Waivers and exemptions for health services in developing countries

In response to shortages in public budgets for government health services, many developing countries around the world, have adopted formal, or informal systems of user fees for health care. In most countries, user fee proceeds seldom represent more than 15 percent of total costs in hospitals, and health centers, but they tend to account for a significant share of the resources required to pay for non-personnel costs. The problem with user fees is that the lack of provisions to confer partial, or full waivers to the poor, often results in inequity in access to medical care. The dilemma, then, is how to make a much needed system of user fees, compatible with the goal of preserving equitable access to services. Different countries have tried different approaches. Those which have carefully designed, and implemented waiver systems (e.g., Thailand and Indonesia) have had much greater success in terms of benefits incidence, than countries that have improvised such systems (Ghana, Kenya, Zimbabwe). Key to the success of a waiver system is its financing. Systems that compensate providers for the revenue forgone from granting exemptions (Thailand, Indonesia, and Cambodia) have been more successful than those who expect the provider to absorb the cost of exemptions (Kenya). Where waiver system exist, performance will improve with the timeliness of the reimbursement. Other success factors include the widespread dissemination among potential beneficiaries, about waiver availability, and procedures; the awarding of financial support to poor patients for non-fee costs of care, such as food and transportation (as in Cambodia); and, the existence of clear criteria for the granting of waivers, thereby reducing confusion, and ambiguity among those responsible for managing the system, and among potential recipients. The review examines various approaches taken by countries, but assessing their relative practical merits is difficult, as the evidence is scattered and mixed.Health Systems Development&Reform,Pharmaceuticals&Pharmacoeconomics,Health Monitoring&Evaluation,Public Sector Economics,Health Economics&Finance

The determinants of hospital costs : an analysis of Ethiopia

The problem of financing health care in poor countries has become increasingly acute. In the context of health financing, hospitals are viewed with skepticism as facilities are not cost-effective in the provision of primary health care services. Given this view, it is increasingly thought that such institutions should become financially independent from government subsidies and find other ways to finance both their recurrent and capital costs. The purpose of this paper is to analyze the determinants of hospital costs in a poor country by conducting a case study using data from Ethiopia. It analyzes the issues of economies of scale and scope in the delivery of hospital based health care services in a poor country. A translog-like cost function specification is used in the analysis. It shows that the number of inpatient days, deliveries and laboratory exams had a positive and statistically significant effect on total cost. A negative and statistically significant coefficient associated with the output interaction term indicated the existence of economies of scope between the number of inpatient days and the number of first outpatient visits. Finally, the number of total beds in a hospital appeared to have a positive and significant independent effect on total hospital cost.Economic Theory&Research,Business Environment,Business in Development,Environmental Economics&Policies,Health Systems Development&Reform

Gastos catastróficos en salud de los hogares: Un análisis comparativo de doce países en América Latina y el Caribe

