Werner Soors

Costa Rica: achievements of a heterodox health policy

Costa Rica is a middle-income country with a strong governmental emphasis on human development. For more than half a century, its health policies have applied the principles of equity and solidarity to strengthen access to care through public services and universal social health insurance. Costa Ricas population measures of health service coverage, health service use, and health status are excellent, and in the Americas, life expectancy in Costa Rica is second only to that in Canada. Many of these outcomes can be linked to the performance of the public health care system. However, the current emphasis of international aid organizations on privatization of health services threatens the accomplishments and universality of the Costa Rican health care system.

Editorial: a view from beneath: community health insurance in Africa.

This paper presents an overview of the development of Community Health Insurance (CHI) in sub‐Saharan Africa. In 2003, nearly 600 CHI initiatives were registered in a dozen countries of francophone West Africa alone. At regional level, coordination networks have been created in Africa with the aim to support and monitor the developments of this innovative model of health care financing. At national level, governments are preparing the necessary legal frameworks for CHI implementation. CHI is increasingly seen as a strategy to meet other development goals than only health. It constitutes an interesting model to finance health care, to pool financial resources in a fair way and to empower health care users. The CHI movement however still faces many challenges. The relevance of more professional inputs in the management of CHI and the need for careful subsidy of CHI schemes are increasingly recognized. There is also need to optimize the relationship of CHI with the other actors in the health system and to scale‐up CHI so as to gain in effectiveness and efficiency. The boom in the number of schemes in Africa during the last years is an indicator of the increasing attractiveness of the model. In practice however, enrolment rates per scheme remain low or are only slowly increasing. Context‐specific research is needed on the reasons that prevent people from enrolling in larger numbers. On that basis, relevant action to be taken locally can be identified.

Health policy processes in maternal health: A comparison of Vietnam, India and China

This article reports on a comparative analysis to assess and explain the strengths and weaknesses of policy processes based on 9 case-studies of maternal health in Vietnam, India and China. Policy processes are often slow, inadequately coordinated and opaque to outsiders. Use of evidence is variable and, in particular, could be more actively used to assess different policy options. Whilst an increasing range of actors are involved, there is scope for further opening up of the policy processes. This is likely, if appropriately managed with due regard to issues such as accountability of advocacy organisations, to lead to stronger policy development and greater subsequent ownership; it may however be a more messy process to co-ordinate. Coordination is critical where policy issues span conventional sectoral boundaries, but is also essential to ensure development of policy considers critical health system and resource issues. This, and other features related to the nature of a specific policy issue, suggests the need both to adapt processes for each particular policy issue and to monitor the progress of the policy processes themselves. The article concludes with specific questions to be considered by actors keen to enhance policy processes.

Community Health Insurance in Developing Countries

Community Health Insurance (CHI) is a health insurance arrangement serving a social purpose, operating at the local level of the health system and thriving on community solidarity. This article describes the origins, formats, and evolution of CHI in Africa, Asia, and Latin America. It discusses the strengths, weaknesses, and opportunities of CHI from different perspectives: its contribution to equitable health-care access, to health sector financing, to provider responsiveness and quality of care, and to wider developmental objectives. Particular attention is drawn to factual issues such as management and support needs, scaling-up, the use of subsidies, and persistent knowledge gaps.

Revisiting health policy and the World Bank in Bolivia

This article analyses the influence of the World Bank on reforms of the health sector in Bolivia during the period 1986–2006, and assesses their impact on the health care delivery system to date. The article examines the transformation of health services undertaken by the current socialist government since 2006. A literature review and interviews with decision-makers critically examine the outcome of reforms on criteria linked to health system integration. The study illustrates that Bolivia applied quite comprehensively the WB recommendations. Among others these included indirect privatization through public health services’ restriction of access to a basic package of care and decentralization with devolution. In consequence, the segmentation and fragmentation of the health system was exacerbated, accessibility and quality of care suffered and health status barely improved. The article attempts to locate the relationship between policy, health care delivery and health systems functioning.

