PROTECTING THE POOR PROTECTING THE POOR AGAINST HEALTH SHOCKSAGAINST HEALTH SHOCKS

Gerald Bloom and Henry LucasGerald Bloom and Henry LucasInstitute of Development StudiesInstitute of Development Studies

Meeting the needs of the very poorest in service delivery

BRAC, Rajendrapur 3-5 December 2006

TYPES OF ILLNESS SHOCKSTYPES OF ILLNESS SHOCKS

Intensity – minor and major illness Intensity – minor and major illness (degree of debility and cost of treatment)(degree of debility and cost of treatment)

Duration and/or frequency (repeated Duration and/or frequency (repeated shocks and progressive chronic disease –shocks and progressive chronic disease –NCDs & HIV/AIDS)NCDs & HIV/AIDS)

Covariance (endemic diseases, Covariance (endemic diseases, epidemics, relationship to other shocks)epidemics, relationship to other shocks)

Resilience and poverty-illness trapsResilience and poverty-illness traps

RESPONSE TO SHOCKS RESPONSE TO SHOCKS

Prevention Prevention (public health, preventive (public health, preventive programmes, response to crisis)programmes, response to crisis)

Mitigation Mitigation (improve basic services, (improve basic services, subsidise access to care, improve unorganised subsidise access to care, improve unorganised services through regulation and information) services through regulation and information)

CopingCoping (support the ill, post-illness (support the ill, post-illness recovery of households, rebuild communities recovery of households, rebuild communities after major shocks)after major shocks)

INSTITUTIONAL REALITIES INSTITUTIONAL REALITIES

Segmented and pluralistic health systems and Segmented and pluralistic health systems and social sectorsocial sector

Importance of household and community Importance of household and community institutional arrangementsinstitutional arrangements

Balance between general social protection Balance between general social protection and earmarked health supportand earmarked health support

Importance of local political economy and Importance of local political economy and differential impact of interventionsdifferential impact of interventions

BALANCE OF APPROACHESBALANCE OF APPROACHES

Rules-based universal coverageRules-based universal coverage

Safety net and special programmes Safety net and special programmes for poor and vulnerablefor poor and vulnerable

Discretionary/charitable supportDiscretionary/charitable support

Community and family arrangementsCommunity and family arrangements

UNIVERSAL COVERAGEUNIVERSAL COVERAGE

ADVANTAGES: rules-based, predicable, ADVANTAGES: rules-based, predicable, strong entitlement, creates possibility strong entitlement, creates possibility of measures to improve supply-sideof measures to improve supply-side

PROBLEMS: hard to define benefit, may PROBLEMS: hard to define benefit, may favour better off or those living near favour better off or those living near hospitals, limited financial capacity, hospitals, limited financial capacity, may neglect the special problems of the may neglect the special problems of the very poor and those excluded because very poor and those excluded because of geography and other factorsof geography and other factors

TARGETED PROGRAMMES TARGETED PROGRAMMES AND SAFETY NETAND SAFETY NET

ADVANTAGES: ADVANTAGES: allocates resources to allocates resources to very poor, special service package, efficient very poor, special service package, efficient use of scarce resourcesuse of scarce resources

PROBLEMS: PROBLEMS: limited resources, may limited resources, may leave beneficiaries trapped in poverty, may leave beneficiaries trapped in poverty, may not reach the poorest, stigmatises not reach the poorest, stigmatises beneficiaries, weak entitlement that depends beneficiaries, weak entitlement that depends on resource availability, limited political on resource availability, limited political supportsupport

DISCRETIONARY BENEFITSDISCRETIONARY BENEFITS

ADVANTAGES: resources used for ADVANTAGES: resources used for poor people with big problems, poor people with big problems, flexible, builds on social concern, less flexible, builds on social concern, less leakageleakage

PROBLEMS: unreliable and PROBLEMS: unreliable and dependent on fund-raising, can dependent on fund-raising, can unfairly target “deserving” poor or unfairly target “deserving” poor or those who capture public interest, those who capture public interest, stigma, little voice for beneficiaries, stigma, little voice for beneficiaries, can reinforce exclusion can reinforce exclusion

INFORMAL ARRANGEMENTSINFORMAL ARRANGEMENTS

ADVANTAGES: well-established social ADVANTAGES: well-established social networks, responds to immediate human networks, responds to immediate human feelings, high levels of trust and good feelings, high levels of trust and good targeting, no need for complex targeting, no need for complex institutionsinstitutions

PROBLEMS: little support for people PROBLEMS: little support for people without large families or in disadvantaged without large families or in disadvantaged communities or social groups, limited communities or social groups, limited financial capacity to deal with major financial capacity to deal with major problems, may stigmatise recipients and problems, may stigmatise recipients and leave them in a dependent positionleave them in a dependent position

BALANCE OF APPROACHESBALANCE OF APPROACHES

Level of economic developmentLevel of economic development

Capacity to support complex, rules-Capacity to support complex, rules-based institutionsbased institutions

Degree of inequality and number of Degree of inequality and number of very poorvery poor

Supply-side inequalities Supply-side inequalities

RESEARCH CONSORTIARESEARCH CONSORTIA

POVILL: POVILL: impact of major illness on poor impact of major illness on poor households and government initiatives to households and government initiatives to mitigate the impact and support household mitigate the impact and support household coping in China, Cambodia and Lao PDR coping in China, Cambodia and Lao PDR j.vaghadia@ids.ac.ukj.vaghadia@ids.ac.uk

FUTURE HEALTH SYSTEMS FUTURE HEALTH SYSTEMS RPC: RPC: strategies for increasing access and strategies for increasing access and reducing the impact of major health shocks reducing the impact of major health shocks http://www.futurehealthsystems.org/http://www.futurehealthsystems.org/

ISSUES FOR PANELISSUES FOR PANEL

Balance of approaches in different Balance of approaches in different development contextsdevelopment contexts

Roles of state, non-state institutions, Roles of state, non-state institutions, charities and “informal” faith-based, charities and “informal” faith-based, community and family arrangements in community and family arrangements in different contextsdifferent contexts

Sequencing, path dependency and the Sequencing, path dependency and the politics of institutional strengthening and politics of institutional strengthening and building rules-based entitlements (balance building rules-based entitlements (balance between meeting short-term needs and between meeting short-term needs and managing social transformation)managing social transformation)