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Voluntary health insurance: what the zombie tells us

6/17/2015

11 Commentaires

 
Symposium, 11th of June 2015 (picture by Michelle Muus)
Igna Bonfrer's PHD thesis (picture by Michelle Muus)
Igna Bonfrer, PHD defence (picture by Michelle Muus)
Picture
Bruno Meessen 

In this blog post, Bruno Meessen (Institute of Tropical Medicine, Antwerp) reports on a recent conference organized by the Rotterdam Global Health Initiative and the Institute of Health Policy and Management (Erasmus University) in Rotterdam, the Netherlands. A nice opportunity to come back on the controversial topic of voluntary health insurance as a track to universal health coverage (UHC), it turns out.
                                                                                                                            
 For people working on UHC in Africa, there were at least two interesting events to follow (or even better, attend!) last week. In New York the first Global monitoring report on UHC was launched on Friday 12th with all bells and whistles; meanwhile, a more intimate symposium entitled “Strategies towards Universal Health Coverage: African Experiences“ took place on Thursday 11th at Erasmus University, Rotterdam. In this blog post, I will say a couple of things on the second event (without Tim Evans, but still with the likes of Eddy Van Doorslaer and Agnès Soucat, among others). The symposium marked the PhD graduation of Igna Bonfrer, a member of the PBF CoP (check here for a blog by her) - a promising start of a bright career, no doubt.   Plenty of interesting things were said during the symposium. I will focus here on the morning program which was dedicated to health insurance. There were two presentations on voluntary health insurance schemes (VHI) in rural areas, a pilot government-led experience in 13 districts in Ethiopia and the Kwara State Health Insurance program initiated by the Health Insurance Fund in Kwara State, Nigeria, respectively; we also got some information on the current situation of the national health insurance in Ghana (where there’s quite an imbalance between revenue and expenditure, as you may know).

Can one learn something from recent voluntary health insurance schemes?

Over the last decade, several Dutch actors have been strong proponents of voluntary health insurance, also through private insurance companies, so Rotterdam was perhaps the right place to review this strategy. It is unclear to me how long this passion for VHI will last in the Netherlands, as it is at odds with growing evidence that there are real issues with VHI: they often only achieve low coverage, they are regressive (those who subscribe are not the poorest) and mark a fragmentation of the pooling. Joe Kutzin, for example, does not mince words about them : “VHI is like a zombie, shot many times, but always coming back”.   

Nevertheless, zombie movies and other ‘Walking Dead’ series are in vogue again, for reasons not entirely clear to me. Could the same happen one day with VHI?

In Rotterdam, we heard evidence that the schemes in Ethiopia and Nigeria achieved rather good coverage rates (around 48% and 33% respectively, which is indeed more than decent), led to an increase in utilization and to a reduction of average out-of-pocket payment (50% and 70% respectively). So results seemed to be going against the - typically rather negative - reported VHI outcomes elsewhere. Let’s review them, in reverse order.

As for the out-of-pocket decreases, we have to qualify them a bit: they are largely due to the heavy subsidies to the schemes (which allow for instance not to request co-payment). Personally, I don’t really want to put emphasis on the out-of-pocket result: if the overall baseline situation is that households forego care, it could even be optimal for them, once they are entitled to the insurance package, to spend as much as they did before (as long as their higher consumption entails better health services).

The metric of utilization of quality health services seems much more important to me, given the pattern of dramatic underutilization we observe in most rural settings. So it is key that these schemes lead to higher utilization of (quality!) services. An important question is of course whether the increased utilization of the insured has positive or negative spillover effects for the non-insured. The two situations are possible, and I understood that there were different findings on this particular issue in the Kwara experience.

