William D. Savedoff

Private health insurance: implications for developing countries

Private health insurance is playing an increasing role in both high- and low-income countries, yet is poorly understood by researchers and policy-makers. This paper shows that the distinction between private and public health insurance is often exaggerated since well regulated private insurance markets share many features with public insurance systems. It notes that private health insurance preceded many modern social insurance systems in western Europe, allowing these countries to develop the mechanisms, institutions and capacities that subsequently made it possible to provide universal access to health care. We also review international experiences with private insurance, demonstrating that its role is not restricted to any particular region or level of national income. The seven countries that finance more than 20% of their health care via private health insurance are Brazil, Chile, Namibia, South Africa, the United States, Uruguay and Zimbabwe. In each case, private health insurance provides primary financial protection for workers and their families while public health-care funds are targeted to programmes covering poor and vulnerable populations. We make recommendations for policy in developing countries, arguing that private health insurance cannot be ignored. Instead, it can be harnessed to serve the public interest if governments implement effective regulations and focus public funds on programmes for those who are poor and vulnerable. It can also be used as a transitional form of health insurance to develop experience with insurance institutions while the public sector increases its own capacity to manage and finance health-care coverage.

Clarifying efficiency-equity tradeoffs through explicit criteria, with a focus on developing countries.

Expenditures on health in many developing countries are being disproportionately spent on health services that have a low overall health impact, and that disproportionately benefit the rich. Without explicit consideration of priority setting, this situation is likely to remain unchanged: resource allocation is too often dictated by historical patterns, and maintains vested interests. This paper explores how prioritization between different health interventions can be rationalised by the use of clearly defined criteria. A number of key efficiency and equity criteria are examined, in particular analysing how potential tradeoffs could be incorporated into the decision making process.

10 best resources on … health workers in developing countries

yet until recently researchers and policymakers paidrelatively little attention to their role in developing countries.This is due in part to the inherent complexities and limitedavailability of data—both of which have also held back researchin the world’s wealthier countries. But in low- and middle-income countries, these difficulties have been exacerbated bya tendency to focus on more visible issues.In recent years, however, this has changed. The need to addresshealth workers in public policy took on particular prominenceafter 2000 when increased foreign aid for health programmesconfronted limited capacity in many developing countries toapply those funds—often for a lack of skilled personnel.Research was also spurred by concerns that emigration ofhealth workers was exacerbating the scarcity of health workersin many low- and middle-income countries. Consequently, healthworkforce issues are now attracting a great deal of attentionfrom politicians, donors, practitioners, advocates and researchers(see, for example, Global Health Workforce Alliance 2006).As attention has increased, research has also improved. Untilrecently, most publications could be characterized as eitherplanning studies, using modelling and simulations, orpersonnel management studies, using interviews and observa-tion to assess health care delivery approaches to staffing. Whilethese studies have their uses, they also miss an important partof the picture because they tend to focus only on employmentwithin the public sector and miss many of the dynamicinteractions that occur between health workers and thelabour markets in which they move. By contrast, a newgeneration of research is explicitly addressing both the privatesector and the broader labour market with increasinglysophisticated data and research tools.Our goal in this essay is not so much to present the ‘10 best’resources on health workers, which would be presumptuousto say the least, but rather to introduce this new generationof research by highlighting a number of good research articlesthat demonstrate this trend. These articles share a growingawareness that the number and quality of health workersengaged in health care services is influenced by more thangovernment decisions about spending and deployment. Theyencompass the behaviour of private practitioners and non-governmental organizations; people who seek health care; andhealth workers themselves as they make choices about theirtraining, employment, location and work effort, all within acontext defined by the broader labour market, politics andculture. This is why recent research is often framed within theperspective of labour market analysis even if it emerges fromfields like political science, sociology, anthropology, publicadministration and business management. The better economicstudies are also enriched by contributions from these otherfields.KEY MESSAGES Until recently researchers and policymakers paid little attention to the role of health workers in developing countriesbut a new generation of studies are providing a fuller understanding of these issues using more sophisticated data andresearch tools. Recent research highlights the value of viewing health workers as active agents in dynamic labour markets who arefaced with many competing incentives and constraints. Newer studies have provided greater insights into human resource requirements in health, the motivations andbehaviours of health workers, and health worker migration. We are encouraged by the progress but believe there is aneed for even more, and higher quality, research on this topic.