Universal coverage in health care financing: is community-based insurance the answer?
Prof. R. Sauerborn, Heidelberg University, Germany
The challenge: Universal access to good quality health care
The reality:
Latin America
25 % without hlth insurance
China
85% of rural 49% of urban popul. without hlh insurance
Burkina Faso
99.1% without insurance 85% of rural popul. without access
Main groups not covered by insurance
Group
Farmers Informal urban Migrant workers
Latin America
China
Sub Saharan Africa
+ +++ +
++ +++ ++
+++ + ++
Share of informal sector in nonagricultural employment, Latin America
Peru
Ecuador 1994 1990 Colombia
Chile
Brazil
Bolivia
Argentina
Source : ILO 1996
0
10
20
30
40
50
60
70 %
Per capita health expenditure by source - rural Burkina Faso 1996
Bagala Werebe Konankoira Bourasso Dembo Bomborokuy Toni Barani Doumbala Berma Kinekuy Koro Dokuy 0 200 400 0,55 0,62 600 800 1000 1200 1400 1600 0,30 0,31 0,38 0,29 0,62 0,41 0,35 1,20 0,33 0,45
Government Donors Users
0,7 0
F CFA
Overview of financing mechanism
fee for service - most developing countries taxes - UK saving funds - Singapore private insurance - US HMO - US social insurance - German and Latin American model community-based insurance - experiments from Africa, Latin America, Asia
Target groups forsocial and voluntary insurance -Vietnam, 1999
Total population 78 m
Civil servants, fomal sector incl. retirees 8m
Social insurance
Informal sector self-employed rural workers 38 m Voluntary insurance 4m User fees 34 m
Dependents in need of coverage 32 m Government subsidies ca 30 m Donor aid
8m
ca 2 m
10 %
5%
44 %
41 %
Jowett and Thompson, 1999
Minimum salaries per hh member
Population and Social Benefits, by Income, Brazil, 1986
Social security Other public programs Population
>20 11-20 6-10 3-5 1-2 0.5-0.99 0.25-0.49 <0.25
-25 -20 -15 -10 -5 0 5 10
Source: World Bank, 1988
15
20
25
%
Price-elasticity of demand for outpatient care
overall = - 0.79
Sub-group By age group <1y 1 - 14 y >=15y By revenue quartile 1 (poorest) 2 3 4 (richest)
Arc price-elasticity of demand ( ) -3,64 -1,73 -0,27 -1,44 -1,21 -1,39 -0,12
Source: Sauerborn et al., 1994
Predicted change in demand for public health services after introduction of user fees, urban Bolivia
predicted change of demand [%] - 30 - 25 20
model: multinomial logit n = 29 996
- 15 - 10 5 Clinic, children 0
(poor)
Hospital, children Hospital, adults
1
2
Clinic, adults 3 4
(rich) 5
Source: Sauerborn et al., 1995
income quintile
Spreading financial risks protects the livelihood of poor households
Cumulative percentage of illnesses, by size of illness cluster
120%
cumulative % of all illnesses
100%
80%
60%
40%
20%
0% 0 1 2 3 4 5 6 7 8 9 10 11 12 Size of illness cluster (# of illness episodes/household)
Illness clustering calls for risk sharing
Case study: Household 028A_S
oo
Hernia
AIDS
oo
Night blindness.
oo
Night blindness. Schisto.
oo
Measles '86
Schisto.
Measles '86 Whooping cough '91
Measles '86
Definition: Community-based health insurance:
Applying the principles of insurance to the social context of communities, guided by their preferences and based on their structures and arrangements.
Approach to create CBI (I)
Identify the excluded
Example: The main groups not covered by insurance in Chinese Cities:
primary dependents of people covered under the government health insurance (gongfei) and workers’ insurance (laobao) people employed by private companies and joint ventures self-employed (getihu) rural to urban migrants
Approach to create CBI (II)
Identify the excluded Understand the informal sector organizations and the existing risksharing arrangements
Types of community risk sharing organizations
- Nouna district, rural Burkina Fasoname
Tontines
function
# organizations # participating
individuals
Traditional saving groups 150 in district (Nouna has 17) (rotative savings) Pre-cooperatives Saving, food aide, social 43 activities, transport, rotative Cooperatives farming and harvesting, 1 house and well construction Associations tree planting, road construction, 13 crafts, environmental hygiene,
2,388 2,000
47 2,800 7,235 (= 12.1% of population)
health (1) 207
Source: Sauerborn et al., 1998
Approach to create CBI (III)
Identify the excluded Understand the informal sector organizations and the existing risksharing arrangements Study community preferences for benefit package content Assess willingness-to-pay for such packages
Comparative research: Willingness-to-pay for communitybased health insurance
Country Burkina Faso Mexico, Bolivia Wuhan Vietnam Target group Farmers, informal urban sector workers Informal urban Informal urban, migrant workers Farmers, informal urban sector workers
Relationship between P(I=1) and price
1.0 0.9 0.8 0.7
Hypothetical data
P(I=1)
0.6 0.5 0.4 0.3 0.2 0.1 0
1 TP W 1 p Ii ise 0 otherw
-2
-1
0
1
-a0/b
2
3
4
5
price (arbitrary units)
Approach to create CBI (IV)
Assess population-based health care needs Establish unit costs of service provision Calculate premium
Germany 1883-2000: gradual increase in social insurance coverage
Year 1885 1895 1910 1914 1925 1934 1950 1955 1960 1965 1968 1976 1980 1985 1990 1995 100
Coverage in % of total population
90 80
Private health insurance Statutory health insurance
70 60
50 40 30 20 10
Germany 1883-2000: consolidation of sickness funds
25000
120000
number of statutory sickness funds average number of insured per fund
Number of statutory sickness funds
100000
20000
Average number of insured per fund
80000
15000
60000
10000
40000
5000
20000
0
0
1885 1895 1905 1915 1925 1935 1945 1955 1965 1975 1985 1995
Year
Germany 1883-2000: gradual inclusion of target groups
Year
1883
Occupational group, societal group covered
Blue collar workers Craftsmen Employees of lawyers, industrial cooperatives, insurance funds Transport workers Commercial office workers Agricultural and forestry workers Domestic servants Itinerant workers Civil servants The unemployed Persons employed in public or private cooperatives Wives and daugthers of insured Sailors Persons employed in the educational and social welfare sectors All primary dependents Midwives Self-employed workers in nursing and child care Retirees Refugees and expellees The seriously disabled The physically disabled Farmers Students All disabled Artists, journalist
1885 1892 1911
1914 1918 1919 1927 1930 1938 1941 1953 1957 1972 1975 1981
From community-based health insurance to universal coverage
Mechanisms: public regulation amalgamation re-insurance risk equalisation scheme
Closing the circle
Global health problems- global solutions Example: Health sector crisis financing of high quality care through insurance Evidence from different places and times may be instructive
Health care crisis
Isolation
Cooperation