Showing papers by "Guy Carrin published in 2002"

Preventing impoverishment through protection against catastrophic health expenditure

Abstract: The article by Kent Ranson on the experience of the Self Employed Women's Association's (SEWA) Medical Insurance Fund in Gujarat, on pp. 613-621 of this issue of the Bulletin, focuses on catastrophic health care expenditure and thereby underlines the importance of ensuring that community financing schemes effectively protect households from impoverishment. It may well be a hope that such schemes will enhance social cohesion and access to routine low-cost services; however, one of their prime objectives ought to be preventing impoverishment through protection against catastrophic health expenditure. "Fairness in financial contribution" is defined by WHO to be one of the three intrinsic goals of a health system. The fairness in financial contribution index measures whether a country collects contributions from households to finance health in a equitable manner (1). It captures the extent of catastrophic health spending by households, and also identifies households thus affected. Catastrophic health expenditure is defined in relation to the households' capacity to pay. (a) Health spending is viewed as catastrophic when a household must reduce its basic expenses over a certain period of time in order to cope with the medical bills of one or more of its members. WHO proposes that health expenditure should be called catastrophic whenever it is greater than or equal to 40% of the capacity to pay. However, individual countries could well adopt a higher or lower percentage in their respective national health policies. Catastrophic health expenditure is only observed when households need and use health services. Such services may, however, be less than those that would ideally be required. For example, there could be limits on use for geographical and/or financial reasons. In some Asian countries such as Indonesia, Malaysia, and some island countries where there are few or no health facilities in remote areas, geographical access to health services is limited. In other countries, such as United Republic of Tanzania and Zambia, households face not only geographical but financial barriers to health service use because they are confronted with excessive fees and other large out-of-pocket payments. A preliminary analysis that we have made of income and expenditure survey data for 60 countries shows that lower income groups have a greater proportion of households with catastrophic levels of health spending than do higher income groups. However, it is also true that the highest proportion of catastrophic health spending does not necessarily occur in the lowest income group. Further analysis at the sub-national level has confirmed this finding, since the poorest regions do not always have the highest proportion of households with catastrophic health expenditure (2). A closer examination of the circumstances under which households face catastrophic health expenditure identifies important determinants such as income, age of household members, and employed/unemployed status of the household head. In addition, households with elderly, handicapped, or chronically ill members are more likely to be confronted with catastrophic health spending due to their greater need for health services and their lack of financial resources. Conversely, younger and healthy households have a greater likelihood of avoiding catastrophic levels of health spending. High fees and out-of-pocket payments increase the probability of catastrophic health spending by households, as is the case today in India (3). Countries should be encouraged to establish prepayment schemes for health financing since there is strong evidence that the larger the proportion of prepayment, the smaller the proportion of households that will face catastrophic health spending. …

Effectiveness of community health financing in meeting the cost of illness.

Abstract: 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.

Social Health Insurance in Developing Countries: A Continuing Challenge

Abstract: This paper addresses the issue of the feasibility of 'social' health insurance (SHI) in developing countries. SHI aims at protecting all population groups against financial risks due to illness. There are substantial difficulties in implementation, however, due to lack of debate and consensus about the extent of financial solidarity, problems with health service delivery, and insufficient managerial capacity. The transition to universal coverage is likely to take many years, but it can be speeded up. Adopting a 'family' approach to financial protection, sustained financial support from governments and donors, and deconcentrating the development of SHI may slash several years from the time needed to achieve full universal protection against healthcare costs.

Social health insurance in developing countries: a continuing challenge

Abstract: This paper addresses the issue of the feasibility of “social” health insurance (SHI) in developing countries. SHI aims at protecting all population groups against financial risks due to illness. There are substantial difficulties in implementation, however, due to lack of debate and consensus about the extent of financial solidarity, problems with health service delivery, and insufficient managerial capacity. The transition to universal coverage is likely to take many years, but it can be speeded up. Adopting a “family” approach to financial protection, sustained financial support from governments and donors, and deconcentrating the development of SHI may slash several years from the time needed to achieve full universal protection against healthcare costs.