair Financing and Health Systems Development

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2.9. The Impact of Global Health Initiatives on Fair Financing and Health Sys-tems 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 popu-lation prefers to use private providers: 68 % reported seeking treatment with private hospi-tals, 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)

Cambodia – Basic social and health data Population: 13.09 million (2003) Total GDP: 3,5 billion € (2004) GDP/capita: 265 € (2004) Nat. poverty rate: 35 % Pop. share below poverty line: 20 % Gov. health budget: 48 million € (2005) Health expenditure as % of GDP: 1.26 % OOP: Total donor spending: 76 million € (2003) Donor spending/capita: 5.9 € (2003)

per illness episode over the past 4 weeks (NIS 2004b). Taking into account the average household size and inci-dence of illness, the World Bank Pov-erty Assessment 2006 estimates out-of-pocket expenditures to be around € 12 per capita and year (World Bank 2006)

The Health Financing Charter was in-troduced in 1996 and allows the estab-lishment of user fees in health facilities. In 2004, the income from user fees was reported to be € 5.2 million. Sixty per-cent of this income is redistributed as in-centives for the staff, with the positive impact of reducing under-the-table pay-ments (Wilkinson et al. 2001). However, combined with inadequate quality of care,

Sources: NIS 2004a+2005, MoH 2005+2006, CDC 2004

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 numer-ous 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 prac-tice.

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 ser-vices 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 mecha-nism 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 Commis-sion 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].


83

track € 70 million (i.e. 93 % of total donor spending officially reported by the Cambodian De-velopment Council). As shown in Figure 1, the United States of America is the principal do-nor 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

USA 32%

Other bilaterals 21%

GAVI 1%GFATM 8%

NGO funds 7%UN Agencies 20%

Development banks 6%

EU 5%

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 €)

Maternal & child health: 11,5 million

(16%)

TB, Malaria, dengue: 9,6 million

(13%)

AIDS: 25,3 million (35%)

Other: 8,8 million (12%)Health sector

strengthening: 11,4 million (16%)

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).


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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-DFID-UNFPA 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 Cambo-dian and International NGOs, implementing 75 % of GFATM funding and all USAID sup-ported 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 re-sources. 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 neces-sarily 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 valu-able 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 pur-chasing 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 fund-ing. While this arrangement makes practical sense in the current Cambodian context, it does


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 dis-bursement 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 im-plementation 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 moni-toring arrangements specific to each donor, each implementer or each geographical location. Both models will significantly contribute to create capacity at central level for financial man-agement, 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 independ-ent from coordinated financing and administrative arrangements, they will initiate and main-tain 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 evalua-tion in place as well as technical planning capacity. GFATM HSS Round 5 proposal also in-cludes objectives related to support to national procurement processes. In addition, Cambo-dia 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 manage-ment through performance-based salary schemes and improve financial management with program-based budgeting. The MoEF is leading this reform process and the health and edu-cation 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 hu-man 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 sys-tem in terms of staff and capacity is not valued in monetary terms and deserves further scru-tiny.

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.cdc-crdb.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


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%2C%20Catherine%20(2005).%20External%20Resource%20Flows%20to%20the%20Health%20Sector%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/index-cses.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/CAMBODIAEXTN/0,,contentMDK:20815621~pagePK:141137~piPK:141127~theSitePK:293856,00.html).


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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

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 high-lighted: “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 fo-cused on the goal of financial protection against health risks. Associated with this is the ob-jective 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 instru-ments or schemes, such as social health insurance (SHI) or community-based health insur-ance (CBHI). Further, the success of particular schemes should be assessed from the sys-temic 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) is the population, not the scheme or just the covered groups.

The simple logic and objectives descri-bed above is often lost in the rhetoric of ‘health insurance’. Indeed, the focus on implementing insurance schemes rather than the objective of insuring the popula-tion has led to the development of cer-tain harmful myths about health insur-ance that can lead to inappropriate pol-icy advice and choices, particularly in the context of low and middle income countries.

Four harmful myths in health insurance: Countries that do not have social health

insurance and wish to introduce it, start best with formal sector workers and gradually ex-pand to the rest of the population There are essentially two broad options

for health financing: SHI systems or “tax-based systems” Introducing SHI will inject more money

into the health system Increasing social protection in health

requires increasing SHI coverage

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. How-ever, 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 ser-vices 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 gov-ernment health facilities provide an insurance function (Kutzin 1999). In many low and mid-

45 WHO/EURO Regional Advisor, Health Systems Financing; Visiting Fellow, Imperial College Centre for Health Management, [email protected].

J. Kutzin: Myths, instruments, and objectives in health financing and health insurance

88

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 insur-ance 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).

Figure 3.3.1: SHI and segmentation in countries with small formal sector: the Mexican case, 1990s

Behind these stringent technical conditions is a political concern. The ini-tially insured group tends to be a well-organised and influential interest group in countries with small for-mal sectors. Their econo-mic interest is not to en-able redistribution to the poor or expansion of cov-erage with the scheme, but instead to expand their benefits and reduce their contributions. Hence, one can question whether this process will, in fact, ‘free up’ resources for the poor, or if there will be even greater concentra-tion of public funds on the relatively well-off. Exam-ples cited in earlier docu

Source/ collection

Pooling

Purchasing

Provision

Population poor middle rich

C o v e r a g e

General taxation

MoH

MoH

uninsured

MoH

Voluntary contribution

VHI and OOPS

SHI

SHI

Payroll taxationSHI insured

SHI

SHI

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


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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 intro-duction 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 coordinat-ing these financing systems, and their vertical integration with service delivery meant duplica-tion of infrastructure as well. In this context, the existence of separate ‘social health insur-ance’ 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). Address-ing 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 dec-ade 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 for-mal 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 com-prehensive 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 illus-trates 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 organisa-tion of health financing functions and population coverage illustrates the following points: Re-

Figure 3.3.2: Health financing functions and coverage arrangements in the USSR

Source/ collection

Pooling

Purchasing

Provision

Population

Oblast, rayon and city administrations

Capital City Finance Dept.

Republican budget

Rayons Oblast

rayon finance depart-ments

rayon hospitals,

polyclinics, SUBs, FAPs

oblast finance depart-

ment

oblast hospitals and

polyclinics

Each oblast

city finance depart-ment

City hospitals and polyclinics

City

MOH

MOH

Republican health facilities

Capital city (and nearby)

Coverage Coverage

rayon finance depart-ments

oblast finance depart-

ment

city finance depart-

ment

Note: FAP = rural physician assistant and midwife post; SUB = rural hospital.

venue collection and distribution of general revenues came from oblast (province), rayon (district), city, and Re-publican (central) levels of government admini-stration (essentially, the Ministry of Finance at each administrative le-vel of the government). Tax and state enterpri-se revenues flowed to these local and central state budgets. Pooling of funds and purchas-ing of services was org-anised by level of gov-ernment and integrated with service delivery units through a hierar-chical budget allocation process. ‘Purchasing - the allocation of resour-

ces from each pool to providers - was via strict line item budgets driven by centrally deter-mined input-based norms (e.g. budget per number of hospital beds). And, population cover-age was universal but not clearly specified. Importantly, coverage responsibilities over-lapped, particularly in urban areas.


90

Health financing arrangements in the USSR were in fact a decentralised ‘budget funded sys-tem’ 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 sys-tem (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 oc-curred 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-the-table, with greatest burden on the poor.

It was in this context that Kyrgyzstan and Moldova, two of the most severely affected ex-USSR 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 orienta-tion. 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 Manda-tory 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 informa-tion and accounting in each oblast of the country. The development of a single, unified hospi-tal 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 addi-tional 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 budg-etary 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 de-partments 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 trans-form the health system by not only having the MHIF administer budget funds but to pay pro-viders from these funds according to the same methods it used for the insured. The exis-tence 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 popula-tion coverage has done so without subsidising the non-contributing population. This approach is crucial for low-middle income countries when starting to implement or extend social protection in health. To maintain the tradi-tional ‘MoH system’ in parallel with the newly created ‘SHI system’ is most likely to create segmented systems with inefficiencies and inequities.


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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.

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 (pur-

chaser-provider split introduced). National MHIF pool for the insured was main-

tained, 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 re-sponsible 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 na-tional pool. Providers were given increased autonomy to

manage their internal resources. Promulgation of an explicit but not highly de-

tailed benefit package with formal co-payments.

The single payer system provi-des universal coverage from each oblast level pool, and com-plementary coverage from the national pool for the ‘insured’; the package for the insured con-sists of a reduced co-payment rate for specialised referral care and access to an outpatient drug package.

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 entitle-ment funded from payroll taxes and transfers from the central budget for groups covered by sta- tute (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 govern-ments to the central government. There are also much less contributions from the self-employed 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.


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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 fragmenta-tion 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

Universality must be de-signed into the reform from the start, rather than hoping that the system will eventu-ally reach those outside the formal sector.

answer on whether initiating contributory compulsory health insurance with the formal sector will improve or worsen the efficiency and equity of the health sys-tem. Key design aspects include financial changes that re-direct general budget revenues to enable non-contributors to be in the same pool as contribu-tors, or at the minimum aim to use all available sour-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 uni-versality 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

Figure 3.3.3: Functional framework for health financing policy

Cost sharing/user fees

Health services

The population

Collection of funds

Provision of services

Purchasing of services

Pooling of fundsCoverage

Coverage

Choice?

Choice?

Contributions

Entitlement?Stew

ards

hip

(gov

erna

nce,

re

gula

tion

and

info

rmat

ion)

Source: Adapted from Kutzin 2001

The notion that health fin-ancing policy can be red-uced to an exclusive choice between Beverid-ge and Bismarck is a fun-damentally flawed pers-pective that limits the scope for adapting health financing systems to the context of low and middle income countries. The functional approach to health financing (Figure 3.3.3) was in part devel-oped in the belief that the source of funds need not determine how the funds are pooled, how providers are paid, nor the specific-ity with which benefit enti-tlement is determined. As revealed in the figure and 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-


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 im-pact was the short-lived experience of SHI in Kazakhstan that introduced its payroll tax-fun-ded 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 fund-ing for health by a full percentage point of GDP from 1996 to 98 even though total govern-ment 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 dec-lines 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.

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 in-strument. Increasing social protection in health is not synonymous with increasing or expand-ing 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 sys-tem has the word ‘insurance’ in its label and the other does not. The idea that universal cov-erage 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-

Figure 3.3.4: Government health spending trends by

2.9%2.7%

2.0%2.5%

2.1%

1.5%

0.4%

0.6%

0.5%

3.0% 2.4%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

1995 1996 1997 1998 1999

Health spending as %GDP

All public State budget MHIF


94

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 ob-jectives associated with universal coverage, but the starting point for any reform is the cur-rent 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, in-cluding their own experience as well as the investments in sys-tems and people that they have made. Imported models of health financing, such as Bever-idge and Bismarck, are of limited value in helping a coun-try define its reform path. Sys-tems (and reform options) must be understood in terms of func-

tions, 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 sys-tem 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 becau-se 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.

There is no one “right way” or blueprint. Complementarity is essen-tial for “low tax revenue” countries. Universal coverage and fair financing are not linked to a particular institutional form or model.

Those providing technical assistance must be ex-tremely clear on the difference between policy ob-jectives 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.”

