1 Atelier sur «l Équité dans la couverture maladie universelle: comment atteindre les plus pauvres» Workshop on Equity in universal health coverage: how to reach the poorest Country Briefs Fiches profiles de pays Hosted by: The Harmonization for Health in Africa (HHA) Financial Access to Health Services Community of Practice (FAHS CoP) in collaboration with The Expanding Coverage Track of the Joint Learning Network for Universal Health Coverage (JLN) and the Moroccan government 24 th 27 th September 2012 Hotel Kenzi Farah, Marrakesh, Morocco
2 Benin Improving Health Care Coverage for the Poorest: BENIN Country Context and Summary of Program(s) In order to expand protection to all social categories, the Government of Benin introduced universal health coverage reforms in 2008 aimed at the entire population. A Plan National de Développement du Secteur de la Santé (PNDS) and a Plan Stratégique de Développement des Mutuelles de Santé ( ) were introduced. A pilot phase of the Régime d Assurance Maladie Universelle (RAMU) was implemented in December 2011 by the Inter ministerial Technical Committee, supported by the Minister of Health. The RAMU was launched nationwide on 1 st April Until then, under 10% of the population was protected through public, private or mutuelles health insurance schemes, and under 4% of indigents (20,000 out of 455,000) were covered through a Fonds Solidaire des Indigents (FSI), introduced in 2005 to finance health user fee exemptions. Source: World Development Indicators Program Name Régime d Assurance Maladie Universelle (RAMU) Fonds Sanitaire des Indigents (Health Equity Fund for indigents) Date launched 19 th December , reforms in 2005 Stage Nationwide expansion from 1 st April 2012 Existing Target Population Place of Operation Services Covered / Benefits Package Mechanism to Reach the Poorest Methods to Identify the Poorest Program Coverage Managing Institutions / Roles Funding Sources and Amounts All populations National General and specialized consultations, nursing care, medicines, laboratory exams, imaging, diagnostic medicine, hospitalization and surgery, pre and postnatal consultations, deliveries and c sections, emergency transportation Exemptions Identification of beneficiaries is conducted at the community level No data available Ministry of Health / ANAM (Agence Nationale de l Assurance Maladie) FASNAS a, state, local authorities, technical and financial partners (Coopération Française, Coopération Suisse, ILO, WHO, World Bank), membership contributions (5% income for formal sector workers; 1,750 to 15,000 FCFA monthly contributions for informal sector workers, according to their activity sector; no membership fees for indigents) Indigents (5% of the population, around 455,000 inhabitants) and under 5 year olds National Free c sections, preventive medicine (vaccinations, anti parasitic treatments, vitamin A supplements, distribution of treated antimosquito nets), chronic disease treatment (HIV/AIDS, TB), medicines and food Exemptions Identification and validation mechanisms are conducted by Comités Locaux d Identification Villageois des Indigents (CLIVI), according to criteria adapted to each context Less than 20,000 beneficiaries Ministry of Health Total Population (millions) 9.1 (2011) OOP health expenditure (% of total expenditure) Life Expectancy at birth (years, both sexes) Infant Mortality (per 1,000 births) Maternal Mortality (per 100,000 births) Hospital beds (per 1,000 people) Public health expenditure (% of total health expenditure) Total health expenditure (% GDP) 46.8% (2010) 55.6 (2010) 73.2 (2010) 350 (2010) 0.5 (2010) 49.5% (2010) 4.1% (2010) State ( Secours et aides sociales budget, 1.25 billion FCFA) a Fonds d Appui à la Solidarité National et à l Action Sociale
3 Highlights of Programs to Reach the Poorest Achievements/Successes Active identification of indigents. Through the Comités Locaux d Identification Villageois des Indigents (CLIVI, community based organizations). CLIVI coordinate with the Projet d Appui à la Zone Sanitaire which processes applications through its Plateforme Société Civile et Santé (PSCS), made up of four facilitators spread over four communes. Facilitators accompany beneficiaries to a health center in their zone where indigents are given an identification card and benefit from free health services through the Fonds Sanitaire des Indigents (FSI). Biometric identification of the poorest. The FSI uses biometric tools to identify the poor and to secure a reliable database, thus ensuring that only eligible persons benefit from fee exemptions. RAMU has received strong political backing. The President of the Republic has been personally involved and monitors the program, and several development partners have demonstrated support (ILO, WHO, World Bank, Coopération Suisse, Coopération Française). A technical committee has been established to ensure adequate health service infrastructure and equipment. An information, education and communication campaign has also been conducted to sensitize the public. Lessons Learned/Challenges The number of beneficiaries of the FSI is still low (4% of indigents). Difficulties linked to active identification of indigents. Facilitators and health agents do not systematically operate according to established