Transcript Social Protection and Services - Institute of Development Studies

Social Protection and Health Services
Nicola Jones, PhD
IDS/ UNICEF Course on Children and Social Protection
Presentation overview
1. Social protection and services: tensions and
complementarities
2. Health vulnerabilities and shocks
3. Health care financing systems
4. Alternative health financing mechanisms
1. Social Protection and Services
Source: Flickr/world bank
Table 1: Types of social protection and household and child-specific measures
Type of social
protection
General
measures
Social assistance
Conditional and unconditional
cash transfers, food aid
Social insurance
Heath insurance and other risk
pooling mechanisms such as
disaster insurance and
unemployment insurance
Preventative and responsive
social welfare services focused
on those needing protection from
violence and neglect – e.g.
shelters for women,
rehabilitation services etc
Anti-discrimination legislation,
affirmative action policies, asset
protection
Social welfare
services
Social equity
measures
Complementary
basic services
Complementary
pro-poor or growth
with equity macroeconomic policy
frameworks
household-level
Specific measures for children
Scholarships, school feeding, cash transfers
with child-related conditionalities, fee waivers
for education, childcare and use of child
health services
Subsidies for health insurance for children
(e.g. waivers on premiums and co-payments)
Child foster systems, preventative and
responsive services to address child-focused
domestic and community violence, child
trafficking and child labour
Adoption and implementation of legislation to
promote child rights and address rights
deprivations, including efforts to promote
children’s voice and agency
Complementary measures
Health, education,
Child-focused health care services, pre,
economic/financial, agricultural
primary and secondary school, childcare
extension
services
Policies which support growth +
Policies which support progressive realization
distribution
of children’s rights in line with macroeconomic growth indicators
Tensions between demand and supply
• Social transfers and social insurance may increase demand for social
services, but is there adequate attention to service supply?
– E.g. Juntos CCT in Peru lead to rapid increase in demand for education
and health services, but without sufficient increase in budget for
increased service supply leading to initial beneficiary disillusionment
– E.g. Cash transfers aimed at addressing food insecurity are likely to
work best in areas with integrated markets, basic physical
infrastructure and financial services
– CCTs have substantially increased service access but gains in outcomes
have been modest at best, highlighting that inadequate investments in
service quality have been addressed (WB, 2009)
– E.g. Rapid expansion of education services to meet MDG enrolment
targets, but real concerns about quality learning
– E.g. In Ghana health service coverage is relatively good, but there is
low levels of uptake. Key reasons include insensitive treatment by
medical staff and inadequate drug availability.
Trade-offs in social sector investments?
• The jury is still out as to whether investment
in social protection provides value for money
vis-a-vis other potential social policy
interventions. A key question we need to
consider is whether a focus on social
protection risks potential trade-offs with
investments in basic service provision in
fiscally constrained contexts?
Defining fiscal space
Government
spending
Total
spending
Available
fiscal space
Discretionary
spending
NonDiscretionary
spending
t-1
t
t+1
t+2
t+3
t+4
t+5
Time
Affordability
Affordability (e.g. 2 - 3% ‘GDP available’
under normal conditions)
Fiscal Space or ‘room in the budget’ (e.g. 5% of
total budget available under ‘normal’ conditions)
Political
space for
social
protection
Other pressing
#3 #2
priority
1 etc.
Political space for...
National
priority #1
Fiscal space for social protection:
the case of Congo
• Significant potential fiscal space due to oil revenues.
• Sustained economic and revenue growth, but with a very
low non-oil tax to GDP ratio.
• Key macroeconomic and fiscal aggregates suggest that
a universal child benefit would be affordable, costing
2.0% of GDP compared with an overall fiscal surplus of
11.1% of GDP in 2007.
• The very low levels of health (2.2%) and education
(1.2% ) spending suggest weak government commitment
to use fiscal space for improved social service provision.
Fiscal space for social protection:
the case of Senegal
• Economic and revenue performance in recent years has been good,
but with a relatively low tax level and revenue yields already
relatively high there is limited scope for creation of fiscal space.
• The overall size of the public sector in relation to the economy as a
whole is also relatively high, as total spending averaged 24.8% of
GDP.
• Reallocation may be an area where fiscal space could be created,
as discretionary spending stood at 17.8% of GDP in 2007.
