SOCIAL SECURITY AND HEALTH INSURANCE: EQUITY AND FAIR FINANCING Ali Ghufron Mukti Master in Health Financing Policy and Health Insurance management Gadjah Mada University 1
Interpretation of the equity concept Many ypossible interpretation of equity in health? 1. Equal resources or use of services Everyone should receive the same services or have the same resources spent on health (is it efficient, i since health needs differ widely) 2. Equal health Does every one have a right to equal health? (some look after themselves less well than the others) -> 3. Fair inning We might set a target age which people are in some way entitled to reach, what happen for people whose genetic inheritance predispose them to early death? 2
Interpretation of the equity concept 4. Equal access/utilization according to need Some income redistribution would be needed to ensure that the real cost of using services is evened out between income groups Equal treatment for equal needs, horizontal equity= people with the same problems be treated in the same say Vertical equity? How to treat people with different health problems 3
Interpretation of the equity concept 5. Treatment according to capacity to benefit This goes beyond needs to the question of whether someone is likely to benefit from treatment. It will depend both on the availability of effective technologies and the characteristics of the patient which make successful treatment likely or unlikely 4
We also have a term for equity in relation to the philosophical concepts : Egalitarian equity (you get what you need, regardless of your socio-economic status) Libertarian equity (you get what you pay for) it relates with your payment 5
EQUITY IN HEALTH Which interpretation of equity is valid and acceptable? Here, we will seek to define equity in health, by defining two central concepts: Equity in delivery Equity in financingi 6
HORIZONTAL AND VERTICAL REPRESENTATION OF SOCIETY (Bitran & Associates, 2003). Horizontal dimension Group 1 Group 2 Vertica al dimens sion Group 3 Group N 7
Check this Two civil servants with different rank, basic salary, and take home income Low rank salary High rank salary $ 120 $ 200 Contribution of = $ 2.40 = $ 4.00 2% Actual earning $ 240 $ 600 Actual burden 1% 0.7% Benefits Same About the same, but may have higher utilization 8
Out of pocket burden: inpatient costs/household monthly expenditure by income groups Indonesian example (Thabrany, 2003) 4,5 4 3,5 3 2,5 2 1,5 1995 1998 Burden (x HHE) 1 0,5 0 Decile3 Decile2 Decile1 Decile4 Decile5 Decile10 Decile9 Decile8 Decile7 Decile6 Income deciles 9
THE PROBLEMS WITH UNIVERSAL PROVISION: EVIDENCE FROM INDONESIA The allocation of public subsidies for health 180 MONTH CAPITA PER RUPIAH PER 160 140 120 100 80 60 40 20 0 25 42 45 49 37 43 39 135 39 99 105 94 32 26 60 51 58 35 22 28 1 2 3 4 5 6 7 8 9 10 INCOME DECILE HOSPITAL SUBSIDY PUBLIC HEALTH CENTER SUBSIDY 10
HORIZONTAL AND VERTICAL REPRESENTATION OF SOCIETY The two questions that concern us: Delivery in relation to health need Financing in relation to ability to pay 11
Horizontal equity EQUITY IN DELIVERY (Bitran & Associates, 2003). Health care delivery system is horizontally equitable if all people with equal need for health care are equally likely to obtain the same type of health care. Equal treatment of equals (Bitran & Associates, 2003). Vertical equity A health care delivery system is vertically equitable if people with greater need for health care are more likely to obtain care than those with a lower need. More health care for those with more need 12
EQUITY IN DELIVERY: EXAMPLE 1 (Bitran & Associates, 2003). Quintile Population People with health problem Percent of all people People obtaining health care Percent of those with problem obtaining care 1 4,000 400 26% 200 50% 2 4,000 320 21% 200 64% 3 4,000 300 20% 180 60% 4 4,000 250 16% 180 72% 5 4,000 250 16% 200 80% Total 20,000 1,520 100% 960 63% Assume that people in all quintiles have health problem of equal severity. Can we say that there is horizontal equity in delivery? 13
EQUITY IN DELIVERY: EXAMPLE 2 (Bitran & Associates, 2003). Illness People with health problem Percent of all people p with health problem People obtaining health care Percent of those with problem obtaining care Common Cold 1,000 26% 700 70% Flu 250 21% 200 80% Tuberculosis 125 20% 40 27% AIDS 120 16% 20 17% Total 1,520 100% 960 63% Assume that illnesses severity varies, and that people p are sorted in ascending order of severity. Can we say that there is vertical equity in delivery? No: sicker people are less likely to obtain health care than those with less severe problems. 14
EQUITY IN DELIVERY: POSSIBLE CASES (Bitran & Associates, 2003). Equitable Horizontal equity Inequitable uitable Equ Ideal Second or third best Ineq quitable Second or third best Worst 15
EQUITY IN FINANCING Possible sources of financing: 1. Out-of-pocket payments by patients 2. Insurance premiums-market system 3. Health social security payments (social health insurance) 4. Taxes (some of which are used by the government to subsidize health care) 5. Others : - community health financing - donor agency etc 16
