The Impact of Health Insurance in Low- and Middle-Income Countries - Softcover

Softcover

ISBN 10: 0815705468 ISBN 13: 9780815705468

Verlag: Brookings Institution Press, 2011

Inhaltsangabe

Over the past twenty years, many low- and middle-income countries have experimented with health insurance options. While their plans have varied widely in scale and ambition, their goals are the same: to make health services more affordable through the use of public subsidies while also moving care providers partially or fully into competitive markets.
Colombia embarked in 1993 on a fifteen-year effort to cover its entire population with insurance, in combination with greater freedom to choose among providers. A decade later Mexico followed suit with a program tailored to its federal system. Several African nations have introduced new programs in the past decade, and many are testing options for reform. For the past twenty years, Eastern Europe has been shifting from government-run care to insurance-based competitive systems, and both China and India have experimental programs to expand coverage. These nations are betting that insurance-based health care financing can increase the accessibility of services, increase providers' productivity, and change the population's health care use patterns, mirroring the development of health systems in most OECD countries.
Until now, however, we have known little about the actual effects of these dramatic policy changes. Understanding the impact of health insurance–based care is key to the public policy debate of whether to extend insurance to low-income populations—and if so, how to do it—or to serve them through other means.
Using recent household data, this book presents evidence of the impact of insurance programs in China, Colombia, Costa Rica, Ghana, Indonesia, Namibia, and Peru. The contributors also discuss potential design improvements that could increase impact. They provide innovative insights on improving the evaluation of health insurance reforms and on building a robust knowledge base to guide policy as other countries tackle the health insurance challenge.

Über diesen Titel

Über die Autorinnen und Autoren

Maria-Luisa Escobar is lead health economist and health systems program leader at the World Bank Institute.

Charles C. Griffin is senior adviser in the European and Central Asia regional office of the World Bank.

R. Paul Shaw, a former World Bank lead economist, advises the Bill and Melinda Gates Foundation on health economics.

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The Impact of Health Insurance in Low- and Middle-Income Countries

By Maria-Luisa Escobar Charles C. Griffin R. Paul Shaw

BROOKINGS INSTITUTION PRESS

Copyright © 2010 The Brookings Institution
All right reserved.
ISBN: 978-0-8157-0546-8

Contents

Preface..............................................................................................................................................xiAcknowledgments......................................................................................................................................xiiiChapter 1 Why and How Are We Studying Health Insurance in the Developing World?......................................................................1Chapter 2 A Review of the Evidence...................................................................................................................13Chapter 3 Low-Cost Health Insurance Schemes to Protect the Poor in Namibia...........................................................................33Chapter 4 Ghana's National Health Insurance Scheme...................................................................................................58Chapter 5 Impact of Health Insurance on Access, Use, and Health Status in Costa Rica.................................................................89Chapter 6 Health Insurance and Access to Health Services, Health Services Use, and Health Status in Peru.............................................106Chapter 7 The Impact of Health Insurance on Use, Spending, and Health in Indonesia...................................................................122Chapter 8 The Impact of Rural Mutual Health Care on Health Care Use, Financial Risk Protection, and Health Status in Rural China.....................137Chapter 9 Colombia's Big Bang Health Insurance Reform................................................................................................155Chapter 10 Main Findings, Research Issues, and Policy Implications...................................................................................178Editors and Authors..................................................................................................................................199Index................................................................................................................................................205

Chapter One

Why and How Are We Studying Health Insurance in the Developing World?

Maria-Luisa Escobar, Charles C. Griffin, and R. Paul Shaw

More than 2 billion people live in developing countries with health systems afflicted by inefficiency, inequitable access, inadequate funding, and poor quality services. These people account for 92% of global annual deaths from communicable diseases, 68% of deaths from non-communicable conditions, and 80% of deaths from injuries. The World Health Organization (WHO) estimates that more than 150 million of these people suffer financial catastrophe every year, having to make unexpected out-of-pocket expenditures for expensive emergency care (WHO various years).

