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8/2/2019 Depth of Financial Risk Portection in Latin American Health Systems and Role of Health Systems Desing 130711
1/23
July, 2011
Felicia Knaul
Rebecca Wong
Hctor Arreola Ornelas
Oscar Mndez
and the Research in
Health Financing
Latin
American Network(RHF-LANET)
Health financing andsocial protection in
Latin America and theCaribbean
UCR
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Outline
1. Context, Origin,
Motivation2. Comparative Analysis
3. Mexico
4. Conclusions
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Origin of LAnet
The Impact of Health Financing and Household HealthSpending on Financial Equity and Impoverishment: Acomparative analysis of 7 Latin American countries(2007)
Mexican Health Foundation Founding funder: International Development Research Center of
Canada
To study household health spending in a group of Latin Americancountries and establish a connection between out of pocketspending and health system organization and health financing
`07: Mexico, Colombia, Chile, Brazil, Argentina, Peru, Costa Rica
`08+: Bolivia, Dominican Republic, Guatemala, Ecuador andNicaragua thru the LAC Health Observatory with support from the
Carlos Slim Health Institute
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LANET in financial protection: ParticipatingCountries (11) and Institutions (18+)
MexicoFUNSALUD, Instituto National de Salud Pblica and the LA HealthObservatory (OS-LAC). Felicia Knaul, Hector Arreola, Gustavo Nigenda
Argentina - Centro de Estudios de Estado y Sociedad (CEDES). Daniel Maceira
Bolivia - Unidad de Anlisis de Polticas Sociales y Econmicas (UDAPE).Cecilia Vidal and Werner Valdes
BrazilFundacin Instituto de Investigaciones Econmicas (FIPE) and
University of Sao Paulo (USP). Roberto Iunes and Antonio Campino
Chile -Ibero American Health Economics Foundation, and the University ofChile. Ricardo Bitran and Vito Sciaraffia
Colombia PROESA, Ramiro Guererro, Centro de Estudios sobre DesarrolloEconmico (CEDE) - Los Andes University. Carmn Elisa Flrez and Ursula Giedion
Costa Rica - Costa Rica University.Juan Rafael Vargas, Jorine Muiser
Dominican Republic - Fundacion Plenitud. Magdalena Rathe
Ecuador - Fundacin Accion Social. EcuadorRuth Lucio and NildhaVillacres
Guatemala - Ministerio de Planeacion Social. GuatemalaRicardo Valladares
Peru - Grupo de Anlisis para el Desarrollo (GRADE). Martn Valdiviaand
Universidad del Pacifico, Janice Natalie Seinfeld Center on Aging and Health, University of Texas. Rebeca Wong
8/2/2019 Depth of Financial Risk Portection in Latin American Health Systems and Role of Health Systems Desing 130711
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Atlas of Health Systems in LatinAmerica and the Caribbean
Countries: 17Argentina, Bolivia, Brazil, Colombia, Costa Rica,
Cuba, Chile, Ecuador, El Salvador, Guatemala,
Honduras, Mexico, Nicaragua, Peru, Dominican
Republic, Uruguay and Venezuela
Contents in design:1. Context
2. Structure and coverage
3. Financing
4. Resources
5. Stewardship
6. Responsiveness
7. Innovations
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Global Networkfor Health Equity: GHNE
EQUITAP, Lanet, SHIELD: a triple South allianceflagship project of IDRC
Equity + UHC + Health financing
35 countries, 113+ researchers, 60+ institutions Initiated work at the First Global Symposium on
Health Systems Research (Nov 15th) with IDRCcatalytic support
3S agenda and proposal to IDRC focussing on: A second-third generation research agenda
Capacity building: students, researchers and PMs
Policy translation: evidence-for-advocacy, for -
decision making and for-action
8/2/2019 Depth of Financial Risk Portection in Latin American Health Systems and Role of Health Systems Desing 130711
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Financial vulnerability and shocks inhealth as a global problem
EQUITAP: van Doorslaer E, ODonnell O, Rannan-
Eliya RP, Somanathan A, et al., TheLancet, 2006.
The total estimated increase in the poverty
headcount was 78 million people, which is almost3% of the population under study in 11 low to
middle-income countries in Asia.
Each year worldwide - the figure is unknown and
grossly underestimated:
??WHO: 150 million people suffer financial catastrophe annually
while 100 million are pushed below the poverty line as a result of
health spending.
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12-country Analysis: Challenges
Heterogeneity of the data Different surveys: living conditions; health
surveys; surveys of income and expenditure Recall period of health expenditures
Questions concerning health expenditures Measurement of income and total expenditure
Homogenization of key indicators Definition of the ability to pay (generally for the poor) Comparability of poverty lines
Threshold levels for catastrophic
Connecting catastrophic health expenditures (CHE)
and impoverishing health expenditures (IHE).
