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Access to health care & social protection

Access to quality health care is one of the important determinants of sound health outcomes in a population. Access has many components: geographical access, financial access, intra-institutional access within the health facility itself, cultural and psychological access, acceptability of the care provided, etc. Problems in access translate into poor utilisation of modern health services. For instance, at the level of the first line, utilisation rates in African health centres rarely reach beyond 0.5 new cases per inhabitant per year. When access to health facilities is good, then the health care utilisation patterns of the population will depend on other factors as well, such as the perceptions of quality and cost, the existence of other priorities and prevailing social patterns. An anthropological study in Mali pointed to differences in health centre utilisation among apparently similar villages. These differences were due to differences in local social organisation, affecting solidarity mechanisms and redistribution of resources. The study indicated that financial access is a major barrier, especially in communities where local solidarity mechanisms are weak. It also revealed increasing expectations towards the quality and responsiveness of modern health services.

If access to health care is to be improved, it would need to be explicitly recognised by policy makers and health systems managers as a top priority. In more operational terms, interventions are needed at the supply-side: improve quality of care (see topic 2) and decrease the organisational barriers within and between health facilities (see topics 3 and topic 4). But interventions are also required at the demand-side with the aim to improve financial accessibility.

In this topic, we will focus on the improvement of financial accessibility to health care. We examine two particular modalities: solidarity-based community health insurance systems based on pre-payment of a premium (1a) and social assistance funds for health care covering people who cannot afford pre-payment (1b).

1a. Community Health Insurance (CHI)

The notion of Community Health Insurance (CHI) refers to insurance arrangements that generally share the following characteristics: i) solidarity, where risk sharing is as inclusive as possible and membership premiums are independent of individual health risks; ii) community-based social dynamics, where the schemes are organized by and for individuals who share common characteristics (geographical, occupational, ethnic, religious, gender etc.); iii) participatory decision-making and management; iv) nonprofit character; and v) voluntary participation. The primary objectives of these insurance arrangements are to improve financial access to care for individuals by pre-payment and pooling of funds and to provide protection against the cost of health care for individuals. The number of CHI projects has exploded over the last years in many low-income countries, mainly in Africa but also in other regions, such as South-East Asia. There is an interest from policy-makers and donors in implementing CHI as one of the strategies to help overcome the financial barrier to health care, even if coverage rates today still remain low.  

Criel B, Waelkens M-P, Soors W et al. Community Health Insurance in Developing Countries. In International Encyclopedia of Public Health, First Ed (2008), vol 1, pp 782-791.

CHI has the potential to improve financial access to care: evidence indicates that CHI members use health care 2 to 5 times more often than non-members do. But its potential for the community at large is not realised: as indicated above, the enrolment generally remains low or grows at a very slow pace - in most African schemes the coverage is less than 10%. However, some successful CHI schemes have shown that higher levels of enrolment (30-60%) are possible indeed. Essential context elements that affect enrolment are: ability for the households to pay the premium in a context of multiple pressing needs; an acceptable level of quality of care in the contracted health facilities; trust in the management of the CHI organisation; and last but not least, a basic understanding and acceptance of the general principles that underlie CHI .

CHI schemes differ in their design, for example in aspects like premium height and payment methods, benefits and target population, exclusion criteria and reimbursement mechanisms to providers. There is still a lack of insight into the optimal links between context, the scheme’s design and the eventual outputs and outcomes of the scheme. There is however more knowledge available on the elements of the implementation strategy needed for CHI to be potentially successful: thorough and continuous information, packed in an appropriate social and cultural format, that targets both population and health workers; a management set-up which is at least partly in professional hands; and, last but not least, the need for external financial and technical support.

Basaza R, Criel B, Van der Stuyft P. (2007) Low enrolment in Ugandan Community Health Insurance Schemes: underlying causes and policy implications. BMC Health Services Research, Vol 7, N°105.

