Sustainability of healthcare financing in the Western Balkans : an overview of progress and challenges

This paper explores the major challenges to the sustainability of health sector financing in the countries of the Western Balkans - Albania, Bosnia and Herzegovina, the Former Yugoslav Republic of Macedonia, Montenegro, Serbia and the province of Kosovo. It focuses on how the incentives created by the different elements of the healthcare financing system affect the behavior of healthcare providers and individuals, and the resulting inefficiencies in revenue collection and expenditure containment. The paper analyzes patterns of healthcare expenditure, finding that there is some evidence of cost containment, but that current expenditure levels - while similar to that in EU countries as a share of GDP - are low in per capita terms and the fiscal space to increase expenditures is extremely limited. It also examines the key drivers of current healthcare expenditure and the most significant barriers to revenue generation, identifying some key health reforms that countries in the sub-region could consider in order to enhance the efficiency and sustainability of their health systems. Data are drawn from international databases, country institutions, and household surveys.Health Monitoring&Evaluation,Health Economics&Finance,Health Systems Development&Reform,Public Sector Expenditure Analysis&Management,Health Law

Health reform, population policy and child nutritional status in China

This paper examines the determinants of child nutritional status in seven provinces of China during the 1990s, focusing specifically on the role of two areas of public policy, namely health system reforms and the one child policy. The empirical relationship between income and nutritional status, and the extent to which that relationship is mediated by access to quality healthcare and being an only-child, is investigated using ordinary least squares, random effects, fixed effects, and instrumental variables models. In the preferred model - a fixed effects model where income is instrumented - the author find that being an only-child increases height-for-age z-scores by 0.119 of a standard deviation. The magnitude of this effect is found to be largely gender and income neutral. By contrast, access to quality healthcare and income is not found to be significantly associated with improved nutritional status in the preferred model. Data are drawn from four waves of the China Health and Nutrition Survey.Health Monitoring&Evaluation,Population Policies,Transport Economics Policy&Planning,Health Systems Development&Reform,Rural Poverty Reduction

The Impoverishing Effect of Ill Health: Evidence from the Western Balkans

This paper investigates the extent to which the health systems of the Western Balkans (Albania, Bosnia and Herzegovina, Montenegro, Serbia and Kosovo) have succeeded in providing financial protection against adverse health events. We examine disparities in health status, health care utilization and out-of-pocket payments for health care (including informal payments), and explore the impact of health care expenditures on household economic status and poverty. Data are drawn from LSMS surveys and methodologies include ‘catastrophic-health’ analysis, poverty incidence analysis adjusted for health payments, and multivariate regression analysis. On balance, we find that economic status is significantly associated with health care-seeking behavior in all transition economies and the cost of illness can increase the incidence and depth of poverty. The impoverishing effect of health expenditures is most severe in Albania and Kosovo, followed by Serbia, Bosnia and Herzegovina and Montenegro. Moreover, health care costs seem to place a heavier burden on the weakest strata of the population, such as children and people with chronic illness, with serious consequences for the breaking out of the illness-poverty vicious circle.Health system, Health care expenditure, Poverty, Western Balkans

The impoverishing effect of adverse health events : evidence from the western Balkans

This paper investigates the extent to which the health systems of the Western Balkans (Albania, Bosnia and Herzegovina, Montenegro, Serbia, and Kosovo) have succeeded in providing financial protection against adverse health events. The authors examine disparities in health status, healthcare utilization, and out-of-pocket payments for healthcare (including informal payments), and explore the impact of healthcare expenditures on household economic status and poverty. Methodologies include (i) generating a descriptive assessment of health and healthcare disparities across socioeconomic groups, (ii) measuring the incidence and intensity of catastrophic healthcare payments, (iii) examining the effect of out-of-pocket payments on poverty headcount and poverty gap measures, and (iv) running sets of country-specific probit regressions to model the relationship between health status, healthcare utilization, and poverty. On balance, the findings show that the impact of health expenditures on household economic wellbeing and poverty is most severe in Albania and Kosovo, while Montenegro is striking for the financial protection that the health system seems to provide. Data are drawn from Living Standards and Measurement Surveys.Health Monitoring&Evaluation,Health Systems Development&Reform,Health Economics&Finance,Population Policies,Rural Poverty Reduction