identification criteria or with the involvement of local authorities. Beneficiaries are not only the very poor. The term indigent is often misinterpreted and includes individuals who are able to pay minimum health service fees. Public resources are therefore spent on non eligible persons ( leakages in enrollment ). Limited strategic steering of the RAMU. The legal issues, benefits package and payment mechanisms of the RAMU still need to be resolved. There remains a lack of inter sectoral coordination and insufficient involvement of all stakeholders (CBHI, healthcare providers, local government units). Way Forward Efforts to help provide uniform criteria to identify eligible households are underway. The World Bank will provide support to the Projet de Renforcement de la Performance du Système de Santé (PRPSS) to strengthen the health program at the community level and improve methodology to register households and better identify eligible segments of the population. Human resources must be trained to implement adequate technical platforms to handle eligible cases. The FSI has received the support of Performance Based Financing (PBF), which enables the evaluation of the quality of services provided to beneficiaries. The tools developed in the context of PBF will be transferred to the RAMU. Actuarial and costing studies were supposed to be conducted during the second semester of 2012 in view of progressivelydefiningtechnicalandfinancialoptionsover the next ten years of program implementation. References Mathauer I, Ntamwishimiro Soumare A, Semegan B, Analyse du financement de la santé et réflexions sur le régime d assurance maladie universelle au Bénin, Rapport technique d une mission d appui de l OMS, décembre Plan National de Développement Sanitaire, , Ministère de la Santé. Tchibozo H, Atemenou A, Edon E, Ayi M, et al., Processus de mise en place d un Régime d Assurance Maladie Universelle (RAMU), Rapport d étape au 30 novembre Les Béninois disposent désormais d un Régime d Assurance Maladie Universelle (RAMU), Le RAMU a été officiellement lancé par le Chef d Etat, Dr Thomas Boni YAYI, Organisation Mondiale de la Santé, Bureau Pays du Bénin, Communiqué de Presse n 30 du 21/12/2011. World Health Organization, Providing for Health, Benin, P4H coordination desk mission report, February 2012, BeninFebmissionreport.pdf (accessed 11th July 2012).
4 Improving Health Care Coverage for the Poorest: ETHIOPIA Country Context and Summary of Program(s) Introduced in 1998, Ethiopia s health care financing strategy provides a framework for reforms aimed at mobilizing resources, ensuring efficient and equitable use, and improving overall quality and delivery of health services. The strategy supports reforms that include revenue retention and use at the health facility level, systematizing a fee waiver system to reduce financial barriers for the poor and standardizing fee exemptions to encourage uptake of preventive health services. These reforms were first introduced in the four largest regions (Amhara, Oromia and Southern Nations, Nationalities and Peoples Region (SNNP)) of the country, and are now being widely scaled up. Second tier reform activities include implementation of a social health insurance scheme (SHI) for the formal sector and community based insurance schemes (CBHI) for the informal sector. The SHI program is expected to cover approximately 12% of the population. The CBHI scheme is intended to serve the informal sector in Ethiopia, which accounts for 89% of the total population. Program Name Fee Waivers Exemptions Community Based Health Insurance Year Launched Stage Existing Existing Pilot, scale up Target Population The fee waiver program is intended to reach populations who are living below the dollar a day poverty line (approximately 29% of the population). All populations Indigent populations Place of Operation Mechanism to Reach the Poorest Methods to Identify the Poorest Program Coverage Services Covered/ Benefits Package Implementing Partners and Roles Implementation in all regions except Afar and Somali Implementation in all regions CBHI schemes are currently being piloted in 13 woredas or districts in the Amhara, Oromia, Southern Nations, Nationalities and Peoples (SNNP) and Tigray regions. The districts were selected on the basis of readiness of health facilities and represent both resource poor and better off districts. Fee Waiver Exemption General subsidy and full coverage of premiums for selected indigents Community based targeting Everyone is eligible regardless of income Community based targeting Information about program coverage is not compiled at the national level. Regional governments track their own coverage rates. There is no reporting of program coverage at the national level. Separate programs HIV, TB, ANC, PNC, Delivery, FP, Fistula, etc., track their own coverage levels. The target is to cover 50% of the total informal sector population in In the pilot program being implemented in the 13 districts, 125,142 heads of households (99,565 paying and 25,577 non paying) became beneficiaries in the one year pilot period, i.e. nearly 42% of the total heads of households of the pilot districts. Inpatient and outpatient Inpatient and outpatient Inpatient and outpatient MoH: Outline