People in poor countries tend to have less access to health services than those in better-off countries, and within countries, the poor have less access to health services. This article documents disparities in access to health services in low- and middle-income countries (LMICs), using a framework incorporating quality, geographic accessibility, availability, financial accessibility, and acceptability of services. Whereas the poor in LMICs are consistently at a disadvantage in each of the dimensions of access and their determinants, this need not be the case. Many different approaches are shown to improve access to the poor, using targeted or universal approaches, engaging government, nongovernmental, or commercial organizations, and pursuing a wide variety of strategies to finance and organize services. Key ingredients of success include concerted efforts to reach the poor, engaging communities and disadvantaged people, encouraging local adaptation, and careful monitoring of effects on the poor. Yet governments in LMICs rarely focus on the poor in their policies or the implementation or monitoring of health service strategies. There are also new innovations in financing, delivery, and regulation of health services that hold promise for improving access to the poor, such as the use of health equity funds, conditional cash transfers, and coproduction and regulation of health services. The challenge remains to find ways to ensure that vulnerable populations have a say in how strategies are developed, implemented, and accounted for in ways that demonstrate improvements in access by the poor.

https://nyaspubs.onlinelibrary.wiley.com/doi/pdf/10.1196/annals.1425.011

Poverty and access to health care in developing countries.

Why are a select few service firms better at what they do - year in and year out - than their competitors? For most senior managers, the profusion of anecdotal "service excellence" books fails to address this key question. In this pathbreaking book, world-renowned Harvard Business School service firm experts James L. Heskett, W. Earl Sasser, Jr. and Leonard A. Schlesinger reveal that leading companies stay on top by managing the service profit chain. Based on five years of painstaking research, the authors show how managers at American Express, Southwest Airlines, Banc One, Waste Management, USAA, MBNA, Intuit, British Airways, Taco Bell, Fairfield Inns, Ritz-Carlton Hotel, and the Merry Maids subsidiary of ServiceMaster employ a quantifiable set of relationships that directly links profit and growth to not only customer loyalty and satisfaction, but to employee loyalty, satisfaction, and productivity. The strongest relationships the authors discovered are those between (1) profit and customer loyalty; (2) employee loyalty and customer loyalty; and (3) employee satisfaction and customer satisfaction. Moreover, these relationships are mutually reinforcing; that is, satisfied customers contribute to employee satisfaction and vice versa. Here, finally, is the foundation for a powerful strategic service vision, a model on which any manager can build more focused operations and marketing capabilities. For example, the authors demonstrate how, in Banc One's operating divisions, a direct relationship between customer loyalty measured by the "depth" of a relationship, the number of banking services a customer utilizes, and profitability led the bank to encourage existing customers to further extend the bank services they use. Taco Bell has found that their stores in the top quadrant of customer satisfaction ratings outperform their other stores on all measures. At American Express Travel Services, offices that ticket quickly and accurately are more profitable than those which don't. With hundreds of examples like these, the authors show how to manage the customer-employee "satisfaction mirror" and the customer value equation to achieve a "customer's eye view" of goods and services. They describe how companies in any service industry can (1) measure service profit chain relationships across operating units; (2) communicate the resulting self-appraisal; (3) develop a "balanced scorecard" of performance; (4) develop a recognitions and rewards system tied to established measures; (5) communicate results company-wide; (6) develop an internal "best practice" information exchange; and (7) improve overall service profit chain performance. What difference can service profit chain management make? A lot. Between 1986 and 1995, the common stock prices of the companies studied by the authors increased 147%, nearly twice as fast as the price of the stocks of their closest competitors. The proven success and high-yielding results from these high-achieving companies will make The Service Profit Chain required reading for senior, division, and business unit managers in all service companies, as well as for students of service management.