OBJETIVO: Comparar los patrones de gastos catastróficos en salud en 12 países de América Latina y el Caribe. MATERIAL Y MÉTODOS: Se estimó la prevalencia de gastos catastróficos de manera uniforme para doce países usando encuestas de hogares. Se emplearon dos tipos de indicadores para medir la prevalencia basados en el gasto de bolsillo en salud: a) en relación con una línea de pobreza internacional; y b) en relación con la capacidad de pago del hogar en términos de su propia canasta alimentaria. Se estimaron razones para comparar el nivel de gastos catastróficos entre subgrupos poblacionales definidos por variables económicas y sociales. RESULTADOS: El porcentaje de hogares con gastos catastróficos variaron de 1 a 25% en los 12 países. En general, la residencia rural, el bajo nivel de ingresos, la presencia de adultos mayores, y la carencia de aseguramiento en salud de los hogares se asocian con mayor propensión a sufrir gastos catastróficos en salud. Sin embargo, existe una marcada heterogeneidad por país. CONCLUSIONES: Los estudios comparativos entre países pueden servir para examinar cómo los sistemas de salud contribuyen a la protección social de los hogares en América Latina.OBJECTIVE: Compare patterns of catastrophic health expenditures in 12 countries in Latin America and the Caribbean. MATERIAL AND METHODS: Prevalence of catastrophic expenses was estimated uniformly at the household level using household surveys. Two types of prevalence indicators were used based on out-of-pocket health expense: a) relative to an international poverty line, and b) relative to the household's ability to pay net of their food basket. Ratios of catastrophic expenditures were estimated across subgroups defined by economic and social variables. RESULTS: The percent of households with catastrophic health expenditures ranged from 1 to 25% in the twelve countries. In general, rural residence, lowest quintile of income, presence of older adults, and lack of health insurance in the household are associated with higher propensity of catastrophic health expenditures. However, there is vast heterogeneity by country. CONCLUSIONS: Cross national studies may serve to examine how health systems contribute to the social protection of Latin American households.Fil: Knaul, Felicia Marie. Harvard University; Estados Unidos. Instituto Carlos Slim de la Salud; México. Fundación Mexicana para la Salud; MéxicoFil: Wong, Rebeca. University of Texas; Estados UnidosFil: Arreola Ornelas, Héctor. Fundación Mexicana para la Salud; México. Instituto Carlos Slim de la Salud; México. University of Texas; Estados UnidosFil: Oscar Méndez, Analis. Fundación Mexicana para la Salud; México. Instituto Carlos Slim de la Salud; México. University of Texas; Estados UnidosFil: Bitran, Ricardo. Federación Interamericana de Economía de la Salud; Chile. Universidade de Sao Paulo; BrasilFil: Campino, Antonio Carlos. Universidade de Sao Paulo; BrasilFil: Flórez Nieto, Carmen Elisa. Universidad de Los Andes; ChileFil: lunes Fontes, Roberto. Federación Interamericana de Economía de la Salud; Chile. Banco Interamericano de Desarrollo; Estados UnidosFil: Giedion, Ursula. Banco Interamericano de Desarrollo; Estados UnidosFil: Maceira, Daniel Alejandro. Universidad de Buenos Aires; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro de Estudios de Estado y Sociedad; ArgentinaFil: Rathe, Magdalena. Fundación Plenitud; República DominicanaFil: Valdivia, Martin. Grupo de Análisis para el Desarrollo; PerúFil: Vargas, Juan Rafael. Universidad de Costa Rica; Costa RicaFil: Díaz, Juan José. Grupo de Análisis para el Desarrollo; PerúFil: Montoya Díaz, María Dolores. Universidade de Sao Paulo; BrasilFil: Valdes, Werner. Ministerio de Salud; BoliviaFil: Valladares Carmona, Ricardo. No especifíca;Fil: Zuniga, Maria Paola. Universidad de Costa Rica; Costa RicaFil: Lafontaine, Liv. Instituto Carlos Slim de la Salud; México. Fundación Mexicana para la Salud; MéxicoFil: Muñoz, Rodrigo. Bitran y Asociados; Chile. Federación Interamericana de Economía de la Salud; ChileFil: Pardo, Renata. Dirección General de Planeación del Ministerio de la Protección Social; ColombiaFil: Reynoso, Ana María. Centro de Estudio de Estado y Sociedad; ArgentinaFil: Santana, María Isabel. Fundación Plenitud; República DominicanaFil: Vidarte, Rosa. Grupo de Análisis para el Desarrollo; Per

Universal Health Coverage and the Challenge of Informal Employment : Lessons from Developing Countries

The aim of the report is to review existing approaches and available policy options to improve access to health care services and financial protection against health shocks for informal-sector workers (ISWs). Along with their families, ISWs represent the majority of the population in many developing countries. The report reviews the definition and measurement of the informal sector and the literature on efforts toward its health insurance coverage. It also examines several country cases based on published and unpublished reports and on structured interviews of expert informants. Developing country efforts to expand health coverage are characterized by a common enrollment and financing pattern, starting with formal-sector workers and following with government-subsidized enrollment of the poor. Thus, ISWs are typically left behind and have been referred to as "the missing middle." They find themselves financially unprotected against health shocks and with limited access to quality and timely health care. ISWs are generally reluctant to enroll in insurance schemes, including social health insurance (SHI), community insurance, and other arrangements. Further, initiatives to enroll them in self-financed contributory schemes have generally resulted in adverse selection, as those with high anticipated health needs are more willing to pay and enroll than others. Successful initiatives to cover this population group are the ones where government has abandoned its expectations to derive relatively substantial revenue from it. Offering this group a benefits package that is relatively smaller than that of formal workers and charging them a premium that is only a fraction of that charged to formal workers is a strategy used by some countries to limit the need for public subsidies. While there is evidence that greater insurance coverage has improved access to health services for ISWs and their dependents, in several countries it has not yet improved financial protection for this target group. A broad set of reforms will be required to strengthen the supply side to ensure that additional public financing translates into improved coverage for ISWs

Health Systems Analysis for Better Health System Strengthening

Health system strengthening and reform are often necessary actions to achieve better outcomes. The World Bank's 2007 strategy for health, nutrition, and population emphasizes the importance of health system strengthening for results. This paper proposes 'health systems analysis' as a distinct methodology that should be developed and practiced in the design of policies and programs for health system strengthening. It identifies key elements of health systems analysis and situates them in a logical framework supported by a wide range of data and methods and a sizable global literature. Health systems analysis includes evidence on health system inputs, processes, and outputs and the analysis of how these combine to produce the outcomes. It considers politics, history, and institutional arrangements. Health systems analysis proposes causes of poor health system performance and suggests how reform policies and strengthening strategies can improve performance. It contributes to implementation and evaluation. Examples from Mexico, Ethiopia, and Turkey illustrate the positive contributions health systems analysis has made to development of successful health system strengthening policies. Health systems analysis should be an integral part of good practice in health system strengthening efforts, including planning, policy development, monitoring, and evaluation. Health systems analysis can be conceived in a coherent and logical fashion and can be practiced and improved