strategy Regional government: Outline legal framework to implement strategy, assign resources, supervise implementation District governments: Secure health facilities that will implement program Partners: Technical assistance MoH: Outline strategy, secure financial resources Regional government: Outline legal framework to implement strategy, assign resources, supervise implementation Districts governments: Secure health facilities, human resources and some financial resources Partners: Provision of supplies, funds, technical assistance Total Population (millions) 84.7 (2011) OOP health expenditure (% of total expenditure) Life Expectancy at birth (years, both sexes) Infant Mortality (per 1,000 births) Maternal Mortality (per 100,000 births) Hospital beds (per 1,000 people) Public health expenditure (% total health expenditure) Total health expenditure (% GDP) Source: World Development Indicators Funding Sources Government budget Government budget and donors Government budget Ethiopia 37.2 (2010) 58.7 (2010) 67.8 (2010) 350 (2010) 0.2 (2008) 53.5% (2010) 4.9% (2010) MoH: Outline strategy, provide general subsidy Regional government: Outline legal framework for implementing strategy, assign resources, supervise implementation District governments: Assign resources, implement program Partners: Technical assistance
5 Highlights of Programs to Reach the Poorest Achievements/Successes The fee waiver and exemption programs are two components of a broader Health Care Financing Reform (HCF) package. Ethiopia s HCF reforms include: First generation supply side reforms such as revenue retention and utilization, user fee setting and revision, fee waiver and exemption, supporting health facility autonomy through the establishment of governing bodies, outsourcing of non clinical services in public hospitals and establishing private wings in public hospitals. Second generation demand side health insurance reforms (Social Health Insurance, Community Based Health insurance and Private Health Insurance) Fee Waivers: A mechanism for providing services free of charge to Ethiopia s poor. Eligible beneficiaries are screened and identified through community participation. Selected beneficiaries are given a certificate entitling them to free health care services. The participatory community targeting approach has been a successful mechanism for identifying beneficiary populations in Ethiopia, where the majority of the economy is informal. Prior to the reform there was no systematic way of identifying beneficiaries. Performance varies from district to district, but overall the fee waiver system has received political support. Districts have a budget allocation for reimbursing providers for fee waiver beneficiaries. This has been important in the face of competing priorities and budget shortages. In some districts where food aid is combined with free medical care through the fee waiver system, beneficiaries donate their labor to environmental protection activities like terracing, farming, afforestation, labor based rural road construction, among others, contributing to local development activities. As an example, the Amhara region is the second most highly populated region in Ethiopia, where nearly 19 million people live within 157,347 sq. km. 13.1% of its population lives in urban areas and the remaining 86.9% in rural areas. The region is divided in to 10 zones, three City Administrations, 167 Districts, 3411 Kebeles (3113 rural and 318 urban). There are 17 public hospitals and 761 health centers (HC). All of the hospitals and 504 HCs are implementing health care financing reforms including fee waivers and exemptions. The remaining health centers are expected to introduce financing reforms in the next two years. Exemption Program: The exemption program requires public health facilities to post a list of exempted services in their waiting areas. Facilities are responsible for creating awareness through postings, broadcasts and other forms of media. Exempted services are almost the same across all regions and include family planning, delivery, pre and postnatal care, TB, VCT, PMTCT, leprosy and ART services and programs. Donor contributions make up 40% of the health budget with the majority going to exempted services. Exempted services covered by donors include the Expanded Program on Immunization, tetanus toxoid vaccine, family planning commodities, ART drugs and test kits, and anti malarial drugs. The government share of the budget covers staff salary, prenatal and antenatal care, delivery, and cost sharing of supplies from UN sources. The exempted services program also benefits from political support and the support of the donor and NGO community. Lessons Learned/Challenges Reaching beneficiary populations in remote areas for identification and enrollment (issuing ID cards/certificates) is a major challenge. It is difficult to determine how long households remain in poverty. Verification/re identification is a cumbersome process. There is no consensus on how this should be done, some regions issue ID cards every three years, others issue ID cards every year. The capacity of lower level government branches and community empowerment to perform this function is weak. In a large and populous country like Ethiopia, it is hard