Financing social health protection in Nepal

Transcription

1 Financing social health protection in Nepal Towards a health financing strategy and how to get there Seite Detlef 1 Schwefel

2 Social health protection Reduction of financial barriers to health care»extension of social protection in health is the key strategy to reduce financial barriers to access health care and moving towards universal coverage (i.e. universal health protection) Reduction of out-of pocket payments»irrespective of the financing mechanisms employed, social protection in health involves a shift towards enhanced risksharing and risk-pooling, i.e. increasing the share of prepayment in total health expenditure and reducing the reliance on out-ofpocket-payments. Source: GTZ-ILO-WHO-Consortium on Social Health Protection in Developing Countries Seite Detlef 2 Schwefel

3 Health expenditure in Nepal How much is spent? Who spends? (in percent) 24,913 million NRs Private households 57 1,038 NRs per head Government million US$ 14 US$ per person National non-profit institutions National corporations Official donor agencies % 5.7 % of GDP International NGOs 11 Source: Nepal national health accounts 2002/ Seite Detlef 3 Schwefel

4 Health expenditure in Nepal Sources of health financing in Nepal according to different sources and periods of time in percentage shares Government Social / private security Private households (OOP) National NGO Corporations / Others External resources MoH 2002/3 WHO 2004 WHO Seite 4 Detlef Schwefel

5 Seite Detlef 5 Schwefel

6 Health expenditure shares % Household health financing Diagnosis: Uninformed expenditure at point of delivery > 50% for drugs and medicines > 50% for catastrophic expenses > 50% of treatments postponed Strategies: Efficiency in household spending» Health (financing) education From post-payment to pre-payment» Health protection & insurance options Seite Detlef 6 Schwefel

7 Household health financing - > 50% for drugs and medicines World Nepal The importance of drugs in out-of-pocket health expenditure in Nepal (World Health Survey 2002) in % All interviewees Poorest quintile Catastrophic cases Drugs Inpatient Outpatient Seite 7 Traditional Other Detlef Schwefel

8 OOP payments as share of total household expenditure in Nepal ,7 5,9 Household health financing - catastrophic health expenses There are many definitions of catastrophic health spending 1995/96 14,7 % of Nepalese households spent more than 5 % of household expenditure for health 2002/03 15,7% of households experienced catastrophic health spending 3,1 1,2 This affects all population groups Catastrophic health expenditure episodes according to income quintiles (in percent) Richest 20% Higher 20% Middle 20% Lower 20% 14,3 15,5 18,3 17, >5% >10% >15% >25% Poorest 20% 13, Source: Doorslaer et al (1995/96 data) Source: World Health Survey (2002/ data) Seite 8 Detlef Schwefel

9 Household health financing - health expenditure distribution Syria Nepal Health expenditure distribution in Nepal R s pe r c a s e Families Seite Detlef 9 Schwefel

10 Household health financing - catastrophic health expenses Syria Nepal Health expenditure distribution in Nepal 100% % % 40% 32 20% % 4 Number of families Mean expenditure per case in Rs Seite Detlef 10Schwefel

11 Household health financing - > 50% of treatments postponed Syria Nepal Affordability of treatment cost no 73% yes 27% Source: Private health financing sources in Nepal (World Health Survey 2002) 87,5 Current income 31,9 31,1 Borrowed from others Borrowed from relatives 13,9 in % 2, Seite 11 0,1 Sold items Savings Health insurance Detlef Schwefel

12 Household health financing - > 50% catastrophic impacts Catastrophic expenses Impact on other household consumption Impact on household productivity Catastrophic non-expenses Postponement of treatment Withdrawal of treatment Incomplete treatment No treatment for some Seite Detlef 12Schwefel

13 Seite Detlef 13Schwefel

14 Households Social protection strategies = health financing strategies From high out-of-pocket payments to sustainable health protection» Rational drug supply and demand» Control of excessive expenses» No postponement of treatments based on MoHP stewardship Government National health financing strategy National health protection policy, five year plan, long-term strategy draft Health education» Informed self-help and efficient health seeking behaviour» Importance of pre-payments and control thereof Seite Detlef 14Schwefel

15 Social protection transition Source: Carrin ppt Nepal Source: Schieber & Maeda Seite 15 Detlef Schwefel

16 Health protection in Nepal Fragmentation of current approaches Lack of studies and evidences Family health financing Updated health accounts»gtz/gfa collage Health benefit and insurance schemes»gtz/gfa surveys Health protection needs & expenditure review»social health protection financing strategy Seite Detlef 16Schwefel

17 GTZ / GFA collage Compilation of relevant information on health financing and health protection in Nepal Seite Detlef 17Schwefel

18 GTZ / GFA surveys 20 pages InfoSure questionnaire Short one page mini-survey on pattern of social protection Seite Detlef 18Schwefel

