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Ethiopia’s Strategy for UHC: Proposed Health Insurance...
Transcript of Ethiopia’s Strategy for UHC: Proposed Health Insurance...
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Ethiopia’s Strategy for UHC: Proposed Health Insurance Schemes
Presentation at 2018 AFREhealth Symposium
August 07, 2018Durban Hilton
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Outline of Presentation1. Country Context2. Overview of Health
Care Financing3. Health Care Financing
Strategy4. Progress in CBHI5. Social Health Insurance6. Lessons Learnt
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Country ContextLocated in Eastern horn of Africa:Surface area of 1.1 million Sq
KMs 9 regional states and 2 city
administrations About 700 Weredas (districts) About 15,000 Kebeles (villages)
Projected population of !05M About 82% living in rural areas)Young population (42% < age of
15 yrs) TFR = 4.6
Very low-income Per capita GNI of $794 (2015/2016) Largely dependent on the agriculture sector
l l b 2%
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Country Context …Experienced changes in health status over the last
three decades Life expectancy at birth from 47 to 63/67IMR from 104 to 48MMR from about 900 to 412
Major health problems are:Of communicable natureDue to poor personal hygiene, improper garbage and waste disposal
practices, lack of adequate and safe water supply. Due to inappropriate nutritional practices, lack of health awareness, and
improper cultural taboos. Epidemiologic transition Double burden - NCDs becoming rampant in urban
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Share of health from national budget (2017) 11.7%
Per capita public expenditure on health (2014) $28.7
Share of total health expenditure to GDP (2014) 4.7%
Health Financing Indicators
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Chart1
1996
2000
2004
2008
2011
2014
Per capita health expenditure
Per capita health expenditure
4.5
5.6
7.1
16.1
20.8
28.7
Sheet1
YearPer capita health expenditureyear199620002004200820112014
1994.5Per capita health expenditure4.55.67.116.120.828.7
20005.6
20047.1
200816.1
201120.8
201428.7
Sheet1
Per capita health expenditure
Per capita health expenditure
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Rest of the World (36%)Households (33%)Government (30%)Employers (1%)Changes between NHA5
(2011) and NHA 6 (2014)Households (176%
increment)Rest of the world (143%
increment)
Sources of Financing (NHA 6, 2014)
Chart1
Rest of the world
Households
Government
Employers
Contribution
Contribution
0.36
0.33
0.3
0.01
Sheet1
FinancierRest of the worldHouseholdsGovernmentEmployers
Contribution36%33%30%1%
Sheet1
Contribution
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Background: Common problems…Too little money
…allocated poorly
…utilized inefficiently
…Mainly benefiting the better-off
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Background: Allocation Curative care consumed most of
the national health expenditure (more than 40%) while prevention of communicable diseases and maternal and child health accounted for about 25%
Even though there was a significant shift from curative to preventive care during the past two decades
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Background: Three Key Questions
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Financing/ Mobilization
Allocation
Payment
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Health Care Financing Strategy - BackgroundDeveloped in 1998 as one of the eight components of HSDPApproved for implementation in 2008Revised in 2018In the ParliamentFor 2017 - 2025 A renewed focus on Universal Health Coverage and achieving the SDGs Anticipated effects of expected Economic Growth on health/health sectorCoping with the local and international aid dynamics Meeting the financing demand of Epidemiological transition of diseases Technological Advancement
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Health Care Financing Strategy - GoalIn line with Ethiopia`s ambition to attain universal health coverage
through primary health care, has set out ambitious goals for:Improving health status, Financial risk protection against catastrophic illness, and Public satisfaction
By investing on the health service delivery system to sustainably provide:Quality, Equitable and affordable essential (or basic) health services
For the realization of universal health coverage
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HCF: Overall ObjectivesIncreasing funding for health by improving resource mobilization;Improving efficiency of resources utilization; Ensuring equitable resource allocation and financial protection of its citizens; andPromote sustainability of health financing.
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HCF Strategy – Guiding PrinciplesResponsivenessSustainabilityFinancial risk protection EquityEfficiencyPublic SatisfactionHealth in all policies
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HCF Strategy – Strategic Objectives1. Mobilize adequate resources, through traditional and
innovative approaches, from domestic and external sources for sustaining and increasing funds for health care services;
2. Reduce Out of Pocket (OOP) Spending at the point of use –through affordable fees, health insurance, exemption/waivers;
3. Enhancing equity, efficiency and effectiveness; 4. Strengthening public-private partnership;5. Capacity development for improved health care financing –
Enhancing health system governance.
