MicroHealth Insurance and User Fees: Quanitifying Horizontal Equity and Impoverishment in Utilizatio

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Micro-Health Insurance and User Fees
Quanitifying Horizontal Equity and
Impoverishment in Utilization and Financing of
Health Care Evidence from Rwanda

• Reaching the Poor Conference
• Washington DC - Feb 19, 2004
• Pia Schneider
• London School of Hygiene and Tropical Medicine
  (LSHTM)
• Abt Assoc. Inc.

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Outline of Presentation

• Financial access to care under
• Micro-health insurance (MHI) and User fees
• Methods
• Indirect standardization to compare horizontal
  inequity in service use
• Minimum standard approach to compare poverty
  impact of health spending
• Findings and Policy Implications

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Uninsured Individuals Pay User fees
Source Rwanda Household and Living Condition
Survey 1999/2001
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AlternativeMicro-Health Insurance
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MHI Enrollment (6/2000 and 6/2003)
Enrollment is independent of SEG
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Source MHI routine data and PHR reports
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Methods

• Compare Impact of health spending under MHI and
  UF on service use and hh income
• Indirect standardization
• to examine horizontal inequity (HI) in
  utilization of care equal use for equal need?
• Minimum standard approach
• to quantify the extent to which user fees
  compared to MHI protect household income against
  dropping below the poverty line (PL)
• Household survey data collected in Sept/00

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Horizontal Inequity (HI) In Utilization

• Equal use for equal need?
• Method Indirect standardization
• Concentration Indices (CI) for
• actual use
• need-adjusted (expected) use
• CI 0 equal use across soc-econ groups
• HI CI (need-adjusted use) CI (actual use)
• HI 0 equal use for equal need
• Need-adjusted (expected) use
• Pr(need-visit) FSAH, age, gen, preg, bed

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Sick MHI Members Have Significantly Higher Actual
Visit Rates Across SEG
User fees Pro-rich visit distribution
Source PHR household survey 2000
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Equal Need Across Income
Equal need distribution
Source PHR household survey
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Horizontal Equity in Utilization of Care for MHI
Members
User fees Pro-rich visit distribution even
when visit adjusted by need
User fees Pro-rich distribution of actual visit
Equal visit distribution expected
Source PHR household survey 2000
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Minimum Standard ApproachPoverty Impact of
Health Payments
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Poverty Measures

• Headcount ratio
• of households below poverty line before and
  after out-of-pocket health payments
• from Ho to H1
• Poverty gap
• average shortfall of income lt PL
• sum of all shortfalls, divided by population, and
  expressed in of PL
• ABC

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Similar Poverty Impact Under MHI and User Fees
but at Different Use Levels
Source PHR household survey 2000
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Conclusions

• Equal MHI enrollment across SEG
• But the poor may have endured economic hardship
  to pay annual premium
• Health service use
• Uninsured report significantly fewer visits
• User fees Utilization is independent of need but
  depends of SEG
• MHI Horizontal equity in utilization
• OOP health spending
• Similar low impact on headcount and poverty gap
  if uninsured dont seek care

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Recommendations for Policy Makers

• Expansion
• MHI to other districts
• Current MHI benefit package to full district
  coverage
• Demand-side subsidies of premium
• MHI enrollment should be associated with targeted
  measures to ensure that the poorest enroll in MHI