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

Dec 28, 2015

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Page 1: Reproductive health and health financing Barbara McPake, London School of Hygiene and Tropical Medicine.

Reproductive health and health Reproductive health and health financingfinancing

Barbara McPake, London School of Barbara McPake, London School of Hygiene and Tropical MedicineHygiene and Tropical Medicine

Page 2: 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

Page 3: Reproductive health and health financing Barbara McPake, London School of Hygiene and Tropical Medicine.

Bangladesh

Public tax-based

Household out-of-pocket

Social security

Sources of finance: Bangladesh

Page 4: Reproductive health and health financing Barbara McPake, London School of Hygiene and Tropical Medicine.

Sources of finance: Uganda

Uganda

Public tax-based

Household out-of-pocket

Social security

Page 5: Reproductive health and health financing Barbara McPake, London School of Hygiene and Tropical Medicine.

Sources of finance: South Africa

South Africa

Public tax-based

Household out-of-pocket

Social security

Page 6: Reproductive health and health financing Barbara McPake, London School of Hygiene and Tropical Medicine.

Sources of finance: Peru

Peru

Public tax-based

Household out-of-pocket

Social security

Page 7: Reproductive health and health financing Barbara McPake, London School of Hygiene and Tropical Medicine.

Sources of finance: Thailand

Thailand

Public tax-based

Household out-of-pocket

Social security

Page 8: Reproductive health and health financing Barbara McPake, London School of Hygiene and Tropical Medicine.

Sources of finance: Russia

Russia

Public tax-based

Household out-of-pocket

Social security

Page 9: Reproductive health and health financing Barbara McPake, London School of Hygiene and Tropical Medicine.

The advantages of pooling

• Pooling creates important opportunities for sharing risks between healthy and sick; rich and poor

• 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

Page 10: Reproductive health and health financing Barbara McPake, London School of Hygiene and Tropical Medicine.

Pooling to redistribute risk and cross-subsidy for greater equity

Contribution Net transfer UtilisationPooling

Low

High

RISK

Subsidy

Low

High

INCOME

Source: World Health Report, 2000

Page 11: Reproductive health and health financing Barbara McPake, London School of Hygiene and Tropical Medicine.

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

Page 12: Reproductive health and health financing Barbara McPake, London School of Hygiene and Tropical Medicine.

The hidden cost of ‘free’ maternity care in Dhaka, Bangladesh

Item Normal delivery CaesarianMedicine 494 2574Blood 24 127Travel 260 780Food 164 602Hospital fees 76 78Ayas 152 400Tips 105 142TOTAL:Taka

1275 4703

US$ 31.9 117.5

Source: Nahar and Costello, Health Policy and Planning, 1998

Page 13: Reproductive health and health financing Barbara McPake, London School of Hygiene and Tropical Medicine.

Public spending: Do the poor benefit?

0

10

20

30

40

50

60

Source: C

astro-Leal et al., B

ulletin of WH

O,

2000

Poorest 20%

Richest 20%

% of public health expenditure consumed

Page 14: Reproductive health and health financing Barbara McPake, London School of Hygiene and Tropical Medicine.

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 schemes

Page 15: Reproductive health and health financing Barbara McPake, London School of Hygiene and Tropical Medicine.

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 increases

(Source, Levin et al. Social Science and Medicine, 1999)

Page 16: Reproductive health and health financing Barbara McPake, London School of Hygiene and Tropical Medicine.

The effect of user fee increases on STD treatment

Men Women1 2 1 2

Gonorrhoea 51 92 Gonorrhoea 132 422Non-STD 5 14 Non-STD 25 16Chancroid 59 77 Chancroid 72 186Syphilis 58 82 Syphilis 55 76Non-gon. urethritis 65 91 Candidiasis 108 353

Trichomoniasis 69 82TOTAL 40 64 TOTAL 65 122

Attendance at STC clinic (seasonally adjusted)

1=Attendance in user charge period as % of pre-charge period

2=Attendance in post charge period as % in pre-charge period

Source: Moses et al., The Lancet, 1992

Page 17: Reproductive health and health financing Barbara McPake, London School of Hygiene and Tropical Medicine.

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

Page 18: Reproductive health and health financing Barbara McPake, London School of Hygiene and Tropical Medicine.

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

Page 19: Reproductive health and health financing Barbara McPake, London School of Hygiene and Tropical Medicine.

Sites where people with STD symptoms had received medicine before attending public

health centres

Men WomenTotal patients 238 167No. taking some medicine before 138 109Site of purchase:Traditional healer 20% 12%Market place/shop 21% 43%Friends/relatives 25% 19%Self treatment 12% 14%Professional health sector 32% 23%

Source: Faxelid et al., EAMJ, 1998

Page 20: Reproductive health and health financing Barbara McPake, London School of Hygiene and Tropical Medicine.

Why the poor pay more

Provider % of cases Mean expend (Le)Government PHC 20.1 133Government hospital 2.2 480Government staff privately 6.5 189Mission hospital 5.4 670Private hospital or doctor 1.1 636

Source: Fabricant et al. Int. J. Health Plann. Mgmt, 1999

Expenditure by provider: Sierra Leone

Page 21: Reproductive health and health financing Barbara McPake, London School of Hygiene and Tropical Medicine.

Why the poor pay more cont’d

Quintile I II III IV VPHC as % income 4.8 3.3 1.8 1.2 0.6‘Other medical’ as% income

16.1 8.1 5.6 2.4 2.3

Source: Fabricant et al.

Page 22: Reproductive health and health financing Barbara McPake, London School of Hygiene and Tropical Medicine.

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 inequity

• Risk sharing and cross-subsidy restricted to within middle and upper income groups

Page 23: Reproductive health and health financing Barbara McPake, London School of Hygiene and Tropical Medicine.

Informal employment

Country 1990 1994Argentina 47.5 52.5Bolivia 56.9 61.3Brazil 52.0 56.4Chile 49.9 51.0Colombia 59.1 61.6Ecuador 51.6 54.2Peru 51.8 56.0

Urban, informal, nonagricultural employment in Latin America,

1990 and 1994

Source, Creese and Bennett, World Bank, 1997

Page 24: Reproductive health and health financing Barbara McPake, London School of Hygiene and Tropical Medicine.

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

Page 25: Reproductive health and health financing Barbara McPake, London School of Hygiene and Tropical Medicine.

Bwamanda hospital insurance, DRC

1986 1987 1988Population 118,612 125,480 129,244Membership rate 27.5% 47.4% 62.3%Hospitalisation rateTotal 2.80% 2.65% 3.14%Members 3.62% 3.32% 3.56%Non-members 2.48% 2.04% 2.47%

Evolution of membership in the early years

Source: Moens et al., 1990

Page 26: Reproductive health and health financing Barbara McPake, London School of Hygiene and Tropical Medicine.

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

Page 27: Reproductive health and health financing Barbara McPake, London School of Hygiene and Tropical Medicine.

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 distribution

• Some NGOs aim to improve equity by locating facilitites in under-served areas

Page 28: Reproductive health and health financing Barbara McPake, London School of Hygiene and Tropical Medicine.

Conclusions• No ‘quick fixes’ in financing policy

• Improving impact and distribution of public finance depends on other reforms eg. strategic purchasing

• Additional sources may sometimes offer ways of increasing revenue but carry important equity risks

• We have given limited attention to the role of fees and insurance in the private sector