8/2/2019 Depth of Financial Risk Portection in Latin American Health Systems and Role of Health Systems Desing 130711
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Comparative Analysis (Wong et al):Research Strategies
Indicators of catastrophic health expenditures Poverty line of 1 dollar PPP
Threshold: 30% of capacity to pay
Any health expenditure greater than zero for poor households isconsidered CHE (Wagstaff-van Doorslaer, World Bank)
Multiple indicatos
Sub-groups to measure the relative risks
Residence (urban/rural)
Quintile (Poorest/Richest)
Household size (Large/Small) Household composition (with children under 5, with adults over
60, with no children, and with no elderly adults)
Insurance status for the household (Insured/Uninsured)
Data from approximately 2006 and is nationally representativeother than Chile (urban)
8/2/2019 Depth of Financial Risk Portection in Latin American Health Systems and Role of Health Systems Desing 130711
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Prevalence of catastrophic health expenditure(% of household per quarter)
I1: simple:
(OOP/Total exp food)>=30%
Indicator WD:
OOP/Total exp
food>=30%Or
PL>Total exp `&` OOP>0
048
1216
Chile
Guatema
la
Nicaragua
Dom
.Rep..
Argentina
Ecuador
Peru
Bo
livia
Co
lom
bia
Mexico
Brazil
C.
Rica
05
101520
Nicaragua
Guate
ma
la
Ecuador
Chile
B
olivia
Peru
Dom
.Rep
.
Arge
ntina
M
exico
Brazil
Colo
mbia
C
.Rica
8/2/2019 Depth of Financial Risk Portection in Latin American Health Systems and Role of Health Systems Desing 130711
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0
1
2
3
45
05
1015202530
Results: Relative Risks ofCatastrophic Health Expenditure (I2)
Rural/Urban
Poorest quintile/ Richest quintile
Note: WD indicator
8/2/2019 Depth of Financial Risk Portection in Latin American Health Systems and Role of Health Systems Desing 130711
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Relative Risks
Rural/ Urban NA
Poor/Rich
Children in the
household
Adults > 60 years
in the household
More than 4
members
Uninsured
households
Relative Risks, Catastrophic HERobustness of the Analysis:
: ratio is significantly LESS than 1 : 1 < ratio
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Conclusions: regional analysis
5-6 million households encounter CHE each period of
analysis (year?) in the 12 countries(Wagstaff style indicator, with 30%)
Range: 60 years
Lack of health insurance Poverty
Residence in rural area
Large households with >60 &
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ALL HEALTH SYSTEM FINANCING COMES FROM HOUSEHOLDS,BUT THERE ARE THREE PAYMENT METHODS: GENERAL TAXES,SOCIAL SECURITY, AND OUT-OF-POCKET (OOP). AS A MEANS OF
FINANCING HEALTH, OOP IS INEQUITABLE AND INEFFICIENT.
OOP LEADS TOFRAGMENTEDRISK, HIGHERCOSTS,IMPOVERISHING
SPENDING, ANDINEQUITY.
PAYMENTS AREAT POINT OFSERVICE, THERE
IS NO PRE-PAYMENT ORRISK-POOLING,AND ABILITY TOPAY IS THECIELING ON
PRICE.
20
40
60
80
Bolivia
Mexico
Peru
France
Germany
PanamaUruguay
ItalyColombia
SpainCosta Rica
ArgentinaChile
VenezuelaBrazil Korea
ThailandMalaysia
Paraguay
EthiopiaEl Salvador
Congo
China
Vietnam
India
%O
OP
LAC
OECD
GDP per capita vs. OOPas a % of healthsystem finance
GDP per capita
8/2/2019 Depth of Financial Risk Portection in Latin American Health Systems and Role of Health Systems Desing 130711
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55 53
144
Overall performance
Level of health
ResponsivenessFair financing
HENCE, MEXICOS POOR RANK IN
FAIRNESS OF FINANCING IN THE W.H.O. (2000)
EVALUATION OF HEALTH SYSTEM PERFORMANCE.
Source: WHO, 2000.
61
WHY? : BEFORE THE 2003 REFORM,
ACCESS TO INSURANCE AND HEALTH
CARE WAS SEVERELY SEGMENTED BY
POPULATION GROUP
Th i id f b l t d l ti
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Relative (more than 30% of disposable income): 3.4%
3.8%Absolute (pushed below the poverty
line or deeper into poverty):
The incidence of absolute and relative
impoverishment from health spending is higher
among the uninsured and the poor, 2000.