The coverage rate metric often receives a lot of attention. Obviously, if the enrolment rate is very low, you are not achieving a lot (as a participant told me during the break, you may even decide not to have a follow-up survey to measure the impact of your scheme which thus creates a bias for the global evidence base). A high coverage rate is certainly what countries are most proud of. Unfortunately, this indicates that people continue to misunderstand what UHC is: they wrongly equate UHC to the enrolment in a formal insurance scheme.  As a reminder, if your country has a Beveridge system that is highly accessible to your people and tends to provide quality care, your coverage rate is probably not far from universal (ok, this is a rare configuration in low and middle-income countries, but it is possible).

Which coverage rate indicates success?

The question we debated in Rotterdam is whether a coverage rate of 40-50% could be already considered as a good result. By and large, participants agreed; more fundamentally, the conversation then focused on the idea that the policy momentum in your province or in your country is the key trend to watch.

After the bulk of disappointing experiences with VHI, we know that if you reach such high levels of coverage, it probably means that you got all the preconditions right, including that ‘something has happened at community and governmental level’. We learnt that in Kwara, the high enrollment (and the decision to scale up the scheme) owes a lot to the personal leadership developed by the governor of the province (a medical doctor, by chance). In Ethiopia, there is strong commitment from the State apparatus which, among other things, materializes into household coercion by the local authorities (as the latter are the fiduciary channels of a social assistance scheme for the poorest, they are able to deduct the premium for the VHI from the allowance).   

Evidence that “something seems to be happening” is probably the real issue about UHC and one of the key dimensions we should try to capture in our monitoring efforts.

Ghana-France: 1-1

For instance, we can apply this lens of ‘something happening’ to a fourth metric sometimes used to assess a health insurance scheme: the balance between revenue and expenditure. When I listened to the presentation on Ghana which is facing huge problems with financing its national health insurance, I leaned over to the French expert sitting next to me and half-jokingly said, “hey, it looks like France!”. The vice-ambassador of Ghana, also present in the room, acknowledged that the country is facing a big challenge, but confirmed that the country would not stop its national health insurance – the momentum remains strong and the policy is very high on the agenda of different political parties. So, as Agnès Soucat put it nicely at the wrap-up session, the difficulties met by Ghana are probably more a sign of maturity and momentum than an indication of failure: progress towards UHC typically brings new problems, bigger problems (as they tend to be at a larger scale), and more visible problems; in short, UHC progress puts pressure on your governance system. Looking like France is a compliment!

The link between UHC and governance

It is clear we touched upon an important issue in Rotterdam: the bidirectional link between governance and UHC. For instance, the Ethiopian case sparked a discussion on the fact that several VHI/CBHI schemes are in fact mandatory schemes. The need to make subscription compulsory seems to provide a premium to authoritarian states with a strong administrative apparatus.(1) But one could also argue, instead, that this premium is short term, as UHC is fundamentally about societal cohesion. To some extent, this echoes the question of the best developmental model: the Chinese one (one ruling party with strong economic growth) or the Indian one (a strong democracy with lower economic growth)? Important governance and development questions like these will never be far away as the UHC agenda is to be implemented in the coming years. And from this perspective, the high coverage rate achieved in Kwara could indeed be a major achievement, as Nigeria is probably less receptive to coercion (however, this is not saying much yet about the scalability of the strategy).

The more I interact with countries’ decision makers and other domestic stakeholders (mainly through the communities of practice nowadays), the more I believe that the current dominant international approach to UHC is far too technical. UHC can and should certainly be measured against some clear objectives, so we need reports like the one presented in New York last Friday. But they won’t suffice.

UHC will be a long journey and the process will be key. Of course, you must head in the right direction from the start, and you should be aware of path dependency. The key, however, is to kickstart the momentum and maintain it. If your ‘UHC system’ is in a learning mode (we will come back on this point later this year), and if your citizens reckon that UHC is a core component of the nation, like seems to be the case in Ghana now, you are most probably on the right track.

 

Note:
(1)    Interestingly enough, China, Rwanda and the regional authorities involved in the Ethiopian pilot have all three (1) introduced performance indicators to measure the performance of their local administrative authorities and (2) incorporated the ‘insurance enrolment rate’ as one of the indicators for this yardstick evaluation.