• Estimates suggest that social protection would be relatively
expensive for Senegal. A targeted child benefit would cost around
3.7% of GDP which would be much higher than total public health
spending, so a more modest option would need to be found.
Discussion question
• Does the distinction between core social
protection interventions and complementary
services make sense to you? Why/why not?
• How would you alter the framework, if at all?
• What are the implications for the definitions
of social protection you developed at the
beginning of the course?
2. Social protection and health shocks
Rationale for Social Health Protection
• 60 year commitment to health as a universal
human right
• Alma Ata (1978) declaration of “Health for All by
2000”
• Children’s right to the “highest attainable
standard of health” (UNCRC)
Key health vulnerabilities:
the example of West and Central Africa
• Of 68 MDG priority countries, not a single WCA country
‘on track’ for MDGs 4 & 5 on child & maternal mortality
[Lancet, 2008]
• In 5 WCA countries, increased U5MRs
• Globally, WCA has highest regional average U5MR of 169
(per 1,000 live births, in 2007)
• Globally, WCA has highest regional average MMR of 1,100
(per 100,000 live births)
• Decrease in ODA for child health in half of WCA countries
[UNICEF 2008]
High Mortality from Preventable Causes
WCA distribution of cause-specific mortality
among children under five years of age,
2000 WHO
Diarrhoeal diseases
16%
Other causes
5%
Pneumonia
20%
Other neonatal
causes
28%
HIV/AIDS
4%
Injuries
2%
Malaria
20%
Measles
5%
WHO Statistical Information System, 2008
High U5MRs parallel low maternal health
service utilisation
U5MRs vs. Maternal Health Service Utilisation [UNICEF, 2008]
300
250
200
150
100
50
0
U5MR (per 1,000 live births)
Antenatal care coverage (at least once, %)
Skilled attendant at delivery (%)
Obstacles to health service access
WCA regional averages
(Source: DHS data)
No perm ission to go
12%
Don't know w here to go
17%
No fem ale provider
19%
Not w anting to go alone
23%
Transport problem s
37%
Distance
40%
Cost (m oney)
56%
0%
10% 20%
30% 40%
50% 60%
70%
[Weighted averages calculated from DHS data, 2001-2005]
The barrier of health care costs
• Widespread poverty & financial barriers to health care services
include:
– 1/3 of total health care spending in 2/3 of all low-income countries is out-ofpocket [WHO, 2003]
– High health care payments result in reduced expenditure for basic needs, loans
and sale of assets
• Financial barriers to preventive & curative health services:
o High levels of morbidity & mortality
o Lost productivity
o Lost time in school (due to child illness & children as caretakers)
• Inducing & entrenching levels of poverty and vulnerability, across
the lifecycle and inter-generationally
Health expenditure can push hhs into poverty
Impact of Health Expenditure on Poverty
Percentage of households falling below PPP$1 poverty line after medical spending
Bangladesh
India
China
Vietnam
Indonesia
Philippines
Sri Lanka
Thailand
Hong Kong
Taiwan
Korea
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
3.5%
4.0%
3. Health care financing in WCA
Equity impacts of health expenditure
Percentage of Total Health Expenditure
Funding source as percentage of total health
expenditure: WCA regional averages, 2006
64.5%
70.0%
60.0%
50.0%
35.5%
40.0%
30.0%
15.8%
20.0%
10.0%
0.0%
External resources
Private health
expenditure
General Government
expenditure
[Data source: WHO 2008]
Out-of-pocket payments (OPPs)
• OPPs are all health related
expenses incurred at the
time of use of health
service, including
consultation fees, drugs
etc.
• Exclude expenditure on
transport to health care
services.
• Exclude reimbursements,
e.g. from insurance.
• Include fees (official &
unofficial) paid to public
and private health
providers, and traditional
healers.
