Combating Exclusion and Removing Barriers: Improving Health

1
Combating Exclusion and Removing Barriers
Improving Health
Roma in an Expanding Europe Challenges for The
Future Budapest, Hungary June 30-July 1, 2003
Cristian Baeza

• The World Bank

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Health Systems as contributors to health
Producers
HR, Goods and Services
Health
Providers
Utilization
Financing
Contributors
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Health Systems as contributors to health
Producers
Citizens
Sector Governance and Stewardship
HR, Goods and Services
Health
Providers
Utilization
Demand
Financing
Preferences, believes and behaviors
Consumers
Contributors
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Objectives of Social Protection and Inclusion in
Health
Housing
Income
Producers
Citizens
Financial Protection
Human Development Household Welfare Production
Function PRS
Health
Utilization
Providers
Dignity
Food
Consumers
Contributors
Education
Social Integration
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The Objectives of Social Protection and Inclusion
in Health

• To maintain and improve the health status,
  ensuring inclusion to those excluded from access
  socially accepted level effective and needed
  health services. Health not only as an essential
  component of their human capital for overcoming
  poverty but as an essential part of the Human
  development objective.
• To do so ensuring sufficient financial protection
  to avoid excess contribution that could force
  households into poverty or make it impossible for
  them to overcome it.
• All under strict respect for the dignity, freedom
  and human rights.

The Key Importance of an Explicit Society
Guaranty Entitlement
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Causes of Exclusion
Not defined or poorly defined priorities of
interventions and/or lack of enforcement of the
GHP (under-coverage) Incongruities between the
type of intervention and the financing and/or
health care delivering mechanisms
Supply problems Demand problems
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Exclusion Due Problems With Access and
Utilization of Health Services
Problems
Possible Solutions
No providers.
Increase eligible providers -
Investments - Reduction of barriers to
enter - Purchasing of Services
Supply
Non-eligible providers
Training and education Incentives
Inefficient or low-productive providers
Providers that discriminate against particular
users
Strengthening purchasing function Purchasing and
regulation mechanisms
Need to address the specific cultural
characteristic of the target population
Dignity barriers
Demand
Educational campaigns to the population Increasing
effectiveness of providers
Services considered unnecesary
Services considered necessary, but there is no
WTP for it
Ensure the congruence between interventions and
instruments in GHP
Services considered necessary, but there is no
ability to pay or high oportunity cost
Improving the efficiency and magnitude of the
equity subsidy negative prices?
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Innovations for Problems on the Demand of Health
Services

• Bolivia Maternal and Child Insurance
• Responding to the cultural context
• Mexico Progresa / Oportunidades
• Stimulating demand via conditional cash transfers

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LURATANAKASA(THE PERFECT EQUILIBRIUM THE COLORS
OF THE LIFE AND GOOD OUTCOMES)BLACK LIFE AND
GOOD OUTCOMESRED SUN, PREVENTION AND PHISYCAL
HEALTHGREEN LAND, NUTRITION AND INCOME YELLOW
DIGNITY AND QUALITY OF LIFEWHITE DEATH
Maternal and Child Insurance in Bolivia
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Maternal and Child Insurance in Bolivia

• Basic health insurance (1998) 92 interventions
  with impact on the 56 of all causes of disease
  and death in Bolivia.
• The cultural dimension 10 more non medical
  services such
• Rescue of the soul,
• Returning back the placenta to the land
  (pachamama)
• Traditional vademecum
• Yanapiri (to hear and give a wise-health advice
  in ancient medicine, etc.)

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Causes of Exclusion Due to Problems in the
Financing Function
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Exclusion Due to Problems in the Risk Pooling
Mechanism
Possible solutions
Problems
There are no pooling arrangememts or those
existing are inefficient
Development and promotion of pooling schemes
Pooling problems (Problems with
cross-subsidization from low to high risk groups.)
Pooling schemes working but users are not
eligible
Elimination of eligibility barriers for the
self-employed and small businesses owners,
modification of legislation, community rating,
and equity subsidies
There are pooling schemes but users consider them
unnecessary (no demand)
Educational campaigns Mandatory affiliation to
insurance schemes (avoid free riders)
There are pooling schemes but no ability to pay
from users
Expand risk pools and development of equity
subsidies
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Innovations in Pooling

• Targeting and adaptations of public health
  insurance to excluded populations
• Bolivia Maternal and Child Insurance
• Chile Guaranteed Health Plan (AUGE)
• Demand side subsidy for Insurance coverage for
  the poor
• Colombia Subsidized modality
• Community Based Health Organizations

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Exclusion due to Problems of Equity Subsidies
Problems
Possible solutions
Users do not participate in existing pooling
schemes because they can not pay the premiums
(insuficient equity subsidy)

• Ensure an adequate level of equity subsidies
• Within pooling schemes
• Among pooling schemes (solidarity funds)
• From public sources (general taxes)

Users participate in existing pooling but pay in
excess due to insuficient equity subsidies
Problems with the equity subsidy
Pooling schemes with sufficient equity subsidies
available but with no portablity of subsidies
Develop portability of subsidies among public
sector or insurance schemes
Improve risk adjustments according to the number
of members of the household Improve purchasing
efficiency in private and public sectors.
Pooling schemes where users pay too much due to
the inefficient portability of subsidies
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Combating Exclusion and Removing Barriers
Improving Health
Roma in an Expanding Europe Challenges for The
Future Budapest, Hungary June 30-July 1, 2003
Cristian Baeza

• The World Bank

16
Effects of risk pooling Cross-subsidization from
lower to higher risk individuals
Required household contribution
Higher Risk
Before risk pooling
Lower Risk
Required household contribution
Lower Risk
Higher Risk
After risk pooling
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Risk pooling Cross-subsidies from lower to
higher risk
Equity Cross-subsidy from higher to lower income
High income
Required household contribution
Required Household contribution
Higher Risk
Lower Risk
Low income
Required household contribution
Required household contribution
Lower Risk
Higher Risk
High income
Low income