The ‘bottom line’ is that, when considering the in-troduction of contributory compulsory health insur-ance in countries in which a large share of the population is outside the formal sector of the econ-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 con-sidered 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 atten-tion 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 Cheasty, Adrienne (1996). The revenue decline in the countries of the former Soviet Union. Finance and Development June, International Monetary Fund


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(http://www.imf.org/external/pubs/ft/fandd/1996/06/pdf/cheasty.pdf#search=%22Cheasty%2C%20A%20(1996).%20The%20revenue%20decline%20in%20the%20countries%20of%20the%20former%20Soviet%20Union%22). Checheybaev, E (2002). Feasibility of achieving planned savings from restructuring of the health sys-tem. Policy research paper 18, MANAS Health Policy Analysis Project. World Health Organization: Bishkek, Kyrgyzstan (http://eng.hpap.med.kg/). Frenk, Julio (1995). Comprehensive policy analysis for health system reform. Health Policy 32 (3), pp. 257-277. Gertler, Paul; Solon, Orvill (2000). Who benefits from social health insurance in developing countries? Monograph, Haas School of Business, University of California, Berkeley, California (http://adfdell.pstc.brown.edu/classes/readings/gersol00.pdf#search=%22Gertler%20Solon%20%22Who%20benefits%20from%20social%20health%20insurance%20in%20developing%20countries%3F%22%22). Kutzin, Joseph (1997). Health insurance for the formal sector in Africa: ‘yes, but.... Current Concerns series, ARA Paper number 14. WHO/ARA/CC/97.4. Geneva: World Health Organization, Division of Analysis, Research and Assessment. Also available, under the same title. In: Beattie, Allison; Doherty, Jane; Gilson, Lucy; Lambo, Eyitayo; Shaw, Paul (eds.). Sustainable Health Care Financing in South-ern Africa: Papers from an EDI Health Policy Seminar Held in Johannesburg, South Africa, June 1996. Washington, DC: World Bank, Economic Development Institute. Kutzin, Joseph (1999). Enhancing the insurance function of health systems: a proposed conceptual framework. In: Nitayarumphong, Sanguang; Mills, Anne (eds.). Achieving Universal Coverage of Health Care. Nontaburi, Thailand: Ministry of Public Health, Office of Health Care Reform. Kutzin, Joseph; Ibraimova, Ainura; Kadyrova, N; Isabekova, G; Samyshkin,Y; Kataganova, Z. (2002). Innovations in resource allocation, pooling and purchasing in the Kyrgyz health care system. Policy research paper 23, MANAS Health Policy Analysis Project. World Health Organization: Bishkek, Kyr-gyzstan (www.blackwell-synergy.com/ doi/abs/10.1111/j.1467-9515.2005.00446.x). Kutzin, Joseph (2001). A descriptive framework for country-level analysis of health care financing ar-rangements. Health Policy 56 (3), pp. 171-204 (http://www.atgci.org/resources/documents/a%20descriptive%20framework%20for%20country-level%20of%20health%20care%20financing%20arrangements.pdf). Kutzin, Joseph; Cashin, Cheryl (2002). Health system funding. In: McKee, Martin, Judith Healy, Jane Falkingham, Eds. Health Care in Central Asia. European Observatory on Health Care Systems. Open University Press, Buckingham (www.euro.who.int/document/Obs/0335209262.pdf http://www.who.dk/InformationSources/Publications/Catalogue/20020225_2). Kutzin, Joseph (2003). Health expenditures, reforms and policy priorities for the Kyrgyz Republic. Pol-icy research paper 24, MANAS Health Policy Analysis Project. World Health Organization: Bishkek, Kyrgyzstan (http://eng.hpap.med.kg/MyFiles/PER%20JK%20for%20PRP24.pdf#search=%22Checheybaev%20Feasibil-ity%20of%20achieving%20planned%20savings%20from%20restructuring%20of%20the%20health%20system%22). Lloyd-Sherlock, Peter (2006). When social health insurance goes wrong: lessons from Argentina and Mexico. Social Policy and Administration 40(4):353-368 (http://www.blackwell-synergy.com/doi/pdf/10.1111/j.1467-9515.2006.00494.x?cookieSet=1). Londoño, José-Luis; Frenk, Julio (1997). Structured pluralism: towards an innovative model for health system reform in Latin America. Health Policy 41 (1), pp. 1-36. Shaw, Paul; Griffin, Charles (1995). Financing Health Care in Sub-Saharan Africa through User Fees and Insurance. Washington, DC: World Bank. Shishkin, Sergej; Kacevicius, Gintaras; Ciocanu, Mihai. (forthcoming). Evaluation of health financing reform in the Republic of Moldova. Copenhagen: Health Systems Financing Program, WHO Regional Office for Europe.

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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 reim-bursing 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 insur-ance. 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 success-ful 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 in-cluded? And what premium should be charged? While universal coverage is generally a cen-tral 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 exam-ple, 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 sys-tem 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 enti-

47 Senior Partner, Social Insight, [email protected]. 48 Senior Health Advisor, Berlin, Germany, [email protected].


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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 cost-containment 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 implica-tions. 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 popula-tion and gradually extending it to more and more groups. Between the initial legislation mak-ing 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 cover-age 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 finan-cial 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 for-mally employed nor are they disabled. In Colombia, by contrast, the 38 % of the population without health insurance coverage in-clude both informally employed individuals but also many dis-abled, 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 re-quired 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 elimi-nating 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 work-ing 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.

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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 indi-vidual eligible at one time but not another.

A third problem occurs when extension of benefits by groups includes a differentiation in lev-els 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’ pro-gram. 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 suc-cess 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 in-surance 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 expendi-tures 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 na-tional 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 rec-reated 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 im-proving 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 gener-ally 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. Ef-forts, at this stage, appear aimed primarily at generating new alternatives for insurance cov-erage without confronting the problems that such fragmentation might engender in the future.


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The Kyrgyz Republic started with a system of public health services that were divided geo-graphically. By introducing a national health insurance scheme, additional funds were mobi-lised 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 work-ers, 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 in-surance 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 uni-fied 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. Interna-tional 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. Discus-sion 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).

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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 in-stability, weak infrastructure, lack of good governance and an accelerated demographic de-velopment 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, hu-man resources, etc.) as well as at the level of demand. The supply side is mainly lacking po-litical will, adequate health care infrastructure, the level of quality medical care, and the nec-essary human and financial resources. The demand side is changing continuously due to demographic pressure and increasing fi-nancial 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 sat-isfy essential needs. That is the reason why mainly in Africa the challenges of social protec-tion 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 meas-ures that have left important eco-nomic and social traces. One of the most visible consequences has been the shut-down of enterprises with a relevant loss of workplaces. This dif-ficult 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. In spite of the devaluation of the re-gional currency, CFA, and the follow-ing increase of the growth rate from 2 to 5 %, the situation described before had a very negative impact on the liv-ing 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 strate-

Senegal is one of the Sub-Saharan Africa countries lo-cated on the coast of West Africa. It has a total popula-tion of 10.6 million (in 2003) of whom 48.1 % live in ur-ban 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 polyg-amy 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 coun-tries and its economy is highly tied to the former colonial power, France. It has limited natural resources and fish-ing, mining, agriculture, tourism, and services are the major sources of foreign exchange earnings. Since January 1994, the country has undertaken various eco-nomic reforms including devaluation of its currency by half and reducing price controls and subsidies. As a re-sult (coupled with good weather conditions), the country has shown considerable economic growth with relatively low inflation rates and fiscal deficit. However, the coun-try is still poor in many indicators and suffers from high level of poverty, very high rural-urban migration, unem-ployment (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).

gy 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 gov-ernment 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].


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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, inef-ficient 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 com-bined 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 ex-penditure, 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. Ex-cept in improved water sources, the perform-ance 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 preva-lent 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 strat-egy (Asfaw 2004, p. 5).

Prior to the elaboration of the PRSP, Sene-gal already had a series of experiences with social protection through mutual health organisations, the Health Welfare Institu-tions (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 ru-ral and urban surroundings.

In order to promote social dialogue and so-cial protection, Senegal adopted a National Tripartite Charter on Social Dialogue in No-vember 2002. The new social regulation in-strument is a framework for reflection and action. It allows the State and other stake-holders 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 de-partments as well as workers’ and employ-ers’ organisations and is the main organ to execute the national Charter. One of the main goals of the National Committee is ex-tending social protection through social dia-logue.

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 con-tributory 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 mu-tual 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 ma-jor 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 situa-tion. Senegal faces the problem of insufficient human resources with acceptable qualification needed for a development policy towards health insurance.

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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 accessi-bility. 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 be-come a priority objective at the centre of several stakes. However, the implementation of ef-fective 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 experi-ence, 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 pro-tection 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 capac-ity 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 Sene-galese 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

1997 1998 1999 2000 2001 Av. growth

rate*

Total expenditure on health as % of GDP 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

Per capita total expenditure on health at average exchange rate (US$) 25 24 22 22 -0.0336

Prepaid plans as % of private health ex-pend.

8.4

Source: Asfaw 2004


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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 Dia-logue Committee (CNDS) may produce satisfactory results within a reasonable time frame-work. 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 be-tween 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%20protection%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/281627-1095698140167/Jutting-TheImpactof-whole.pdf#search=%22Senegal%20%22social%20protection%22%20%22health%20insurance%22%22). Jutting, Johannes (2003). Health Insurance for the Poor? Determinants of Participation in Community-Based 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 Pro-tection 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/9A78584264041A1A85256F5C00030078/$file/senegal_cae_approach_paper.pdf#search=%22Senegal%20%22social%20protection%22%22).

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3.4. The German perspective on the Importance of social dialogue in the ex-tension 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 protec-tion. 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 munici-pal 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 organ-ise wide-ranging social insurance against life’s most serious risks. These laws on health in-surance 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 protec-tion 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 dif-ferent 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. In-stead, 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 dele-gated 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 be-lieve that these co-operative bodies, under state protection and support, were more appro-priate 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].


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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 bene-fits 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 self-administrative body. This system also fulfils another important function: leaving aside dis-putes between employers’ organisations and trade unions, it forces their functionaries to en-gage 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 estab-lishes that the scope of benefits covered under statutory health insurance is defined in per-manent dialogue with service providers, i.e. doctors, therapists and hospitals. Funding agen-cies, 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, in-patient 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 decision-making 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 sec-tions of society such as employers' organisations and trade unions. The purpose of both ini-tiatives 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 par-ticular 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.

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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 De-partment of Health for policy coordination.

PhilHealth has five major membership categories and they are as follows: For formally em-ployed 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 cov-ers 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 pro-tection 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 mi-nor and ambulatory surgeries, normal deliveries, treatment of tuberculosis through direct ob-servation 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 Phil-Health 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 po-tential 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].


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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, utilisa-tion 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 ac-tive 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.

Figure 3.1.1: PhilHealth Program Several reasons are responsible for the low population coverage of the IPP. One is the lack of infor-mation of the target groups. While PhilHealth has managed to in-crease substantially its presence in the provinces, it remains insuf-ficient to reach potential informal sector enrolees. The diversity of the target market especially pres-ents a challenge to the organis-ation. Although the target seg-ment perceives a contribution of PHP 1,200 per family a year as reasonable, the nature and some-times seasonality of income make it difficult for many affiliates to comply with the prescribed ann-ual, 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 har-nessing 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 in-volve the informal sector, while organised groups, co-operatives and other types of organisa-tions 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 im-plementation of the IPP. It also provided PhilHealth the opportunity to make some enhance-ments in a series of processes particularly with regard to contribution collection and remit-tance, 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 capac-ity. 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-


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 bene-fits available for PhilHealth beneficiaries. Thus, they can claim inpatient and selected outpa-tient benefits including ambulatory surgeries in any accredited hospital. Affiliates who pay the full annual contribution are entitled to receive an additional outpatient package including di-agnostic services and basic consultations in rural health units (RHUs).

Figure 3.1.2: PhilHealth Affiliation: Actual versus Potential

1,8%

24,0%

5,2%2,7%1,6%

31,0%

9,0%

16,3%

0%

5%

10%

15%

20%

25%

30%

35%

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 im-prove 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 con-tribution 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 pay-ment 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 reim-bursing 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.


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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 ex-periences, 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 Phil-Health 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 pre-rogative 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 Members

Enrolled Band Group Premium

4,000 and up 85 % 8A P 1,083

70 % 7A P 1,089

3,000 to 3,999 85 % 6A P 1,094

70 % 5A P 1,100

2,000 to 2,999 85 % 4A P 1,106

70 % 3A P 1,112

1,000 to 1,999 85 % 2A P 1,117

70 % 1A P 1,123 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

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 pro-gram 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 re-payment 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 dis-counts. 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 Re-gion of Muslim Mindanao. GTZ, Manila/Eschborn (http://www-users.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 Remit-tance 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. Phil-Health 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 (sitere-sources.worldbank.org/INTHSD/Resources/topics/Health-Financing/HFRChap3.pdf).


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3.6. 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 indi-viduals. 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 treat-ment. 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 indi-viduals 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 con-notation, 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 in-surance as a part of health sector reforms. There are various important reasons for this in-terest in health sector reforms and health insurance. Social protection in health can contrib-ute 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 to-wards 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 re-sources 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].