Income and child nutritional status in China in the 1990s: three essays

Exploiting the availability of panel data, the first paper examines the trends in child malnutrition in China, both across cohorts and within cohorts. Descriptive analyses and the results of pooled OLS and probit models provide evidence of a dramatic downward secular trend in underweight, stunting and wasting. While the aggregate picture is overwhelmingly positive, disaggregation of the data by subgroup reveals some disturbing trends: urban-rural, gender and provincial disparities in nutritional status have increased over time; gains appear to have slowed; and, in some provinces, the prevalence of stunting appears to be increasing. The second paper explores the robustness of the estimated effect of economic status on child nutritional status to alternative income and assets constructs. The internal and external performance of three income measures and eleven asset indices is examined. Then, a series of reduced-form child health demand models, in which these constructs enter the models as income/asset quintiles, is estimated. The analysis reveals that the choice of construct - income or assets - affects results. Further, it provides an indication of the potential direction of bias if one class of measures is chosen over another: income measures tend to produce smaller coefficients than asset measures, but coefficients are more likely to increase progressively, and significantly, with each successive quintile. The third paper explores the role of income as a determinant of child nutritional status in China, and examines how its effect has been mediated by the one-child policy and changes in the accessibility, cost and quality of healthcare. Pooled OLS and probit models produce large income coefficients. These coefficients shrink when the effects of policies are incorporated into the model, but remain significant. Being an only-child, having shorter traveling times to healthcare facilities and having access to better quality healthcare are all correlated with improved nutritional status. Once community fixed-effects are introduced, however, the effect of income and healthcare becomes insignificant. This pattern is reproduced in pooled OLS and fixed-effects models in which income is instrumented. In addition, it is shown that the one-child policy and healthcare variables are both gender-neutral and income-neutral in their effects on nutritional status

Falling through the cracks : income security and the South African social security system

Thesis (MA)--Stellenbosch University, 2001.ENGLISH ABSTRACT: This thesis focuses on the extent to which the South African social security system succeeds in providing protection in the vulnerable periods of the life-cycle and against the major contingencies of unemployment, disability and disease. Through a detailed examination of the different social insurance and assistance programmes, it isolates which particular population segments (by occupation, income quintile and race group) "fall through the cracks" in the provision of income security. It does not look only at the articulation between different social insurance and social assistance programmes, but also acknowledges how social security complements other governmental interventions, such as social services, and non-state sources of income security, such as those provided by the private insurance market and the family and community. Part One of the thesis is devoted to an examination of social insurance in South Africa, in other words, to those programmes that seek to compensate for a loss of income in the event of particular contingencies and that are funded by contributions from employers and employees. In addition, theoretical perspectives on social security, and social insurance in particular, are provided, with a discussion of the various economic arguments in favour of and against the provision of social security. Part Two of the thesis examines the range of non-contributory social assistance - cash benefits paid form general revenue - that are available to South Africans who qualify in terms of the means tests. Each chapter provides an analysis of the extent to which the social assistance programme under analysis provides a safety net for the relevant category of vulnerable people. It does this by examining the appropriateness of the programme structure, take-up rates and the fiscal sustainability of the programmes. In addition, the budgetary process by which revenue is allocated to social assistance programmes and expenditure trends are examined. The thesis concludes that although the South African social security system has achieved a fairly advanced level of development and covers a fairly wide range of risks, there are a number of constraints facing its further expansion. Social insurance schemes provide generous benefits, but their membership is restricted to the employed. Expanding coverage by social insurance would require substantial growth in remunerative employment which, given prevailing labour market conditions, seems unlikely. The provision of more generous social assistance programmes catering for a broader range of contingencies is severely curtailed by already high fiscal expenditure on welfare and macroeconomic constraints. Moreover, changing demography, household structures and dependency burdens, especially as the HIV/AIDS epidemic spreads, seem likely to increase demands on social assistance programmes. Consequently, until employment can be expanded so that more people can contribute to their own income security, the informal social security provided by the family and/or community will remain the first line of support for many.AFRIKAANSE OPSOMMING: In hierdie tesis word gefokus op die mate waartoe die Suid-Afrikaanse bestaansbeveiligingstelsel daarin slaag om ondersteuning tydens kwesbare periodes in die lewensiklus en beskerming teen groot gebeurlikhede soos werkloosheid, ongeskiktheid of langdurige siekte te bied. Daardie bevolkingsegmente (volgens beroep, inkomstegroep of ras) wat nie volledig toegang tot inkomstesekuriteit het nie, word uitgesonder deur 'n gedetaileerde ondersoek van die verskillende maatskaplike versekerings- en bystandsprogramme. Daar word ook gekyk na die artikulasie tussen die verskillende programme sowel as na hoe ander regeringsintervensies (bv. verskaffing van maatskaplike dienste) en private bronne van inkomstesekuriteit - verskaf deur die privaat versekeringsmark, die gemeenskap en die familie - deur maatskaplike bystand aangevul word. Deel Een word gewyaan 'n ondersoek van maatskaplike versekering in Suid-Afrika - daardie programme wat vir inkomsteverlies weens spesifieke gebeurlikhede probeer kompenseer en wat tipies deur bydraes van werkgewers en werknemers befonds word. Teoretiese perspektiewe op bestaansbeveiliging in die algemeen en maatskaplike versekering in besonder word ook verskaf en argumente vir en teen die verskaffing van bestaansbeveiliging word bespreek. Deel Twee ondersoek die reeks nie-bydraende bestaansbeveiligingsprogramme wat uit algemene owerheidsinkomste befonds word, asook bestedingstendense in maatskaplike bystand. Die tesis kom tot die gevolgtrekking dat, alhoewel Suid-Afrikaanse bestaansbeveiliging 'n redelik gevorderde vlak van ontwikkeling bereik het en 'n wye reeks risiko's dek, daar 'n aantal beperkinge op verdere uitbreiding is. Maatskaplike versekeringskemas bied uitgebreide voordele, maar lidmaatskap is tot indiensgeneemdes beperk. Uitbreiding van dekking vereis beduidende groei in formele indiensneming, wat onwaarskynlik lyk, gegewe huidige arbeidsmarktendense. Die verskaffing van gunstiger maatskaplike bystandsprogramme gemik op meer gebeurlikhede word ernstig deur reeds hoë fiskale uitgawes op welsyn en deur makroekonomiese oorweginge beperk. Verder sal veranderende demografiese strukture, huishoudingstrukture en afhanklikheidslaste, veral teen die agtergrond van die toename in HIVNIGS, aansprake op maatskaplike bystandsprogramme vergroot. Gevolglik sal die informele inkomstesekuriteit gebied deur die familie en/of gemeenskap die eerste of enigste ondersteuning vir groot dele van die bevolking bly, totdat indiensneming genoeg uitgebrei kan word sodat meer mense tot hul eie inkomstesekuriteit kan bydra