11 Commentaires
Pascal
6/17/2015 01:25:13 pm

Thanks Bruno for the report here above. I would like just to comment on some point you stressed out in the report, mainly on the Ghana Experience. As a Rwandan, who has been working for a long moment with the MoH, The National Health Insurance Coverage , mainly when is the Community Based Health Insurance concern, Rwanda and Ghana share almost the same experience with some differences.
1. Rwanda has a Community Health Insurance which covers more than 80% of the population, mainly those living in the rural area and working in informal sector, I don't know the coverage rate for GHANA but I think is also relatively high comparing to our fellow African Sub Saharan countries. In the report, it was clearly pointed out the most confusion of UHC and the membership rate. I do agree on that and my point is that these are two different things and which could be very well distinguished. Though, coverage membership is one point of UHC but not all. some time, coverage, can also be a major problem to the health facility mainly when the CBHI is not paying the health care bill. In this case, the quality of health care is undermined by the coverage. Hence, lack of correlation between insurance coverage and access. Secondly, the entitlement of service; when CBHI members are discriminated due to the fact that the organization charge is not paying the bill; then at this point, a CBHI could pay extra charges to get right to service when the service is covered by his insurance (This has been report many time in the Rwandan case). My reflection will be :" Should we abandon the CBHI because of those bottleneck? I think no!!! Our experience in Rwanda showed us as Agnes stressed it out when doing Wrap up as you report: "difficulties met by Ghana are probably more a sign of maturity and momentum than an indication of failure" in Rwanda we experienced the reality. After reevaluating the financing mechanism of the scheme by the deeply reflect on our collection mechanisms, pooling the district from section(lowest organization of CBHI) to the district level up to the National pooling risk in the ministry of health, we changed strategies and we introduced the new policy in 2010 with some different arrangement in fund collection, cross subsidization through different health insurance and among districts, as sign of national unity and but also enhance our rooming mechanism. But, still the issue of imbalance between the collection and health care bill payment still there. However, this is now the social responsibility of the government when it plays it role. (Is what you meant governance?) if so yes but if your governance consideration was in regard of the structure and leadership of mutual organization? then I will say here the governance of Mutual does not play much role in my view. To conclude, I would really like to just say " better start and then adjust up to the time you get a kind of model which is less challenged". The challenge will always be there and solutions are also around...
In Rwanda, we see that the mutual effort between local population and the central government can be a better arrangement to easier the healthcare access in most poorest settings like are the cases of many developing countries and mostly in Africa. It is then important to be covered by a kind of health insurance but is not a condition toward Universal Health Coverage because Quality and services entitled are also of main importance, if not the pile of the Concept!!!!... Thank you

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Bruno Meessen
6/22/2015 11:50:49 am

Dear Pascal ,

I agree that Rwanda and Ghana are, whatever their respective coverage rates, struggling with a same challenge (getting the financial balance of their health insurance). There may be mechanisms to reduce this imbalance, but it is probably also an indication of the structural need of funding from the North.


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Joe Kutzin link
6/21/2015 12:10:10 pm

Bruno,
Very good, thoughtful blog. Just to set the record straight, however, when I speak of zombies in our training courses (the latest of which took place at exactly the same time as the Rotterdam Conference), I am typically referring to Beveridge and Bismarck. The message is that we are trying to change how people think about financing options: away from a choice between these 2 "models" and instead to think in terms of functions (revenue raising, pooling and purchasing), policies on benefit design and rationing, and governance arrangements for the system.