I. Gupta: Health Coverage for All: Strategies and Choices for India

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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 dis-eases, 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 hospital-ised 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 devel-opment 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 pub-lic health, primary care and family welfare in total expenditure is very low, and has experi-enced a decline in the recent past.54 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 hospi-tals. 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 hospi-talisation. 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, indi-viduals 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.


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families in contingencies such as sickness, maternity, temporary or permanent physical dis-ablement, 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 other-wise. 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 de-ductions 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 suf-fers 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 medi-cal 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, employ-ees 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 Ac-countant 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, polyclin-ics and government-recognised hospitals and cover out patients facilities under all systems of medicine, emergency services in allopathic system, free supply of necessary drugs, labo-ratory 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 per-form 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 hospi-talisation.

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

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 sec-tor 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 mar-ket 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 seg-ment 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 of-fered by the four public sector companies, National Insurance, New India Assurance, Orien-tal Insurance and United India Insurance. Mediclaim was until recently a reimbursement pol-icy 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 of-fered 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 Insur-ance 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, sev-eral 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 Community-based 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 acci-dent 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.


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Table 3.2.1: CHI with insurance company: some examples

Scheme/Characteristics

Services covered Beneficiary Premium structure Health/ Composite

Insurance company

Vimo SEWA, Ahmedabad

Hospitalisation expenses with an upper limit (Additional benefits of Maternity cover, Denture and Hearing Aid at subsidised rate for Fixed De-posit members)

SEWA union mem-bers - 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 Natio-nal Insu-

rance

BAIF, Pune 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. 50,000Annual health examination

Members of Self Help groups of BAJF, Individuals coming from a family having annual income con-sidered as BPL, or marginally above it.

Rs. 225 for SHG member and Rs. 260 for others. (The addi-tional benefits like, concession at the health facilities and loan for hospitalisation, can not be extended to non-SHG mem-bers)

Composite UIIC

Rag Picker’s. Insurance scheme, Pune

Hospitalisation, Standard jan Arogya policy coverage with an upper cap and life cover

Rag Pickers, kabadi-walaha, Dabba-batliwalahs

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 Munici-pal 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

Cooperative Health Soci-ety Ltd, Kolkata

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 domi-ciliary 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 Medi-claim - prescribed premium, UTI - One time payment de-pending on the age of enrol-ment

Health GIC group (National)

Sri Mayapur Vikas Sangha, Mayapur

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.

Karuna Trust, Mysore

lnsured amount for Hospitalisation 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.

Population of (lie T. Narasipura taluk in Mysore district and

Baihongal tatuk in Belgaum district, focussing mainly on BPL and SC/ST population

Rs. 30 per person per annum for general population For SC/ST and BPL popula-tion, the premium is fully sub-sidised. For BPL and non-SC/ST popu-lation, the premium is subsi-dised to the extent of Rs.10 from the project funds and the insured have to pay the bal-ance amount

Health National

Insurance Co. Ltd

BUCCS (Buldhana Urban Co-operative Credit Soci-ety) Health Insurance Scheme,

Accidental death of member Rs. 25,000. If member is hospitalised for more than 3 days al a time Rs. 50/- 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

Rural population of Buldana district, mostly farmers

Individual: INRs 365/-

Family of 5 (husband, wife, three children): INRs 548/-

Family of 7 (husband, wife, 3 children and insured’s par-ents): Rs 730

Composite United India

Insurance Co. Ltd

Sri Mayapur Vikas Sangha, Mayapur

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.


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A recent analysis of the voluntary commercial insurance sector, and in particular the penetra-tion 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 attrac-tive 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 signifi-cant 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/ Cha-racteristics

Services covered Beneficiary Premium structure Health/ Composite

AKHS, Ahmed-abad

Registration and Consultation for any dis-eases 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 co-operatives, irre-spective of the amount of the milk.

Rs. 25/year/family for the mem-bership 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 & Financial Eye Care – Pilot Proect, L.V. Prasad Eye Institute Hy-derabad

Complete eye examination & Cataract surgi-cal service and other secondary level eye care and minor surgical services.

All individuals pertaining, to rural areas of selected villages in the adopted areas.

Rs. 1/persons/month on yearly basis.

Health

Sludtnt Health Hcnw, Kalkita

Free consultation across all the specialties medicine @ Rs. 2 per day All diagnostic tests @ subsidised rate Hospital facilities: Admission charges for medical investigation Rs. 25 Adm. Charges for surgical Rs. 75 Maintenance charges per dav Rs. 10

Students Universal subscription @ Rs. 4 per year/student Individual membership @-Rs. 60/year

Health

Surul Health co-operative, Shantiniketan

Primary health care and minor surgeries Poor people of surrounding vil-lages 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 indi-cated 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 organisa-tions 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 in-surance 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


117

sector involvement as well. It is increasingly felt that to meet the requirements of the uncov-ered 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 benefi-ciaries 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 policy-holders 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 achieve-ment of the Health for All objective.

Figure 1: The three models of community health insurance in India

NGO(ACCORD, JRHIS, SHH, VHS)

COMMUNITY

Premium Health care

NGO(KKVS, RAHA)

COMMUNITY

PROVIDERSPremium

Health careReimbursement (KKVS)

Reimbursement (RAHA)

NGO(SEWA, BAIF,

Navsarjan and Karuna)

COMMUNITY

PROVIDERS

INSURANCE COMPANY

Group Premium

Premium

Reimbursement

Reimbursement(SEWA, BAIF)

Health care

Reimbursement(Karuna Trust, Navsarjan Trust)

Type 1

Type 2

Type 3

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 sche-mes and their estimated coverage in India. These are best guesses, since no firm numbers are


118

Table 3.2.3: Health insurance coverage in India56

Schemes Beneficiaries (in mill.)

The Employees State Insurance Scheme (ESIS)57 25.3 Central Government Health Scheme (CGHS)58 4.3 Railways Health Scheme 8 Defence employees59 6.6

Ex-servicemen 7.5 Mining and plantations (public sector)60 4 Health insurance (Public sector non-life companies)61 10 Health insurance (Private sector non-life companies)62 0.8 Health segment of Life insurance companies63 (public + private sector) 0.23 State sponsored schemes <0.5

Employer run facilities/reimbursement schemes of private sector64 6

Employer run facilities/reimbursement schemes of public sector65 <8

Community health schemes 3

Total ~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 pub-lic health facilities are open to all, there are serious problems regarding quality and accessi-bility 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 employ-ment 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. 57 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. Approxi-mately 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. corpo-rate 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.


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due to organisational and technical constraints. The potential of private or voluntary insur-ance is currently limited due to both demand and supply side issues.

What are the challenges and questions India faces in thinking of the objective of Cover-age 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 insur-ance 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 allo-

cations for the health sector? Earmarked tax? User fees? Centre-state sharing?

It is proposed that for achieving Health for All, India must think of extending ‘Health Coverage to All’. It has to find ways of cov-ering the unorganised and self-employed workers, those not employed: elderly, un-employed, 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 con-sidered and analysed. In the recent past, several studies have discussed and de-bated 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 supervi-sory commission IRDA have shown keen-ness and resolve to tackle the gap between current coverage and the targeted cover-age necessary to ensure better health care options for the population.

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 out-side it. The IRDA regulations can also be suitably altered so that regulation of health insur-ance 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-


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stances of what is possible if all this energy is harnessed properly by a systematic and well-thought 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 Hospi-tal Care. Munnetra Sangham (AMS) Team Economic and Political Weekly 39 (28) (July 10), pp. 3179-3183. 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 Pro-spectus. Economic and Political Weekly 35 (4), p. 207-217 (http://adfdell.pstc.brown.edu/classes/readings/ellala00.pdf#search=%22Worldbank%20Shaw%20Ainsworth%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%20Insurance%22%20India%20%22). Gupta, Indrani; Trivedi, Mayur (2005d). A Few Ways Forward: The State of Voluntary Health Insur-ance 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 (site-maker.umich.edu/fafridi/files/cv_afridi_.pdf). Shariff, Abusaleh (1994). Employees State Scheme in Gujarat; Key Results of a Survey. Report pre-pared by the Gujarat Institute of Development Research, Ahmedabad.


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3.7. Universal Coverage in Thailand: the Respective Roles of Social Health In-surance 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 (Univer-sal 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 respec-tively (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, 1994-2001

0

50.000

100.000

150.000

200.000

250.000

1994 1995 1996 1997 1998 1999 2000 2001

Mill

ion

bath

0,0%

2,0%

4,0%

6,0%

GD

P

investment Ratio of THE to GDP (%)

The ratio of THE to Gross Domestic Pro-duct (GDP) at cons-tant price was 3.2 % in 1994 and peaked at 3.9 % in 1997, the year which Thailand faced the economic crisis. After that per-iod the ratios of THE to GDP had decrea-sed continuously to 3.2 % in 2001.

The ratio between government and non-government financing (mostly households and a negligible amount of donor res-ources in financing healthcare) had grad-ually changed over the period between

Source Thai working group on NHA (2003)

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 piece-meal 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 International Health Policy Program, Ministry of Public Health, Thailand, [email protected]. 67 National Health Security Office, Thailand.

V. Tangcharoensathien, P. Prakongsai, W. Patcharanarumol, P. Jongudomsuk: Universal Coverage in Thailand

122

67.1

28 21.6 19.7 20.3

0%

20%

40%

60%

80%

100%

1991 1995 1997 1998 2000

% c

over

age

Social Welfare Scheme Civil Servant Medical Benefit Scheme Compulsory Social Security Scheme MOPH Voluntary Health Card Private Health Insurance Uninsured people

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 (1994- 2001)

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000 180,000

1994 1995 1996 1997 1998 1999 2000 2001

M io . B aht

G overnm ent N on-governm ent

55%

56% 56%

51% 45% 48% 43% 43%

44% 44% 45%

49% 52% 55%

57% 57%

Source: Thai Working Group on NHA (2003)

Figure 3.4.3: Insurance coverage extension 1991-2000


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Table 3.4.1: Population covered by various insur-ance 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 per-formed 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 downsiz-ing, 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 employ-ment 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 In-come 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 mini-mise 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 em-ployees & de-pendents, retirees

Formal sector em-ployees:

Poor, elderly, children under 12 years

Non-poor and mar-ginal poor house-hold in rural areas

Population Coverage 7.62 millions 6.9 millions 17.7 millions 7.92 millions

Health Benefit Ambulatory ser-vice & Inpatient service (Public)

Ambulatory service & Inpatient service (Public & Private)

Ambulatory ser-vice & 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, Co-payment for IP in private hospital

Tripartite 1.5% (1650 -15000 Baht/month); co-payment for ma-ternity and emergen-cy services if beyond ceiling

Non contributory scheme, full funded by gov-ernment

HH 500 Baht/yr

Gov. 500B/yr, al-most no co pay

Financing Body Ministry of Fi-nance

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.


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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 co-payment 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.


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 dis-trict 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 dump-ing IPC into OPC and limited admission to general margin especially by private for profit con-tractor 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 con-ventional 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 pack-ages were integrated into the curative services. Historically, the SHI law only covers the em-ployee, excluding their non-working spouse and children. This precedent does not help ex-tend 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 UC Scheme SHI Service con-tractor

Primary Care Network, typical model: health centres and district hospital, as mostly rural population

100 bed-hospital, as mostly ur-ban population

Referral Ensure better referral No referral, covered within the contractor provider

Payment method

Capitation for outpatient care, global budget and case-based payment (DRG) for inpatient care. This is to prevent un-der-admission of inclusive capitation

Capitation inclusive of outpatient and inpatient care

Dental, ma-ternity

Integrated into curative package Separate packages Maternity: flat-rate payment Dental: fee-for-service + ceiling. Higher administration costs

Coverage All family members, individual member card issued (not a family card)

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

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 require-ment 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 num-ber 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

Pre hosp care - 10 10 10

Capital replacement 93 83 85 77

Adj remote areas - - 10 7

No fault liability - - 5 0

Capitation Baht 1202 1202 1309 1396

USD 30 30 33 35

Beneficiaries are entitled to individual prevention and promotion services and to free curative care at the regis-tered 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 ca-pitation method for outpatient ser-vices, prevention and health promo-tion. Accidents and emergencies out-

side 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.


127

The International Health Policy Program (IHPP) has estimated capitation rate based on actu-arial 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 under-went an external peer review by the ILO headquarters (see table 3.4.4).

