Social health insurance Policy Brief (PowerPoint)

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					Social Health Insurance
      Policy Brief

              Than Sein*
       World Health Organization
   *the viewpoints expressed are those of the author only.



                                                             1
                    WHO-EIP/SEARO
             WORLD HEALTH EXPENDITURE, 1998

               Aid, 138                              Other, 8


Private Insurance,
       484                                                        Taxes, 931




      Out of Pocket, 731
                                                                Social Insurance,
                                                                       790



In 1998, the World Spent I$ 3.1 Trillion on Health Care.
                                                                                    2
                                WHO-EIP/SEARO
Health Expenditure as a share of GDP, 2000 (WHR2002)




           Legend
                1.0   -   2.6   6.5 - 7.3
                2.7   -   3.6   7.4 - 8.4
                3.7   -   4.5   8.5 - 9.8
                4.6   -   5.4   9.9 - 13.0
                5.5   -   6.4   No Data




                                                        3
                                        WHO-EIP/SEARO
                                           Composition of Health Spending, 1998
                                    100%
Share of Total Health Expenditure




                                    80%

                                                                                  Other
                                    60%                                           OOP
                                                                                  Insurance
                                                                                  External
                                    40%
                                                                                  Soc.Sec.
                                                                                  Tax
                                    20%



                                     0%




                                                                                        4
                                                         WHO-EIP/SEARO
SOCIAL HEALTH INSURANCE


A financing mechanism
based on pooling both the
health risks and the
financial contributions

                            5
         WHO-EIP/SEARO
     Health Risks
Minimum health risks,
that in the absence of
insurance, would entail a
financial burden on the
households as a result of
the cost of health care
                            6
           WHO-EIP/SEARO
    Financial Contributions
 Contributors paid out-of-pocket,
  based on ability to pay and not on
  individual risks
 Government Taxation : indirect
  contribution by the people (implicit)
 Social Health Insurance : directly
  aware of the contribution (explicit)

                                      7
                WHO-EIP/SEARO
Social vs. private health insurance
  social health insurance:
   premium depend on risks in
   society as a whole (community
   rating)
  private health insurance:
   premium related to risks of
   particular individuals or groups
   (experience rating)

                                      8
               WHO-EIP/SEARO
       Social Health Insurance in Asia, 1999
Health         South     Malaysia     Philip-   Japan   Thailand   Indonesia   India
Insurance      Korea                  pines
Factors

Population     Univ.     ND           48 %      Univ.   95%        27%         11%D
Coverage

Mandatory or   M         M            M/V       M       M          M/V         M/V
Voluntary

With Risk      Y         Y            Y         Y       Y          Y           Y
sharing

With Cost      Y         Y            Y         Y       Y          Y           Y
Sharing

Emphasis of    Cure-Hi   Cure/        Cure/     Cure/   Cure/      Cure/Prev   Cure/
Care           Inten     Prev         Prev      Prev    Prev                   Prev
Provision



                                                                                   9
                                    WHO-EIP/SEARO
         Trends in coverage by health insurance schemes in Thailand
                                 1991-2000
 90

 80                                                                                     Total

 70

 60                                               Medical care for the poor and the socially
                                                  supported (underprivileged) groups

 50

 40

 30
                                                                                  Voluntary health
 20                  Medical services for civil servants and state                insurance
                     enterprise employees
 10
                                                                     Compulsory health insurance
  0
         1991           1992            1995             1997              1998           1999       2000
Source: Thailand Health Profile 1997-1998                                                                   10
                                               WHO-EIP/SEARO
      INDONESIA HEALTH INSURANCE COVERAGE, 1998
                                   Social security for
                                        workers           Health Cards for
                                    (JAMSOSTEK) ,               Poor
            Private Health
                                           0.8%          (KARTU SEHAT),
              Insurance
                                                                 2.5%
          (SWASTA), 0.3%

                                                          Civil Service Health
                                                                 Insurance
                                                             (ASKES), 8.5%




                                                               Community
                                                                Financing
                                                             (DANA SEHAT),
                                                                  13.5%




Un-insured, 74.4%




   Source: Indonesia Health Vision 2010, MoH, 1999

                                                                                 11
                                   WHO-EIP/SEARO
                National Health Insurance
             Philippines, Membership, 2001
       Indigent             Non-Paying
          8%                    2%
Individually
  Paying
    11%
                                                   Gov't
                                                 Employed
                                                   24%



  Private
                          PhilHealth covers 37.5 million or
 Emloyed                  48% of population
   55%               WHO-EIP/SEARO
                                                              12
              Health Insurance in formal sector workers in Chile,
                    1994. Adverse selection (WHR 2000)

               100
               80
% of formal




               60
               40
               20
                0
                     <99   99-244   245-      371-         495-   618-   742-     >875
                                    370       494          617    741    875

                                            US$ per month

                                FONASA (Public)               ISAPRES (Private)

                                                                                         13
                                           WHO-EIP/SEARO
 Jamsostek (Social Security for employees
     from enterprises) in Indonesia

• Expensive medical care is not covered
  (cancer, haemodialysis, congenital
  diseases)
  – Impoverish members when it occurs
  – Higher burden for lower income members
• Ceiling of earnings of Rp 1 m (about US$
  112), create relative higher burden for low
  income companies
• Retired employees are not covered
                                                14
                   WHO-EIP/SEARO
 How the ceiling creates inequity?
   Let compare two married employees with
   different earnings per month

                           Earn $ 80      Earn $ 500

Contribution 6 %,
$112 ceiling (Rp 1 mil)
                           $ 4.8          6.72
Actual burden                6%           1.3%

Benefits                   Same           Same, but may
                                          have higher
                                          utilization

                                                          15
                          WHO-EIP/SEARO
  Askes Scheme (compulsory) for
Government Employees in Indonesia
                    Large out of pocket resulting
                     from:
         Out of
        pocket.
                       – low (inadequate) contribution of
        Vary for         2% basic salary
        various        – Low reimbursement level to
        services
                         hospitals, higher out of pocket
                         from balance billings
                       – Perceive poor quality of
                         services obtaining services
        Covered          from out of network, higher out of
        expenses         pocket payment
                    Higher burden for the lower
                     income civil servants
                                                         16
                    WHO-EIP/SEARO
 Comparison of Current Schemes

 Variance in nature, population
  coverage, benefits provision
 Variance in patterns of risk
  sharing and cost sharing between
  government, beneficiaries, and
  private sectors
 Quality of health services variable

                                        17
                WHO-EIP/SEARO
Key issues
 Lack of nation-wide consensus between
  stakeholders (solidarity)
 Long-term financial viability /sustainability
  (relative size of formal and informal sector;
  level of income)
 Inadequate health care provided to insured
  members (essential packages/
  reimbursement schemes/ capitation, etc.)
 Lack of managerial or administrative
  capacity (institutional arrangements)

                                                  18
                   WHO-EIP/SEARO
Future challenges
 Globalization and trade liberalization
  (expansion of insurance market)
 Decentralization (governance and
  financing)
 Expanding risk pools (single, multiple
  pools)
 Poor political stability
 Time implications (30 years plus)
                                           19
                  WHO-EIP/SEARO
                20
WHO-EIP/SEARO

				
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