A Framework to discuss Social Assistance for Health Care

Bruno Meessen, ITM

International Workshop

Health Care and Poverty, Solutions Ahead?

Objectives

The analytical framework must help us to:

• Ex ante:– Assess relevance in a specific context. – Identify possible bottlenecks / obstacles.– Identify who should do what.– Get the highest impact.

• Ex post:– Compare different schemes.

Social Assistance in 6 steps

• (1) Programme Formulation.

• (2) Design of the intervention.

• (3) Identification.

• (4) Entitlement.

• (5) Delivery of assistance.

• (6) Evaluation.

The six steps

• Are not necessarily sequential. You can climb 3 steps at once. Ex: HEF in Cambodia.

• Are a grid to identify sub-issues within a social assistance intervention.

Steps determining the effectiveness

Total population of poor households

Recognised as deserving assistance Ex: geographical exclusion

Meeting the theoretical criteria of poverty Ex: missing criteria

Identified as meeting the criteria by the identifiers Ex: low proximity of the identifier

Duly and early entitled and informed Ex: delay in the distribution of the health cards

Using the health facility Ex: no confidence in the entitlement, low quality of health care

Using the waiver Ex: low empowerment

Significantly assisted Ex: not enough gratuities because of a limited budget

Four “positions” for poor households

• (1) Poor: the actual status.

• (2) Eligible households: match the theoretical criteria of the intervention.

• (3) Entitled households: enrolled in the programme.

• (4) Assisted households: has been assisted at least once.

(1) Programme Formulation

• Content: formulation of the desirable goals that an intervention must achieve.

• Desirable goals with Social Assistance:– Helping the poor in a significant way through

targeting.

(1) Programme Formulation

• Key things to get for a social assistance intervention:– Awareness of the problem.– All stakeholders around the table.– Agreement on the target group.– Management of conflicting goals.– Financial commitment.

• It is the political step.

(1) Programme Formulation

• Key criteria for the decision:– Burden of the problem;– A reference to an explicit definition of social

justice (“enrighting the intervention”);– Political sustainability for the intervention

funding;– Cost-effectiveness of the intervention.

A key step: agreeing on what is poverty

• Poverty is multidimensional and context related.

• Amartya Sen: deprivation of basic capabilities. – Health status;

– Dignity and self-esteem;

– Economic security;

– Engagement into social relationships (empowerment);

– Literacy and education.

Desirable goals of social assistance

• Benefits for the poor:– Preserve health status (through enhancement of access to effective

health care services);

– Prevent even deeper poverty and subsequent loss of well-being;

– Protect dignity and self-esteem (within the community and during the stay at the health facility);

– Reassurance and empowerment;

– Protect children welfare (school attendance…)

• They must be sustainable. Perception by others?

(2) Design of the intervention

• Content: Agreement on the benefit package, the eligibility criteria and the institutional set-up to reach the desirable goals agreed upon in step 1.

(2) Design of the intervention

• Key rule: the intervention must be fair and cost-effective.

• Effectiveness: real benefits for the poor.

• Costs within the budget, but not only.

• The Key question: Individual means testing or characteristic targeting?

Coverage and incidence of the intervention

• Coverage analysis: True Positive / Target Population = True Positive / (True Positive + False Negative)

• Incidence analysis: True Positive / Beneficiary Population = True Positive / (True Positive + False Positive)

Actual statusPoor Non-Poor

Classified as Poor True Positive False positive(error of inclusion)

Classified as Non-Poor False Negative(error of exclusion)

True Negative

Classical arguments against individual means testing

• High and effective coverage may be better reached through strategies with lower incidence (i.e. leakage).

• Characteristic targeting (or universal coverage) interesting if: – high proportion of poor in the general population;– reluctance in the population for individual targeting;– high administrative cost of means testing.

Answers from reported experiences

• With individual targeting, benefits may fall on others also.– Higher revenues for the hospitals better income for the staff better health

services better health status for every user.– Support to the social sector or civil society (if local NGO in charge of the fund).

