Reproductive health and health financing

1
Reproductive health and health financing

• Barbara McPake, London School of Hygiene and
  Tropical Medicine

2
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

3
Sources of finance Bangladesh
4
Sources of finance Uganda
5
Sources of finance South Africa
6
Sources of finance Peru
7
Sources of finance Thailand
8
Sources of finance Russia
9
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
Source World Health Report, 2000
11
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

12
The hidden cost of free maternity care in
Dhaka, Bangladesh
Source Nahar and Costello, Health Policy and
Planning, 1998
13
Public spending Do the poor benefit?
Source Castro-Leal et al., Bulletin of WHO, 2000
of public health expenditure consumed
Poorest 20
Richest 20
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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

15
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)

16
The effect of user fee increases on STD treatment
Attendance at STC clinic (seasonally adjusted)
1Attendance in user charge period as of
pre-charge period 2Attendance 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
19
Sites where people with STD symptoms had received
medicine before attending public health centres
Source Faxelid et al., EAMJ, 1998
20
Why the poor pay more
Expenditure by provider Sierra Leone
Source Fabricant et al. Int. J. Health Plann.
Mgmt, 1999
21
Why the poor pay more contd
Source Fabricant et al.
22
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

23
Informal employment
Urban, informal, nonagricultural employment in
Latin America, 1990 and 1994
Source, Creese and Bennett, World Bank, 1997
24
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
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