to verify, appraise and obtain approval and endorsement of the proposed beneficiaries from many lower government administrative structures/units and villages. Transport and accommodation costs are an additional cost for fee waiver beneficiaries who are sent to referral hospitals located in big urban centers where the cost of living is expensive. A lack of essential drugs, supplies, medical equipment, surgeons and health workers has hampered the delivery of quality services for the poor at public facilities. Funding shortages in the government s budget limit the enrollment of additional beneficiaries and the availability of resources for reimbursement of health care facilities. Budget shortages also compromise incentive programs for specialists and other key health care professionals, and as a result some services are not delivered or sustained. The government s budgeting system does not track resources by type of intervention, but uses line item budgeting (e.g. salaries, drugs, equipment, etc.). Many of the budget items reflect cross cutting costs, as such the budget allocation for exemptions, fee waivers and community based health insurance is not directly known. Fee waiver beneficiaries cannot access services at private facilities with higher prices which are beyond the capacity of the government to reimburse. There is a lack of clear guidance on whether to fully or partially charge for exempted services. Fee waiver beneficiaries follow a referral system to access care at secondary and tertiary levels, but grass roots level health facilities (health posts and health centers) located in remoteareas are not yet well equipped to follow this system. Way Forward Based on the pilot experience, CBHIs will be scaled up to cover 50% of the informal population by Regional and district authorities will cover premiums for indigent population through the CBHIs which are expected to reach 10% of the total population (approximately 8 million people). The federal government will provide a general subsidy to CBHI schemes that will be based on the number of registered household members, and that amounts to 25% of premiums collected from members. Implementation of the SHI scheme is expected to begin in the next few months. References Ethiopia Health Sector Financing Reform Midterm Project Evaluation, USAID, December Interview with Genet Anteneh Delele, Regional Director, USAID/Health Sector Financing Reform Project, Amhara and Benishangul Gumuz Regional Office, Bahir Dar, Ethiopia
6 Ghana Improving Health Care Coverage for the Poorest: GHANA Country Context and Summary of Program(s) In 2003, Ghana passed a Health Insurance Law and embarked on a process of developing and implementing a National Health Insurance Scheme(NHIS)to replace out of pocket fees at point of service. The National Health Insurance Authority (NHIA) was designated as the regulator and supervisor of the NHIS and given the responsibility of managing the National Health Insurance Fund from which subsidies are paid to District Mutual Health Insurance Schemes. Operation of the scheme at the district level is by District Mutual Health Insurance Schemes (DMHISs). Service Provision within the NHIS is by the Ghana Health Service, faith based groups such as the Christian Health Association of Ghana and the private for profit sector. The NHIS is a voluntary scheme which provides coverage for both formal workers and the informal sector. It provides exemptions for pregnant women, the elderly, children under 18 and the indigent who NHIS defines by law, as persons with no income or other means of support or home. Total Population (millions) 24.9 (2011) OOP health expenditure (% of total expenditure) Life Expectancy at birth (years, both sexes) Infant Mortality (per 1,000 births) Maternal Mortality (per 100,000 births) Hospital beds (per 1,000 people) Public health expenditure (% of total health expenditure) Total health expenditure (% GDP) Source: World Development Indicators 26.9% (2010) 63.8 (2010) 50 (2010) 350 (2010) 0.9 (2011) 59.5% (2010) 5.2% (2010) Program Name National Health Insurance Scheme (NHIS) Year launched 2004 Stage Scale up Target Population Pregnant women, the elderly, children under 18 and the indigent defined by NHIS law as persons with no income or other means of support or home. Place of Operation National Mechanism to Reach Exemptions for the indigent and vulnerable groups the Poorest Methods to Identify the Poorest DMHISs are responsible for identification and enrollment. Though guidelines for identifying the poorest exist, mechanisms for identifying the poorest vary between DMHISs. Some DMHISs leverage community representatives, NGO s and other non state groups to identify and enroll the poorest. With the recent scale up of the Livelihood Empowerment Against Poverty (LEAP) program implemented by the Ministry of Employment and Social Welfare, the program is increasingly being used to enroll the poorest into the NHIS. Program Coverage 8,204,116 active members (33.3%) (2011) 313,578 indigents (3.8%) (2011) Services covered Benefits Package Coverage of 95% of health problems reported in Ghanaian health facilities. Includes: outpatient services, inpatient services, oral health, maternity care, emergency care Implementing Partners and Roles Funding Sources and Amounts Ministry of Health: Policy oversight National Health Insurance Authority: Regulator supervisor/fund manager District Mutual Health Insurance Schemes: Member enrollment/provider payment 72.7% 2.5% health insurance levy added to VAT 17.4% Contributions from formal sector workers to the Social Security and National Trust (SSNIT) 5.3% Interest on fund 4.5% Premium payments 0.1% Other income 0.03% Donor funding
