Presentation done during the FAHS CoP workshop: Equity in Universal Health Coverage – reaching the poorest.

1. Extend health cover
to the poorest in Africa
V. Ridde, Ph.D.
Workshop on “Equity in universal health coverage:
How to reach the poorest.”
24th September 2012, Marrakesh, Morocco

2. WHO, 2010

3. OUTLINE
1985-2000 2000-2012 POST 2012
• USER FEES • FREE FOR • UHC
FOR ALL MDG
• EXEMPTION GROUP
FOR THE
WORST-OFF

4. OUTLINE
1985-2000 2000-2012 POST 2012
• USER FEES • FREE FOR • UHC
FOR ALL MDG
• EXEMPTION GROUP
FOR THE
WORST-OFF

5. 25 YEARS OF USER FEES
0.40
pre-IB IB + 5 Y 2010
0.35
0.30
0.25
0.20
0.15
0.10
0.05
0.00
BENIN GUINÉE BURKINA FASO MALI

6. PUBLIC SPENDING IN PHC + USER FEES
40
Poorest Richest
35
30
25
20
15
10
5
0
Côte d'Ivoire Ghana Guinea Kenya Madagascar Tanzania South Africa
Castro Leal, et al. 2000

7. 1985-2000
USER FEES
FOR ALL
LOW
UTILIZATION
+ HIGH
EXCLUSION
EXEMPTION
FOR
WORST-OFF

8. OUTLINE
1985-2000 2000-2012 POST 2012
• USER FEES • FREE FOR • UHC
FOR ALL MDG
• EXEMPTION GROUP
FOR THE
WORST-OFF

9. ABOLITION SUPPORT
• 2007 : WORLD BANK IF COUNTRIES…
• 2009 : UN AGENCIES (Preg. Women + < 5 Y)
• 2010 : AFRICAN UNION (Preg. Women + < 5 Y)
• 2012 :
– UHC = WHA +UN GENERAL ASSEMBLY
– THE LANCET

10. NO MORE CONSENSUS FOR USER FEES
FREE HEALTH CARE ?
NUANCED 50 GLOBAL HEALTH ACTORS
2%
NEGATIVE NO STANCE
0% 29%
POSITIVE
59%
NEUTRAL
10%
Robert et Ridde, 2012

11. 25 YEARS OF USER FEES
0.40
pre-IB IB + 5 Y 2010
0.35
0.30
0.25
0.20
0.15
0.10
0.05
0.00
BENIN GUINÉE BURKINA FASO MALI

12. 2 or 3 YEARS OF ABOLITION
3.50
pre-IB IB + 5 Y 2010
3.00
2.50
2.00
1.50
1.00
0.50
0.00
Benin Guinée Burkina Faso Mali Burkina 3 y free Mali 2 y of free
<5y <5y

13. HEALTH SEEKING BEHAVIOUR
100
WHITOUT USER FEES
90
80
70
60
USER FEES
50
40
30
20
10
0
Rwanda Burkina Mali 2006 Niger 2006 Sierra Sierra Burkina 1 y. Mali 1 y Niger 2 y
2008 2010 Leone 2008 Leone 3 m. 2009 2008 2009
2010

14. Benefit incidence analysis of abolition
160%
BURKINA FASO
140%
120%
100%
80%
60%
40%
20%
0%
< 5km 5 - 10 km >=10 km
Ridde et Haddad, 2012

15. Severe illness < 5 years after abolition :
Incidence rate ratios BURKINA FASO
POOREST OTHER
< 5 km 5,23 [1,30- 2,23 [1,29-
20,99] 3,86]
> 5 km 1,28 [0,90- 1,56
1,82] [0,87-2,79]
Ridde et Haddad, 2012

16. Ghana, South Africa, Tanzania
Mills et al, 2012

17. 2000-2012 ????
WORST-OFF
????
HIGH
FREE FOR
UTILIZATION
MDG
+ LOW
TARGET
EXCLUSION

18. OUTLINE
1985-2000 2000-2012 POST 2012
• USER FEES • FREE FOR • UHC
FOR ALL MDG
• EXEMPTION GROUP
FOR THE
WORST-OFF

19. INSURANCE AND WORST-OFF
• Rwanda : « one of the major challenges faced
by the GoR is how to ensure that the poorest
benefit equally from Mutuelles (Lu et al. 2012)
• « even nominal copayments can lead to
massive exclusion of the poor from life-saving
health services »(Sachs, Lancet 2012)

20. «as long as careful attention is given
to specific design features, such as
government subsidies to ensure
that the poor are included in
them, otherwise [UHC] can actually
harm progress towards this goal».
Joe Kutzin, OMS, 2012

21. Measures to promote health insurance
membership among the poor
• Premium subsidised 100%
• Premium partially subsidised
• Premium varies based on income
• Premium paid in kind or by work
• Loans to help pay the premium
• Dividing the premium into smaller payments
• Payment of the premium at harvest time
Morestin et Ridde, 2010

22. 100 % subsidised for the worst-off

23. CHALLENGES/DESIGN
• Who will finance the subsidise ?
– Local cost-recovery : contribution and conflict of interest
– Values and targeting paradox
• Who are the worst-off ?
– Materiel and social
– Beyond the health sector
• How to select the worst-off ?
– Identification at the point of use is not enough
– Pre-identification is costly and time-consuming
• Community-based are accepted (rural) but challenging to scale
up
• Administrative-based are complex, need criteria and budget for
survey for pre-identification

24. TO READ
• Bitran, R., & Giedion, U. (2002). Waivers and exemptions
for health services in developing countries. Final Draft (p.
89): World Bank.
• Aryeetey, G. C. et al . (2012). Costs, equity, efficiency and
feasibility of identifying the poor in Ghana’s National
Health Insurance Scheme: empirical analysis of various
strategies. Tropical Medicine & International Health, 17(1),
43-51
• Ridde, V., et al. (2010). Low coverage but few inclusion
errors in Burkina Faso: a community-based targeting
approach to exempt the indigent from user fees. BMC
Public Health, 10:631
• Ridde, V., et al. (2011). Targeting the worst-off for free
health care: a process evaluation in Burkina Faso.
Evaluation and Program Planning, 34(4), 333-342

25. OUTLINE
1985-2000 2000-2012 POST 2012
• USER FEES • FREE FOR • UHC
FOR ALL MDG
• EXEMPTION GROUP
FOR THE
WORST-OFF

26. UHC : A WINDOW OF OPPORTUNITY
FOR THE WORST-OFF ?
• POLITICAL WILL
• ACTION AND EVIDENCE

27. 1985-2000 2000-2012 POST 2012
• USER FEES • FREE FOR • UHC
FOR ALL MDG
• EXEMPTION GROUP
FOR THE
WORST-OFF
LOW HIGH FREE FOR
UTILIZATION UTILIZATION ALL AT THE
HIGH LOW POINT OF
EXCLUSION EXCLUSION USE +
SCHEMES
FOR THE
WORST OFF