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Combating Exclusion and Removing Barriers: Improving Health. The World Bank. Roma in an Expanding Europe: Challenges for The Future Budapest, Hungary June 30-July 1, 2003. Cristian Baeza . Health interventions. Health Systems as contributors to health. Producers. HR, Goods and Services.

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combating exclusion and removing barriers improving health

Combating ExclusionandRemoving Barriers: Improving Health

The World Bank

Roma in an Expanding Europe: Challenges for The Future

Budapest, Hungary

June 30-July 1, 2003

Cristian Baeza

slide2

Health interventions

Health Systems as contributors to health

Producers

HR, Goods and Services

Health

Providers

Utilization

Financing

Contributors

slide3

Health interventions

Health Systems as contributors to health

Producers

Citizens

Sector Governance and Stewardship

HR, Goods and Services

Health

Providers

Utilization

Demand

Financing

Preferences, believes and behaviors

Consumers

Contributors

slide4

Health interventions

Objectives of Social Protection and Inclusion in Health

Housing

Income

Producers

Citizens

Financial

Protection

Human

Development

Household Welfare

Production Function

PRS

Health

Utilization

Providers

Dignity

Food

Consumers

Contributors

Education

Social

Integration

the objectives of social protection and inclusion in health
The Objectives of Social Protection and Inclusion in Health
  • To maintain and improve the health status, ensuring inclusion to those excluded from access socially accepted level effective and needed health services. Health not only as an essential component of their human capital for overcoming poverty but as an essential part of the Human development objective.
  • To do so ensuring sufficient financial protection to avoid excess contribution that could force households into poverty or make it impossible for them to overcome it.
  • All under strict respect for the dignity, freedom and human rights.

The Key Importance of an Explicit Society Guaranty:

Entitlement

causes of exclusion
Causes of Exclusion
  • Not defined or poorly defined priorities of interventions and/or lack of enforcement of the GHP (under-coverage)
  • Incongruities between the type of intervention and the financing and/or health care delivering mechanisms

Supply problems

Demand problems

exclusion due problems with access and utilization of health services
Exclusion Due Problems With Access and Utilization of Health Services

Problems

Possible Solutions

No providers.

Increase “eligible” providers:

- Investments

- Reduction of barriers to enter

- Purchasing of Services

Supply

Non-eligible providers

Training and education

Incentives

Inefficient or low-productive providers

Providers that discriminate against particular users

Strengthening purchasing function

Purchasing and regulation mechanisms

Need to address the specific cultural characteristic of the target population

“Dignity” barriers

Demand

Educational campaigns to the population

Increasing effectiveness of providers

Services considered unnecesary

Services considered necessary, but there is no WTP for it

Ensure the congruence between interventions and instruments in GHP

Services considerednecessary, but there is no ability to pay or high oportunity cost

Improving the efficiency and magnitude of the “equity subsidy”; negative prices?

innovations for problems on the demand of health services
Innovations for Problems on the Demand of Health Services
  • Bolivia: Maternal and Child Insurance
    • Responding to the cultural context
  • Mexico: “Progresa” / “Oportunidades”
    • Stimulating demand via conditional cash transfers
slide9

LURATANAKASA(THE PERFECT EQUILIBRIUM: THE COLORS OF THE LIFE AND GOOD OUTCOMES)BLACK: LIFE AND GOOD OUTCOMESRED: SUN, PREVENTION AND PHISYCAL HEALTHGREEN: LAND, NUTRITION AND INCOME YELLOW: DIGNITY AND QUALITY OF LIFEWHITE: DEATH

Maternal and Child Insurance in Bolivia

slide10

Maternal and Child Insurance in Bolivia

  • Basic health insurance (1998): 92 interventions with impact on the 56% of all causes of disease and death in Bolivia.
  • The cultural dimension: 10 more non medical services such:
      • Rescue of the soul,
      • Returning back the placenta to the land (pachamama)
      • Traditional vademecum
      • Yanapiri (to hear and give a wise-health advice in ancient medicine, etc.)
exclusion due to problems in the risk pooling mechanism
Exclusion Due to Problems in the Risk Pooling Mechanism

Possible solutions

Problems

There are no pooling arrangememts or those existing are inefficient

Development and promotion of pooling schemes

“Pooling” problems

(Problems with cross-subsidization from low to high risk groups.)

Pooling schemes working but users are not eligible

Elimination of eligibility barriers for the self-employed and small businesses owners, modification of legislation, community rating, and equity subsidies

There are pooling schemes but users consider them unnecessary (no demand)

Educational campaigns

Mandatory affiliation to insurance schemes (avoid free riders)

There are pooling schemes but no ability to pay from users

Expand risk pools and development of equity subsidies

innovations in pooling
Innovations in Pooling
  • Targeting and adaptations of public health insurance to excluded populations
    • Bolivia: Maternal and Child Insurance
    • Chile: Guaranteed Health Plan (AUGE)
  • Demand side subsidy for Insurance coverage for the poor
    • Colombia: Subsidized modality
  • Community Based Health Organizations
exclusion due to problems of equity subsidies
Exclusion due to Problems of Equity Subsidies

Problems

Possible solutions

Users do not participate in existing pooling schemes because they can not pay the premiums (insuficient equity subsidy)

  • Ensure an adequate level of equity subsidies:
  • Within pooling schemes
  • Among pooling schemes (solidarity funds)
  • From public sources (general taxes)

Users participate in existing pooling but pay in excess due to insuficient equity subsidies

Problems with

the equity subsidy

Pooling schemes with sufficient equity subsidies available but with no “portablity of subsidies”

Develop “portability” of subsidies among public sector or insurance schemes

Improve risk adjustments according to the number of members of the household

Improve purchasing efficiency in private and public sectors.

Pooling schemes where users pay too much due to the inefficient “portability of subsidies”

combating exclusion and removing barriers improving health1

Combating ExclusionandRemoving Barriers: Improving Health

The World Bank

Roma in an Expanding Europe: Challenges for The Future

Budapest, Hungary

June 30-July 1, 2003

Cristian Baeza

slide16

Effects of risk pooling

Cross-subsidization from lower to higher risk individuals

Required household contribution

Higher

Risk

Before risk pooling

Lower

Risk

Required household contribution

Lower

Risk

Higher

Risk

After risk pooling

slide17

Risk pooling

Cross-subsidies from lower to higher risk

Equity

Cross-subsidy from higher to lower income

High

income

Required household contribution

Required Household contribution

Higher

Risk

Lower

Risk

Low

income

Required household contribution

Required household contribution

Lower

Risk

Higher

Risk

High

income

Low

income