Conditional Cash Transfer Conditional Cash Transfer PATH PATH -- JamaicaJamaica

World BankWorld Bank’’s Human s Human Development ForumDevelopment Forum

Dr. Sheila CampbellDr. Sheila Campbell--ForresterForresterChief Medical Officer Chief Medical Officer

Ministry of Health, JamaicaMinistry of Health, Jamaica2006 October 302006 October 30

Jamaica

Objectives for PATH Objectives for PATH ((Program for the Advancement Through Health and Education)Program for the Advancement Through Health and Education)

To implement a single system of benefits, To implement a single system of benefits, fiscally sound and more efficient; also to provide fiscally sound and more efficient; also to provide better and more costbetter and more cost--effective social assistance effective social assistance to the extreme poor with outcomes of: to the extreme poor with outcomes of:

Increased education attainmentIncreased education attainmentImproved health outcomesImproved health outcomesReduced child laborReduced child laborReduced povertyReduced povertyServe as a safety net for poor familiesServe as a safety net for poor families

Jamaica

Expected Outcomes for (PATH)Expected Outcomes for (PATH)

The expected results are to break the The expected results are to break the cycle of poverty by increasing the access cycle of poverty by increasing the access of poor children to education, and to of poor children to education, and to improve health status, productivity and improve health status, productivity and longevity of the poor.longevity of the poor.

Demographic Profile of JamaicaDemographic Profile of JamaicaPopulationPopulation -- 2.66 Million2.66 MillionChildren < 1 yearChildren < 1 year -- 47,50047,500Children up to age 18Children up to age 18 -- ~ 45% of ~ 45% of populationpopulationPopulation >60 yearsPopulation >60 years -- 10%10%Population Growth ratePopulation Growth rate -- 0.6% 0.6% Age dependency ratio Age dependency ratio -- 61.5%61.5%

Social indicatorsSocial indicators

Poverty rate Poverty rate -- Range Range –– 10% 10% -- 24%24%Children < 18 Children < 18 -- ½½ the poorthe poorElderlyElderly -- 10%10%Female headed households Female headed households -- 66%66%

Literacy rate Literacy rate 15 years & over 15 years & over -- 88%88%School Drop Out Rate School Drop Out Rate -- ~ 20%~ 20%

Jamaica

INCIDENCE OF POVERTY BY REGION, 1995 - 2005

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Years

Perc

enta

ges

KMA Other Towns Rural Areas Jamaica

The Poor The Poor …………

Have more protracted illnessesHave more protracted illnessesHave more days of illnessHave more days of illnessHave more days of impairmentHave more days of impairmentAre less likely to seek care and demand Are less likely to seek care and demand servicesservicesMake greater use of public facilities and Make greater use of public facilities and medical caremedical care

3434Out of Pocket Expenditure as a % of Out of Pocket Expenditure as a % of Total Health ExpenditureTotal Health Expenditure

5151Public Health Expenditure as a % of Public Health Expenditure as a % of Total Health ExpenditureTotal Health Expenditure

4949Private Health Expenditure as a % Private Health Expenditure as a % of Total Health Expenditureof Total Health Expenditure

6.46.4Total Health Expenditure as a % of Total Health Expenditure as a % of GDPGDP

JamaicaJamaicaIndicatorsIndicators

Health Expenditure Health Expenditure --1997 1997 --20012001

Target PopulationTarget PopulationThe population targeted for CCT are the The population targeted for CCT are the most vulnerable groups among the poor, and most vulnerable groups among the poor, and stands at 236,000stands at 236,000

168,000 children168,000 children11,000 pregnant and lactating women11,000 pregnant and lactating women33,000 elderly poor33,000 elderly poor19,000 disabled persons19,000 disabled persons5,000 indigent persons.5,000 indigent persons.

Targeting is based on a proxy means test.Targeting is based on a proxy means test.

Role of the Ministry of HealthRole of the Ministry of Health

To ensure provision of basic health To ensure provision of basic health services to beneficiaries according to the services to beneficiaries according to the agreed calendar of visitsagreed calendar of visitsTo complete compliance reports which To complete compliance reports which validate whether or not the beneficiaries validate whether or not the beneficiaries have been attending the health centres as have been attending the health centres as required by PATH.required by PATH.

Service delivery and MixService delivery and MixService delivery provided through a network of Service delivery provided through a network of Primary health care (PHC) centers of varying Primary health care (PHC) centers of varying levels and hospitals based on the levels and hospitals based on the catchmentcatchmentpopulation and staffing levels.population and staffing levels.Referrals are between health centers, hospitals Referrals are between health centers, hospitals and the community.and the community.PHC service mix varies by level of health facility PHC service mix varies by level of health facility and is defined in the Ministry of Healthand is defined in the Ministry of Health’’s Policy s Policy guidelines.guidelines.Scheduling of the service mix and clinic activities Scheduling of the service mix and clinic activities e.g. time of service, at some health centres to e.g. time of service, at some health centres to facilitate access.facilitate access.

