«T he link between employment and health insurance has been central to the extension of coverage to entire populations in most industrial coun- tries ...»
The Role of Communities in Combating Social
David M. Dror, Alexander S. Preker, and Melitta Jakab
T he link between employment and health insurance has been central to
the extension of coverage to entire populations in most industrial coun-
tries where urbanization and formal labor-market participation are high.
This link is more difficult-if not impossible-to forge in the case of rural, agri-
cultural, or self-employed workers or the urban poor who have neither formal employers nor steady work. These groups make up most of the population in most low- and middle-income countries. For these excluded populations, access to health services is still inadequate (WHO 2000; ILO 2000a; and Sen 2000).
ORIGINS OF SOCIAL EXCLUSION FROM FORMAL HEALTH CARE FINANCINGThe following section summarizes the origin of social exclusion from formal health care financing.
Where Does Social Exclusion in the Health Sector Originate?
Excluded populations share some similar characteristics: little cash income, lim- ited education, poor health, and difficult access to services because of residential remoteness, minority status, ethnic or tribal affiliation, or gender inequality. Thus, the root causes of exclusion from health services are multifactorial but not always or only related to poverty. This exclusion often translates into a low ability on the part of the excluded to identify their health needs, set priorities, and pay for their care. In addition to their inability to pay and to express demand, several other underlying reasons account for their exclusion from health care.
First, the economic interactions of excluded populations are often nonmon- etary (for example, barter, share-cropping work, or intertemporal lending of goods).
In rural areas, even the poorer segments of the population can and do engage in The authors acknowledge, with thanks, the insightful comments on this work from Wouter van Ginneken, Senior Social Security Specialist, Planning, Standards, and Development Branch, Social Protection Sector, International Labour Office; and of Charles C. Griffin, Sector Manager, World Bank, Latin America and the Caribbean Region, Health Sector.
Electronic copy available at: http://ssrn.com/abstract=1021662 38 Social Reinsurance: A New Approach to Sustainable Community Health Financing economic activity, but it is often based on full or partial exchanges of goods or services rather than on cash. Cash has a premium because of its commutability outside a local barter economy. Hence, requiring cash payments for access to health services (or health insurance) may create an additional difficulty for cer- tain population segments.
Second, health insurance schemes frequently require a fixed monthly pay- ment. This periodicity, modeled on wage earners' circumstances, is too rigid for people with irregular income patterns. Excluded populations may be reluctant or unableto assume an obligation to pay a fixed amount each month when their income is irregular.
Third, living, working, and societal circumstances in the informal economy are less amenable to risk-averse choices, quite apart from the relatively highoften unavoidable-exposure to risks (including, but not limited to, health). An environment that is both less health conscious and less risk averse, and which simultaneously also needs to ration spending, may be inhospitable to insurance in general and health insurance in particular (Soriano, Dror, Alampay, and Bayugo, chapter 19, this volume).
This state of affairs explains why excluded populations' health needs are often not expressed in terms of demand (priority requirements that the needy can satisfy by paying money). It also explains why the link between health services and health insurance is not self-explanatory, since solvent demand is materialized in spot transactions between patient and healer, whereas health insurance occurs through prepayment to a financial intermediary.
Demand for health services (as distinct from demand for health insurance) does not in itself reflect coherent priorities. The informal sector shares with the formal sector the characteristic that needs and demand are not identical in health.
Thus, a more accurate description of the situation underlying the lack of a market would require an examination of the interactions of three parameters: needs, demand, and supply (figure 2.1). Seven different zones can be distinguished, each FIGURE 2.1 Schematic Description: Interaction of Needs, Demand, and Supply
representing a different equilibrium in market interactions. These zones are particularly valid where health services are partial and severely rationed:
* Zone 1-Undetected and unmet needs. This may include public goods with large externalities for which the population will rarely demand services.
* Zone 2-Needs in demand but inadequate market to offer services. This could occur, for example, in low-density and low-income areas where the transaction cost of services may be much higher than potential revenues, shifting some of the operating costs to providers.
* Zone 3-Demand for unavailableservices correspondingto consumerpreferences, not urgent medical needs. Such services might include, for example, cosmetic surgery and medically unnecessary, excessive diagnostic services.
* Zone 4-Adequate supply and priority needs for which the population is willing to pay (solvent demand). This zone represents the area of activity of communityfunded health schemes, and the ideal balance would be to maximize this zone.
* Zone 5-Needs but no real demand. This situation often occurs in the case of communicable diseases, which have large externalities but often little demand for prevention even when public financing and production of services are adequate.
* Zone 6-Supplier-induceddemand unrelated to real medical needs and perhaps medically unnecessary or medically damaging. Aggressive marketing of diagnostic services, C-sections, or prostatectomies could result in this situation.
* Zone 7-Excess supply but neither need nor demand. This often happens in the case of low- quality, poorly equipped and staffed public clinics in rural areas.
This graphic presentation illustrates the impact of certain forms of subsidization or service targeting. For example, when subsidies are directed toward suppliers (as often done by missionary and disaster-relief organizations that operate field hospitals or sell medical material below cost), an increase will occur in Zone 4 but also in Zones 5, 6, and 7. In other words, an increase in supply could enhance the overlap of supply and need, but at the same time an undesirable increase could occur in excess supply and in supply-induced demand (figure 2.2).
Subsidizing the poor instead of the supply would produce an increase in Zones 2, 3, and 6, in addition to Zone 4, the province of community-funded health schemes.
