Financing universal health care in developing countries

The number of Filipinos ages 60 and over is expected to increase from 6.8 million in 2010 to almost 10 million in 2020. However, previous studies indicate that the projected expansion in the size of the Filipino older population could also mean a corresponding increase in the number of persons with disability. In light of this projected scenario are there enough provisions, especially health insurance, to meet their future demands for health care?

Using the 2008 National Demographic Health Survey, this study aims to: a) present the characteristics of Filipino older persons covered by any health insurance system to identify which segment of this population should be targeted in the expansion of health insurance coverage; and b) examine the role of health insurance coverage in the health care utilization of older persons in the Philippines.

Preliminary results reveal that less than half (45.8%) of Filipino older persons are covered by health insurance, most common of which is the PhilHealth (35.7%). Coverage is higher among men, those who are younger, and those who are better educated and wealthier. Among those who were hospitalized in the past year significant proportion relies on health insurance, especially PhilHealth (41%), to cover their medical expenses.

In Bangladesh, low use of facilities for maternal health services in rural areas has been a critical challenge to the health system in reducing maternal mortality. Health facilities in rural areas operate at less than their capacity due to shortage and sub-optimal performance of service providers. An operations research was conducted to test the feasibility of pay-for-performance (P4P) approach, through which financial incentive was provided to motivate the team of managers, direct and indirect providers, and administrative and support staff of a facility for achieving both quantity and quality targets on maternal health services set for the institution on quarterly basis. Performance of a facility was measured using service statistics and quality assessment reports. An external body with an obstetrician, an anesthesiologist and a pediatrician was formed to assess the facility performance every three months and subsequently incentive was paid to the eligible facility. Performance-based incentive motivated additional efforts which caused to increase service volume remarkably, and the facilities also succeeded in improving quality of services. Performance-based incentive is required until it significantly increases the rate of institutional delivery, a key requirement to reduce maternal mortality.

Globally, delivering in health facilities is encouraged as a single most important strategy in preventing maternal and neonatal deaths. However, access to facility-based delivery care remains very low in many developing countries including Tanzania, despite the user-fee exemption policy. The study assesses the relationship between socioeconomic status and place of delivery in three districts in Tanzania.

Data originate from a larger cross-sectional survey of random households conducted in three districts in Tanzania in 2011. Logistic regression model was fitted to examine how socioeconomic status and other factors influence place of delivery.

Overall, 75.5% of all participants delivered in facilities. The wealthier and more educated a woman was, the more likely that she would deliver in a health facility (OR=4.34, 95% CI 1.86-10.13). Also Sukuma and Ngindo ethnic groups were less likely compared to ndengereko to deliver in health facilities (OR=0.60, 95% CI 0.36-0.98) and (OR=0.40, 95% CI 0.18-0.89) respectively. Other significant predictors were gravidity, religion, district and type of residence.

Access to facility-based delivery care in Tanzania is significantly skewed in favor of socioeconomically wealthier and more educated women, despite the user-fee exemption policy for delivery care being operational.

Well established theory by Wilkinson said that income is closely related to health care. This study tried to reveal whether maternal health care varies by wealth quintiles in selected states. DLHS data from 2002- 2008 were utilized for the purpose. Orissa showed the pro-poor distribution among social-group as well as by wealth quintiles. Percentage of women had ANC visit in first trimester and full ANC of their pregnancy was higher in Orissa and Chhattisgarh compared to other states. Natal care showed different pattern. MP improved its level in safe births substantially from a 20 percent to 44 percent during survey interval. It was higher in state of Madhya Pradesh (MP), Rajasthan and Orissa and even a sharp increase was seen for institutional births at public institutions these states. Proportion of women had ANC visit in first trimester increases from poorest to richest quintiles. Concentration index shows the inequality has reduced in all states except Chhattisgarh. Low prevalence has been observed among poorer group in all EAG states while richer section is dissimilar in different indicators of maternal care. Inequality is higher for full ANC than other two indicators; safe and institutional births. Greater within caste economic inequality was observed in states with low levels opposite to state with better performance.

Comprehensive data on financial resources in reproductive health sector is critical for planners and policy makers, particularly in developing countries. Low level of funding for reproductive health is a cause of concern, given that RH service utilization in the vast majority of the developing world is well below the desired levels. Though there is an urgent need to track the domestic and international financial resource flows for reproductive health, the instruments through which financial resources are tracked in developing countries are limited. In this paper we examined the methodological and conceptual challenges of monitoring financial resources for family planning and reproductive health services at the international and national level. Results suggest that the Creditor Reporting System (CRS), which is the best possible data source to track donors contribution fails to give the complete picture of the Official Development Assistance (ODA) for reproductive health. At the national level Reproductive Health sub-accounts (RHA) suffers from country specific challenges related to definitional and boundary issues of RH activities. Lastly, weak link between data production by the RHA and its application by the stakeholders and lack of political will act as decelerate factor for the institutionalization of RHA at the country leve