Maternal & Child Health, Dental Care, Maternal & Child Health, Dental Care, Curative, Environmental Health Curative, Environmental Health Preventative and Preventative and PromotivePromotive and and Specialist servicesSpecialist services

Doctor, Dentist, Nurse Practitioner, Doctor, Dentist, Nurse Practitioner, Public Health Nurse, Public Health Public Health Nurse, Public Health Inspector, Registered NurseInspector, Registered Nurse

Type 5Type 5

Maternal & Child Health, Dental Care, Maternal & Child Health, Dental Care, Curative, Preventative and Curative, Preventative and PromotivePromotive

Doctor, Dentist, Nurse Practitioner, Doctor, Dentist, Nurse Practitioner, Public Health Nurse, Public Health Public Health Nurse, Public Health Inspector, Registered NurseInspector, Registered Nurse

Type 4Type 4

Maternal & Child Health, Dental Care, Maternal & Child Health, Dental Care, Curative, Preventative and Curative, Preventative and PromotivePromotive..

Doctor, Dentist, Nurse Practitioner, Doctor, Dentist, Nurse Practitioner, Public Health Nurse, Public Health Public Health Nurse, Public Health Inspector, Registered NurseInspector, Registered Nurse

Type 3Type 3

Maternal & Child Health, Dental care, Maternal & Child Health, Dental care, Curative, Environmental Curative, Environmental Preventative and Preventative and PromotivePromotive..

Public Health Nurse, registered Public Health Nurse, registered Nurse, Public health Inspector, Nurse, Public health Inspector, Doctor and Visiting DentistDoctor and Visiting Dentist

Type 2Type 2

Maternal & Child Health and Home Maternal & Child Health and Home visitsvisits

Midwife, Community Health AideMidwife, Community Health AideType 1Type 1

Services ProvidedServices ProvidedLevel of PersonnelLevel of PersonnelHealth Centre Health Centre TypeType

Health Centre Service MixHealth Centre Service Mix

Contact with beneficiariesContact with beneficiaries

Community visits are an integral part of Community visits are an integral part of the functions of designated health the functions of designated health providers.providers.Community Health Aides visit the patients Community Health Aides visit the patients who attend the health centres and drop who attend the health centres and drop outs e.g. children who do not attend for outs e.g. children who do not attend for immunization.immunization.

Achievements and Challenges Achievements and Challenges

AchievementsAchievements38% increase in health 38% increase in health centre visits of children centre visits of children age 0age 0--6 years6 years

ChallengesChallengesNonNon--Compliance has Compliance has been a major challenge been a major challenge for beneficiaries aged 0for beneficiaries aged 0--6 years. 6 years. Some clients not aware of Some clients not aware of the compliance the compliance requirements.requirements.Compliance requirements Compliance requirements were not in sync with the were not in sync with the immunization scheduleimmunization schedule

Advantages and DisadvantagesAdvantages and Disadvantages

AdvantagesAdvantagesPATH has helped to PATH has helped to

boost immunization boost immunization among children who among children who are most vulnerable.are most vulnerable.

DisadvantagesDisadvantagesDue to urban rural Due to urban rural population shift in population shift in some areas and some areas and increasing informal increasing informal settlements, settlements, CHACHA’’ssare not always are not always assigned to some assigned to some areas to follow up areas to follow up casescases

Institutional Achievements and ChallengesInstitutional Achievements and Challenges

AchievementsAchievementsCommunity Health Aides Community Health Aides seek out non compliant seek out non compliant families and ensure that families and ensure that children are tracked for children are tracked for immunization immunization –– a flagship a flagship priority of the Ministry of priority of the Ministry of Health Health Majority of beneficiaries use Majority of beneficiaries use health facilitieshealth facilities

ChallengesChallengesShortage of Human Shortage of Human resources in some health resources in some health facilities mainly due to facilities mainly due to migration migration Access to health service Access to health service delivery delivery visvis. . Services not . . Services not offered on a daily basis at offered on a daily basis at some facilities.some facilities.Beneficiaries whose names Beneficiaries whose names were listed on compliance were listed on compliance listing but they choose not listing but they choose not attend their assigned health attend their assigned health centrecentre

Human Resources in Primary Human Resources in Primary Health CareHealth Care

40%40%MidwivesMidwives

Range 28% Range 28% -- 46%46%Public Health NursesPublic Health Nurses

% Vacancy% VacancyCategoryCategory

Managing the increase demand on Managing the increase demand on service deliveryservice delivery