7 Highlights of programs to Reach the Poorest Achievements/Successes NHIS policy allows indigents to enroll in the NHIS and access comprehensive care for free. Exemptions for the indigent cover the cost of premium and processing fees for enrolling in the NHIS. Once the indigent enroll, NHIS is structured such that comprehensive care is provided and no co payments or top up payments are to be expected. Automatic eligibility for premium exemptions for beneficiaries of social protection program. Ministry of Health policy confers automatic eligibility for premium exemption for any beneficiary of the LEAP program. The LEAP program was initiated in 2008 and now operates in 20 districts and supports 68,000 households. The LEAP program is the leading poverty targeting program in the country and uses a proxy means test and community based identification to identify the poorest. The Ministry of Health policy has practically broadened exemptions under the NHIS to the extreme poor who are the focus of the LEAP program. This effectively puts to rest the dilemma of whether the indigent are synonymous with the extreme poor. Identification of exempt groups through NGOs and other non state actors. Some District Mutual Health Insurance Schemes obtain lists of exempted populations through NGOs and other non state actors. This allows the schemes to leverage the efforts of these organizations to identify the extreme poor and obtain the proof required to grant exemptions. Lessons Learned / Challenges Strict requirements for exemptions are severely limiting. TheNHISisoperatedbydistrict levelmutualhealth Insurance Schemes (DMHISs) which use community agents to identify and enroll new beneficiaries including the poor and indigent. During the initial implementation phase of the NHIS, agents of DMHISs used a community based identification system to enroll beneficiaries. In the course of implementation, it was observed that there were significant leakages in the enrollment process. In response, the NHIA began requiring that DMHISs submit proof for exemptions granted and utilized the audit process to enforce this. However, documentation of poverty, especially where no well developed tools for identification exist is difficult, if not impossible. This has led to the unintended exclusion of many of the extreme poor from exemption (under coverage). The NHIS law s restrictive definition of indigent further restricts the Schemes ability to identify and enroll the extreme poor. In practice, the NHIA would like to broaden exemptions to cover all the extreme poor those considered to be in the bottom quintile or 20%. However, due to the law s restrictive definition of indigent and the low scale of the LEAP program, there are many extreme poor who do not qualify for exemptions because they do not meet criteria required to be classified as indigent or are yet to be covered by the LEAP program. District schemes are not incentivized to enroll the extreme poor. DMHISs rely on the revenue they collect from premiums and processing fees to cover their operating costs. There is therefore little incentive for the schemes to identify the extreme poor because exempt persons do not pay these premiums and processing fees. Moreover, agents do not earn any commissions when they enroll the extreme poor and are therefore not motivated to identify and enroll them. The lack of an accountability mechanism in place for schemes to identify and enroll the extreme poor further aggravates their willingness and ability to enroll this category of persons. Barriers to healthcare remain for the indigent. In practice, even where the extreme poor are covered through exemptions, they have had significant problems navigating the healthcare provision system due to their limited knowledge of the available benefit package. In some cases exempt beneficiaries have been required to make top up payments or have incurred other OOP expenditures for accessing healthcare. Way Forward Working towards a Common National Targeting Mechanism. The NHIA is currently working with the LEAP program and other stakeholders to develop a national common targeting mechanism based on the process developed by the LEAP program for identifying the poor. The success of this approach will be contingent on resource availability for the LEAP program. As an additional next step, the NHIS law should institutionalize the use of the Common National Targeting Mechanism. In September 2012 parliament introduced an amendment that will require the NHIA to report on health equity, including utilization of services by the poor, in the NHIS. References Data and information provided by Mr. Nat Otoo, Director of Administration and General Counsel, National Health Insurance Authority, Ghana UNICEF, Social Protection and Children: Opportunities and Challenges in Ghana. 2009, Accra: UNICEF, ODI.