Government expenditure on health
Health share of total government expenditure (%)
(Source: WHO)
40
36.3
35
30
25
18.4
20
15
12.0 12.2
10.9 11.0 11.2
9.5 10.2
10
5
6.7
3.5
4.0
4.0
4.2
4.7
6.9
6.9
7.0
7.2
13.2 13.5 13.9
7.8
5.0
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[Data source: WHO 2008]
Emergence of User Fees in WCA
• Introduced following structural adjustment policies in
1980s
• 1987 Bamako Initiative: introduced community
participation elements to user fee policies
• User fees aimed to:
o
o
o
o
o
Increase revenue with high efficiency
Counteract moral hazard
Improve quality and coverage of services
Rationalise pattern of health care-seeking behaviour
Safeguard equity through exemptions for the poor
[James et al., 2008; Schieber and Maeda, 1997; SC UK, 2005]
Multi-layered negative equity effects
• Impoverishing impacts of user fees include:
o Selling assets
o Health expenditure at expense of other needs
o Loans
o Lost labour time
• Regressive, leading to decline in health service usage
by poorest quintiles
• Undermining prevention & treatment of childhood
illness
User fee exemptions
Mali:
• Vaccinations
• Bed nets to protect against
malaria
• Free malaria care to women
and children
• Free TB and ARV treatment
and preventive care for
leprosy and other
‘neglected’ diseases
Senegal
• Free deliveries and Csections
• Coverage of individuals with
a certificate of destitution:
beneficiaries receive free
care at public health
facilities
• Free malaria care
4. Alternatives to user fees
Source: Flickr World Bank
Community-based Financing Schemes
• Complementary coverage
of SHI excluded
populations
• Voluntary, private, nonprofit insurance schemes
• Largely participatory
• Smoothing private
expenditure
• Pooling health risks
• Strategic purchasing to
encourage quality
• Low cost-recovery, on
average 25% [Ekman,
2004]
• Continued OOPs to meet
total costs
• High administrative costs
• Catch-22 of contributions
from poorest
• Exclusion of the poorest
• Low coverage in region –
highest is just 3% in Mali
Social Health Insurance in WCA:
pros and cons
Pros
• Pooling health risks
• Pooling financial
contributions
• Aim of universal coverage,
regardless of income level
• Redistributive
• Government contributions
for indigent
• Protection from
catastrophic expenditure
Cons
• Difficulty covering large
informal sector & population
with unstable incomes
• WCA: ~1/10 population
employed in formal sector
• Inequity in coverage: lower
enrolment in poorest quintiles
Source: Scheil-Adlung, et. al, 2006
Ghana: National Health Insurance Scheme
• Est. 2004, coverage of 54%
population by mid-2008 –
12.5 million individuals
• Fees range from between 7
and 20 GHS (approx 5-15USD
per annum)
• This is still a significant
barrier to enrolment for the
poor according to 2008
participatory study
• Lower registration among
lowest wealth quintiles
•
National Health Insurance Fund covers:
i) formal sector workers who contribute
ii) children under 18 years whose parents
are both card holders
iii) people over the age of 70;
iv) pensioners; and
v) the indigent
• Exemptions:
i)
All pregnant and lactating women,
and new-borns
ii) Announced but not yet implemented
exemptions for children under 18
years.
Removal of user fees for U5MR impact
• Direct linkages between user fee removal,
increases in service utilisation & reductions in
child mortality
• Removal of user fees in 20 African countries
would result in:
o Estimated 233,000 under-five deaths prevented
annually
o 6.3% of under-five deaths
User fee removal prerequisites
• Estimating resource requirements
o ~5-10% recurrent health care budgets annually
o Uganda: increase of US$7 to $8.4 per capita
• Consider district level implications
o Current allocation of user fee revenue to be replaced
o District level decision making control over user fee revenue
o Plan sequencing of user fee roll out carefully
o Plan for increased health service demand
o Plan for increased demand for drugs
o Plan for short-term shortfall in health budgets through for
instance donor bridge funding
Facilitating removal of user fees
Implementation challenges of exemptions
• Selective exemptions by socio-economic status prone
to costly and complex administrative procedures
• Confusion regarding who qualifies for exemption
• More effective: blanket exemptions for specific services
• Step towards removal of all fees: exemption
mechanisms for the poor and particularly vulnerable
populations requiring health services
Conclusions
5) Build
political will
nationally and
with donors
4) Understand
potential of SHI
and MHOs
2) Address
prerequisites
3)Strengthen
budget
management
1) Prioritise fee abolition for MCH
Discussion questions
• What political economy factors do you
envisage facilitating or constraining a decision
to remove health user fees in your context?
• If the removal of user fees were only feasible
for a limited array of health services, which
criteria would you use to select these
services? How does your decision link back to
discussions about economic and social risks
and vulnerabilities?