The reduced capacity to achieve service The reduced capacity to achieve service delivery targets lead to the revision of the delivery targets lead to the revision of the conditionalties for children conditionalties for children visvis::

4 visits for 12 4 visits for 12 month periodmonth period

6 visits for 12 6 visits for 12 month periodmonth period

0 0 -- 12 months12 months

Revised targetRevised targetOriginal targetOriginal targetAge GroupAge Group

Managing the increase demand on Managing the increase demand on service deliveryservice delivery

Innovative approaches for accommodating Innovative approaches for accommodating PATH beneficiaries implemented such as PATH beneficiaries implemented such as special clinic days specifically for special clinic days specifically for beneficiaries which contribute to reducing beneficiaries which contribute to reducing the waiting and turn around times for the waiting and turn around times for beneficiaries. beneficiaries.

Mechanisms of InterMechanisms of Inter--Agency Agency LinkagesLinkages

Improvement in communication between Improvement in communication between ministries.ministries.Liaison Officer placed in the Ministry of Liaison Officer placed in the Ministry of Health who works across MinistriesHealth who works across MinistriesSensitization parish staff to policies and Sensitization parish staff to policies and protocols of the different agencies.protocols of the different agencies.

Perception of service providers of Perception of service providers of PATHPATH

While the programme is highly rated among While the programme is highly rated among service providers. service providers. A significant number of persons who fall within A significant number of persons who fall within PATHPATH’’s target population were not selected as s target population were not selected as beneficiaries.beneficiaries.The monitoring of compliance is very The monitoring of compliance is very challenging especially in the larger types health challenging especially in the larger types health centers.centers.Manual system of recording is tedious and Manual system of recording is tedious and inadequate. inadequate.

Financial ChallengesFinancial ChallengesMore vulnerable are More vulnerable are exempted from user fees exempted from user fees and are able to access and are able to access care and health care and health information.information.This program is a public This program is a public good which benefits the good which benefits the poor poor

Cost of providing goods Cost of providing goods and services not and services not reimbursable and this reimbursable and this creates an additional creates an additional burden on limited budget. burden on limited budget. Exemptions not reflected Exemptions not reflected in budget.in budget.Impact of catastrophic Impact of catastrophic events on the health events on the health servicesservices

Operational ChallengesOperational ChallengesAchievementsAchievements

Level of coverage Level of coverage significantsignificant

ChallengesChallengesProvision of health cards Provision of health cards to beneficiaries.to beneficiaries.Manual information Manual information management system and management system and Need for an electronic Need for an electronic health information system health information system that links with the that links with the Ministry of Labour and Ministry of Labour and Social Security databaseSocial Security databaseCompliance recording and Compliance recording and timely reporting.timely reporting.

ConclusionsConclusionsPATH is contributing to meeting the Millennium PATH is contributing to meeting the Millennium Development Goals 4 and 6 Development Goals 4 and 6 –– reducing childhood reducing childhood mortality and maternal mortality mortality and maternal mortality The program has contributed to the health and wellbeing The program has contributed to the health and wellbeing of the most vulnerable.of the most vulnerable.Some results:Some results:

increase in immunization coverageincrease in immunization coverageIncreased school attendanceIncreased school attendanceReduced leakage among income transfer program consequent of Reduced leakage among income transfer program consequent of better targetingbetter targetingPoverty reductionPoverty reduction

A Benefits Information study is presently being done to A Benefits Information study is presently being done to improve the proxy means test.improve the proxy means test.The greatest challenge is the impact on financial, human The greatest challenge is the impact on financial, human and material resourcesand material resources

Jamaica

ConclusionConclusionCountries must be mindful of sustainability issues such Countries must be mindful of sustainability issues such as the percentage of budget for health services delivery as the percentage of budget for health services delivery should not be less than 6% to be able to support CCT in should not be less than 6% to be able to support CCT in the short to medium term.the short to medium term.Economic analysis should be applied to the different Economic analysis should be applied to the different models of alternative financing mechanismsmodels of alternative financing mechanismsCountries will need to consider the best option for their Countries will need to consider the best option for their particular situation particular situation -- CCT versus national insurance CCT versus national insurance scheme providing universal social protection.scheme providing universal social protection.CCT Program must be evidence based with the capacity CCT Program must be evidence based with the capacity for monitoring, evaluation and research.for monitoring, evaluation and research.

““The world of ideas and the world The world of ideas and the world of action are not separate, as some of action are not separate, as some

would have us think, but would have us think, but inseparable parts of each other. inseparable parts of each other.

Ideas, in particular, are truly potent Ideas, in particular, are truly potent forces that shape the tangible forces that shape the tangible

world.world.”” -- A. A. DonabedianDonabedian

End of PresentationEnd of Presentation

Thank you. Thank you.