19 GTZ / GFA pilot survey Companies' health protection schemes in Nepal (in percent) Two results Protection pattern Satisfaction Medical Allowance Health Benefits Related to Ilness in cash and/or in kind work insurance Health Insurance health benefits and/or insurance medical allowances Dissatisfied Satisfied Accident Insurance Source: Sarmiento Detlef Schwefel Seite 19

20 Health protection & financing strategy Partners Steps Strategy fragmented they all have their strategies! incremental consensus learning exercises knowledge driven Seite Detlef 20Schwefel

21 Seite Detlef 21Schwefel

22 How to get there? 1. Institutional arrangement Technical secretariat (attached to MoHP) Provision of technical expertise Legal and information support Capacity building and networking Support by WHO, ILO, GTZ Consortium and/or other partners Additional local funds as sign of Nepali commitment Gradual involvement of other partners Solidarity schemes, health insurances, workers, employers, women organizations, civil society organizations, health economists, public health experts, universities, external experts, etc. Government: PM, MoF, etc Seite Detlef 22Schwefel

23 How to get there? 2. Knowledge basis Search for evidences and research» Studies and compilations, e.g. GTZ/GFA approaches Training, knowledge and awareness generation» and dissemination e.g. on Market failures - Information asymmetry - Supply side power Health insurance Role of government Sources: WHO, Worldbank (Schieber, Gottret) Seite Detlef 23Schwefel

24 Seite Detlef 24Schwefel

25 How to get there? 3. Dialogues Strategy finding is not technical engineering but a social process with many partners Especially in a future federal setting Source: P4H Seite Detlef 25Schwefel

26 Interpretation dialogues Rights to Health interpretation Basic health services interpretation BHS BHS, too? (1) Every citizen shall have the right to food Seite Detlef 26Schwefel

27 Scenario dialogues Scenarios on primary health financing sources to be added Seite Detlef 27Schwefel

28 How to get there? 4. Drafting of plans Review of background Vision Strategic objectives Government efficiency Households prepayments Services quality Donors coordination Master plan Vision availability, affordability, accessibility for all by 2015 Goal develop and implement sustainable health system Strategic approaches» Consolidating existing schemes ( )» Building a national system ( ) Implementation plan Source: Cambodia s social protection plan Seite Detlef 28Schwefel

29 Source: Schieber ppt Seite Detlef 29Schwefel

30 How to get there? 5. Reviewing experiences Drug use rationalization Catastrophic expenses Treatment postponement Smart card = smart idea? Rashtriya Swasthya Bima Yojana Programme, BPL, India Only inpatient drugs included Upper ceiling of Rs per family and year No prevention No outpatient care Relevance for Nepal????????? Rs ~ 440 Euro ~ 660 US$ Seite Detlef 30Schwefel

31 Just copy India?? Smart card = smart idea?? Social health protection Made in Nepal! is a mandate Seite Detlef 31Schwefel

32 How to get there? 5. Evidence-based advocacy Who? Key team» MoHP ++ Committed partners Knowledgeable experts Experienced collaborators» Senior interviewers» Outspoken interviewees Media experts What for? Goodness Fairness Responsiveness Effectiveness Efficiency Universality Solidarity Subsidiarity Seite Detlef 32Schwefel

33 Seite Detlef 33Schwefel

34 Socio-economic background Employment sectors in Nepal 2001 Formal public 7% Formal private 25% Self-employed 68% Seite Detlef 34Schwefel

35 Options for Nepal? Main concerns Formal sector programme Informal sector programme Seite Detlef 35Schwefel

36 Collective bargaining and new labour act Social health protection strategies Learning from existing best practices Protecting the poor and catastrophic expenditures Informal sector programme Seite Detlef 36Schwefel

37 Inclusion of the poor in the national health system is mandatory South Korea health insurance Started with a benefit programme for the poor Thailand health system 41% of population considered to be vulnerable & poor Philippines health insurance 25% of population to be included without contributions Egypt health insurance Pensioners, widows, schoolchildren, newborn Germany health insurance Everybody has to be insured tax money support for poor Seite Detlef 37Schwefel

38 Importance of health insurance 94% of opinion leaders say: A national health insurance system is really needed now in Nepal Risk and uncertainty in health and health care Unpredictable occurrence of diseases Unaffordable prices of health care Risk of postponing health care (in the individual case) (in the individual case) A typical response is the set-up of health insurance schemes to remove uncertainty and risk Regular prepayments Rational spending for health Health insurance markets are often not efficient Adverse selection & moral hazard cause significant market failure Questionable effects on the labour market competitiveness Government has to provide back-up, regulation, and stewardship Seite Detlef 38Schwefel

39 Some messages The drive towards a comprehensive system of social health protection is a social process Many actors and agents are involved Conflicts and confrontations are sure This drive needs a good knowledge base,» Expanded national and family health accounts» Compilations, studies and surveys» Health economics and financing understanding A full fledged social health protection or social insurance system takes time and needs evidence based policy dialogues Seite Detlef 39Schwefel

40 Thanks for your attention! नम त Danke schön! Seite Detlef 40Schwefel