Achievements

By early 2002, there were three public insurance schemes cov-ering 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, cov-ered 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. Unfortun-ately 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 provi-ders is dominated by the close-end method in SHI and UC Scheme; the exception is CSMBS which applies a fee-for-service 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 em-ployee, retiree and dependants

6 million, 10% General tax, non contributory

Fee for service reimbursement model

Social Health Insurance* Since 1990

Private sector em-ployee

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 pro-poor financing policy (Low Income Scheme) began in 1975. Universal Coverage was com-pletely achieved in April 2002. The new UC Scheme is a general tax financed, non-contributory, public mandatory scheme. The Scheme replaces the previous two public insur-ance 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

4% 1%

25%7%

5%

25%

11% 14%

23%

26% 31%

17%52% 49%

10%

0%

20%

40%

60%

80%

100%

CSMBS SSS UC

Q1 (poorest) Q2 Q3 Q4 Q5 (the richest)

1.447 1.5121.670

1.901

1.202 1.2021.309 1.396

1.6591.788

-

500

1.000

1.500

2.000

2002 2003 2004 2005 2006

Bah

t per

cap

ita

Proposed Approved

Figure 3.4.4: Scheme beneficiaries by income quintiles, 2004

Source: NSO Health and Welfare Survey 2004

Financing of UC scheme

Figure 3.4.5: Discrepancy of the proposed & approved capitation rate FY2002-2006

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.


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ally 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 foster-ing 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 medi-cal 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 indi-cates 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 3.3-2.8 % in post-UC 2002-2004. On impoverishment, the increase in the poverty headcounts

Table 3.4.6: Utilisation by UC members

OP million visits IP million admission Level of care 2001 2003 2004 2001 2003 2004

Primary Care Unit

29.7 43.7 63.8

District hosp. 19 36.7 46.2 1.1 2.1 2.2

Provincial Hosp. 24.5 14.8 20.1 2.1 1.4 1.8

Annual changes Primary Care Unit

47% 46%

District hosp. 93% 26% 91% 5%

Provincial Hosp. -40% 36% -33% 29%

Source: NSO HWS2001, 2003 and 2004

Evidence from the Na-tional Statistical Office (NSO) Health and Wel-fare Survey (HWS), prior to UC scheme in 2001, and after the scheme in 2003 and 2004 indicated a sig-nificant increase in utilisation of OP and IP and significant reorien-tation of service utilisa-tion by beneficiaries towards the use of ser-vices at district health systems (DHS). Pri-mary care units and district hospitals are the major providers especi-


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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 evi-dent 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 Na-tional 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 va-

Table 3.4.7: Various sources of financing healthcare

Concentration Index Weight

Direct tax 0.9057 0.1868

Indirect tax 0.5776 0.3155

Social insurance 0.5760 0.0582

Private insurance 0.3995 0.0668

Direct payments 0.4864 0.3728

Total Health Financing 0.5929

General Tax 0.6996

lue of zero is when everyone pays the same irrespective of ability to pay. Based on macro financing using the National Health Account, and micro-level household survey by the National Statistical Office Socio-Economic Survey (SES); empipirical evidence indicates the total health financing in Thailand is quite progressive, the CI-index equals to 0.5929.

Direct tax is the most progres-sive 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 progres-sive, 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, esti-mated by the consultant is quite satisfactory, as it is more progressive than the income re-lated SHI contribution. If Thailand would go for the contributory scheme for the informal sec-tor (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 contribu-tion would be less than using general taxes.

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, ef-forts 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 im-plications 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 ther-apy, € 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


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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 gov-ernment 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. Nonth-aburi, International Health Policy Program, Ministry of Public Health. Mills, Anne; Bennett, Sarah; Siriwanarangsun, Porntep; Tangcharoensathien, Viroj (2000). The re-sponse 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 imple-menting 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 mak-ing 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 in-cluding ILO for peer reviews of capitation rate in 2002 and long term financing forecast for 2005-2020; 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 fi-nally 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.

X. Scheil-Adlung,G. Carrin, J. Jütting, K. Xu: Impact of social health protection in three African countries

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4. 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 eco-nomic 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 envi-ronment. 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. How-ever, 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 sys-tems 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 condi-tions (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. 70 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 (Univer-sity 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.


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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 expec-tancy

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 coun-tries, 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 im-proving 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 addi-tion, 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 (or-ganised 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 pub-lic 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 statu-tory 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 pub-lic 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 pub-lic facilities to all people with various user fees for different services and at different adminis-trative 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


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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. Prepay-ment 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 expen-diture as % of GDP

Government spending as % of total expenditure

Out-of-pocket payments as % of total ex-penditure

Private pre-payments as % of total expenditure

Population share covered (%)

Kenya 4.9 44 44.8 11.2 7 (NHIF)

Senegal 5.1 45.2 43.6 11.2 11.4 (IMPs and MOHs)

South Africa 8.7 40.6 12.4 47 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 govern-ment 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 in-cludes health insurance contributions/premiums and even the imputed taxes allocated to health through the government budget. However, in this study we concentrate on out-of-pocket 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 cov-erage of social health protection, health service utilisation, catastrophic health expenditure, financial sources for paying for health services and poverty impact.


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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 pri-vate 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 pay-ments 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 neces-sities for a period of time. It is measured as a household’s total expenditure minus its subsis-tence 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 house-hold 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 receiv-ing health services. Out-of-pocket payments typically include doctors’ consultation fees, pur-chases 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 ser-vices reflect the burden of ill health to a household. In addition to a reduction of funds avail-able 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-of-pocket health payments. The incidence of poverty is measured by the percentage of house-holds 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 associ-ated 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 insur-ance coverage, as well as health service utilisation and out-of-pocket payments, an endoge-neity test is performed (using the Hausman test or the bivariate probit model) when the im-pact 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 hy-pothesis of endogeneity could be rejected, however.


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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 protec-tion, 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 coun-tries 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 Ken- ya, for example, 2.3 % of the poorest quintile are covered while the richest quintile has coverage of 24.7 %. Results also show that higher popu-lation coverage at the national level does not necessarily reduce the dif-ference in coverage among income groups. Table 3 lists the results from the multiple logistic regression. A positive sign indicates that the indi-vidual with that characteristic is more likely to be covered by a social pro-tection scheme than those without this characteristic given that all other conditions are the same. A negative sign indicates the opposite direction.

The results suggest some common socio-economic characteristics associated with the cov-erage of social protection in all three countries:

73 It should be noted that household consumption expenditures were collected differently in the two types of sur-veys. 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 expendi-ture section in 8 items for a one-month period.

Figure 4.1.1: Percentage of population with social health protection

0%

10%

20%

30%

1 2 3 4 5

Quintile (poor to rich)Senegal Kenya South Africa


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Income is the factor that has a positive relationship with social health protection cover-age. 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 cov-erage 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 Af-rica.

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 Insur-ance 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

Employment + + ns

Urban Ns + +

Ethnic group + ns NA

Senior person + ns ns

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 cur-rent social health protection schemes are lacking coverage of specific, most likely vulner-able, groups of the population. The social protection deficit concerns particularly house-holds with low or no income, persons without formal em-ployment, women and rural households. In Kenya and Senegal, the elderly are par-ticularly neglected. These ex-cluded groups should be given more attention when imple-menting 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 catas-trophe 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 under-utilisation in developing countries (Dor/van der Gaag 1993, Müller et al. 1996). At the same


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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 rea-

Figure 4.1.2: Utilisation of outpatient services

0%

20%

40%

60%

80%

100%

South Africa Kenya Senegal

uninsured insured

sons for not seeking care in Sene-gal, 85 % of respondents in the poorest income quintile cited "could not afford" as the principal reason, whereas availability of services ("could not get health care") seems to be a minor problem. Comparable results were observed regarding the affordability of medicines pre-scribed (figure 4.1.3).

What is the impact of health insu-rance on seeking care if needed? 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).

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 in-sured 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

0 20 40 60 80

100

%

Need health care

Could not get health care

Could not afford health care

Could not get most of the medicine

Could not afford to get the medicine

Health Utilisation Indicators

1st quintile 3rd quintile 5th quintile

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, edu-cation, 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).


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Figure 4.1.4: Health Care Utilisation by Insurance Status in Senegal

0 2 0 4 0 6 0 8 0

1 0 0

%

N e e d h e a lth ca re

C o u ld n o t g e th e a lth c a re

C o u ld n o ta ffo rd h e a lth

ca re

C o u ld n o t g e tm o s t o f th em e d ic ine

C o u ld n o t a ffo rd to g e t

th e m e d ic in e

N o n -in su re d In su re d

Table 4.1.4: Effects of indicators on health service utilisation Indicators South Africa Kenya Senegal Insurance + ns (+* for inpat.) + Income Ns + + Education Ns + + Male Ns Ns - Health condition Ns - NA Employment Ns Ns NA Urban Ns Ns ns Ethnic group Ns Ns NA Senior person + - ns

Note: Significance level is set at 10% level except * which indicate 20% level. ns: not significant; NA: the variable is not available. +: positive; -: negative

Other socio-economic indicators also influence the use of health servi-ces. Income and educa-tion are found to have a positive effect on utilisa-tion in both Kenya and Senegal but not in South Africa. Urban location does not have a signifi-cant impact on utilisation controlling all the other variables. Sex makes no difference on service utilisation in South Africa and Kenya, but females are more likely to use services controlling all the other indicators in Sene-gal. Use of health servi-

ces 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.

Impact of social health protection on poverty

Health services are essential to improve people's health and health is a necessary prerequi-site 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 expendi-ture, income generation, households' strategies to finance health care costs and poverty al-leviation. 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


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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 sim-ple tabulation result shows that the percentage of households with catastro-phic expenditure is lower among the insured than the uninsured in all three coun-tries while the magnitude of the difference varies across countries (figure 5).

Figure 4.1.5: Percentage of households facing catastrophic expenditure

0%

5%

10%

15%

20%

25%

South Africa Kenya Senegaluninsured 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

Table 4.1.5: Socio-economic characteristics associated with catastrophic health expenditures

Indicators South Africa Kenya Senegal

Insurance ns (first 3 quintiles) ns -

+ (4th quintile) - (5th quintile)

Income (1st quintile as control group)

2nd quintile Ns - ns 3rd quintile Ns - ns 4th quintile + - - 5th quintile - - - Education NA - - Urban NA - - Children < 5 NA - + Senior person NA ns ns

Note: Significance level is set at 10% level. ns: not significant; NA: the variable is not available. +: positive; -: negative

it only works for the richest quintile and in Kenya no sig-nificant impact emerges. This result may not be surprising given the fact that in South Af-rica, the rich enjoy a better benefit package through dif-ferent insurance schemes than the poor who are only entitled to very limited benefit from public program or low cost in-surance schemes.

In Kenya the insurance cover-age is mostly based on em-ployment status and the main insurance program, NHIF, only covers inpatient service with a high cost-sharing rate by pa-tients. Two important results emerge from the analysis: First, social health protection can help to better shield households against financial shocks. Secondly, however, the current forms of health in-surance are far from being complete or perfect.

Other socio-economic indicators, such as rural locations are associated with a higher prob-ability 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


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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 gen-eration 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 diffi-culty 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 bor-rowing, except in Kenya. Table 4.1.6: Household financial mechanisms to cope with health care expenses (%)


Uninsured Insured Uninsured Insured Uninsured Insured

Sales of assets 5.9% 10.6% 1.0% 0.2% 15.4% 4.4% Borrowing from family or friends 10.5% 7.0% 27.9% 12.3%

Borrowing from outside 11.5% 3.0%

4.1% 4.3% 13.2% 6.1%

Social health protection and depth of poverty 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 house-holds poverty might be deep-ened by health expenditure. These facts have been con-firmed in numerous research findings and led to special attention and conclusions of the international community e.g. in establishing health-related MDGs, the WHO Commission on Macroeco-nomics and Health and ILO resolutions and conclusions on a new consensus in social security.