Social protection in health: the need for a transformative dimension

1 Research Centre for Longitudinal and Life Course Studies, University of Antwerp, Belgium2 Unit of Health Policy and Financing, Institute of Tropical Medicine, Antwerp, Belgium3 Institute of Public Health, Bangaluru, India4 Institute of Development Policy and Management, University of Antwerp, Belgium5 Herman Deleeck Centre for Social Policy, University of Antwerp, Belgium

The Role of Social Health Protection in Reducing Poverty: The Case of Africa

This literature review aims to increase our knowledge of the potential that social health protection has in reducing poverty in sub-Saharan Africa. Of all regions in the world, sub-Saharan Africa ranks lowest in income per capita, life expectancy at birth, and highest in mortality. It is the only region with a negative growth for the period 1980-2000. Trapped in poverty and excluded from decent health care, the African poor have to face both the catastrophic costs of seeking health care and bear the burden of lost productivity. Evidence for the link between illness and poverty is particularly striking in the case of malaria and AIDS. Social protection is increasingly seen as a key strategy to contribute to poverty reduction and to sustainable development. But in Africa, where the informal economy sector remains huge and where poorly effective risk management strategies often prevail, there still is a long way to go. Community health insurance, however, appears to be an interesting option for meeting the goal of universal social protection. There is convincing evidence of its positive effect on access to health care. Moreover, community health insurance constitutes a promising channel to give voice to the poor. Today, this particular instrument of social health protection reaches only a small fraction of the African population, but enjoys a growing acceptance and is subject to increasing demands. Besides the ethical imperative of providing social protection, there is evidence today, albeit limited, indicating that the expansion of social health protection, by improving access to care, may increase peoples participation in the labour market, improve their income and contribute to economic growth.

Lack of access to health care for African indigents: a social exclusion perspective

BackgroundLack of access to health care is a persistent condition for most African indigents, to which the common technical approach of targeting initiatives is an insufficient antidote. To overcome the standstill, an integrated technical and political approach is needed. Such policy shift is dependent on political support, and on alignment of international and national actors. We explore if the analytical framework of social exclusion can contribute to the latter.MethodsWe produce a critical and evaluative account of the literature on three themes: social exclusion, development policy, and indigence in Africa–and their interface. First, we trace the concept of social exclusion as it evolved over time and space in policy circles. We then discuss the relevance of a social exclusion perspective in developing countries. Finally, we apply this perspective to Africa, its indigents, and their lack of access to health care.ResultsThe concept of social exclusion as an underlying process of structural inequalities has needed two decades to find acceptance in international policy circles. Initial scepticism about the relevance of the concept in developing countries is now giving way to recognition of its universality. For a variety of reasons however, the uptake of a social exclusion perspective in Africa has been limited. Nevertheless, social exclusion as a driver of poverty and inequity in Africa is evident, and manifestly so in the case of the African indigents.ConclusionThe concept of social exclusion provides a useful framework for improved understanding of origins and persistence of the access problem that African indigents face, and for generating political space for an integrated approach.

Impact of RSBY on enrolled households: lessons from Gujarat

Launched in 2008, the Rashtriya Swasthya Bima Yojana (RSBY) insurance scheme has the mandate of improving access to quality health services of families living below the poverty line (BPL) while providing financial protection against health shocks. Four years following implementation, it is yet to find its presence in all districts of the twenty-eight States in India. Budgetary limitations, the balance between maintaining the claims ratio and sustainability, the contractual relationship between insurance companies and empanelled hospitals, and the weak monitoring system are few challenges that the scheme faces today. In this paper, we explore implementation of RSBY based on the three dimensions of universal health coverage (UHC) stated in the World Health Report 2010 i.e. “the proportion of the population to be covered” (breadth of coverage), “the range of services to be made available” (depth of coverage) and “the proportion of the total costs to be met” (height of coverage).

International aid policy: public disease control and private curative care?

Integrating disease control with health care delivery increases the prospects for successful disease control. This paper examines whether current international aid policy tends to allocate disease control and curative care to different sectors, preventing such integration. Typically, disease control has been conceptualized in vertical programs. This changed with the Alma Ata vision of comprehensive care, but was soon encouraged again by the Selective Primary Health Care concept. Documents are analyzed from the most influential actors in the field, e.g. World Health Organization, World Bank, and European Union. These agencies do indeed have a doctrine on international aid policy: to allocate disease control to the public sector and curative health care to the private sector, wherever possible. We examine whether there is evidence to support such a doctrine. Arguments justifying integration are discussed, as well as those that critically analyze the consequences of non-integration. Answers are sought to the crucial question of why important stakeholders continue to insist on separating disease control from curative care. We finally make a recommendation for all international actors to address health care and disease control together, from a systems perspective.