8 Improving Health Care Coverage for the Poorest: KENYA Country Context and Summary of Programs The National Hospital Insurance Fund (NHIF) is the primary provider of health insurance in Kenya with a mandate to enable all Kenyans to access quality and affordable health services. NHIF requires compulsory membership for all salaried employees, with premium contributions automatically deducted through payroll. Contributions are calculated on a graduated scale based on income, with a majority contributing between KES 30 to KES 320 per month. For the self employed and others in the informal sector, membership is contributory and is available for a fixed premium of 160 KES per month. While Kenya has achieved high levels of coverage of the formal sector, coverage of the informal sector has proven to be more challenging. Total membership in NHIF rose from about 206,000 in 1998 to 1,372,000 in As of 2011, NHIF has 2.7 million contributors, of which 2.1 million are employed in the formal sector. Approximately 88% of the people with insurance in Kenya are insured by NHIF. Currently only about 25% of the poor have medical coverage. NHIF is embarking on a subsidy program to improve access to health care for poor populations. Program Name Fee Waiver and Exemption Program Sponsored Program Health Insurance Subsidy Program (HISP) Year Launched Late TBD, project is in final design stage Stage Existing Existing Project is in design stage Target Population Those who are marginalized and face financial barriers to accessing health care services. The program targets population groups that include children under 5 years, HIV/AIDS patients, patients with mental disabilities, and services such as antenatal and postnatal care, and family planning. Indigent population Indigent population. Based on World Bank definition. Place of Operation National level National level Regions to be selected based on poverty indices Program Affiliation Mechanism to Reach the Poorest MoH program introduced to reduce the adverse effect of user fees on the poor Stand alone Stand alone pilot Exemptions and fee waivers Sponsorships to cover premiums A fund to subsidize premiums for the poorest Program Coverage Not available Approximately 3500 Not yet implemented Services Covered/ In patient Benefits Package Methods to Identify the Poorest Managing Institutions and Roles Geographic targeting and proxy means testing Implementing Agency: MoH Other Partners: USAID, Elizabeth Glaser Foundation, Aphiaplus, among others In patient. Enhanced coverage including outpatient cover is provided at a premium rate that is negotiated between the donor/sponsor and NHIF. Geographic targeting and proxy means testing Implementing Agency: NHIF Total Population 41.6 mill. (2011) OOP health expenditure (% of total expenditure) Life Expectancy at birth (years, both sexes) Infant Mortality (per 1,000 births) Maternal Mortality (per 100,000 births) Hospital beds (per 1,000 people) Public health expenditure (% of total health expenditure) Total health expenditure (% GDP) Kenya Source: World Development Indicators 42.7 (2010) 56.5 (2010) 55.1 (2010) 360 (2010) 1.4 (2010) 44.3% (2010) 4.8% (2010) Outpatient and in patient with a focus on increasing access to primary health care Geographic targeting and proxy means testing Implementing Agency: NHIF Donor Partners: Rockefeller Foundation Funding Sources and Amounts MoH subsidizes all services provided in public health facilities, including fee waivers and exemptions. Donors, private corporations, religious institutions, philanthropic individuals NGOs. As of August 30, 2012, the program had raised (KSH) 43, 721, 793. Rockefeller Foundation (KSH) 17, 000, 000