37%

4%

25%

2% 54%

10%

0%

20%

40%

60%

80%

Pov

erty

gap


Figure 4.1.6: Impact of health payments on poverty gap

before payment increased

The impoverishment due to health expenditures ranges between 1.5 % and 5.4 % of house-holds 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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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 protec-tion 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 econ-omy 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 coun-tries, 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 bar-rier to access health services for households in need. Under the condition of insufficient tax-based 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 cov-erage of social protection schemes to the poor and investing in social health protection de-velopment. 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 ad-justing 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 princi-pally 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 fi-nancial 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 statu-tory 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 com-plex 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 regard-ing identification of persons, adjusting to reduced capacities to pay for contributions, arrang-ing 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


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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 micro-insurance schemes in African countries is very interesting in this respect. Programs have either been initiated by health care providers (e.g. hospitals), non-governmental-organisations, 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, mi-cro 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 commu-nity institutions, such as co-operatives, to disseminate the insurance product and link com-munity 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 conse-quences 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 catastro-phic 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 comprehen-siveness 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. Re-cently, 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 eco-nomic 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.


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The topic of risk and vulnerability is gaining more and more attention in the international are-nas. 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 im-portant 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 wel-come as labour is often the only asset of the poor. Increasing worker productivity is a corner-stone 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

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4.2. Social Health Insurance Development as an Integral Part of National Pol-icy: 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 Constitu-tion amended in 2002. The Indonesian government has reformed the National Social Secu-rity 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 Indo-nesia; 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 ac-cess 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 Indo-nesians 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, in-cluding 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 Table 4.2.1: Basic Indicators of Indonesia

Indictors Value

Land area (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 is located between Asia and Aus-tralia, 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 de-fined by the World Bank. Successful family planning programs implemented in the last 30 years have controlled population growth and Indonesia now has an annual popula-tion 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).

Indonesia had achieved a GDP per capita of more than US$ 1,200 in 1996. However,

Sources: BPS 2005; WHO 2006, pp. 170ff

the Asian financial crisis of 1997 hit the Indonesian economy and led to a political crises re-sulting 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 envi-

74Deputy Coordination for Social Welfare, Coordinating Ministry for People’s Welfare the Republic of Indonesia, Jakarta, [email protected]; [email protected].


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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 ba-sic 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 dis-trict hospitals (less than 50 beds with four specialists - internist, obstetric-gynaecologist, sur-geon, and paediatrician) provide basic secondary care at district level; (2) municipality hospi-tals (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, de-pending 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 com-panies. The growing numbers of privately owned and foreign investor hospitals are compet-ing 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 geo-graphical (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 non-insured. On the other hand, hospital days were less than 100 per 1,000 people for the poor-est 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


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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 insur-ance. 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 com-pletely 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 pay-ment. Regardless of an employee’s wage level, all beneficiaries are entitled to comprehen-sive 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 em-ployees 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. Con-tracted 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 Jam-sostek. 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 ceil-ing 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 mil-lion 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 mil-lion 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 rela-tively 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 commer-cial insurance companies shows that total membership of the private health insurance mar-ket 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.


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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 so-cial 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 con-tribute 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 desig-nated 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 peo-ple 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 compensa-tion 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 distri-bution 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


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amount was adequate to cover already heavily subsidized user charges in public health fa-cilities). In 2003, the number of poor covered by this program was expanded to 167,000 peo-ple (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 contri-bution 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 is-sued 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 dis-tricts 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 accommo-date 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, govern-ment pays contributions for the poor for comprehensive services to Askes

Direct provision of primary care in public health centres. Health insur-ance scheme covers inpatient only, in third class ward of public hospitals and participating private hospitals

Number of beneficiar-ies

Poor population: 36,146,700 The poor and nearly poor: about 60,000,000 persons

Appointment of Askes To cover comprehensive health care

Outpatient referral and inpatient hospital care

Budget Rp. 1 Trillion (€80 million) in the first semester of 2005

Rp 3.7 Trillion (about € 300 million)

Rp. 1.323 trillion (€110 million)

Description First Semester 2005 and in 2006

Second Semester 2005

Scheme Health insurance, govern-ment pays contributions for the poor for comprehensive services to Askes

Direct provision of primary care in public health centres. Health insur-ance scheme covers inpatient only, in third class ward of public hospitals and participating private hospitals


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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 deliv-ery) 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 avail-able. 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 imple-mented, 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.


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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 proc-ess 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 re-lieves 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 Aske-skin. 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 indi-gent 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 entitle-ments of health care. In the first semester of 2006, 2.9 million hospital outpatient referral vis-its and 800,000 inpatient care have been recorded to Askes (Marisi 2006). 2005 data indi-cated 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 corre-sponding 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 Proce-dures, in Indonesian Currency (Rp) as of September 2005

No Medical Procedures Costs incurred

1 Heart surgery 3,134,600,000

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 5,384,330,979


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Table 4.2.4: Reported Health Care Utilisation for the Askeskin Program by September 2005

Description Utilisation Ratios to Population

Total visits 50,517,586 15.02

Referral visits 4,051,512 8.02

Secondary health care visits 3,277,438 6.48

Number of admissions 429,223 0.84

Number of haemodialysis cases 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

10 Bronchial asthma 7,170 2.74

Total 261,681 100.00

Conclusion Coverage by social health insurance is dominated by formal sector employees and benefici-aries of government subsidised contribution (Askeskin). In the formal sector, coverage ex-tends 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 ex-pansion 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 Indone-sia 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 Millen-nium Development Goals.

References Badan Pusat Statistik (BPS - Central Bureau of Census (2005). Indonesian Profile of 2005. BPS, Ja-karta (http://www.bps.go.in/index.shtml). Djaelani, Firdaus (2002). Development of Health Insurance Products in Indonesia. Paper presented at the Asia-Pacific Summit on Health Insurance, Jakarta, May 22-24, 2002.


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Hidayat, Budi; Thabrany, Hasbullah; Dong, Hengjin; Sauerborn, Rainer (2004). The effects of manda-tory health insurance on equity in access to outpatient care in Indonesia. Health Pol & Plann 19 (5), pp. 322-335 (http://heapol.oxfordjournals.org/cgi/reprint/19/5/322). International Labour Office (2005). Labour Survey of Indonesia. Jakarta, 2000 Jamsostek. Paper pre-sented in SHI seminar. October 18-19 2005. Jakarta. Lindenthal, Roland (2004). The Challenge of Social Protection for All: Policy Options for Indonesia. Working Paper UNSFIR/ILO, Jakarta. Marisi, Umbu (2006). Askeskin: Concept and the Progress. Paper presented on Workshop on Aske-skin for Women Organizations. Cisarua, September 6, 2006 Ministry of Health (MoH) (2001). Health Profile 2000. Pusdakes MoH, Jakarta. 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/cgi-bin/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-ilo-mirror.cornell.edu/public/english/protection/socsec/download/esspaper19.pdf#search=%22Scheil-Ad-lung%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/pdf-files/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 Insur-ance 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 pre-sented in IHEA Conference, Barcelona, July 10-13, 2005.


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4.3. Achieving Universal Coverage through Social Health Insurance in Asia

Dorsjuren Bayarsaikhan75

Today, most developing countries need additional financial resources to meet their increas-ing 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 re-sources 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 So-cial 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 rap-idly because of many factors associ-ated with the epidemiological shift due to ageing populations, the burden of diseases and new medical technolo-gies. 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 ex-penses if the frequency of their use is sufficiently high.

High out-of-pocket payments Table 4.3.1: Health Expenditure in Asia

Private HE % Public HE (%)

India 78.7 21.3 Viet Nam 70.8 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

Recent national health accounts statistics estimate that health systems in most devel-oping 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 catas-trophic health spending with a large poverty impact can be found in countries where out-of-pocket payment dominates in health care financing.

In Asia and the Pacific, coverage by prepay-ment schemes including social health insur-ance, is relatively low except for a few coun

Source: World Health Report 2005

tries such as Australia, Japan and the Republic of Korea that have achieved universal cover-age. 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 out-of-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

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necessary for successful social health insurance. But there are some challenges that coun-tries 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, evi-dence, 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

0

5

10

15

20

25

0 1000 2000 3000 4000 5000 6000

Annual Income Per Capita (in 1,000 dong)

Per

cent

of P

opul

atio

n

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 so-cially-oriented scheme to provide comprehensive health care benefits and universal cover-age through various types of health insurance seems to be a very attractive policy for Indo-nesia. 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 cover-age, and to benefit particularly rural and self-employed people.

The Indonesian experience represents several important issues that can be discussed fur-ther. 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 af-fordable 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.

Health ExpenditurePoverty Line


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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 in-surers 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 pol-icy 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 pro-tection 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 tech-niques 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 Se-ries 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). Pay-ing 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_M-0305.pdf#search=%22World%20Health%20Organisation%20Social%20Health%20Insurance%3A%20Se-lected%20case%20studies%20from%20Asia%20and%20the%20Pacific.%20WHO%20Regional%20Offices%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_REC1-en.pdf#search=%22World%20Health%20Organisation%20World%20Health%20Assembly%20Resolution%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 Ma-nila(http://www.wpro.who.int/sites/hcf/documents/hcf_strategy.htm).

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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 pay-ment explain a good portion of the cause of impoverishment. This in turn indicates that pov-erty can be prevented by reducing the burden of catastrophic payment, whose primary de-terminant is OOP payment in total health expenditure. The linkages among high OOP pay-ment in health care, catastrophic payment, and poverty is more evident among developing countries, which do not have advanced social protection mechanisms such as social insur-ance 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 pre-vent households from facing catastrophic spending in health. Nevertheless, many countries fail to develop social mechanisms to pool financial risks, even with rising income. Experi-ences 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 stew-ardship by President Park Jung-hee. Social health insurance in Korea started with enter-prises 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 un-covered 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 cov-erage for the self-employed and made a strong advocacy to extend SHI coverage towards the excluded sectors of Korean society.

76 Dean of the School of Public Health, Seoul National University, South Korea, [email protected]. 77 Senior Health Advisor, Berlin, Germany, [email protected].


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During the 1988 presidential election campaign, the then ruling party candidate Mr. Noh Tae-woo 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 contribu-tion 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 la-bour force.

Expansion of SHI Schemes to Get to NHI Taiwan The Republic of Taiwan started the implementation of social protection in health by establish-ing 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 cover-age 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 Farm-ers’ Insurance during a county governor election. Most candidates in presidential, parliamen-tary 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 independ-ent and to establish a new, additional scheme to cover the rest of the population. Other pro-posals 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 administra-tion.

The process of implementing universal social health insurance in Korea and Taiwan illus-trates 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 con-tributions 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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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 protec-tion 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 co-insurance 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 insur-ance financing and proved to be highly regressive (Yang et al. 2004). The diversified struc-ture, 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 in-surance 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 man-agement.

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 FFS-reimbursement to a form of prospective payment system, such as the global budgeting sys-tem. 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 eco-nomic 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.


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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 bar-gaining 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 sys-tem to move forward towards further health system reforms. Without universal coverage hav-ing 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 sys-tem’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 ur-gently needed in order to face the challenges of an aging society characterised by an in-creasing prevalence of chronic diseases and need for home-care. At the same time, well-designed and affordable cost containment mechanisms are necessary for controlling not only demand but also mainly supply-side induced cost escalation. The comprehensive NHI bene-fits 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 ob-taining 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 co-payment 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 out-patient care was implemented, charging high costs to those who went to a hospital for ambu-latory 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 pay-ment system is intended to enhance providers’ responsibility and improve the efficiency of the health care system. Introducing quality-based payment according to proven effective-ness, expanding the currently piloted Family Physician Initiatives, and strengthening a well


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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 ad-vance.

The NHI plan was designed to incorporate the mechanism of collective bargaining with pro-vider 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 estab-lishment 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 philoso-phy 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 mecha-nisms institutionalised by the solidarity principle. The ideas of mutual help and social coher-ence 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 lob-bies, market mechanisms and options of choice according to the basic concepts of neo-liberalism 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 de-pendents, 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 de-pendents (limited coverage). It is financed through contributions shared equally between em-ployer 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 repre-sents 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; bene-ficiaries 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 popu-lation) 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 techni-cal support, while International organisations and foreign donors including WHO, ILO and others are promoting health insurance reforms aimed at universal coverage. All previous ef-forts 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.


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additional reforms. However, a payment reform with the CSMBS has been suggested in or-der 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-for-service 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 palpa-ble 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 Citi-zens’ 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 Mongo-lian 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 capi-tation 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 man-agement 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 pro-viders 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 Pro-gram (MP) in 1969. It was compulsory for public and private sector salaried workers and de-pendents, 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 reim-bursement 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 inde-pendent 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 contribu-tions. The NHIP scheme includes both inpatient and ambulatory care benefits and coverage of indigent population is priority. The insurance scheme has established standards and regu-lations 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 achiev-ing 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.