Absolute and/or relative: 6.3%1.5 million families per trimester
Insured: 2.2%
Uninsured: 9.6%
Poorest quintile: 19.6%910,000 familiesQuintiles 2,3,4 and 5: 3.1%
In the poorest quintile, 2/3 of families are below the povertyline and spend less than 30% of disposable income, and
22% cross the poverty line due to health spending.
8/2/2019 Depth of Financial Risk Portection in Latin American Health Systems and Role of Health Systems Desing 130711
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Before the reform, public insurance coverage in Mexico
was limited to social security which was highly inequitableand regressive: by state, health needs, and by income.
Source: Authors own estimation using data from the 2000 Census;ENIGH, 2000; and Salud: Mxico 2002, Ssa (2003).
Insurance coverage by quintile
20%
60%
100%
I II IV V TOTALIII
Uninsured Insured
Epidemiological backlog(mortality rate)
48 a 68
69 a 95
96 a 195
rate X 10,000
51 a 7035 a 50
18 a 49
% Covered by Social Security
Distribution of federal funds:
2.4 times more for the insured
55% uninsured
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Mexico: Research Questions
End
ogeneit
y
1. What is theprevalence of
catastrophic andimpoverishing health
spending?
2. What are thedeterminants of
catastrophic andimpoverishing healthspending? Population
groups in need of
protection, policy levers
8/2/2019 Depth of Financial Risk Portection in Latin American Health Systems and Role of Health Systems Desing 130711
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Catastrophicspending in health:
Simple indicator(Den. Spending
total-food) at 30%
2.82.4
Impoverishingspending in health:Newly poor + poor
from healthexpenditures>0 (LP
one dollar PPP)
4.2
1.0Catastrophic and/or
impoverishingexpenditure:
Wagstaff et al.
indicator
6.0
3.1
1992 20080
2
4
6
%of
households
Evolution of Catastrophic and ImpoverishingHealth Spending. Mxico, 1992 to 2008
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Determinants: HH catastrophic or impoverishinghealth expenditure (Mexico, 1992-2008)
Catastrophic
expenditure k=30%
Impoverishing
expenditure1992-2008 1992-2008
Household insurance
Social Security -0.749 0.413
Seguro Popular -0.118 0.352
Composition of HouseholdWith >65 years 0.625 0.209
With
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Next Steps: LaNET + GHNE
Analyze financial protection through tracer diseases:cancer (breast), diabetes, HIV/AIDs
Link financial and non-financial dimensions of equityand interventions
Explore other dimensions of financial vulnerability toshocks in health (Access to care, Loss of income)
GHNE:
Cross-country and regional comparative analysis ofimpact of financial reforms and UHC
Cross-country and cross-region capacity building
Advocacy through evidence to contribute to the UN
work on UHC
8/2/2019 Depth of Financial Risk Portection in Latin American Health Systems and Role of Health Systems Desing 130711
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July, 2011
Felicia Knaul
and the Research inHealth Financing
Latin American Network
(RHF-LANET)
Health financing andsocial protection in
Latin America and theCaribbean
UCR
8/2/2019 Depth of Financial Risk Portection in Latin American Health Systems and Role of Health Systems Desing 130711
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LLR
Pseudo R2
N
Argentina
-0.0070.0330.0300.0210.014
0.0790.0390.010
0.021-5352
0.096729031
Brazil
0.0090.0270.0240.0180.0150.043-0.0070.010-0.004
-5434.70.068648470
Chile
-0.081-0.061
0.1500.209
-1823.90.0504
4539
Colombia
0.030-0.006-0.006
0.021
-0.019-1642.20.057916442
Costa Rica
-0.003
-0.003
0.013
-112.60.0976
3779
Guatemala
0.038-0.117-0.082-0.064-0.0290.0260.1250.108
0.026-0.055
-4787.40.049613686
Mexico
0.010-0.013-0.010-0.005-0.0040.0120.0400.0500.011
-0.016-2953.13
0.073129468
Peru
0.028-0.035-0.023-0.016
0.0350.048
-0.006-0.023
-3980.70.039420577
Ecuador
0.051-0.015
0.016
0.0160.0990.0540.032-0.018-0.020
-3556.1540.0613581
Nicaragua
0.083-0.059-0.026
0.1260.086
0.025-0.049
-2347.424263.77
6882
Variables in the model
Household
Size
Insurance With insurance
QuintileI
QuintileII
QuintileIVWith seniors
With children
QuintileIII
With seniors
and children
1-2 people
with 5 +
RuralResidence zone
Level of
poverty
Household
composition
Econometric Analysis:
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