The Service Profit Chain: How Leading Companies Link Profit and Growth to Loyalty, Satisfaction, and Value (Цепочка создания прибыли в сфере услуг: как ведущие компании связывают прибыль и рост с лояльностью, удовлетворением и ценностью)

Many countries rely heavily on patients’ out-of-pocket payments to providers to finance their health care systems. This prevents some people from seeking care and results in financial catastrophe a...

Protecting households from catastrophic health spending.

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Bureaucracy: What Government Agencies Do And Why They Do It

Health policy makers are faced with competing alternatives, and for systems of health care financing. The choice of financing method should mobilize resources for health care and provide financial protection. This review systematically assesses the evidence of the extent to which community-based health insurance is a viable option for low-income countries in mobilizing resources and providing financial protection. The review contributes to the literature on health financing by extending and qualifying existing knowledge. Overall, the evidence base is limited in scope and questionable in quality. There is strong evidence that community-based health insurance provides some financial protection by reducing out-of-pocket spending. There is evidence of moderate strength that such schemes improve cost-recovery. There is weak or no evidence that schemes have an effect on the quality of care or the efficiency with which care is produced. In absolute terms, the effects are small and schemes serve only a limited section of the population. The main policy implication of the review is that these types of community financing arrangements are, at best, complementary to other more effective systems of health financing. To improve reliability and validity of the evidence base, analysts should agree on a more coherent set of outcome indicators and a more consistent assessment of these indicators. Policy makers need to be better informed as to both the costs and the benefits of implementing various financing options. The current evidence base on community-based health insurance is mute on this point.

/pdf/community-based-health-insurance-in-low-income-countries-a-4jcklsd9vt.pdf

Community-based health insurance in low-income countries: a systematic review of the evidence

Actual community-based health insurance (CBHI) premium payments often fall short of Willingness-to-Pay (WTP) estimates. This study examines the gap between the estimated premiums and actual payments for CBHI by analyzing data from 3,685 households in rural India. Descriptive statistics are used to analyze the gap between the estimated premium and actual payments. Heckman two-stage sample-selection model is applied to analyze the predictors of actual payment, subject to household enrolment in CBHI. The estimated premiums were 0.50–1.26% of per-capita gross domestic product (PCGDP). The actual payments were ~50% of the estimates. The gap resulted as households enrolled fewer family members than expected. Further analysis indicates that a quadratic function (to estimate expected enrollees from the household) combining with a fixed premium (expressed as a percentage of PCGDP) can better predict actual income. Heckman analysis indicates that focusing on greater awareness and financial literacy can lead to an increase in actual payments.

Estimating Willingness to Pay

This volume presents findings of a World Bank review of the existing and potential role of private voluntary health insurance in low- and middle-income countries and is the third volume in a series of reviews of health care financing. Also, this volume is about managing risk. Not the risk of national or man-made disasters but the risk of illness. The developing world is plagued by many of the historical scourges of poverty: infectious disease, disability, and premature death. As countries pass through demographic and epidemiological transition, they face a new wave of health challenges from chronic diseases and accidents. In this respect, illness has both a predictable and an unpredictable dimension. Contributors to this volume emphasize that the public sector has an important role to play in the health sector, but they demonstrate that the private sector also plays a role in a context in which private spending and delivery of health services often composes 80 percent of total health expenditure. Managing risks in the private sector begins at the household level. Private voluntary health insurance is merely an extension of such nongovernmental ways to deal with the risk of illness and its impoverishing effects in low- and middle-income countries. The authors examine frameworks for analyzing health financing and health insurance. They conclude that most studies are hampered by lack of data on the impact of private voluntary health insurance on broad social goals, such as financial protection. They find no overall consensus on the impact of voluntary health insurance on public health activities or on the quality, innovation, and efficiency of personal health services.

Private Voluntary Health Insurance in Development : Friend or Foe?