Since there is no theoretical or practical assurance the subsidy would be used only to enlarge Zone 4, such a subsidy could provoke feelings of unfairness and dissatisfaction among donors, providers, and the target population (figure 2.3).
These pitfalls could be avoided by expanding Zone 4 by enhancing overlap of all the zones (figure 2.4). An allocative system operating only (or predominantly) in Zone 4 would do this. In later chapters, we will see how the community can fill this role in the informal sector, both by mobilizing societal structures that encourage the poor to contribute to a prepayment scheme and by serving as the 40 Social Reinsurance: A New Approach ti Sustainable Community Health Financing FIGURE 2.2 Subsidizing Supply
beneficiary of subsidies to improve the cost-benefit ratio of voluntary contributions (through external financing of some components of the benefit package), particularly services that-if unsubsidized-would fall into Zones 1 and 5.
Measuring the gap between needs and demand (Zones 1 and 3) to identify Zones 2 and 4 is complex, and not just because of methodological difficulties. It would also require a comparison of modern medical care with alternative, traditional, or ethnic forms of healing. This raises qualitative issues such as: Should microinsurance schemes cover the cost of traditional medicine? If people trust traditional healers and are willing to pay for their care, can microinsurance units completely ignore that trust? As the target population of microinsurance schemes is normally less educated, the influence of traditional beliefs may be more pervasive there than in other population groups. Willingness to affiliate with microinsurance units may be dampened by traditional beliefs about metaphysical causes of illness rather than cause-effect links to exogenous elements (microbial infection, viruses, unhealthy lifestyle, malnutrition) and endogenous elements (heredity, predisposition, psychosomatic responses). On this topic, there is very little knowledge, yet it is essential in the assessment of financial impact.
Exclusion also occurs when some segments of the population cannot access certain services. The reality in low- and middle-income countries is that a disproportionately low share of public spending reaches the lower-income deciles of the population, even when governments try to target public expenditure (figure 2.5). Global strategies to extend coverage are often too far removed from the grass-roots level where the problem is situated. Without finely calibrated FIGURE 2.5 Pro-Rich Bias of Public Subsidies
Source: Adapted from Gwatkin 2000.
42 Social Reinsurance: A New Approach to Sustainable Community Health Financing targeting, such communities may never gain access to adequate services or financial protection against the cost of illness.
In summary, exclusion from health services can manifest itself as-and originate directly from-unstructured demand for health services, or an inadequate supply, or both.
Mentioning sparse supply as one cause of exclusion does not mean that the market for health services is supply based or that health service providers also create the market and facilitate the transfer. Precisely because insufficient private supply of health services to the poor and rural dwellers is a reaction to insufficient demand, spot transactions have to be shifted to some form of prepayment, from risk segregation to risk pooling, and from fee-for-service to averaging out unit costs.
Historical Roots The realization that communities can play a role in addressing exclusion is neither new nor can it be construed to excuse the government from assuming some responsibility in health care financing. The international community has, since World War II, recognized the need to provide universal access to health care, but the consensus on how to achieve this goal has evolved slowly. As early as 1944, the Declaration of Philadelphia, adopted by the International Labour Conference (ILC), recognized "the solemn obligation of the International Labour Organisation to further among the nations of the world programmes which will achieve... the extension of... comprehensive medical care...." I In 1952, the ILC adopted the Convention concerning Minimum Standards of Social Security (No. 102), containing a chapter on provision of medical care to workers, by states ratifying that part of the convention. 2 This convention was adopted in a world where most development theories were tied to the existence of a formal sector.
A new approach, delinking health coverage from individuals' employee status, was the "WHO Declaration Concerning Health for All by the Year 2000," also known as The Alma-Ata Declaration (1978).3This declaration was the launching pad for a two-pronged approach: primary health care and universal coverage by the year 2000. "Health for All" was fundamentally a call for social justice as part of overall development. The primary health care platform promoted a top-down "global" strategy on health policy at the country level.
A decade later, the focus shifted from governmental health systems to empowerment of communities through "their ownership and control of their own endeavours and destinies." 4 The Bamako Initiative (1987),5 adopted in a meeting of ministers of health from Africa, 6 went a step farther. It recognized the importance of behavioral change by households, and bottom-up action by communities, to complement or replace weak public institutions. The Bamako Initiative also recognized that even poor households can, and do, pay modest charges for health care and that their communities can generate income to cover the recurrent, nonsalary costs of basic health units. The Bamako Initiative has promoted substantial decentralization of decisionmaking from central government to district or The Role of Communities in Combating Social Exclusion 43 lower level, community financing of health services, and community control over health system management and the flow of community funds.
The Jakarta Declaration (1997) also calls for health promotion action by community-based organizations (CBOs), nongovernmental organizations (NGOs), the labor movement, the private sector, governments, development banks, and United Nations (U.N.) organizations, among other actors. 7 In addition, all global UN conferences since 1990 have included a resolution recognizing primary health care as a basic human right.8 As if to confirm developments since it adopted its Convention in 1952, in 2001 the ILC adopted conclusions concerning social security. They recognize that "there is no single right model of social security"; that "of highest priority are policies and initiatives which can bring social security to those who are not covered by existing systems"; that the extension should be achieved notably through insurance; and that the potential of microinsurance should be explored, particularly in access to health care.9 These high-level political milestones have shifted attention from government operations alone to emphasize community action.' 0 International support for decentralized activity, where government expenditure on health services is insufficient, has stopped short of identifying the specific operative conditions that enable community-based organizations to play
that role. These conditions are:
* Local communities need help to launch complex programs such as health care or health insurance. Rarely are such initiatives completely spontaneous. A wide