La mise en réseau de mutuelles de santé en Afrique de l’Ouest. L’union fait-elle la force ? Les enseignements d’un colloque international organisé à Nouakchott, Mauritanie, 19 et 20 décembre 2004 (Eds. Waelkens M-P & Criel B), ITGPress, Avril 2007.

Devadasan N, Ranson K, Van Damme W, Acharya A, Criel B. The landscape of community health insurance in India: An overview based on 10 case studies. Health Policy 2006; 78:224-234.

Criel B, Ahmadou Diallo A, Van der Vennet J, Waelkens M-P & Wiegandt A (2005). La difficulté du partenariat entre professionnels de santé et mutualistes: le cas de la mutuelle de santé Maliando en Guinée-Conakry. Tropical Medicine & International Health, Vol 10, N°5, pp 450-463.

Devadasan, N, Ranson K, Van Damme W & Criel, B (2004).  Community Health Insurance in India. An overview. Economic and Political Weekly, Vol XXXIX, N°28, July 10-16, 2004

Waelkens MP & Criel B (2004). Les mutuelles de santé en Afrique sub-saharienne; état des lieux et réfléxions sur un agenda de recherche. Preker AS (ed.). Washington: International Bank for Reconstruction and Development/World Bank, pp. 99.

Apart from improving access to care, CHI may also pursue other objectives, such as active purchasing of quality health care and protection against catastrophic health expenditure. Increasingly, there is also interest in investigating the socio-political effects of CHI. It is hypothesised that CHI may positively influence the quality of health care via its purchasing function and/or via altered power relationships between the CHI members and the providers. However, at present the evidence for such leverage remains largely anecdotal. The need for more research in that domain is obvious.

Criel B, Ahmadou Diallo A, Van der Vennet J, Waelkens M-P & Wiegandt A (2005). La difficulté du partenariat entre professionnels de santé et mutualistes: le cas de la mutuelle de santé Maliando en Guinée-Conakry. Tropical Medicine & International Health, Vol 10, N°5, pp 450-463.

Carrin G, M-P Waelkens & Criel B (2005). Community based Health Insurance in Developing Countries. A study of its contribution to the performance of health financing systems. Tropical Medicine & International Health, Vol. 10, N°8, pp 799-811.

Waelkens M-P, Soors W, Criel B, 2005. The role of social health protection in reducing poverty : the case of Africa. ESS Paper No 22. International Labour Office, Geneva.

What has become clear today is that CHI is not an option for the poorest because they cannot afford to pay the premium – unless somebody else pays for them. In these cases, social assistance systems should be developed. The operational combination of the two types of system – CHI for those who can afford pre-payment and social assistance for health care for those who can’t – is a promising avenue for further action and research.

Jacobs B, Bigdeli M, Van Pelt M, Por I, Salze C, Criel B, 2008. Editorial: bridging community-based health insurance and social protection for health care – a setp in the direction of universal coverage? Trop Med Int Health 13(2): 1-4.

Musango, L, Dujardin, B, Dramaix M & Criel, B (2004). Le profil des membres et des non membres des mutuelles de santé au Rwanda: le cas du district sanitaire de Kabutare. Tropical Medicine & International Health, Vol 9, N° 11, pp 1222-1227.

1b. Social Assistance for Health

The Health Equity Fund (HEF) is one particular implementation modality of social assistance for health launched in Cambodia in the last decade. In other contexts, other denominations than ‘HEF’ may be used (for instance: destitute fund, indigent fund, solidarity fund, etc.). However, the objectives of such a ‘social assistance for health’ fund are universal: improve access to health care for the poorest people in the community and compensate the health care providers for the cost of treating those people.

It does so by taking over the direct cost of health service utilisation by the beneficiaries of the fund - other costs, such as transport and nutrition may sometimes be covered as well – and by acting as a third party payer on behalf of the poor patients. The revenue of the health care providers is thus not affected; providers are paid the same amount as is the case for paying patients.

The history of HEF in Cambodia has shown that these arrangements functionally evolved from a system where monies are transferred to a health care provider, to progressively take up other social assistance functions such as the provision of information and more multi-purpose social support to HEF beneficiaries. Obviously, this has contributed to increase the transaction costs of the HEF model.

