1. Poverty-Targeted Social Assistance and Health Utilization in Armenia Edmundo Murrugarra Nazmul Chadhury Jeff Hammer Rodica Cnobloch REACHING THE POOR CONFERENCE February 18-20, 2004 World Bank Washington, D.C.

2. Contents 1.Introduction 2.Health sector background 3.Fee waivers and targeting reform 4.Effects on utilization 5.Conclusions

3. 1. Introduction How to improve health care access among the poor? Price: Fee-waivers Income transfers Exploit a natural experiment Eligibility expansion change in Armenia Effects on utilization (not OOPs, type of provider)

4. 2. Background Armenia: Fiscal collapse, low public expenditures on health (less than 2% GDP) High poverty incidence (>50%) Decreased utilization Relying on OOPS Marked inequality in health care utilization

5. 2. Background

6. 3. Fee waivers (1) Social Assistance Reform (1998-1999) Improved incidence of social assistance 1998 Before1999 After 26 social benefits Eligibility based on categories Poverty Family Benefit Household allocation Proxy-mean targeting

7. 3. Fee waivers (2) Basic Benefit Package (BBP), part of the reform Provided freely for eligible individuals –A.Demographics (4+ kids, orphans) - Majority –B. Disability Previous findings (1996-1998) –Improved utilization for those disabled (group B) –No effect on other groups –Group A: largest decline in utilization –Worked as an income transfer.

8. 3. Fee waivers (3) 2001 Reform: Eligibility expansion Poverty Family Beneficiaries entitled to BBP freely: poverty targeting in health care Before 20012001 Categorical Eligibility PFB Eligibility

9. 3. Fee waivers (4) Data: National Household surveys 1998/99, 2001 –Similar sample design and instruments –Focus on health care utilization

10. 4. Effects on utilization

12. 5. Conclusions After dramatic adverse effects on utilization, gradual reduction in inequality Reflects the financial protection of the poor The better off suffered declines anyway Also reflects improvements in institutional and budgetary arrangements