Elements of Universal Coverage: Political will toward universal coverage Government financing commitment for vulnerable

population groups Technical support in planning and implementa-

tion, plus effective administrative capacity Followed by amendment of the system for ex-

pansion of coverage and refinement of the sys-tem for improved performance

As health care becomes costly under universal coverage, various structure reforms for long-run sustainability are required

With regard to the implementa-tion of social protection in health, a series of lessons can be drawn for developing coun-tries. Once a society realises that societal health goals – bet-ter health status, financial risk protection, health equity – can be achieved through social health insurance, the concept has to be shared among the public and has to be expressed in the political agenda. Certain-ly, social security has to start with a firm political will, but po-litical 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, govern-ment 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 implemen-tation 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 fi-nancing mechanisms, service delivery modality, organisational structure and other key ele-ments 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 imple-mentation 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.


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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, stake-holders and also the better-off members of society. It certainly provides more choices espe-cially for the better off and is more appealing when government funding is scarce and insuffi-cient 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 in-creasingly important role in most developing countries is even enhanced through develop-ment 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 rea-sonable 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 pro-gram 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 imple-mented mechanisms available and SHI possesses reasonable bargaining power against pro-fessional 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 achiev-ing universal coverage in the long-term and require further reforms.

Basic questions The experiences from Taiwan and Korea raise two interesting for developing countries cur-rently 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 eco-nomic 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 experience-based framework, rather than a concept-based theoretical framework. Contributing factors for NHI, common to both countries, were; sustained economic growth, strong consumer de-mand for insurance coverage, public trust in bureaucratic leadership, democratisation proc-ess81 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 administra-tion structure.


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The political leadership in both countries understood the value of NHI in the first place, rec-ognised the opportunity of achieving it, and seized it boldly. During the implementation proc-ess of NHI, there were various conflicts among stakeholders, resistance from vested interest groups, political struggle, bureaucratic misunderstanding, and financial impediments. Over-coming all these obstacles was possible, in both countries, only by strong government lead-ership, 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 so-cial 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, fi-nancial 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. Neverthe-less, 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 eco-nomic evaluation information in decision making. The prospect of desirable changes is prom-ising, 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 ex-ample, 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 im-plementation of universal health insurance and successive health insurance reforms in the


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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.

References Arhin-Tenkorang, Dyna (2000). Mobilizing Resources for Health: The Case of User Fees Revisited. CMH Working Paper Series, Paper No WG3:6. Washington DC (http://www.cmhealth.org/docs/wg3_paper6.pdf). Cheng, Tsung-Mei (2003). Taiwan’s new national health insurance program: genesis and experience so far. Health Affairs 22 (3), pp. 61-76 (http://content.healthaffairs.org/cgi/reprint/22/3/61). Chiang, Tung-liang (2005). The first decade of universal health insurance in Taiwan: performance assessment. Paper prepared for Taiwan Development Perspectives 2005, National Policy Foundation, Taipei, Taiwan. Gottret, Pablo; Schieber, George (2006). Health Financing Revisited. A Practitioner’s Guide. World Bank, Washington DC (http://siteresources.worldbank.org/INTHSD/Resources/topics/Health-Financ-ing/HFRFull.pdf#search=%22%22Wilkinson%22%20%22Impact%20*%20User%20Fees%22%22). Hsiao, William (2000). A Strategic Framework in Mobilizing Domestic Resources for Health, unpub-lished draft, Harvard University. Kawabata, Kei;, Xu, Ke; Carrin, Guy (2002). Preventing impoverishment through protection against catastrophic health expenditure. Bull World Health Organ 80 (8), S. 612 (http://www.who.int/bulletin/archives/80(8)612.pdf). Lu, Jui-Fen; Hsiao, William (2003). Does Universal Health Insurance Make Health Care Unaffordable? Lessons From Taiwan. Health Aff 22 (3), pp. 77-88 (http://content.healthaffairs.org/cgi/reprint/22/3/77). Pauly, Mark; Zweifel, Peter; Scheffler, Richard; Preker, Alexander; Bassett, Mark (2006). Private Health Insurance In Developing Countries. Health Affairs 25 (2), S. 369-379 (http://content.healthaffairs.org/cgi/reprint/25/2/369). Penn Table, Centre for International Comparison, University of Pennsylvania, various years Sekhri, Neelam; Savedoff, William (2005). Private health insurance: implications for developing coun-tries. Bull World Health Organ 83 (2), S. 127-134 (http://whqlibdoc.who.int/bulletin/2005/Vol83-No2/bulletin_2005_83(2)_127-134.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). Wagstaff, Adam (2005).Health Systems in East Asia: What Can Developing Countries Learn from Japan and the Asian Tigers? Working Paper WPS3790, World Bank, Washington DC (http://www.equitap.org/publications/wps/wps3790.pdf). Yang, Bong-Min (1991). Health Insurance in Korea: Opportunities and Challenges. Health Policy Planning 6 (2), pp. 119-129 (http://heapol.oxfordjournals.org/cgi/reprint/6/2/119). Yang, Bong-Min (2003). Consolidation process of insurance funds. Paper prepared for and presented at the Public Administrator Workshop, KDI School, Seoul. Yang, Bong-Min (2005). National Health Insurance in South Korea: opportunities and challenges. Pa-per presented at the International Conference on Health Insurance, Taipei, Taiwan, March 2005. Xu, Ke; Evans, David; Kawabata, Kei; Zeramdini, Riadh; Klavus, Jan; Murray, Christopher (2003). Household catastrophic health expenditure: a multicountry analysis. Lancet 362 (9378), pp. 111–117 (http://www.thelancet.com/journals0/lancet/article/PIIS0140673603138615/fulltext). World Bank (1993). World Development Report 1993: Investing in Health. Washington D.C. (http://publications.worldbank.org/ecommerce/catalog/product?item_id=194651). World Bank (2004). Making Services Work for Poor People. World Development Report 2004. World Bank/Oxford University Press. Washington DC/Oxford (http://media.worldbank.org/secure/wdr/wdr2004/pdfs/complete.pdf).

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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 So-cial Health Insurance 2005”85; and the GTZ initiatives on Social Health Insurance.

The international conference was a concrete contribution to the implementation of the rec-ommendations 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 Depart-ment, Directors-General, Directors, Chief Executive Officers (e.g. in the field of health, fi-nance, 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 perspec-tives 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 Millen-nium 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 malnutri-tion.

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 af-ford 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 cover-age at all. The poor are the most vulnerable as they are less able to recover from the finan-cial 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 indi-viduals 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

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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. Espe-cially 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, pre-ventive, 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 allo-cate 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 develop-ment 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 cov-erage (i.e. universal health protection). Social protection in health comprises a variety of fi-nancing 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 strat-egy 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 health-care 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 respon-sibility and participatory governance by social partners and insured. In many systems, gov-ernance 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 gov-ernments (though of course accountability relations between the insurance fund(s) and the


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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 strat-egy 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 hu-man 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. Be-yond the health sector, the broader determinants of ill-health such as social exclusion of spe-cific groups (e.g. the rural population, ethnic minorities, migrants, and unemployed), low lev-els 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 di-rectly 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 inequali-ties and promoting a better overall health status, it enhances human capital formation, thereby increasing overall economic productivity. According to estimates by the WHO Mac-roeconomic 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 ex-pectancy 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 ac-cumulation 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 re-quires a strong political will. Combining contribution-based financing with tax-financed subsi-dies 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 contribu-tors 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 suf-ficient to finance approaches to include the poor. Depending on country-specific needs, ex-ternal funds can assist in financing measures of social protection in health. Innovative financ-ing 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 substi-tute national funding. Moreover, transfer of funds must be made in such a way to ensure sus-tainability 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.


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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 macro-economic, 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 struc-ture of the economy, partic-ularly on the relative size of the informal and formal sec-tor. The manner by which countries coordinate mech-anisms for revenue collec-tion, pooling of prepaid funds, and purchasing of services has critical implica-tions for the extent to which financing systems contribu-te to health gain, financial protection, and other performance objectives. Certainly, economic growth enhances govern-ments' 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 vol-untary contributions.

Areas of Action For countries aiming to promote and expand universal health protection under their leader-ship, 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 gov-ernments 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 effec-tive, 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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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 con-trolling 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, creat-ing 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 pro-vide 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 do-mestic 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 success-ful 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 mak-ers, employers and workers’ organisations, key actors from the private sector and from vari-ous 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 exten-sion 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, govern-ments 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 participa-tory forms of decision-making. In the case of social health insurance, this may include a di-rect 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


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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 gender-related 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 com-munity-based) can offer supple-mentary 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 insur-ance. Community-based health insurances might be important organisational devices in exten-ding 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 cover-age 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 purchas-ing 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


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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, universal-ity and solidarity in health are invited to join the global partnership and cooperate at the inter-national, 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 decision-making authorities often face limited capacities and experience to develop socially balanced and pro-poor health care sys-tems. In principle, technical cooperation and collaboration at regional, country and community level to strengthen capacities and expertise in the devel-opment of health financing sys-tems 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 macro-economic 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 (includ-ing contracting), extending protection to those at greater risk of non-use of needed ser-vices or impoverishment, health insurance coverage and registering members, design-ing 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 en-vironmental 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 socio-economic 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 ap-proaches to social protection.

Networking and Advocacy

86 Available tools comprise, for instance, of InfoSure, an Internet based information and evaluation tool for assess-ing 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 de-signing, implementing and improving social protection mechanisms and governance such as social dialogue and STEP tools to administer, monitor and evaluate micro insurance schemes.


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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 de-velop 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 aca-demic 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. Activi-ties should focus on:

Introducing mechanisms and developing indicators to monitor progress, evaluate im-pacts, and document the results of financing reforms aimed at improving social protec-tion, 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 in-creased 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 develop-ment 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

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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 manage-ment. General practitioner and regional director of public health until 1986, since 1987 director of hospi-tals 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 Gen-eral 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 spon-sored 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 Re-gional 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 Sci-ences (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) (1993-1994), 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) (1999-2001), 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 dec-ades 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 Cor-poration (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, re-searcher at the Center for Operations Research and Econometrics in Leuven, Takemi Fellow in interna-tional 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 pub-lic health at Boston University in 1990. Currently coordinator of health financing policy within WHO's De-partment of Health Systems Financing in Geneva.


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Xiaoming Cheng, graduated from Shanghai Medical University in 1976. He is Professor at Health Eco-nomics 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 interna-tional 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 Organiza-tion 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) (1993-2001), 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 Ri-can 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. Econo-mist 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 Ger-man 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 Uni-versity, 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 Eco-nomics from the University of York (2003). Management of health projects in Africa with Save the Chil-dren 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, habilita-tion 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 Ad-ministrator at the OECD Development Centre, team leader for the Centre's work programme on institu-

Contributors

178

tions, poverty and health, culture and gender. Scientific adviser of the World Bank, WHO and ILO in mat-ters 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 mem-ber 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 His-tory 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 experi-ence 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 in-surance; 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 Uni-versity 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 pol-icy 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 investi-gator of several research studies on health policy, health insurance, and health financing at the Interna-tional 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 Sci-ence, 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 teach-ing faculty for the Harvard/World Bank Institute Flagship Course on Health Sector Reform and the Berke-ley/Barcelona Leadership Forum, regular lecturer at Columbia University and McGill University. Sec-onded 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.


179

Xenia Scheil Adlung, Dr. rer. pol. (Ph.D) degree obtained the Free University of Berlin. Head of Divi-sion, Federal Government of Germany, Ministry of Youth, Family Affairs, Women and Health (1979-1991), Programme Manager and Research Officer at the International Social Security Association (1991-2003). Since 2003, Health Policy Coordinator in the Social Security Department of the International La-bour 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 Insti-tute 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 Shang-hai 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. Nu-merous 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 Pro-gram, 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 advi-sor 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 (1993-1997), 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 or-ganisation „Jungsozialisten“ (Young Socialists (1974-1979), Member of the European Parliament (Com-mittee 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 re-search interest focuses on health services and health insurance in China.