• Administrative costs can be limited if (1) the identifying body is appropriate; (2) asset index instead of income test; (3) passive case finding instead of active one.

If we go for individual means testing

• What eligibility criteria?– As poverty is multidimensional, criteria must

be holistic We need a set of criteria.– We must identify criteria with the best

correlation with poverty.

• It is the step for the experts, but local involvement may enhance political support and acceptance.

(3) Actual identification

• Content: Action aiming at the identification, within an actual population, of individuals meeting the eligibility criteria agreed upon in step 2.

• Key challenge: specificity and sensibility of the identification within the community.

(3) Actual identification

• The test will be specific and sensitive if (1) identifiers are close to the community; (2) conflicts of interests are avoided; (3) barriers for the households to be identified are limited.– (1) tries to deal with the asymmetry of information between

the identifier and the community.

– (2) tries to deal with the asymmetry of information between the policy-makers & sponsors and their identifier.

– (3) with the costs faced by the eligible households.

Best agent for identification (Cambodia)

High proximity to the community

High conflicts of interests Low conflicts of interests

Low proximity to the community

Local Elites

Local NGO

International NGO

HC Staff

Religious Group

Hospital Staff

Local Authorities

(3) Actual identification

• Possible options:– in several steps: a first inclusive screening (by

an agent with an incentive to include) followed by a more restrictive agent?

– Passive case finding in community (limit: knowledge and opportunity cost of applying!)

– Passive case finding at the point of use.

• This is the local step.

(4) Entitlement

• Content: action of granting the entitlement to the sub-population identified in step 3.

• Key objective: give to the entitled households a strong and early confidence in their new rights. (reassurance and empowerment).

(4) Entitlement

• Key challenge:– Clear message about the entitlement (no uncertainty).

– If enrolment is not at point of use, it must be rapid and low cost.

– Fraud-resistant (leakage).

– Data generation.

A health card scheme is better than identification at point of use.

• A step for an agent accountable to the sponsors.

(5) Assistance to beneficiaries

• Action of assisting the sub-population entitled in step 4.

• The last step, two consequences :– Targeting has been done. If steps 1-4 have been

poorly achieved, it is too late: the target population is missed.

– If steps 1-4 have been very expensive, remaining resources for assistance are limited.

Effectiveness is early determined

Total population of poor households

Recognised as deserving assistance Ex: geographical exclusion

Meeting the theoretical criteria of poverty Ex: missing criteria

Identified as meeting the criteria by the identifiers Ex: low proximity of the identifier

Duly and early entitled and informed Ex: delay in the distribution of the health cards

Using the health facility Ex: no confidence in the entitlement, low quality of health care

Using the waiver Ex: low empowerment

Significantly assisted Ex: not enough gratuities because of a limited budget

An effective assistance

• Key criterion: the assistance must bring a real benefit for the assisted household.

Assistance must tackle the real bottlenecks of interventions with a significant impact.

Definition of the benefit package.

The bottlenecks

• With social excluded groups, we must be “holistic”.– Transport,– The opportunity cost of the patient or his

accompanying person,– User fees,– Other goods necessary during the hospital stay.

The interventions

• They must be effective in terms of health or welfare protection.– Hospital care.– Chronic illnesses.– Counselling for non-curable diseases.– First contact with the health system for those

totally disconnected?

Two options for assistance

• Purchasing (ex: fees, transport…)– Requirements: cash, negotiation, contracting and

monitoring capacity, objective rules, accounting system.

• Provision (ex: social care)– Requirement: presence in the ward, empathic and

reactive social assistants…

• A step for an agent accountable to the sponsors.

(6) Evaluation

• Assessment of the interventions (1) as an accountability mechanisms towards the multiple stakeholders; (2) as a quality process.

• Key criteria:– Outcome for the assisted households,– Distribution of the benefits (Equity),– Cost-Effectiveness,– Sustainability (political, financial and managerial).