The role of subsidized health in promoting access to affordable quality health care: the case of Kwara State community health insurance (Nigeria) 1
Overview Presentation 1. Facts on health in Africa & relevance of health insurance 2. Performance of Kwara State community health insurance 3. Application of innovations in the administration of health insurance 2
1. Facts on health in Africa About 13% of the world s population 44% of the burden of communicable diseases, 25% of global health burden Less than 1% of global health expenditure Population (millions) Burden of communicable diseases (million DALYS) Total health expenditure (million USD) Africa Rest of the world Source, WHO 2008 3
1. Facts on health in Africa 40% in lowest income quintile receive healthcare from private for-profit providers 51% 64% 67% 53% 61% 48% 45% 44% Highest income quintile Lowest income quintile Nigeria Uganda Kenya Ethiopia Source: World Bank, 2006, Africa Development Indicators 4
Percent of total health expenditure 1. Facts on health in Africa More than 50% of health expenditure is out of pocket payments Social security and private prepaid health care spending 50% 40% 30% 20% Only 4% of total health expenditure in Africa is financed through health insurance 10% 0% South Africa Cape Verde Namibia Mali Zimbabwe Botswana Senegal Swaziland Rwanda Kenya Côte d'ivoire Togo Mauritius Benin Nigeria Niger Tanzania Madagascar Seychelles Gabon Malawi Guinea-Bissau Burkina Faso Ethiopia Guinea Chad Mozambique Uganda Cameroon Source: WHO 2008 5
2. Relevance of subsidized health insurance in Africa Access to health care is a great hurdle to many low-income people Subsidized health insurance can facilitate access to health care: It protects people from high out-of-pocket costs: risk pooling It reduces financial burden; more than 100 million individuals are driven into poverty due to health related costs It prevents people from using their savings on health, which they could use to improve their businesses It prevents people from selling assets in case of ill-health It is an important means of re-distributing income Investments in health insurance and the steady stream of income to providers stimulate trust in the healthcare system and sustainability 6
3. Challenges of premium subsidy in health insurance Huge premium subsidy funded by donors can jeopardize long term sustainability of a health insurance program Wrong targeting of premium subsidy can lead to inequity: rich people may benefit at the expense of the poor, as the case is in many social health insurance programs in Africa Huge subsidy without effective monitoring can lead to fraud by service providers Moral hazard: huge subsidy can lead to over utilization of health care services Huge premium subsidy without co-premium by participants can discourage ownership and empowerment of communities 7
4. Premium subsidy in Kwara State community health insurance program Kwara is ranked the 4th poorest State in Nigeria Poverty rate in Kwara is 62%; national poverty rate is 55% 65% of health expenditures in Nigeria are private; Kwara has the highest, 90% is out-of-pocket Kwara State community health insurance was launched in 2007 for smallscale farmers It involves the provision of subsidized health insurance and upgrading of health facilities: stimulating the demand and supply of health care It offers comprehensive healthcare primary and secondary care 8
Kwara State Community Health Insurance Program (2) Primary and secondary care services covered: Inpatient care Outpatient care Antenatal care Neonatal care Child care Treatment of malaria Preventive care including immunization Treatment of sexually transmitted diseases Eye examination and care Minor and intermediate surgeries Annual check ups Health education Hospital care and admissions Specialist consultation Prescribed drugs and pharmaceutical care Laboratory investigations and diagnostic tests Radiological investigations 9
Kwara State Community Health Insurance Program (4) Upgrade Plan Quality improvement activities address the following service elements: Health care organization management Leadership and management Human resource management Patient rights and access to care Management of information Risk management Care of patients Primary health care services In-patient care Specialized services Operating theatre and anesthetic services Laboratory services Diagnostic imaging services Medication management Ancillary Services Facility management services Support services 10
Kwara State Community Health Insurance Program (2) Premium for health insurance: 4300 Naira ($28) annually 2010 % 2011-2013 % 2014 % Premium 4000 100 4400 100 4300 100 Subsidy KSG Copremium 800 20 2200 50 2580 60 300 7.5 300 6.8 500 12 Subsidy HIF 2900 72. 5 1900 43. 2 790 28 >> 500 Naira = ca. $4.00 11
Enrollment and Health care utilization(2007-13) Enrollment: 80,000 Enrollment rate: 44% Renewal rate: 60% Utilization of care (#) HIV tests 16,652 ANC and pregnancy related visits 61,959 Deliveries 7,518 Visits with Malaria medication prescribed 94,834 TBC related visits 780 12
Post-intervention data: insured versus uninsured: ANC 90% Healthcare utilization among pregnant women 85% 80% 70% 60% 50% 40% 40% 52% control group uninsured (treatment group) 30% insured (treatment group) 20% 10% 0% Choice for ANC (at hospital) 13
% hospital deliveries of all deliveries Post-intervention data: insured versus uninsured 90% 80% Health care utilization among pregnant women 80% 70% 60% 50% 40% 30% 20% 10% 0% 48% 49% Choice for hospital delivery control group uninsured (treatment group) insured (treatment group) 14
% change Impact of intervention on treatment group 80% 70% Health care utilization among pregnant women 71.15%*** 60% 50% 40% 40.38%** 30% 2009/2011 2009/2013 20% 10% 0% Choice for hospital delivery 15
Main conclusions: Health insurance is a form of performance-based financing focused on health systems strengthening In areas, where PBF works effectively, it can help reduce the cost of insurance (premium) Critical conditions for success e.g. sensitivity to local customs, clarity on mutual benefits and responsibilities, support of government, monitoring & evaluation to enforce contracts and performance-based contracts Capitation paid to healthcare providers is performance-based; Additionally, capitation stimulates cost-effectiveness and innovation Risks and responsibilities are shared among diverse entities: insurer, participants, healthcare providers, governments Stimulates additional private resources and investments in healthcare (avoids crowding out). Less dependent on donors, which is vital for sustainability 16