A Framework to discuss Social Assistance for Health Care

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A Framework to discuss Social Assistance for
Health Care

• Bruno Meessen, ITM
• International Workshop
• Health Care and Poverty, Solutions Ahead?

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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.

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Social Assistance in 6 steps

• (1) Programme Formulation.
• (2) Design of the intervention.
• (3) Identification.
• (4) Entitlement.
• (5) Delivery of assistance.
• (6) Evaluation.

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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.

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Steps determining the effectiveness
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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.

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(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.

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(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.

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(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.

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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.

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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?

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(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.

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(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?

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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)

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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.

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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.

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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.

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(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.

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(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.

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Best agent for identification (Cambodia)
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(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.

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(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).

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(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.

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(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.

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Effectiveness is early determined
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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.

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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.

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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?

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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.

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(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).