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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 Wieczorek-Zeul, Minister of Economic Cooperation and Develop-ment, Germany

Introduced by Dr Assia Brandrup-Lukanow, GTZ

“Health, Solidarity and Social Protection: The Ger-man contribution to the Millennium Development Goals”

1330 1415 Inaugural address:

H.E. David Fuentes Montero, Minister of Finance, Costa Rica

“Social health insurance and its role in economic development and poverty reduction”

1415 1445 Break

1445 1510 Mr. Assane Diop, Executive Director General, Interna-tional Labour Office

“Decent work and Decent Health: A Goal for Fair Globalization”

1510 1535 Dr. Stefan Helming, Director General for Planning and Development, German Technical Cooperation (GTZ)

“Social Protection and Health Improvements”

1535 1600 Dr Timothy Evans, Assistant Director General, World Health Organization

“Social Health Insurance and Poverty Reduction”

1600 1630 Break

1630 1730 Open Debate

MODERATOR: Michel Gabrysiak, CEO Finance Foun-dation / Television Producer

1930 2200 Evening reception at the GTZ-House


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

“Poverty, health and social protec-tion”

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 so-cial health insurance framework: The strategies applied in Viet Nam” DISCUSSANT: Dr. Claude Bodart, GTZ Programme Manager, Philip-pines 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 cover-age” DISCUSSANT: Dr Rüdiger Krech, Head of Social Protection, GTZ

SESSION 2: Advancing the socio-economic development agenda CHAIRPERSON: Dr Nata Me-nabde, Director of Division Country Health, WHO Regional Office for Europe PRESENTER: Prof Shenglan Tang, University of Liverpool “Economic and social develop-ment: New challenges to social protection and the health care sys-tem 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 Ouat-tara, Union Technique de la Mutu-alité Malienne, Mali

SESSION 3: Social Protection and Global Health Initiatives CHAIRPERSON: Dr Alimata J. Di-arra-Nama, Director Health Systems, WHO Regional Office for Africa (AFRO) PRESENTER: Dr Bernhard Schwartländer, GFATM, Director, Strategic Information and Evaluation “The Global Fund and solidarity-based 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


181

1115 1145 Break

1145 1245 CHAIRPERSON: Dr Timothy Evans, Assistant Director Gen-eral, WHO

Ministerial Round Table on challenges to implementation: Discussion among Ministers of finance, health and labour + keynote speaker and rappor-teurs (Dr Ponmek Dalaloy, Minister of Health, Laos; Mr David Fuentes Mon-tero, Minister of Finance, Costa Rica; Prof Amara Cisse, Minister of Health, Guinea; Dr Sodnompil Tserendorj, Deputy Minister of Health, Mongolia )

1245 1415 Lunch

1415

1545 SESSION 4: Social health protection - linking up in mixed health financ-ing systems

CHAIRPERSON: Dr Mark Blecher, Director, Ministry of Finance, South Africa

PRESENTER: Dr Indrani Gupta:

“The challenge of universal cover-age in mainly rural settings: New approaches in India”

DISCUSSANT: Mr Joseph Kutzin, Regional Advisor Health Financing, WHO Office for Europe

PRESENTER: Dr Viroj Tangcharoen-sathien, Director, International Health Policy Programme, Ministry of Public Health, Thailand “Universal coverage in Thailand: The respective roles of social health insur-ance and tax-based financing”

DISCUSSANT: Dr William Savedoff, Senior Partner, Social Insight (Consult-ant)

PRESENTER: Dr Ainura Ibraimova Sultanovna, Deputy Minister of Health, Director Mandatory Health Insurance Fund, Kyrgyz Republic “Health Fi-nancing Reform in the Kyrgyz Re-public: Addressing Equity, Access and Efficiency”

DISCUSSANT: Dr Walter Seidel, EuropeAID, European Commission

SESSION 5: Current reforms in the extension of health insur-ance coverage

CHAIRPERSON: Mr Assane Diop, Executive Director, ILO

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”

DISCUSSANT: Dr. Bergis Schmidt-Ehry, GTZ Tanzania

PRESENTER: Dr Youssoufa Wade, President, Comité du Dia-logue Social, Sénégal

”The importance of social dia-logue in the extension of cover-age: Lessons learned in Senegal”

DISCUSSANT: Dr Ursula Enge-len-Kefer, Deputy Chairperson, German Confederation of Trade Unions, Germany

PRESENTER: Mr Emmanual Humba, Director General of NHIF “Experience of Extending Health Insurance Coverage in Tanza-nia”

DISCUSSANT: Dr Eduardo Levcovitz, Regional Advisor Health Financing, PAHO

SESSION 6: Implementation of social health insurance: learning from the evidence and setting of policy objectives

CHAIRPERSON: Mr Alejandro Bonilla-Garcia, Acting Secretary General, International Social Secu-rity Association

PRESENTERS: Dr Xenia Scheil-Adlung, Health Policy Coordinator, Social Security Department, Interna-tional 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 Devel-opment as an Integral Part of the National Health Policy: Recent Reform in Indonesian Health Insur-ance System” DISCUSSANT: Mr Dorsjuren Bayarsaikhan, Regional Advisor Health Financing, WHO Office for the Western Pacific

PRESENTER: Prof Dr Vlad Iliescu, Secretary of State, Ministry of Health: ”Lessons Learned in the Health Financing Reform in Romania”

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 after-noon (Dr. Ainura Ibraimova Sultanova, Deputy Min-ister of Health, Kyrgyzstan; Mr Julio Frenk, Health Minister of the United States of Mexico; Dr. Adang Setiana, Deputy Minister of People’s Welfare, Indone-sia; Mr. Abu Md. Maniruzzaman Khan, Secretary of State, Ministry of Health and Family Welfare, Bangla-desh )

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0900 0930 Conference Reporter Michel Gabrysiak, CEO Finance Foundation / Television Producer

Feedback from the Working Sessions of Day 2

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

“Implementation of health insur-ance in developing countries: lessons from international ex-perience”

1000 1100 Moderator: Ms Andrea Fischer, Department of Health, Institute for Or-ganisational Communi-cation, Germany

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

1100 1130 Break 1130 1215 Mr. Stefan Helming, Director General, GTZ

Mr. Assane Diop, Executive Director, ILO

Dr. Timothy Evans, Assistant Director General, WHO

Conference Conclusion: Enhanc-ing the responses to international commitments on Social Health Protection (WHA Resolution 2005, New Consensus on Social Security from ILC 2001)

1215 1230 Closure: GTZ


183

6.3. Participants Bangladesh

Abu Md. Maniruzzaman Khan State Secretary, Ministry of Health and Family Welfare Shamim Ara Deputy Director, Ministry of Health and Family Welfare, Health Econom-

ics Unit Md. Jahangir Joint Chief, Ministry of Health & Family Welfare, Health Economics Unit Günter Dietz German Technical Cooperation (GTZ), Office Bangladesh

Belgium

Alain Coheur Mutualités Socialistes Pierre de Paepe Institute for Tropical Medicine (ITG) Antwerp Werner Soors Institute for Tropical Medicine (ITG) Antwerp, Public Health Jean Hermesse Secrétaire National, Alliance Nationale des Mutualités Chrétiennes Dominique Evrard Mutualités Chrétiennes

Cambodia

H.E. Mam Bun Heng Deputy Minister of Health Ouk Samvithyea Lo Veasnakiry Ministry of Health Olivia Nieveras German Technical Cooperation (GTZ), Support to the Health Sector

Reform

Cameroon

Saa Ministry of Public Health Theophile Moulong Technical Director, La Citoyenne Komi Alain Ahawo Technical Consultant, German Technical Cooperation (GTZ), Office

Yaoundé

Chile

Michael Hagen Fondo Nacional de Salud (FONASA)

China

Song Daping Ministry of Health, China Health Economics Institute Sheng-Lan Tang Liverpool Institute of Tropical Medicine

Columbia

Beethoven Herrera Valencia University of Bogota

Costa Rica

H.E. David Fuentes Montero Minister of the Treasury Alberto Pacheco Sáenz 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 Agence Française de Développement, Dép. du Développement Humain Michel Gabrysiak CEO, Finance Foundation Alain Letourmy Centre de Recherche Médecines, Maladie et Sciences Sociales (CERMES)Agnès Plassart Public Interest Group, Social Security Kulmie Samantar Mutualité Française, Direction Générale Groupe

Participants

184

Ghana

E. Appiah-Denyira Eastern Regional Director, Ministry of Health

Guinea

H.E. Amara Cisse Minister of Health El Hadj Aboubacar Dione Ambassador, Embassy of Guinea in Germany Alhassane Barry Conseiller Technique/ RECAP, German Technical Cooperation (GTZ),

Office Guinea, Programme Santé et lutte contre le VIH/SIDA Helga Piechulek Programme Santé et lutte contre le SIDA

Honduras

Richard Zablah Director, Instituto Hondureño de Seguridad Social

India

Narayan Devadasan Institute of Tropical Medicine, Bangalore Alok Kumar Gosh Chief Technical Officer, Governm. of West Bengal, Basic Health Project Indrani Gupta University Enclave, Institute of Economic Growth and Health Policy Re-

search Subhash Sharma Ministry of Finance N. K. Roy Deputy Director, Government of West Bengal, Basic Health Project Thomas Thampan President, Hind Mazdoor Sabha (HMS) Johann Peter Steinmann Principal Advisor Health, German Technical Cooperation (GTZ), Office

New Delhi

Indonesia

H.E. Sjafii Ahmad State Secretary, Ministry of Health H.E. Adang Setiana Deputy Minister for Social Security, Coordinating Ministry for People’s

Welfare Ida Bagus Indra Gotama Director of Health Insurance, Ministry of Health, Directorate General of

Public Health Aditiarsih Destriani Miroslaw W. Manicki Team-Leader, Social Health Insurance Project, GTZ/GVG Bambang Purwoko Asih Eka Putri National Advisor, Social Health Insurance Project, GTZ Orie Andari Sutadji President Director, PT ASKES Hasbullah Thabrany Dean, University of Indonesia, Faculty of Public Health Claude Bodart 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 Director, Ministry of Health, Dep. of Standards and Regulatory Services Burkard Kömm German Technical Cooperation (GTZ), Office Nairobi, Kenya Inke Mathauer 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 Deputy Minister of Health, Ministry of Health, Social and Family Affairs Ninel Kadyrova Deputy Director, Mandatory Health Insurance Fund, Ministry of Health


185

Laos

H.E. Ponmek Dalaloy Minister, Ministry for Health Khouanta Phalivong Ambassador, Embassy of the Lao PDR in Germany Khamphet Manivong Head of Planning Division, Ministry of Health Vorasarn Somnuk President and General Director, ASSA Jürgen Hohmann Belgian Technical Cooperation, Laos

Mali

Aissata Diallo Advisor, Ministry of Health Oumar Ouattara Union Technique de la Mutualité Malienne

Mexico

H.E. Julio Frenk Minister of Health Carlos Dittmann Fernández Embassy of Mexico in Germany Felicia Knaul Principal Economist, Fundacion Mexicana para la Salud (FUNSALUD)

Mongolia

H.E. Sodnompil Tserendorj State Secretary, Ministry of Health T. Galbaatar Ambassador, Embassy of Mongolia in Germany Erdenesuvd Derem Ministry of Social Welfare and Labour D. Tegshargal Embassy of Mongolia in Germany Amar Bazarragchaa Deputy Director, State Social Insurance General Office Surenchimeg Vanchinkhuu Coordinator, ADB/TA, Support for Health Sector Reform

Netherlands

Anno H.Y.Galema Senior Advisor in Health Systems, Netherlands Ministry of Foreign Af-fairs, Social and Institutional Development Department

Pakistan

Muhammad Mukhtiar Health Department NWFP Peshawar Muhammad Bashir Law Government of NWFP Muhammad Iqbal Afridi Health Department Inayatullah Health Department Zakirullah Khan Provincial Assembly Paul Josef Rückert German Technical Cooperation (GTZ), Health Project NWFP

Philippines

Donabelle de Guzman Department of Health Eduardo Banzon Vice President for Health Financing Policy, Philippines Health Insurance

Corporation Ruben Basa Head of Corporate Planning, PhilHealth Tito Mendiola Philippinian Health Insurance Corporation Matthew Jowett German Technical Cooperation (GTZ), Office Manila, Philippines