As the world recently turned its attention to the struggle of expanding health insurance coverage for 40 million people in the United States, it is important not to forget the 4 billion people in low- and middle-income countries that face the same hardship. Millions of the poor have already fallen back into poverty as a result of the ongoing global financial crisis. Millions more are at risk before full recovery. It is the poor and most vulnerable that are at greatest risk due to lack of protection against the impoverishing effects of illness. The research for this volume shows that, when properly designed and coupled with public subsidies, health insurance can contribute to the well-being of poor and middle-class households, not just the rich. And it can contribute to development goals such as improved access to health care, better financial protection against the cost of illness, and reduced social exclusion. Opponents vilify health insurance as an evil to be avoided at all cost. To them, health insurance leads to overconsumption of care, escalating costs-especially administrative costs-fraud and abuse, shunting of scarce resources away from the poor, cream skimming, adverse selection, moral hazard, and an inequitable health care system. Today many low-and middle-income countries are no longer listening to this dichotomized debate between vertical and horizontal approaches to health care. Instead, they are experimenting with new and innovative approaches to health care financing. Health insurance is becoming a new paradigm for reaching the Millennium Development Goals (MDGs). They emphasize the need to combine several instruments to achieve three major development objectives in health care financing: 1) sustainable access to needed health care; 2) greater financial protection against the impoverishing cost of illness; and 3) reduction in social exclusion from organized health financing instruments. The use of insurance was recommended to pay for less frequent, higher-cost risks and subsidies to cover affordability for poorer patients to higher-frequency, lower-cost health problems.

Scaling Up Affordable Health Insurance: Staying the Course

The development challenges of addressing health problems in low- and middle-income countries are daunting but not insurmountable. There are now known and affordable interventions to deal with many aspects of the HIV/AIDS crisis as well as the continued challenge posed by malaria and other major infectious diseases. Three major development objectives of health insurance in low- and middle income countries are highlighted in this volume: securing sustainable financing for health care providers that serve the health needs of vulnerable populations; providing financial protection against the impoverishing cost of illness; and reducing social exclusion from organized health financing and delivery systems. Private health insurance schemes can address the needs of the poor and other vulnerable populations with appropriate combinations of subsidies, risk pooling, household savings, and user charges. The authors of this book argue in favor of a multipillar approach to health care financing in low- and middle-income countries that combines these instruments in addressing the underlying development objectives described above, while putting a strong emphasis on private voluntary health insurance. In this way, private means can make a significant contribution to public ends.

Global Marketplace for Private Health Insurance: Strength in Numbers

How to finance and provide health care for the more than 1.3 billion rural poor and informal sector workers in low- and middle-income countries is one of the greatest challenges facing the international development community. This article presents the main findings from an extensive survey of the literature of community financing arrangements, and selected experiences from the Asia and Africa regions. Most community financing schemes have evolved in the context of severe economic constraints, political instability, and lack of good governance. Micro-level household data analysis indicates that community financing improves access by rural and informal sector workers to needed heath care and provides them with some financial protection against the cost of illness. Macro-level cross-country analysis gives empirical support to the hypothesis that risk-sharing in health financing matters in terms of its impact on both the level and distribution of health, financial fairness and responsiveness indicators. The background research done for this article points to five key policies available to governments to improve the effectiveness and sustainability of existing community financing schemes. This includes: (a) increased and well-targeted subsidies to pay for the premiums of low-income populations; (b) insurance to protect against expenditure fluctuations and re-insurance to enlarge the effective size of small risk pools; (c) effective prevention and case management techniques to limit expenditure fluctuations; (d) technical support to strengthen the management capacity of local schemes; and (e) establishment and strengthening of links with the formal financing and provider networks.

https://papers.ssrn.com/sol3/Delivery.cfm/SSRN_ID1017213_code667896.pdf?abstractid=1017213&mirid=1

Alexander S. Preker

Papers

Estimating Willingness to Pay

Private Voluntary Health Insurance in Development : Friend or Foe?

Scaling Up Affordable Health Insurance: Staying the Course

Global Marketplace for Private Health Insurance: Strength in Numbers

Effectiveness of Community Health Financing in Meeting the Cost of Illness