To operate a HEF, several functions need to be fulfilled in a proper way: identification of beneficiaries, providing of benefits to beneficiaries, financing the fund, paying the health care providers for the care offered to the funds beneficiaries, daily management of the fund and monitoring of the overall process.

Meessen B, Criel B (2008). Public interventions targeting the poor: an analytical framework. In Health and Social Protection: experiences from Cambodia, China and Lao PDR. ITM in Studies in health services organization and policy.

Noirhomme M, Meessen B, Griffiths F, Por I, Jacobs B, Thor R, Criel B and Van Damme W (2007) Improving access to hospital care for the poor: comparative analysis of four health equity funds. Health Pol and Pl, advance access published May 25, 2007.

Criel, B, Noirhomme M, 2004. Implémentation d’un fonds d’Equité hospitalier au niveau du CHD II Maravoay. GTZ Province de Mahajanga, Madagascar. World Health Organisation Collaboration centre for Primary Health Care. ITM.

From the limited documented experience with HEF (Cambodia, Mali, Madagascar and Mauritania), the following lessons can be drawn:

  • Functions of financing, purchasing, delivery of care and monitoring of process need to be divided between different actors.
  • The organisation who takes up the daily management needs to meet the following criteria: experience in dealing with poor people, knowledge of the local context, sound management capacity, no conflict of interest, presence of mechanisms of accountability towards the funders and the presence of a trustworthy contact person for the beneficiaries at health service level.
  • A strong organisation that steers the process throughout all stages of implementation of a HEF is vital.
  • Enough financial resources are essential, including external funds.
  • Access is further improved if the benefit package of the HEF goes beyond paying for direct costs, especially through the provision of information and social support before and during health service utilisation.

Noirhomme M, Thomé JM. Les fonds d'équité, une stratégie pour améliorer l'accès aux soins de santé des plus pauvres en Afrique? In: Dussault G, Fournier P, Letourmy A, editors. L'assurance maladie en Afrique francophone; améliorer l'accès aux soins et lutter contre la pauvreté. Washington: Banque Internationale pour la Reconstruction et le Développement/La Banque Mondiale, 2006: 431-452. (Série Santé, Nutrition et Population).

Noirhomme M, 2006. Rapport Final. Documentation at performance des Fonds d’Indigence en Mauritanie. ITM World Health Organisation Collaboration centre for Primary Health Care.

There is a need to design valid indicators that enable the follow-up of the performance of HEF, like for instance the proportion of the target population that is identified as beneficiary and the utilisation of health services by the beneficiaries. When comparing how such systems of social assistance for health care function in Asia and in Africa (for instance, differences in identification of the beneficiaries and in utilisation of health care by the beneficiaries), it is obvious that context factors matter: the acceptability of targeting and the quality of health care services play a role for instance. European countries have a longstanding tradition of social assistance. Without aiming to be prescriptive or normative, we believe that useful lessons may be learned from the European experience for the development of HEF-like systems in low-income countries.

Noirhomme M, Thomé JM. Les fonds d'équité, une stratégie pour améliorer l'accès aux soins de santé des plus pauvres en Afrique? In: Dussault G, Fournier P, Letourmy A, editors. L'assurance maladie en Afrique francophone; améliorer l'accès aux soins et lutter contre la pauvreté. Washington: Banque Internationale pour la Reconstruction et le Développement/La Banque Mondiale, 2006: 431-452. (Série Santé, Nutrition et Population).

Hardeman W, Van Damme W, Van Pelt M, Por I, Kimvan H, Meessen B, 2004. Access to health care for all? User fees plus a Health Equity Fund in Sotnikum, Cambodja. Health Policy and Planning 19 (&):22-32.

Meessen B, Van Damme W, Kirunga Tashobya C, Tibouti A, 2006. Poverty and user fees for public health care in low-income countries: lessons from Uganda and Cambodja. The Lancet 368: 2253-2257.