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HCF Strategy - Components Improving efficiency of available resources Revenue retention and utilization, facility governance Revising user feesImproving the fee waiver and exemption systemContracting and privatization including hospital reform (private wing to
autonomy)Cost sharing/recovery – including RDFs
Public-private partnershipHealth insuranceSocial insurance (for the formal sector) – will be operational Community based health insurance (for the rural and urban informal
sectors) – being piloted
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Social Health Insurance (SHS)Compulsory membership and contributionEmployers,Employees as well as Government
Worker’s salary is base for workers’ and employers’ contributionsጰጰ
8/11/2018 6:49 PM HealthEconomics
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SHS: AdvantagesMembers pay predictable premiums when
healthy to cover unpredictable costs when sickNo adverse selectionNo fear of fund diversion (since ear-marked)EquityCross subsidy between rich/poor, sick/healthyPremiums are income related but Those unable may be subsidized by government
8/11/2018 6:49 PM HealthEconomics
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SHS - EstablishmentSocial health insurance was established in accordance
with:Article 55 (1) of the Constitution of the FDRE Under proclamation number 690/2010.
Curative inpatient and outpatient services delivered through accredited public and private health facilities. Coverage is mandatory for everyone in the formal
sector. Financed through payroll/pension contributions made
by employers and employees.
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SHS - ReimbursementThe government will contribute to start-up costs. The
scheme will use a fee for service payment mechanism.The Departmental Based Grouping (DBG) A form of case-based payment mechanisms- was chosen
as a mechanism to reimburse providers 16 DBG has been identified. Different rates for different DGB and for public/private
facilities
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SHS - EnrollmentA member is eligible to enrollWith his or her spouse, and children under the age of 18 years
A member having more than four children or more than one spouse can register his or her dependents as beneficiaries:With additional monthly premium per other family members
Even though the average number of children per family in rural families of Ethiopia is more than four:Coverage is only for four children and one spouse.
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Community Based Health Insurance (CBHI)
Common Features: Targets households in informal sector(in contrary to social insurance);
Voluntary enrollment;Not-for-profit (solidarity oriented);Some level of involvement of local
leadership/influential groups.8/11/2018 6:49 PM HealthEconomics
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CBHI: P ilotingIn 2010 in 13 woredas in five populous regionsEvaluated after two yearsIndigent’s contributions paid through targeted
subsidies from regional and woreda subsidiesWith minimum threshold membership levels for
initiating schemesInitially 30% of eligible householdsThen raised to 60% (10% for indigents with subsidies)
8/11/2018 6:49 PM HealthEconomics
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CBHI – Scale UpWith target of 80% of woredas (80%
population) by 2020Implemented in 512 woredas (about
70%) by 2017About 4 million households and 18
million beneficiary population enrolledPremium contributions increased from
41.42 million in 2013 to 518.8 million in 2017Premiums amounted to 84% of total CBHI
revenues (rest being subsidies
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Chart1
2012
2013
2014
2015
2016
2016
2017
Number of Woredas
Scale Up by Woreda
13
173
203
318
365
487
512
Sheet1
Year2012201320142015201620162017
Number of Woredas13173203318365487512
Y
Sheet1
Number of Woredas
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CBHI – Reported ImpactIncreased health care utilization0.67 visits per year among beneficiaries as compared to 0.39 for
non-beneficiariesPremium revenues amounting to about 1.5% of total
health care spending (for 2014)Other (potential) impact:Social protection of households from iatrogenic poverty;Financial stability for those with seasonal income;Means/entry point for empowerment in exercising socio-political
power.
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CBHI – ChallengesLimited effectiveness in closing
financial gaps at macro-levelsServices covered by social and
CBHI not very appealing at present (in terms of quality)Only to public hospitals and health centersPossibility of shortages of drugs, investigations,
and other crucial resourcesTransaction costs covered through
partnership8/11/2018 6:49 PM HealthEconomics
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Way ForwardIncremental approach with
awareness enhancement among beneficiariesNeed for addressing the quality
and availability of servicesNeed for forging public-private
partnershipImportance of capacity building in
governance and monitoring & evaluation
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Ethiopia’s Strategy for UHC: �Proposed Health Insurance SchemesOutline of PresentationCountry ContextCountry Context …Slide Number 5Slide Number 6Slide Number 7Slide Number 8Background: Common problemsBackground: Allocation Background: Three Key QuestionsHealth Care Financing Strategy - BackgroundHealth Care Financing Strategy - GoalHCF: Overall ObjectivesHCF Strategy – Guiding PrinciplesHCF Strategy – Strategic ObjectivesHCF Strategy - Components Social Health Insurance (SHS)SHS: AdvantagesSHS - EstablishmentSHS - ReimbursementSHS - EnrollmentCommunity Based Health Insurance (CBHI)CBHI: PilotingCBHI – Scale UpSlide Number 26CBHI – Reported ImpactCBHI – ChallengesWay ForwardSlide Number 30