Romania

H.E. Vlad Iliescu Deputy Minister of Health Catalin Victor Arjoca Embassy of Romania in Germany Mihai Laurentiu Ministry of Health

Rwanda

Laurent Musango Director of the Public Health School, National University of Rwanda Andreas Kalk German Technical Cooperation (GTZ), Office Kigali, Rwanda

Senegal

Youssoufa Wade Comité National du Dialogue Social, Dakar

Participants

186

South Africa

Mark Blecher Director, Ministry of Finance, Health Care Financing Michael Thiede Director, University of Cape Town, Health Economics Unit Neva Makgetla 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 Advisor for Health, Swiss Development Agency, Social Development Division

Alexander Schulze Manager Health Projects, Novartis Foundation for Sustainable Devel-opment

Fritz Brugger Brugger & Partner

Syria

Mahmoud Dashash Director, Ministry of Health, Planning Department

Tanzania

Faustin Njau Head of Health Sector Reform Department, Ministry of Health Emmanuel Humba Director General, National Health Insurance Fund (NHIF) Bergis Schmidt-Ehry German Technical Cooperation (GTZ), Health Sector Support Program

Thailand

Viroj Tangcharoensathien Director, Ministry of Public Health, International Health Policy Program Pongpisut Jungudomsuk Ministry of Public Health, National Health Security Office Samrit Srithamrongsawat National Health Security Office Kaemthong Indaratna Chulalongkorn University, Faculty of Economics Ernst Tenambergen German Technical Cooperation (GTZ), Office Bangkok

Tunisia

Abdessalem Hichem Director, Ministry of Public Health Hédi Achouri Directeur de la Tutelle des Hôpitaux, Ministère de la Santé Publique

Uganda

H.E. Alex Kamugisha Minister of State for Primary Health Care Rogers Enyaku Ministry of Finance, Planning and Economic Development Robert K. Basaza Senior Health Planner, Ministry of Health Francis M. Runumi 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 Deputy Director, Ministry of Health, Health Insurance Department Van Tien Tran Health Policy and Strategy Institute

Yemen

Rashad Sheikh Bin Shujaa Health Policy Unit, Public Health and Population


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 Vice President, KfW Entwicklungsbank, Sector and Policy Division Health / Sub-Saharan Africa

Ulrich Dorf Division Chief Health Asia, KfW Entwicklungsbank Katharina Anschütz Senior Sector Specialist, KfW Entwicklungsbank Joachim Schürmann Senior Public Health Expert, KfW Entwicklungsbank Astrid von Kutzleben 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 "Aids-

Bekämpfung 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 InWent – Capacity Building International gGmbH Claudia Kornahrens Head of Health Section, InWent – Capacity Building International gGmbH

— AOK

Alfred Heigl AOK-Bayern, Direktion Augsburg Karin Dobberschütz AOK Consult GmbH Klaus Jacobs Leiter, Wissenschaftliches Institut der AOK (WIdO) Michael Stahl AOK-Bayern, AOK Systems Jan van Lente AOK Bundesverband Thomas Uhlemann AOK Research Institute Boris Velter AOK Bundesverband Christina Weinreich AOK Berlin

Jürgen Borchardt German Development Service (DED) Stephan Burger Geschäftsführer, Wissenschaftlicher Beirat der Betrieblichen Kranken-

versicherung, BKK Bundesverband Joachim Gromotka GFA Consulting Group Hamburg Jürgen Huppenbauer Gesamtverband der Deutschen Versicherungswirtschaft e.V.,

Abteilung Politik Rolf Jordan Asienstiftung Essen Harald Kröck German Trade Union Confederation (DGB) Helmuth H. Leuters Consultant Frank Micheel Federal Institute for Population Research Michael Niechzial EPOS Health Consultants GmbH Andreas Plate Techniker Krankenkasse Mathias Rompel University of Giessen, Institute of Sociology Cornelius Schmaltz Volkswagen Stiftung Hartmut Welscher Institute of Asian Affairs Barbara Schmidt-Eule Arbeitsgemeinschaft für Entwicklungshilfe Martin Wrede Gesellschaft für Versicherungswissenschaft und –gestaltung e.V. Stefan Zimmer Executive Assistant to the Director General, Hauptverband der ge-

werblichen Berufsgenossenschaften

International Organisations

EU – European Union

Walter Seidel European Commission (EuropeAid E3), Operations Quality Support – Health Sector

GFATM

Rolf Korte Chair, GFATM TERG Bernhard Schwartländer Director Monitoring & Evaluation, Global Fund to Fight AIDS, Malaria

and Tuberculosis

ILO

Assane Diop Executive Director, International Labour Office (ILO) Christine Bockstal International Labour Office (ILO), STEP Regional Coordination Michael Cichon Director, International Labour Office (ILO), Social Security Department Wolfgang Heller Direktor, Internationale Arbeitsorganisation (ILO), Vertretung in

Deutschland Frank Hoffer International Labour Office (ILO), ACTRAV Fiona Howell CTO ILOSSP, International Labour Office (ILO) Christian Jacquier Coordinator, International Labour Office (ILO), STEP PROGRAM Xenia Scheil-Adlung Health Policy Coordinator, International Labour Office (ILO), Social

Security Policy and Development Branch Carmen Solorio International Labour Office (ILO) Philippe Vanhuynegem Advisor, International Labour Office (ILO), STEP PROGRAM


189

John Woodall International Labour Office (ILO) Hiroshi Yamabana Social Security Specialist, International Labour Office (ILO), Subre-

gional Office

ISSA

Alejandro Bonilla-Garcia Acting Secretary General, International Social Security Association (ISSA)

Jens Schremer International Social Security Association (ISSA)

OECD

Johannes Jütting 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 Clus-

ter (EIP) David Evans Director, Department of Health System Financing, Evidence and In-

formation 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 Sys-

tems 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 World Health Organization (WHO), Viet Nam Maryam Bigdeli World Health Organization (WHO), Cambodia Hana Brixi World Health Organization (WHO), China

Participants

190

Stephanus Indradjaya National Professional Officer, World Health Organization (WHO), In-donesia

Dick Jonsson Senior Advisor, World Health Organization (WHO), Uganda, Head of Programme Coordination

Sunil Nandraj National Professional Officer, World Health Organization (WHO), India Diosdado-Vicente Nsue-Milang

Representative, World Health Organization (WHO), Rwanda

Nguyen Kim Phuong Public Health Officer, World Health Organization (WHO), Viet Nam Ibrahim Mohamed Abdel Ra-him

Representative, World Health Organization (WHO), Tunisia

World Bank

Oscar Picazo Sr. Economist (Health), The World Bank, AFTHD Africa Region Alex Preker Senior Health Economist, The World Bank

World Bank Institute

Gilles Dussault Senior Health Specialist (Policy), The World Bank Institute


191

6.4. Bibliography for further reading Achouri, Hédi, Jarawan, Eva (2003). Autonomous Hospitals in Tunisia. In: World Bank (2003). Innova-tions 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 Hu-man 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 mala-die dans les pays du Maghreb : Défis et réformes planifiées. Tunis. Adam, Erfried; von Hauff, Michael (Eds.) (2002). Social Protection in Southeast & East Asia. Friedrich-Ebert-Stiftung/Toennes Satz + Druck GmbH, Erkrath. ISBN 3-89892-122-0 (http://library.fes.de/pdf-files/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.svr-gesundheit.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._13.pdf). Ahuja, Rajeev; Jütting, Johannes (2004). Are the Poor Too Poor to Demand Health Insurance? Jour-nal 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, New-Delhi(http://www.icrier.res.in/wp118.pdf; http://www.iaae-agecon.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 Ver-gleich. Bundesrepublik Deutschland, Schweiz, Frankreich, Italien, Großbritannien. Campus-Verlag Frankfurt/New York. Alber, Jens (2002). Besser als sein Ruf. Der Sozialstaat als erfolgreiches Modell. WZB-Mitteilungen 98. Wissenschaftszentrum Berlin für Sozialforschung. Berlin (http://www.wz-berlin.de/publikation/pdf/wm98/WM98_24-28.pdf). Almeyda, Gloria; Jaramillo, Francisco de Paula (2005). La Equidad, Colombia, Good and Bad Prac-tices. CGAP Working Group on Microinsurance, Good and Bad Practices, Case Study No. 12 (http://microfinancegateway.org/files/27891_file_Equidad_Good_and_Bad_Practices_No._12.pdf).

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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 Develop-ment

Centre for Agriculture and Rural Devel-opment

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, Mala-die 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 Prévoy-ance 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


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 Infor-mation

Department of Planning and Health Infor-mation

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 Immuniza-tion

Global Alliance for Vaccines and Immuni-zation

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 Zu-sammenarbeit

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 Reduc-tion

Abbreviations

220

HEU Household Expenditure & Utilisation Survey Household Expenditure & Utilisation Sur-vey

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 institu-tions

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 So-cial 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 Políti-ca Económica

Ministry of National Planning and Eco-nomic Policy


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 Commis-sion

National Development Planning Commis-sion

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 Exclu-sion and Poverty

Strategies and Tools against social Exclu-sion 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

United Nations Research Institute for So-cial 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


223

6.6. Social protection in health: Links to Important Websites http://www.afdb.org/portal/page?_pageid=473,970558&_dad=portal&_schema=PORTAL

African Development Bank, Social Protection And Risk Management

http://www.alliance-hpsr.org Alliance of Health Policy and Systems Re-search

http://www.adb.org/SocialProtection/default.asp Asian Development Bank, Social Protection

http://www.ausaid.gov.au/hottopics/topic.cfm?ID=8626_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

http://www.eldis.org/healthsystems/index.htm; http://www.eldis.org/healthsystems/financing/index.htm

Eldis Health systems/Health Sector Financing

http://www.diplomatie.gouv.fr/en/ministry_158/publications_2288/international-cooperation-and-development_2289/reperes-serie_2290/attacking-poverty-inequality-and-exclusion_2722/social-protection_3239.html#nb20

French International Cooperation Social protec-tion

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/soziale-entwicklung/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 re-search)

http://www.ids.ac.uk/ids/ Institute of Development Studies (IDS), Univer-sity of Sussex

http://www.iadb.org/topics/subtopics.cfm?subtopicID=SEG&language=English&topicID=IS&parid=2&item1id=10

Inter American Development Bank (IADB, BID), Social Inclusion & Equality

http://www.ilo.org/public/english/protection/ International Labour Office Social Security De-partment

http://www.issa.int International Social Security Association

http://www.jica.go.jp/english/global/soci/index.html JICA, Social Security

http://www.kfw-entwicklungs-

KfW Health Division

Weblinks

224

bank.de/DE_Home/Fachthemen/Gesundheit32/index.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; http://www.minbuza.nl/en/ministry,organisational_structure/Policy-Theme-Departments.html#a8

Netherlands Ministry of Foreign Affairs; Social and Institutional Development Depart-ment Netherlands

http://www.novartisfoundation.com/en/health_cooperation/index.htm

Novartis Foundation for Sustainable Develop-ment

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&language=en_US

SIDA, Health and development

http://www2.sdc-health.ch/ Swiss Development Agency, Social Develop-ment Division

http://www.worldbank.org/; http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTHEALTHNUTRITIONANDPOPULATION/0,,menuPK:282516~pagePK:149018~piPK:149093~theSitePK:282511,00.html

World Bank, Health, Nutrition & Population

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 Of-fice for Africa

http://www.euro.who.int WHO Regional Office for Europe

http://www.euro.who.int/healthtopics/HT2ndLvlPage?HTCode=health_economics

Health Economics at the WHO Regional Of-fice for Europe

http://www.wpro.who.int WHO Regional Office for the Western Pacific

http://www.wpro.who.int/health_topics/health_economics_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 Mediterra-nean

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


225

6.7. The Consortium

Scope The GTZ-ILO-WHO Consortium is a joint effort to coordinate work of the participating organi-sations and collaborate at country, regional and global level. The Consortium strives for ex-tending 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 Con-sortium makes use of an informal, light and flexible organisational structure. The three orga-nisations 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. There-fore the Consortium provides a forum for improved coordination and harmonisation with do-nors 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. Fur-thermore, 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 inter-

est 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

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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

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2005. The book tackles issues as diverse as universal coverage, social dialogue, poverty reduction

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SHI_Umschlag.pmd 29.03.2007, 14:481