# Presentation: 745110

## Innovative Health Care Approaches

- Organizer: Bryn Sakagawa
- Panel: Mark Landry, Dr. Sara Bennett, and Dr. Pia Schneider
- Tuesday, August 24, 2004

- Welcome to _**Session 9**_

## Agenda

- Introductions/Overview (USAID)
- Presentations
- “Improving Health Care Systems Using Geographic Information Systems (GIS)” **Mark Landry, **Abt Associates
- “Scaling Up Community-Based Health Financing” **Sara Bennett** and **Pia Schneider, **Abt Associates
- Closing Remarks
- Q&As (please hold your questions to the end!)

## Scaling Up Community Based Health Financing

**Scaling Up Community Based Health Financing**

**Sara Bennett PhD and Pia Schneider PhD,**
**Abt Associates**
**USAID**
**August 24, 2004**

## Outline of Presentation

**Why Scale up CBHF/MHO/mutuelles**
**Approaches to Scaling up CBHF**
**Country Experience**
**Ghana**
**Rwanda**
**Philippines**
**Key Issues and Recommendations for Support**

## User fees restrict access to care for low-income groups: Rwanda

- Source: Household and Living Condition Survey 1999/2001

**Notes:**
This presentation focuses on 1 poor country: Rwanda.

Rwanda is a HIPC country. Compared to Sub-Saharan Africa, it scores worse on most socio-economic, demographic and health indicators:  One of the lowest GDP per capita, highest mortality rates for mothers and children, high HIVAIDS rate and life expectancy of around 40 years. About 66% of rural pop live < consumption PL; and 46% below the food PL

This socio-economic situation has an impact on access to care. 
Patients pay user fees in all public and private health facilities. User fees become financial barriers for the poor. It causes service utilization to be highly income dependent.

## In response, people start CBHF schemes

**Bottom-up approach:**
**Driven by community or health facility**
**Member governance**
**Community participation in definition of benefit package and premium**
**Preconditions:**
**Willingness to pay for health care**
**Trust in CBHF scheme**
**Providers offering quality care**
**Advantages to the population**
**Improved financial access to care when sick**
**Protection against the catastrophic costs of illness**
**Improved ability to plan household expenditures**

## CBHF Improves Equity in Access to Care in Rwanda

- Source: hh-survey

## Also international support for CBHF schemes 

**“****The Commission recommends that out-of-pocket expenditures in poor communities should increasingly be channeled into “community financing” schemes to help cover the costs of community-based health delivery.”**
**	****Report of the Commission on Macroeconomics and Health, WHO, 2001.**

## Leading to a growing number of CBHF schemes

***Ghana data is from ‘ 99, ‘ 01, ‘ 02**

**Notes:**
West Africa : Bénin, Burkina Faso, Cameroun, Côte d'Ivoire, Guinée, Mali, Mauritanie, Niger, Senegal, Tchad, Togo

## But still low membership....

**Few low income countries have greater than 1% of the population covered by CBHF schemes.**
**Key challenge – how to scale up such schemes**

## The process of scaling-up

## Challenges in Scaling up

**To ensure equity between schemes, or regions or sub-groups of the population – need to adapt government subsidy patterns**
**Preventing financial instability that may arise due to small scheme size and lack of reinsurance**
**Ensuring that providers are equipped to work with schemes and can manage shifts in forms of payment**
**Preventing the emergence of fraudulent schemes**
**Maintaining the advantages of social solidarity within communities while going to scale**

## Ghana

## The growth of CBHF schemes in Ghana

**In 2002, 159 schemes, but many still nascent, only about 12 functional & providing benefits**
**Political pressure to drop “cash and carry” led to the National Health Insurance Act, August 2003**
**All districts mandated to establish CBHF schemes by September 2004, and everyone to join.**
**Funded by (i) sales tax, (ii) formal sector worker contributions and (iii) voluntary payments by informal sector workers**

## Challenges to Implementation

**Lack of prior local institutional capacity to support nationwide roll out – fraudulent consultants**
**Break neck speed of implementation**
**Lack of clarity about many aspects of implementation and communities concerned that “their” ownership of schemes will be taken away. **
**Act requires accreditation of providers, establishment of reinsurance functions etc. that challenge local capacity**
**Act mandates standardized national benefit package and premiums – that don’t respond to differences between localities**

