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Reproductive health and health Reproductive health and health financingfinancing
Barbara McPake, London School of Barbara McPake, London School of Hygiene and Tropical MedicineHygiene and Tropical Medicine
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The main sources of finance for reproductive health services
• Public tax-based revenues
• Households’ out-of-pocket expenditures
• Employers’ contributions to health insurance
• External donations
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Bangladesh
Public tax-based
Household out-of-pocket
Social security
Sources of finance: Bangladesh
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Sources of finance: Uganda
Uganda
Public tax-based
Household out-of-pocket
Social security
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Sources of finance: South Africa
South Africa
Public tax-based
Household out-of-pocket
Social security
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Sources of finance: Peru
Peru
Public tax-based
Household out-of-pocket
Social security
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Sources of finance: Thailand
Thailand
Public tax-based
Household out-of-pocket
Social security
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Sources of finance: Russia
Russia
Public tax-based
Household out-of-pocket
Social security
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The advantages of pooling
• Pooling creates important opportunities for sharing risks between healthy and sick; rich and poor
• If funds are earmarked, reallocation to more cost-effective services is constrained
• The wider the risk pool, the more opportunities there are for cross-subsidy
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Pooling to redistribute risk and cross-subsidy for greater equity
Contribution Net transfer UtilisationPooling
Low
High
RISK
Subsidy
Low
High
INCOME
Source: World Health Report, 2000
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Public finance• Generally offers greatest potential to pool
resources and risk
• However, potential rarely achieved– Resources allocated to low priority investments and
interventions
– Health and wealthier individuals receive more than their fair share: access; staff attitudes; patient choices
– Resources concentrated in high level health facilities and towns
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The hidden cost of ‘free’ maternity care in Dhaka, Bangladesh
Item Normal delivery CaesarianMedicine 494 2574Blood 24 127Travel 260 780Food 164 602Hospital fees 76 78Ayas 152 400Tips 105 142TOTAL:Taka
1275 4703
US$ 31.9 117.5
Source: Nahar and Costello, Health Policy and Planning, 1998
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Public spending: Do the poor benefit?
0
10
20
30
40
50
60
Source: C
astro-Leal et al., B
ulletin of WH
O,
2000
Poorest 20%
Richest 20%
% of public health expenditure consumed
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User fees in the public sector
• Additional revenue
• Potential to improve quality of services
• Potential to apply cross-subsidies
BUT
• Deterrent effect of fees on utilisation
• Difficulties of implementing effective exemption schemes
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Do user fees deter family planning?• Individuals are not very responsive to changes in price of
contraceptives (eg. Thailand, Philippines, Jamaica, Bangladesh)
• As the price of contraception increases, the price elasticity of demand increases
• Choice of contraceptive method and provider is sensitive to price
• The probability that contraception is used declines as distance to health facilities increases
(Source, Levin et al. Social Science and Medicine, 1999)
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The effect of user fee increases on STD treatment
Men Women1 2 1 2
Gonorrhoea 51 92 Gonorrhoea 132 422Non-STD 5 14 Non-STD 25 16Chancroid 59 77 Chancroid 72 186Syphilis 58 82 Syphilis 55 76Non-gon. urethritis 65 91 Candidiasis 108 353
Trichomoniasis 69 82TOTAL 40 64 TOTAL 65 122
Attendance at STC clinic (seasonally adjusted)
1=Attendance in user charge period as % of pre-charge period
2=Attendance in post charge period as % in pre-charge period
Source: Moses et al., The Lancet, 1992
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User fees in the private sector
• Private sector has flexibility in the operation of fee scales
• Poorer consumers use formal primary level private providers and the informal sector
• Higher prices do not always mean better quality
• The private sector is the main recipient of expenditures made by the poor
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User fees and maternity services
Prevention of maternal mortality network (range of country studies in West Africa)
• After fees: Normal deliveries • Complicated deliveries or • The ways fees applied affected these trends
• Poor quality of care was most important factor in case fatality rate
Source: Prevention of Maternal Mortality Network,
Social Science and Medicine,1995
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Sites where people with STD symptoms had received medicine before attending public
health centres
Men WomenTotal patients 238 167No. taking some medicine before 138 109Site of purchase:Traditional healer 20% 12%Market place/shop 21% 43%Friends/relatives 25% 19%Self treatment 12% 14%Professional health sector 32% 23%
Source: Faxelid et al., EAMJ, 1998
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Why the poor pay more
Provider % of cases Mean expend (Le)Government PHC 20.1 133Government hospital 2.2 480Government staff privately 6.5 189Mission hospital 5.4 670Private hospital or doctor 1.1 636
Source: Fabricant et al. Int. J. Health Plann. Mgmt, 1999
Expenditure by provider: Sierra Leone
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Why the poor pay more cont’d
Quintile I II III IV VPHC as % income 4.8 3.3 1.8 1.2 0.6‘Other medical’ as% income
16.1 8.1 5.6 2.4 2.3
Source: Fabricant et al.
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National insurance programmes
• Can seldom achieve universal coverage– Restricted formal sector employment– Limited government ability to subsidise rest
• Subsidy to national insurance tends to entrench inequity
• Risk sharing and cross-subsidy restricted to within middle and upper income groups
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Informal employment
Country 1990 1994Argentina 47.5 52.5Bolivia 56.9 61.3Brazil 52.0 56.4Chile 49.9 51.0Colombia 59.1 61.6Ecuador 51.6 54.2Peru 51.8 56.0
Urban, informal, nonagricultural employment in Latin America,
1990 and 1994
Source, Creese and Bennett, World Bank, 1997
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Community based insurance programmes
• Community based insurance might do better– eg. Bwamanda, DRC enrolls 65% of population– potential in urban maternal programme, Mexico
BUT
• Remaining inequities in this successful and heavily externally supported programme
• Little use of sliding scales and exemptions
• Cost of premiums still very high
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Bwamanda hospital insurance, DRC
1986 1987 1988Population 118,612 125,480 129,244Membership rate 27.5% 47.4% 62.3%Hospitalisation rateTotal 2.80% 2.65% 3.14%Members 3.62% 3.32% 3.56%Non-members 2.48% 2.04% 2.47%
Evolution of membership in the early years
Source: Moens et al., 1990
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CIMIGEN: a pre-paid package of antenatal care in Mexico City
• Stratification of prices by income group based on willingness to pay survey
• Uptake apparently price responsive• Quality of care good• Demand rather low• Failure to compete with public sector for low-
income women• Attempt to cross-subsidise limited the market for
middle income women
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External sources of finance
• Not clear to what extent services financed by bilateral agencies, charities, NGOs achieve more equitable distribution
• Where external financing channelled through government, it presumably achieves the same distribution
• Some NGOs aim to improve equity by locating facilitites in under-served areas
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Conclusions• No ‘quick fixes’ in financing policy
• Improving impact and distribution of public finance depends on other reforms eg. strategic purchasing
• Additional sources may sometimes offer ways of increasing revenue but carry important equity risks
• We have given limited attention to the role of fees and insurance in the private sector