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Reproductive health and health financing


Employers' contributions to health insurance. External donations. Sources of finance: Bangladesh ... Do user fees deter family planning? ... – PowerPoint PPT presentation

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Title: Reproductive health and health financing

Reproductive health and health financing
  • Barbara McPake, London School of Hygiene and
    Tropical Medicine

The main sources of finance for reproductive
health services
  • Public tax-based revenues
  • Households out-of-pocket expenditures
  • Employers contributions to health insurance
  • External donations

Sources of finance Bangladesh
Sources of finance Uganda
Sources of finance South Africa
Sources of finance Peru
Sources of finance Thailand
Sources of finance Russia
The advantages of pooling
  • Pooling creates important opportunities for
    sharing risks between healthy and sick rich and
  • If funds are earmarked, reallocation to more
    cost-effective services is constrained
  • The wider the risk pool, the more opportunities
    there are for cross-subsidy

Pooling to redistribute risk and cross-subsidy
for greater equity
Source World Health Report, 2000
Public finance
  • Generally offers greatest potential to pool
    resources and risk
  • However, potential rarely achieved
  • Resources allocated to low priority investments
    and interventions
  • Health and wealthier individuals receive more
    than their fair share access staff attitudes
    patient choices
  • Resources concentrated in high level health
    facilities and towns

The hidden cost of free maternity care in
Dhaka, Bangladesh
Source Nahar and Costello, Health Policy and
Planning, 1998
Public spending Do the poor benefit?
Source Castro-Leal et al., Bulletin of WHO, 2000
of public health expenditure consumed
Poorest 20
Richest 20
User fees in the public sector
  • Additional revenue
  • Potential to improve quality of services
  • Potential to apply cross-subsidies
  • BUT
  • Deterrent effect of fees on utilisation
  • Difficulties of implementing effective exemption

Do user fees deter family planning?
  • Individuals are not very responsive to changes in
    price of contraceptives (eg. Thailand,
    Philippines, Jamaica, Bangladesh)
  • As the price of contraception increases, the
    price elasticity of demand increases
  • Choice of contraceptive method and provider is
    sensitive to price
  • The probability that contraception is used
    declines as distance to health facilities
  • (Source, Levin et al. Social Science and
    Medicine, 1999)

The effect of user fee increases on STD treatment
Attendance at STC clinic (seasonally adjusted)
1Attendance in user charge period as of
pre-charge period 2Attendance in post charge
period as in pre-charge period
Source Moses et al., The Lancet, 1992
User fees in the private sector
  • Private sector has flexibility in the operation
    of fee scales
  • Poorer consumers use formal primary level private
    providers and the informal sector
  • Higher prices do not always mean better quality
  • The private sector is the main recipient of
    expenditures made by the poor

User fees and maternity services
  • Prevention of maternal mortality network (range
    of country studies in West Africa)
  • After fees Normal deliveries ?
  • Complicated deliveries ? or ?
  • The ways fees applied affected these trends
  • Poor quality of care was most important factor in
    case fatality rate

Source Prevention of Maternal Mortality Network,
Social Science and Medicine,1995
Sites where people with STD symptoms had received
medicine before attending public health centres
Source Faxelid et al., EAMJ, 1998
Why the poor pay more
Expenditure by provider Sierra Leone
Source Fabricant et al. Int. J. Health Plann.
Mgmt, 1999
Why the poor pay more contd
Source Fabricant et al.
National insurance programmes
  • Can seldom achieve universal coverage
  • Restricted formal sector employment
  • Limited government ability to subsidise rest
  • Subsidy to national insurance tends to entrench
  • Risk sharing and cross-subsidy restricted to
    within middle and upper income groups

Informal employment
Urban, informal, nonagricultural employment in
Latin America, 1990 and 1994
Source, Creese and Bennett, World Bank, 1997
Community based insurance programmes
  • Community based insurance might do better
  • eg. Bwamanda, DRC enrolls 65 of population
  • potential in urban maternal programme, Mexico
  • BUT
  • Remaining inequities in this successful and
    heavily externally supported programme
  • Little use of sliding scales and exemptions
  • Cost of premiums still very high

Bwamanda hospital insurance, DRC
Evolution of membership in the early years
Source Moens et al., 1990
CIMIGEN a pre-paid package of antenatal care in
Mexico City
  • Stratification of prices by income group based on
    willingness to pay survey
  • Uptake apparently price responsive
  • Quality of care good
  • Demand rather low
  • Failure to compete with public sector for
    low-income women
  • Attempt to cross-subsidise limited the market for
    middle income women

External sources of finance
  • Not clear to what extent services financed by
    bilateral agencies, charities, NGOs achieve more
    equitable distribution
  • Where external financing channelled through
    government, it presumably achieves the same
  • Some NGOs aim to improve equity by locating
    facilitites in under-served areas

  • No quick fixes in financing policy
  • Improving impact and distribution of public
    finance depends on other reforms eg. strategic
  • Additional sources may sometimes offer ways of
    increasing revenue but carry important equity
  • We have given limited attention to the role of
    fees and insurance in the private sector
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