Guy Carrin

Health financing reform in Kenya- assessing the social health insurance proposal

Kenya has had a history of health financing policy changes since its independence in 1963. Recently, significant preparatory work was done on a new Social Health Insurance Law that, if accepted, would lead to universal health coverage in Kenya after a transition period. Questions of economic feasibility and political acceptability continue to be discussed, with stakeholders voicing concerns on design features of the new proposal submitted to the Kenyan parliament in 2004. For economic, social, political and organisational reasons a transition period will be necessary, which is likely to last more than a decade. However, important objectives such as access to health care and avoiding impoverishment due to direct health care payments should be recognised from the start so that steady progress towards effective universal coverage can be planned and achieved.

Issues in the Cross-National Assessment of Health Technology

With the growing international literature in economic evaluation and the rapid spread of new health technologies, there is a need to undertake, or at least interpret, economic evaluations on the international level. However, the ways in which cross-national differences affect the cost-effectiveness of health technologies or their evaluations have never been studied. This paper explores these issues by taking advantage of a unique situation in which the same economic evaluation of a new indication for a health technology was conducted simultaneously in four countries using an identical methodology. The study showed that if prior agreement on methods can be reached and local data applied, economic evaluations can be undertaken in a way that facilitates the extrapolation of results from country to country.

Mutual health insurance in Rwanda: Evidence on access to care and financial risk protection

OBJECTIVE Rwanda has expanded mutual health insurance considerably in recent years, which has a great potential for making health services more accessible. In this paper, we examine the effect of mutual health insurance (MHI) on utilization of health services and financial risk protection. METHODS We used data from a nationally representative survey from 2005-2006. We analysed this data through summary statistics as well as regression models. FINDINGS Our statistical modelling shows that MHI coverage is associated with significantly increased utilization of health services. Indeed, individuals in households that had MHI coverage used health services twice as much when they were ill as those in households that had no insurance coverage. Additionally, MHI is also associated with a higher degree of financial risk protection and the incidence of catastrophic health expenditure was almost four times less than in households with no coverage. Nonetheless, the limitations of the MHI coverage also become apparent. CONCLUSION These promising results indicate that MHI has had a strong positive impact on access to health care and can continue to improve health of Rwandans even more if its limitations are addressed further.

The role of institutional design and organizational practice for health financing performance and universal coverage

Many low- and middle income countries heavily rely on out-of-pocket health care expenditure. The challenge for these countries is how to modify their health financing system in order to achieve universal coverage. This paper proposes an analytical framework for undertaking a systematic review of a health financing system and its performance on the basis of which to identify adequate changes to enhance the move towards universal coverage. The distinctive characteristic of this framework is the focus on institutional design and organizational practice of health financing, on which health financing performance is contingent. Institutional design is understood as formal rules, namely legal and regulatory provisions relating to health financing; organizational practice refers to the way organizational actors implement and comply with these rules. Health financing performance is operationalized into nine generic health financing performance indicators. Inadequate performance can be caused by six types of bottlenecks in institutional design and organizational practice. Accordingly, six types of improvement measures are proposed to address these bottlenecks. The institutional design and organizational practice of a health financing system can be actively developed, modified or strengthened. By understanding the incentive environment within a health financing system, the potential impacts of the proposed changes can be anticipated.

GENERAL BUDGET SUPPORT: HAS IT BENEFITED THE HEALTH SECTOR?

There has been recent controversy about whether aid directed specifically to health has caused recipient governments to reallocate their own funds to non-health areas. At the same time, general budget support (GBS) has been increasing. GBS allows governments to set their own priorities, but little is known about how these additional resources are subsequently used. This paper uses cross-country panel data to assess the impact of GBS programmes on health spending in low-income and middle-income countries, using dynamic panel techniques to estimate unbiased coefficients in the presence of serial correlation. We found no clear evidence that GBS had any impact, positive or negative, on government health spending derived from domestic sources. GBS also had no observed impact on total government health spending from all sources (external as well as domestic). In contrast, health-specific aid was associated with a decline in health expenditures from domestic sources, but there was not a full substitution effect. That is, despite this observed fungibility, health-specific aid still increases total government health spending from all sources. Finally, increases in total government expenditure led to substantial increases in domestic government health expenditures.

Economic evaluation of health care interventions: a review of alternative methods

This study analyzes a number of economic evaluation techniques that can be used by the economist in helping decision-makers make choices about the allocation of scarce resources in health care and the organization of health interventions. The evaluation techniques discussed are cost-benefit analysis, cost-effectiveness analysis, multi-attribute problem analysis, linear programming and econometric modelling. The main purpose of this paper is to study the merits of the different techniques and to point at certain difficulties in their application.

Viet Nam: The development of national health insurance

Since 1987, Viet Nam has been moving from a centrally planned to a market economy. The public sector became weaker, and public resources were no longer sufficient to respond to all healthcare needs. The government then recognized the need for cost-sharing, and in August 1992 issued a national Health Insurance Decree calling for compulsory health insurance for salaried workers in both the public and private sectors. Voluntary membership for dependants, farmers and the self-employed was also encouraged from the start. Currently, the number of insured persons reaches almost 9.5 million. Future challenges include the extension of coverage, especially to the low-income rural and urban population, modification of provider payment methods so as to enhance cost-containment, and organizational development in general.

Is universal coverage via social health insurance financially feasible in Swaziland

OBJECTIVE The Government of Swaziland decided to explore the feasibility of social health insurance (SHI) in order to enhance universal access to health services. We assess the financial feasibility of a possible SHI scheme in Swaziland. The SHI scenario presented is one that mobilises resources additional to the maintained Ministry of Health and Social Welfare (MOHSW) budget. It is designed to increase prepayment, enhance overall health financing equity, finance quality improvements in health care, and eventually cover the entire population. METHODS The financial feasibility assessment consists of calculating and projecting revenues and expenditures of the SHI scheme from 2008 to 2018. SimIns, a health insurance simulation software, was used. Quantitative data from government and other sources and qualitative data from discussions with health financing stakeholders were gathered. Policy assumptions were jointly developed with and agreed upon by a MOHSW team. RESULTS AND CONCLUSION SHI would take up an increasing proportion of total health expenditure over the simulation period and become the dominant health financing mechanism. In principle, and on the basis of the assumed policy variables, universal coverage could be reached within 6 years through the implementation of an SHI scheme based on a mix of contributory and tax financing. Contribution rates for formal sector employees would amount to 7% of salaries and the Ministry of Health and Social Welfare budget would need to be maintained. Government health expenditure including social health insurance would increase from 6% in 2008 to 11% in 2018.

Reaching universal coverage by means of social health insurance in Lesotho? Results and implications from a financial feasibility assessment

This article discusses the process, results and implications of a financial feasibility assessment of social health insurance (SHI), as one part of Lesothos exploration of how to move towards achieving universal health care coverage. Quantitative data from government and other sources, and qualitative data from discussions with stakeholders, were entered into SimIns, a health insurance simulation software, through which SHI revenue and expenditure for 11 years was projected. In principle, the assessment reveals that through a mix of tax financing and SHI contributions, all citizens of Lesotho could be covered with a defined benefit package of health services under the defined policy assumptions. Such a financing scheme would provide financial risk protection and enhance equity in access and health financing.