Ce diaporama a bien été signalé.
Nous utilisons votre profil LinkedIn et vos données d’activité pour vous proposer des publicités personnalisées et pertinentes. Vous pouvez changer vos préférences de publicités à tout moment.
Extend health coverto the poorest in Africa                 V. Ridde, Ph.D.  Workshop on “Equity in universal health cover...
WHO, 2010
OUTLINE1985-2000       2000-2012      POST 2012  • USER FEES     • FREE FOR     • UHC    FOR ALL         MDG  • EXEMPTION ...
OUTLINE1985-2000       2000-2012      POST 2012  • USER FEES     • FREE FOR     • UHC    FOR ALL         MDG  • EXEMPTION ...
25 YEARS OF USER FEES0.40          pre-IB   IB + 5 Y   20100.350.300.250.200.150.100.050.00       BENIN         GUINÉE    ...
PUBLIC SPENDING IN PHC + USER FEES 40                                               Poorest      Richest 35 30 25 20 15 10...
1985-2000USER FEES FOR ALL                    LOW                 UTILIZATION                   + HIGH                 EXC...
OUTLINE1985-2000       2000-2012      POST 2012  • USER FEES     • FREE FOR     • UHC    FOR ALL         MDG  • EXEMPTION ...
ABOLITION SUPPORT•   2007 : WORLD BANK IF COUNTRIES…•   2009 : UN AGENCIES (Preg. Women + < 5 Y)•   2010 : AFRICAN UNION (...
NO MORE CONSENSUS FOR USER FEES                                  FREE HEALTH CARE ?           NUANCED             50 GLOBA...
25 YEARS OF USER FEES0.40          pre-IB   IB + 5 Y   20100.350.300.250.200.150.100.050.00       BENIN         GUINÉE    ...
2 or 3 YEARS OF ABOLITION3.50               pre-IB     IB + 5 Y     20103.002.502.001.501.000.500.00       Benin     Guiné...
HEALTH SEEKING BEHAVIOUR100                                                                   WHITOUT USER FEES90807060   ...
Benefit incidence analysis of abolition160%                                   BURKINA FASO140%120%100%80%60%40%20% 0%     ...
Severe illness < 5 years after abolition :          Incidence rate ratios     BURKINA FASO                  POOREST       ...
Ghana, South Africa, Tanzania                                Mills et al, 2012
2000-2012              ????                                WORST-OFF                                  ????                ...
OUTLINE1985-2000       2000-2012      POST 2012  • USER FEES     • FREE FOR     • UHC    FOR ALL         MDG  • EXEMPTION ...
INSURANCE AND WORST-OFF• Rwanda : « one of the major challenges faced  by the GoR is how to ensure that the poorest  benef...
«as long as careful attention is given to specific design features, such as  government subsidies to ensure    that the po...
Measures to promote health insurance   membership among the poor•   Premium subsidised 100%•   Premium partially subsidise...
100 % subsidised for the worst-off
CHALLENGES/DESIGN• Who will finance the subsidise ?  – Local cost-recovery : contribution and conflict of interest  – Valu...
TO READ• Bitran, R., & Giedion, U. (2002). Waivers and exemptions  for health services in developing countries. Final Draf...
OUTLINE1985-2000       2000-2012      POST 2012  • USER FEES     • FREE FOR     • UHC    FOR ALL         MDG  • EXEMPTION ...
UHC : A WINDOW OF OPPORTUNITY      FOR THE WORST-OFF ?• POLITICAL WILL• ACTION AND EVIDENCE
1985-2000         2000-2012      POST 2012  • USER FEES       • FREE FOR     • UHC    FOR ALL           MDG  • EXEMPTION  ...
Prochain SlideShare
Chargement dans…5
×

Extend health cover to the poorest in Africa : abolishing fees and target the worst-off

572 vues

Publié le

Presentation done during the FAHS CoP workshop: Equity in Universal Health Coverage – reaching the poorest.

Publié dans : Santé & Médecine, Business, Voyages
  • Soyez le premier à commenter

  • Soyez le premier à aimer ceci

Extend health cover to the poorest in Africa : abolishing fees and target the worst-off