That being said, we also are critical of an overoptimistic perspective on VHI, where countries or those advising them suggest they may get high rights of enrollment through voluntary contribution and affiliation. We know the phenomenon of adverse selection is one of the main reasons why "health economics" was invented. And with very few exceptions, voluntary participation in health coverage has failed - even when subsidized. As no doubt was pointed out by Eddy Van Doorslaer, this was also one of the main findings of the excellent work led by Erasmus on the Health Equity and Financial Protection in Asia (HEFPA) study (overall findings summarized nicely here: http://www.bmg.eur.nl/fileadmin/ASSETS/bmg/HEFPA/Policy_Briefs/HEFPA_Report_8pp_4.pdf). Their work also does an excellent job of distinguishing between affiliation in an insurance scheme and "real coverage".

But what about those "very few exceptions"? Here I think your emphasis on the link between governance and financing is key, and actually consistent with our most recent work. In most cases, and even where subsidized, contributory-based enrollment in health insurance doesn't work. But two countries are exceptions: China and Rwanda. While no one would doubt that the overall political context of these two countries makes a difference, it is still worth looking at the details of what they do and how they get high levels of affiliation. Without going into huge detail, we reach the same conclusion as you - the role of local government officials as active intermediaries is key. In addition to this is both the process of implementation (Rwanda starting with the fully subsidized poor before moving on to the contributory approach for the rest), and both the level and process of budget subsidies (on average now in China, government matches individual contributions at a ratio of 4:1). Yes, it is true that e.g. unlike Nigeria, the governments of China and Rwanda have the power to "instruct" local government officials. But there are still potential lessons for countries that choose to (or for fiscal reasons, must) go for a contributory approach. One lesson seems to be this: there is a need for active intermediation; just leaving it between the insurer and individual is not going to work.

So no zombie issue here, but we should recognize that a contributory approach is difficult and requires a highly organized set of policies and actions from central to local levels.That comes back to my "model" issue; with VHI as with SHI or "NHS", it will not help to think in terms of the overall model. Instead, need to disaggregate in functional terms, take on the lessons learned from experience, and then to adapt them to the specifics of the national context. Zombie policy making involves just importing models or expecting success from reforms that have repeatedly failed.

Last point on the informal sector issue, and where I concluded in the session on the topic at our course in Barcelona: the focus of us in the financing world has largely been around how to get people into a scheme, or else how to make certain services free (e.g. MCH) and then pay for them through a PBF mechanism. But what I think is missing in our/my approach so far is (a) sufficient attention to demand-side barriers; and (b) thinking about innovations in service delivery rather than in health financing. This comes back to the "coverage vs affiliation" issue. The design of a financing scheme, working out the mix of budget subsidies and contributions, etc., will be irrelevant if people have no time to seek care (even if free at point of use) or do not trust the services. At the end of my session, slightly for a laugh but actually quite seriously, I called for our community to make health financing more boring (we don't need more schemes and more fragmentation) but to make health service delivery much more exciting. For the researchers and practitioners, it is important to think about how to reform service delivery to respond to informality. While we want to keep financing/pooling very broad and unfragmented, there is no doubt a need for a very nuanced, tailored approach to get services to people. If there are a lot of people selling their products in the market from morning til evening, a subsidized health insurance scheme or free health center visits won't help very much if that health center is only open from 9am to 5pm, if see

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Joe Kutzin
6/21/2015 03:14:47 pm

sorry, ran out of space. But nothing more to add...hope that last message is clear on thinking about the demand side and giving at least equal if not more attention to service delivery reforms as compared to financing reforms.

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Bruno Meessen
6/22/2015 11:59:30 am

Dear Joe, thanks for your comment.

On the zombie quote: I heard you making this comparison for VHI in Yogjakarta, just after the presentations of the various HEFPA results related to VHI schemes ;-). - Maybe Eddy, Owen or Ellen want to back me on this?

I agree with your new joke on health care financing and health delivery. If countries want to progress towards UHC, the latter should receive much more attention. In low-income countries, it is particularly key to get the basics right. As probably many other experts, I am a bit upset when I see national authorities getting excited by launching a national health insurance and forgetting that the services should remain their first priority.

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