## Lessons from Ghana

**Institutional Framework**
**Established via Act very early – prematurely?**
**Organizational Sustainability**
**Scale up places heavy institutional burden –establish local institutional capacity prior to legislating.**
**Importance of ongoing M&E – will the government be sufficiently flexibility to alter course if need be?**
**Financial Sustainability**
**Substantial government investment to launch schemes distorts incentives**
**Is this level of funding sustainable?**
**Provider performance**
**Provider concern about prompt payment, and increased demand.**

## Rwanda

## Replication Strategy in Rwanda:	Findings from CBHI pilot-test 	lead MOH to replicate CBHF in 	other areas

## Ngarama

**Ngarama**
**5 MS**

**Byumba**
**22 MS**

**Umutara**
** ****5 MS**

**Bugesera**
** ****10 MS**

**Ruli**
** ****10 MS**

**Kabgayi**
** ****17 MS**

**Gakoma:**
**4 MS**

**Kabutare:**
**15 MS**

**Kibilizi:**
**5 MS**

**Ruhengeri:**
-  **10 MS**

**Mugonero**:
**7 MS**

**Cyangugu**:
**4 MS**

**Gikongoro:**
**2 MS**

**Gisenyi**:
**6 MS**

**SITUATION AS OF MARCH 2004: 122 MHO**

## Challenges to Implementation

**Lack of institutional capacity (legal framework, national health strategy)**
**Lack of human capacity among community members to manage CBHF**
**Premium levels too high for poorest**
**Low levels of quality of care affect willingness to insure**

## Lessons from Rwanda

**Support needed when replicating CBHF**
**Institutional Framework**
**Legal framework**
**National Health Financing Strategy**
**Organizational Sustainability of CBHF**
**Continuous human capacity building**
**Financial Sustainability of CBHF**
**Subsidize premium of poor households**
**Provider Performance**
**M&E and improve quality of care **

## Philippines

## PhilHealth Philippines

***Universal Coverage Law***
**Formal sector workers **
**Poor enroll in PhilHealth Indigent Plan (IP), subsidized by Government**
**Independent workers (e.g. dentists, street vendors) pay same fixed premium per year, independent of income**

## Results from the Philippines

**Formal sector **
**100% enrolled**
**Poor households (subsidized)**
**> 100% enrolled following elections**
**Mayor’s picture on back of PhilHealth membership card sends confusing message to members**
**Independent workers **
**Low enrollment rates**
**Unaffordable premium for low-income groups**
**Rich insure in private insurance companies**

## Support needed when integrating CBHF into national insurance

**Institutional Framework**
**Organizational Capacity Building of National Health Insurance**
**Financial Sustainability and Equity in Financing**
**Income dependent premium levels for  independent workers (includes dentists and street vendors)**
**Some solidarity enforcement between rich and poor**
**Provider Performance**
**M&E and improve quality of care **

## Conclusions and Remaining questions

**There is no defined path from individual CBHF schemes to universal coverage – processes are iterative and not always logical **
**The role of government in developing a national health financing  policy is critical in scale-up **
**Distinction between replication and integrating into Social health insurance strategy**
**In-country capacity to manage CBHF and scale up is major barrier **
**Lack of human, organizational, financial capacity**
**What happens to trust in CBHF if scheme governance is moving up?**

## Recommendations

**There are TA needs throughout the process of scale-up – these vary according to stage of scale up and local capacity but include:-**
**Assistance to individual schemes**
**Assistance with institutionalization of local TA capacity**
**Assistance with development of financing policy**
**Assistance with the establishment of legal frameworks, reinsurance functions, subsidy systems, billing systems etc.**
**M&E and documentation throughout**

## Thank You ........ And more on:www.phrplus.org

## For More Information...

**Web Site:**
**  ****http://www.usaid.gov **
**Enter Keyword: ‘**_**Summer Seminars**_**’**
**or**
**  ****http://www.usaid.gov/policy/cdie/**
**WEBBoard:**
_**http://forums.info.usaid.gov/~USAIDSummerSeminars**_** **

## Muslim World Outreach and Engaging Muslim Civil Society

**Organizer: Ann Phillips****Panel: Krishna Kumar, **
- Tuesday, August 31, 2004

- Come back next week for _**Session 10**_