Financing social health protection in Nepal Towards a health financing strategy and how to get there 15.12.2009 Seite Detlef 1 Schwefel
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 http://www.socialhealthprotection.org/social_protection_health.php 15.12.2009 Seite Detlef 2 Schwefel
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 17 333 million US$ 14 US$ per person National non-profit institutions National corporations Official donor agencies 1 4 10 % 5.7 % of GDP International NGOs 11 Source: Nepal national health accounts 2002/2003 0 10 20 30 40 50 60 15.12.2009 Seite Detlef 3 Schwefel
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 0 0 0 4 3 3 1 4 5 15 13 17 21 23 32 46 MoH 2002/3 WHO 2004 WHO 2007 57 54 0 10 20 30 40 50 60 15.12.2009 Seite 4 Detlef Schwefel
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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 15.12.2009 Seite Detlef 6 Schwefel
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) 100 90 80 70 in % 60 50 40 All interviewees Poorest quintile Catastrophic cases 30 20 10 0 Drugs Inpatient Outpatient 15.12.2009 Seite 7 Traditional Other Detlef Schwefel
OOP payments as share of total household expenditure in Nepal 16 14 12 10 8 6 4 2 14,7 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 17,2 0 1 2 3 4 >5% >10% >15% >25% Poorest 20% 13,5 0 5 10 15 20 Source: Doorslaer et al (1995/96 data) Source: World Health Survey (2002/03 15.12.2009 data) Seite 8 Detlef Schwefel
Household health financing - health expenditure distribution Syria Nepal Health expenditure distribution in Nepal 8000 7000 6000 R s pe r c a s e 5000 4000 3000 2000 1000 0 1 10 19 28 37 46 55 64 73 82 91 100 109 118 127 136 145 154 163 Families 15.12.2009 Seite Detlef 9 Schwefel
Household health financing - catastrophic health expenses Syria Nepal Health expenditure distribution in Nepal 100% 25 9 126 350 750 80% 68 3500 60% 40% 32 20% 40 7500 21 0% 4 Number of families Mean expenditure per case in Rs 15.12.2009 Seite Detlef 10Schwefel
Household health financing - > 50% of treatments postponed Syria Nepal Affordability of treatment cost no 73% yes 27% Source: 100 90 80 70 60 50 40 30 20 10 0 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 % 2,6 15.12.2009 Seite 11 0,1 Sold items Savings Health insurance Detlef Schwefel
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 15.12.2009 Seite Detlef 12Schwefel
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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 15.12.2009 Seite Detlef 14Schwefel
Social protection transition Source: Carrin ppt Nepal Source: Schieber & Maeda 15.12.2009 Seite 15 Detlef Schwefel
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 15.12.2009 Seite Detlef 16Schwefel
GTZ / GFA collage Compilation of relevant information on health financing and health protection in Nepal 15.12.2009 Seite Detlef 17Schwefel
GTZ / GFA surveys 20 pages InfoSure questionnaire Short one page mini-survey on pattern of social protection 15.12.2009 Seite Detlef 18Schwefel
GTZ / GFA pilot survey Companies' health protection schemes in Nepal (in percent) Two results 100 90 80 70 60 50 40 30 20 10 0 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 51 70 69 0 20 40 60 80 Source: Sarmiento Detlef Schwefel 15.12.2009 Seite 19
Health protection & financing strategy Partners Steps Strategy fragmented they all have their strategies! incremental consensus learning exercises knowledge driven 15.12.2009 Seite Detlef 20Schwefel
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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. 15.12.2009 Seite Detlef 22Schwefel
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) 15.12.2009 Seite Detlef 23Schwefel
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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 15.12.2009 Seite Detlef 25Schwefel
Interpretation dialogues Rights to Health interpretation Basic health services interpretation BHS BHS, too? (1) Every citizen shall have the right to food. 15.12.2009 Seite Detlef 26Schwefel
Scenario dialogues Scenarios on primary health financing sources to be added 15.12.2009 Seite Detlef 27Schwefel
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 (2009-2011)» Building a national system (2011-2015) Implementation plan Source: Cambodia s social protection plan 15.12.2009 Seite Detlef 28Schwefel
Source: Schieber ppt 15.12.2009 Seite Detlef 29Schwefel
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 30.000 Rs per family and year No prevention No outpatient care Relevance for Nepal????????? 30.000 Rs ~ 440 Euro ~ 660 US$ 15.12.2009 Seite Detlef 30Schwefel
Just copy India?? Smart card = smart idea?? Social health protection Made in Nepal! is a mandate 15.12.2009 Seite Detlef 31Schwefel
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 15.12.2009 Seite Detlef 32Schwefel
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Socio-economic background Employment sectors in Nepal 2001 Formal public 7% Formal private 25% Self-employed 68% 15.12.2009 Seite Detlef 34Schwefel
Options for Nepal? Main concerns Formal sector programme Informal sector programme 15.12.2009 Seite Detlef 35Schwefel
Collective bargaining and new labour act Social health protection strategies Learning from existing best practices Protecting the poor and catastrophic expenditures Informal sector programme 15.12.2009 Seite Detlef 36Schwefel
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 15.12.2009 Seite Detlef 37Schwefel
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 15.12.2009 Seite Detlef 38Schwefel
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 15.12.2009 Seite Detlef 39Schwefel
Thanks for your attention! नम त Danke schön! 15.12.2009 Seite Detlef 40Schwefel