Devising social security interventions for maximum poverty impact

Social security, designed to provide protection against various contingencies, is not well suited to the elimination or redress of large-scale, endemic poverty, nor is it effective against the deep poverty caused by events such as the Great Depression. Social security on its own cannot overcome poverty of this magnitude, particularly in developing countries. For reasons of fiscal and administrative capacity, inter alia, social security usually expands through piecemeal reforms rather than through grand schemes. The basic income grant was, in its conception, just such a grand scheme and its proponents' untempered enthusiasm has unfortunately done harm to the cause of social security's realistic expansion. Now even the Taylor Committee, after initial enthusiasm, has accepted that a basic income grant is not viable. And so the time has come to return to the job at hand for social security: to painstaking and piecemeal analysis, to the careful weighing of alternatives, and to informed debate. This article attempts to contribute to this end. We show that the South African social security system, though very advanced for a country at this level of per capita income, still has pervasive gaps in its coverage and is close to the limits of its capacities. Yet the Constitution obliges government to work towards the progressive expansion of social security and in this article we support incremental and targeted social security interventions as the strategy most likely to contribute to poverty reduction. We use an analysis of 1995 income distribution data to assist us in identifying where such social security interventions are most likely to have a significant poverty alleviating effect

Monitoring for Nutrition Results in ICDS: Translating Vision into Action

This article focuses on the Integrated Child Development Services (ICDS), India's largest nutrition and early child development programme. It describes the political, organisational and technical challenges to building and sustaining an outcomes?oriented approach to nutrition monitoring in India. We show that the environment is conducive to strengthening nutrition programme monitoring and evaluation. Political commitment is growing, financial allocations have increased and there have been a number of reforms to strengthen the ICDS monitoring systems, but weaknesses remain. The article analyses seven technical challenges to improving the outcomes?orientation of ICDS and suggests steps that could be taken to improve monitoring

Falling through the cracks : income security and the South African social security system