To tackle the issues of inequality in healthcare utilisation, impoverishment due to increasing out of pocket (OOP) health expenditure and increasing dependence on the recourse of informal sources of healthcare, strengthening the role of insurance within the health systems has been gaining importance in low and middle income countries, where India is no exception. Even for universal health coverage, provision of health insurance (HI) is seen one of the major agenda for policy makers. However, a little is known in aggregate level whether HI status leads to change in utilisation behaviour in India. Hence, this paper aims to analyse the impact of HI status on healthcare utilisation behaviour of the individuals using Indian Human Development Survey (IHDS) 2004-05, a nationally representative survey data. Logit, Tobit and Multinomial Logit Models have been used to analyse the impact of HI status along with socio-economic factors on healthcare utilisation behaviour. From the result we found that HI doesn’t have statistically significant impact on utilisation behaviour after controlling various socio-economic variables. On the other hand various socio-economic factors significantly have affected the utilisation. However, the possible reasons for the insignificant result of HI have been explained and various policy recommendations out of

Poor households find it difficult to finance their health expenditure which leads to poor health and non utilization of the health care. The catastrophic payment as defined in the literature in terms of a threshold share of expenditure may not be comparable across the expenditure hierarchy rather than conceptualising the same in terms of source of financing the health expenditure. The notion of `disproportionate’ may well depend on how one finances the same? The objective of this paper is to examine the socio-economic vulnerability of the household incurring catastrophic expenditure in terms of its source of finance and role of an event in incurring catastrophic payment. Further, it also attempts to figure out the type of morbidities associated with catastrophic payment. This paper uses the National Sample Survey Organization data on Morbidity and Health Care during Junuary-June 2004. Catastrophic payment in health care need not only be based on the criterion of disproportionateness but also its source of financing, which is evident from this analysis. Further, catastrophic payments are selectively conditioned by intra-household relational domain and household vulnerabilities associated with presence/absence of children and elderly. Instead of focussing on universal health care we should focus on the most vulnerable population.

Emerging economies are showing signs of health improvements with average levels of key health outcomes increasing but with levels of inequalities at times worsening. Using the National Family Health Surveys (1992, 1998, 2005) for India and Household Demographic Surveys (PNDS) (1992, 1996, 2006) in Brazil this paper analyses how the stages in public spending reforms in both countries have progressed at a time of health improvements and how they have might have had an impact on health inequalities focusing on maternal and child health (MCH). This has been at the forefront in low and middle income countries in widening access to health care. The aims of this paper are to chart the evolution of health reforms in both Brazil and India and to assess how inequalities in MCH have changed over this period. Without aiming to assess the impact, the following issues are addressed: Have health reforms over the last two decades improved or worsened inequality? What can be learnt from the experiences and how can we benefit from the comparison between Brazil and India? What are the key challenges in comparing two culturally and politically different countries? The paper shows how Brazil is succeeding in reducing inequalities whereas India has still a long way to go. This paper is set within a wider call for universal health coverage in LMICs.

In India, though the prevalence rate is low (0.39%) (NFHS-III), yet due to her population size, it is important for the authorities to provide adequate provisions and healthcare in response to HIV. Response to HIV not only includes accessibility to affordable healthcare to needy but preventive actions to curtail new cases. Public spending on HIV is primarily comes from budgetary allocation. This paper attempts to investigate the benefit incidence of public spending i.e. the distributional incidence of benefit for different group of interest of public spending on HIV/AIDS. Data pertaining to government spending is obtained from the budget expenditure 2004-05 of Ministry of Health and Family Welfare, which gives directions and implementation of programmes directed in response to HIV. Individual or household level data from household survey on usage of public service is obtained from NFHS-III data. In an attempt to know how many HIV positive households/ individuals opt public health facilities. In an attempt to know how many HIV positive households/ individuals opt public health facilities for healthcare quintile wise distribution of HIV positive population accessing healthcare is obtained. Based on this information, paper investigates the distributional incidence of public spending on HIV/AIDS in India.

This paper examines the community-level effect of the maternal health voucher program on out-of-pocket spending on delivery services at private health facilities in Uganda. Household-level data were collected before (in 2008) and two years after the program started (in 2010-2011) among women aged 15-49 years who had a birth in the 12 months preceding the survey. A total of 1,569 women were interviewed in 2008 with 327 most recent births occurring at a private health facility; the corresponding figures for 2010-2011 were 666 women with 196 most recent births occurring at a private health facility. The effect of the program is determined by difference-in-differences estimation through simple comparison of changes in proportions as well as the estimation of a multilevel random-intercept logit model. The results show that there was a significantly greater decline in the proportion of women that paid for delivery services and in the likelihood of paying for the services at private facilities in exposed than in non-exposed villages. The findings indicate that the maternal health voucher program significantly contributed to reductions in the likelihood of paying out-of-pocket for delivery services at private health facilities in the regions where it is implemented.