  1. 1. Extend health coverto the poorest in Africa V. Ridde, Ph.D. Workshop on “Equity in universal health coverage: How to reach the poorest.” 24th September 2012, Marrakesh, Morocco
  2. 2. WHO, 2010
  3. 3. OUTLINE1985-2000 2000-2012 POST 2012 • USER FEES • FREE FOR • UHC FOR ALL MDG • EXEMPTION GROUP FOR THE WORST-OFF
  4. 4. OUTLINE1985-2000 2000-2012 POST 2012 • USER FEES • FREE FOR • UHC FOR ALL MDG • EXEMPTION GROUP FOR THE WORST-OFF
  5. 5. 25 YEARS OF USER FEES0.40 pre-IB IB + 5 Y 20100.350.300.250.200.150.100.050.00 BENIN GUINÉE BURKINA FASO MALI
  6. 6. PUBLIC SPENDING IN PHC + USER FEES 40 Poorest Richest 35 30 25 20 15 10 5 0 Côte dIvoire Ghana Guinea Kenya Madagascar Tanzania South Africa Castro Leal, et al. 2000
  7. 7. 1985-2000USER FEES FOR ALL LOW UTILIZATION + HIGH EXCLUSIONEXEMPTION FORWORST-OFF
  8. 8. OUTLINE1985-2000 2000-2012 POST 2012 • USER FEES • FREE FOR • UHC FOR ALL MDG • EXEMPTION GROUP FOR THE WORST-OFF
  9. 9. ABOLITION SUPPORT• 2007 : WORLD BANK IF COUNTRIES…• 2009 : UN AGENCIES (Preg. Women + < 5 Y)• 2010 : AFRICAN UNION (Preg. Women + < 5 Y)• 2012 : – UHC = WHA +UN GENERAL ASSEMBLY – THE LANCET
  10. 10. NO MORE CONSENSUS FOR USER FEES FREE HEALTH CARE ? NUANCED 50 GLOBAL HEALTH ACTORS 2%NEGATIVE NO STANCE 0% 29% POSITIVE 59% NEUTRAL 10% Robert et Ridde, 2012
  11. 11. 25 YEARS OF USER FEES0.40 pre-IB IB + 5 Y 20100.350.300.250.200.150.100.050.00 BENIN GUINÉE BURKINA FASO MALI
  12. 12. 2 or 3 YEARS OF ABOLITION3.50 pre-IB IB + 5 Y 20103.002.502.001.501.000.500.00 Benin Guinée Burkina Faso Mali Burkina 3 y free Mali 2 y of free <5y <5y
  13. 13. HEALTH SEEKING BEHAVIOUR100 WHITOUT USER FEES90807060 USER FEES5040302010 0 Rwanda Burkina Mali 2006 Niger 2006 Sierra Sierra Burkina 1 y. Mali 1 y Niger 2 y 2008 2010 Leone 2008 Leone 3 m. 2009 2008 2009 2010
  14. 14. Benefit incidence analysis of abolition160% BURKINA FASO140%120%100%80%60%40%20% 0% < 5km 5 - 10 km >=10 km Ridde et Haddad, 2012
  15. 15. Severe illness < 5 years after abolition : Incidence rate ratios BURKINA FASO POOREST OTHER < 5 km 5,23 [1,30- 2,23 [1,29- 20,99] 3,86] > 5 km 1,28 [0,90- 1,56 1,82] [0,87-2,79] Ridde et Haddad, 2012
  16. 16. Ghana, South Africa, Tanzania Mills et al, 2012
  17. 17. 2000-2012 ???? WORST-OFF ???? HIGHFREE FOR UTILIZATION MDG + LOW TARGET EXCLUSION
  18. 18. OUTLINE1985-2000 2000-2012 POST 2012 • USER FEES • FREE FOR • UHC FOR ALL MDG • EXEMPTION GROUP FOR THE WORST-OFF
  19. 19. INSURANCE AND WORST-OFF• Rwanda : « one of the major challenges faced by the GoR is how to ensure that the poorest benefit equally from Mutuelles (Lu et al. 2012)• « even nominal copayments can lead to massive exclusion of the poor from life-saving health services »(Sachs, Lancet 2012)
  20. 20. «as long as careful attention is given to specific design features, such as government subsidies to ensure that the poor are included inthem, otherwise [UHC] can actually harm progress towards this goal». Joe Kutzin, OMS, 2012
  21. 21. Measures to promote health insurance membership among the poor• Premium subsidised 100%• Premium partially subsidised• Premium varies based on income• Premium paid in kind or by work• Loans to help pay the premium• Dividing the premium into smaller payments• Payment of the premium at harvest time Morestin et Ridde, 2010
  22. 22. 100 % subsidised for the worst-off
  23. 23. CHALLENGES/DESIGN• Who will finance the subsidise ? – Local cost-recovery : contribution and conflict of interest – Values and targeting paradox• Who are the worst-off ? – Materiel and social – Beyond the health sector• How to select the worst-off ? – Identification at the point of use is not enough – Pre-identification is costly and time-consuming • Community-based are accepted (rural) but challenging to scale up • Administrative-based are complex, need criteria and budget for survey for pre-identification
  24. 24. TO READ• Bitran, R., & Giedion, U. (2002). Waivers and exemptions for health services in developing countries. Final Draft (p. 89): World Bank.• Aryeetey, G. C. et al . (2012). Costs, equity, efficiency and feasibility of identifying the poor in Ghana’s National Health Insurance Scheme: empirical analysis of various strategies. Tropical Medicine & International Health, 17(1), 43-51• Ridde, V., et al. (2010). Low coverage but few inclusion errors in Burkina Faso: a community-based targeting approach to exempt the indigent from user fees. BMC Public Health, 10:631• Ridde, V., et al. (2011). Targeting the worst-off for free health care: a process evaluation in Burkina Faso. Evaluation and Program Planning, 34(4), 333-342
  25. 25. OUTLINE1985-2000 2000-2012 POST 2012 • USER FEES • FREE FOR • UHC FOR ALL MDG • EXEMPTION GROUP FOR THE WORST-OFF
  26. 26. UHC : A WINDOW OF OPPORTUNITY FOR THE WORST-OFF ?• POLITICAL WILL• ACTION AND EVIDENCE
  27. 27. 1985-2000 2000-2012 POST 2012 • USER FEES • FREE FOR • UHC FOR ALL MDG • EXEMPTION GROUP FOR THE WORST-OFF LOW HIGH FREE FOR UTILIZATION UTILIZATION ALL AT THE HIGH LOW POINT OF EXCLUSION EXCLUSION USE + SCHEMES FOR THE WORST OFF

×