Thesis (MA)--Stellenbosch University, 2001.ENGLISH ABSTRACT: This thesis focuses on the extent to which the South African social security system succeeds in providing protection in the vulnerable periods of the life-cycle and against the major contingencies of unemployment, disability and disease. Through a detailed examination of the different social insurance and assistance programmes, it isolates which particular population segments (by occupation, income quintile and race group) "fall through the cracks" in the provision of income security. It does not look only at the articulation between different social insurance and social assistance programmes, but also acknowledges how social security complements other governmental interventions, such as social services, and non-state sources of income security, such as those provided by the private insurance market and the family and community. Part One of the thesis is devoted to an examination of social insurance in South Africa, in other words, to those programmes that seek to compensate for a loss of income in the event of particular contingencies and that are funded by contributions from employers and employees. In addition, theoretical perspectives on social security, and social insurance in particular, are provided, with a discussion of the various economic arguments in favour of and against the provision of social security. Part Two of the thesis examines the range of non-contributory social assistance - cash benefits paid form general revenue - that are available to South Africans who qualify in terms of the means tests. Each chapter provides an analysis of the extent to which the social assistance programme under analysis provides a safety net for the relevant category of vulnerable people. It does this by examining the appropriateness of the programme structure, take-up rates and the fiscal sustainability of the programmes. In addition, the budgetary process by which revenue is allocated to social assistance programmes and expenditure trends are examined. The thesis concludes that although the South African social security system has achieved a fairly advanced level of development and covers a fairly wide range of risks, there are a number of constraints facing its further expansion. Social insurance schemes provide generous benefits, but their membership is restricted to the employed. Expanding coverage by social insurance would require substantial growth in remunerative employment which, given prevailing labour market conditions, seems unlikely. The provision of more generous social assistance programmes catering for a broader range of contingencies is severely curtailed by already high fiscal expenditure on welfare and macroeconomic constraints. Moreover, changing demography, household structures and dependency burdens, especially as the HIV/AIDS epidemic spreads, seem likely to increase demands on social assistance programmes. Consequently, until employment can be expanded so that more people can contribute to their own income security, the informal social security provided by the family and/or community will remain the first line of support for many.AFRIKAANSE OPSOMMING: In hierdie tesis word gefokus op die mate waartoe die Suid-Afrikaanse bestaansbeveiligingstelsel daarin slaag om ondersteuning tydens kwesbare periodes in die lewensiklus en beskerming teen groot gebeurlikhede soos werkloosheid, ongeskiktheid of langdurige siekte te bied. Daardie bevolkingsegmente (volgens beroep, inkomstegroep of ras) wat nie volledig toegang tot inkomstesekuriteit het nie, word uitgesonder deur 'n gedetaileerde ondersoek van die verskillende maatskaplike versekerings- en bystandsprogramme. Daar word ook gekyk na die artikulasie tussen die verskillende programme sowel as na hoe ander regeringsintervensies (bv. verskaffing van maatskaplike dienste) en private bronne van inkomstesekuriteit - verskaf deur die privaat versekeringsmark, die gemeenskap en die familie - deur maatskaplike bystand aangevul word. Deel Een word gewyaan 'n ondersoek van maatskaplike versekering in Suid-Afrika - daardie programme wat vir inkomsteverlies weens spesifieke gebeurlikhede probeer kompenseer en wat tipies deur bydraes van werkgewers en werknemers befonds word. Teoretiese perspektiewe op bestaansbeveiliging in die algemeen en maatskaplike versekering in besonder word ook verskaf en argumente vir en teen die verskaffing van bestaansbeveiliging word bespreek. Deel Twee ondersoek die reeks nie-bydraende bestaansbeveiligingsprogramme wat uit algemene owerheidsinkomste befonds word, asook bestedingstendense in maatskaplike bystand. Die tesis kom tot die gevolgtrekking dat, alhoewel Suid-Afrikaanse bestaansbeveiliging 'n redelik gevorderde vlak van ontwikkeling bereik het en 'n wye reeks risiko's dek, daar 'n aantal beperkinge op verdere uitbreiding is. Maatskaplike versekeringskemas bied uitgebreide voordele, maar lidmaatskap is tot indiensgeneemdes beperk. Uitbreiding van dekking vereis beduidende groei in formele indiensneming, wat onwaarskynlik lyk, gegewe huidige arbeidsmarktendense. Die verskaffing van gunstiger maatskaplike bystandsprogramme gemik op meer gebeurlikhede word ernstig deur reeds hoë fiskale uitgawes op welsyn en deur makroekonomiese oorweginge beperk. Verder sal veranderende demografiese strukture, huishoudingstrukture en afhanklikheidslaste, veral teen die agtergrond van die toename in HIVNIGS, aansprake op maatskaplike bystandsprogramme vergroot. Gevolglik sal die informele inkomstesekuriteit gebied deur die familie en/of gemeenskap die eerste of enigste ondersteuning vir groot dele van die bevolking bly, totdat indiensneming genoeg uitgebrei kan word sodat meer mense tot hul eie inkomstesekuriteit kan bydra

Policy-related determinants of child nutritional status in China: The effect of only-child status and access to healthcare

This paper examines the determinants of child nutritional status in China, focusing specifically on those determinants related to health system reform and only-child status. Data are drawn from four waves of the China Health and Nutrition Survey (1991-2000). The empirical relationship between nutritional status, on the one hand, and income, access to quality healthcare and being an only-child, on the other hand, is investigated using ordinary least squares (OLS), random effects (RE), fixed effects (FE) and instrumental variables (IV) models. In the preferred model - a fixed effects model where income is instrumented - we find that being an only-child increases height-for-age z-scores by 0.12 of a standard deviation. By contrast, measures of access to quality healthcare are not found to be significantly associated with improved nutritional status.China Nutritional status Health Fertility One-child policy Healthcare Income Children