Within countries, the burden of dysfunctional health systems is disproportionately felt by the poorest households. Their access and use of services, such as immunizations and attended deliveries, tend to be half those of richer households. They have limited recourse to purchase quality services from private providers. Their enrollment in health insurance tends to be marginal. And they are unable to shield themselves from catastrophic health expenditures by drawing on accumulated wealth.

In view of these shortcomings, policymakers in many low- and middle- income countries are debating the virtues of scaling up health insurance to improve health outcomes. Major international conferences have been convened in Berlin (2005) on social health insurance in developing countries and in Paris (2007) on social health protection in developing countries. Regional conferences have followed, as in Africa in 2009. Related to these initiatives, the World Health Assembly passed a policy resolution whereby the WHO would advocate formally mandated social health insurance to mobilize more resources for health in low-income countries, pool risk, provide more equitable access to health care for the poor, and deliver better quality care (WHO 2005a).

All rich countries have adjusted their health finance systems to reduce out-of-pocket expenditures for health, which plunge as per capita income rises across countries (table 1.1). In terms of purchasing power parity (PPP), our preferred measure, per capita gross national income (GNI) is 29 times higher in the richest group than in low-income countries, but health spending per capita is 63 times higher. The share of gross domestic product (GDP) devoted to health more than doubles, the governments' share in the total rises, and the burden on individuals plummets as out-of-pocket spending falls as a proportion of the total. The bottom of table 1.1 shows how much this result reflects the situation in South Asia because of its large share of the total low-income population. The situation is slightly less dire in Africa, but only a bit.

Rich countries achieve these results through general revenue tax financing in support of national health insurance or subsidies for specific groups (such as the poor or the elderly), payroll taxes to support social health insurance, or, most commonly, some combination of both. Rich countries provide prepaid entitlement to health care benefits, reduce vulnerability to the expenses of care at times of illness or injury (financial risk protection), and use copayments and deductibles chiefly to manage demand rather than to raise revenue. They seek to reduce the discontinuity of care so common when people are navigating the system on their own and paying out of pocket at each point of contact. For the most part, richer countries have also separated financing from the provision of care, depend on a mix of public and private providers that are reimbursed through the insurance system, and rely increasingly on primary care providers as gatekeepers to more expensive higher level services. In a nutshell, poor countries want to mimic these successful and desirable behaviors of rich countries sooner rather than later. Mysteriously, donors have historically financed the direct delivery of health services in poorer countries with almost no attention paid to helping them build sustainable financial and purchasing institutions that could emulate some of the core successes of richer countries.

Whatever policymakers and donors want to do or think they should do to emulate successful health financing reforms, there are knowledge gaps that create enormous risks of failure for any reformer. This book attempts to begin filling some of them, but much more work remains.

The widest knowledge gap concerns the impact of health insurance on health status. Do people with health insurance in low- and middle-income countries, or even rich countries, have better health status indicators than those without? Evidence from rich countries suggests yes (box 1.1). But what about low- and middle-income countries? An affirmative on this issue would surely seem essential to consider health insurance as a health policy intervention rather than simply as a financial protection intervention. The vast array of people involved in health care because they want to improve health—nutrition advocates, family planning advocates, tuberculosis and AIDS activists, vaccine supporters, Millennium Development Goal supporters, health systems improvers—would have to see health insurance as an...

Details zur Ausgabe

• Verlag: Brookings Institution Press
• Erscheinungsdatum: 2011
• Sprache: Englisch
• ISBN 10: 0815705468
• ISBN 13: 9780815705468
• Einband: Taschenbuch
• Anzahl der Seiten: 239
• Herausgeber: Escobar Maria-Luisa
• Kontakt zum Hersteller: Nicht verfügbar
• Verantwortliche Person: Nicht verfügbar