EQUITY IN FINANCING: THE 4 SOURCES OF FINANCING (Bitran & Associates, 2003). Government Health insurance Social security administration Provider payment Provider payment (4) taxes Health care providers (2) Premiums (1) Out-of-pocket payments (3) Contributions Members of society 17
EQUITY IN FINANCING (Bitran & Associates, 2003). Horizontal equity Horizontal equity in financing is when people with equal ability to pay make equal payments for health care Equal payments by equals Vertical equity A health system is vertically equitable when payment and ability to pay are positively correlated Greater ability to pay higher payment Smaller ability to pay lower payment To some, a financing system is considered to be vertically equitable if those with greater ability to pay contribute a greater share of their income to pay for health care ( progressive financing.) 18
DOES EQUALITY OF HEALTH STATUS IMPLY EQUITY IN DELIVERY OR IN FINANCING? (Bitran & Associates, 2003). Should a health system could be considered equitable if all citizens had the same health status No. Too many factors other than health care influence health status. Still, although health status is an incomplete and sometimes misleading measure of equity in health, it is an important input in design of targeting policies and in design and evaluation of social welfare programs. 19
ARE EQUITY AND EQUALITY SYNONYMOUS? (Bitran & Associates, 2003). Some think that: Inequity will not necessarily arise as a result of differences in consumption levels among individuals, but will always be present when consumption by any one individual or group is below a minimum socially acceptable MINIMUM SOCIALLY ACCEPTABLE = EQUITY GAP = HEALTH CARE 20
ARE EQUITY AND EQUALITY SYNONYMOUS? (Bitran & Associates, 2003). In other words, some think that: As long as everybody has access to a minimum health benefits package, there is equity. If some have access to more than the minimum, there is inequality, but the system is still equitable. MINIMUM SOCIALLY ACCEPTABLE = CONSUMPTION ABOVE MINIMUM = CONSUMPTION ABOVE MINIMUM = HEALTH CARE 21
INCIDENCE ANALYSIS: WHO PAYS AND WHO BENEFITS? (Bitran & Associates, 2003). Van Doorslaer et al.: Who pays for health care and who receives how much health care? Who pays for government health care subsidies and who benefits from these subsidies? Equity in delivery and financing: incidence in delivery and financing Incidence as a measurement that helps us judge equity 22
WHO GETS THE BENEFITS? (Bitran & Associates, 2003). One question: who is getting the benefits of governmentsubsidized health services? First: we need to define who the target or intedended beneficiaries of government subsidies are Natural (and correct) to assume that beneficiaries are the poor the non-poor can look after themselves And we need to measure progressivity Who is poor? Poverty line; the 40% poorest Progressivity: A program is progressive in delivery of benefits if the share of benefits e received ed by each income group drops as income increases 23
EXAMPLE OF PROGRESSIVITY IN BENEFITS (Bitran & Associates, 2003). Population group Percent of total population Cumulative percent of population Percent of program benefits going to each population group Program 1 Program 2 Percent of program benefits going to Cumulative percentage of benefits each population group Cumulative percentage of benefits Quintile 1 20 20 30 30 40 40 Quintile 2 20 40 20 50 30 70 Quintile 3 20 60 19 69 20 90 Quintile 4 20 80 18 87 8 98 Quintile 5 20 100 13 100 2 100 Which of the two programs is more progressive in the delivery of benefits? 24
WHAT IS A FAIR ALLOCATION? (Bitran & Associates, 2003). To assess incidence in delivery: need conceptual framework for what a fair allocation of subsidies would be Previous definition of progressivity is somewhat vague: the poor have a lesser ability to buy services and also tend to be sicker Horizontal or vertical equity in the delivery of health care: to assess incidence in relation to need Illness concentration index 25
Equity Checklist Resources The funding base: is it progressive or regressive? What proportion of household disposable income (after tax) is being spent on health? Is there evidence of inability to pay for fees, drugs etc (borrowing: non-use of services, alternative strategies?) What is the balance between private and public funding of health care in general? 26
Resources Equity Checklist Is there evidence of differential use of services by different income groups, adjusted for need? Is the allocation of resources between regions carried out according to the need? Are exemption mechanisms for fees/drugs or differential charges being targeted effectively at those in most need? 27
Infrastructure Equity Checklist Are services evenly distributed in different parts of the country, or according to the need? Is the quality of services even between different areas? Are supplies, drugs, manpower, etc. equally available 28
Health Status Equity Checklist Are there significant variations in health indicators between income groups, the sexes, ethnic minorities or other significant groups? 29