1. The PHRplus Project is funded by U.S. Agency for International Development and implemented by: Abt Associates Inc. and partners, Development Associates, Inc.; Emory University Rollins School of Public Health; Philoxenia International Travel, Inc. Program for Appropriate Technology in Health; SAG Corp.; Social Sectors Development Strategies, Inc.; Training Resources Group; Tulane University School of Public Health and Tropical Medicine; University Research Co., LLC. Micro-Health Insurance and User Fees: Quanitifying Horizontal Equity and Impoverishment in Utilization and Financing of Health Care Evidence from Rwanda Reaching the Poor Conference Washington DC - Feb 19, 2004 Pia Schneider London School of Hygiene and Tropical Medicine (LSHTM) Abt Assoc. Inc.

2. Outline of Presentation  Financial access to care under:  Micro-health insurance (MHI) and User fees  Methods  Indirect standardization to compare horizontal inequity in service use  Minimum standard approach to compare poverty impact of health spending  Findings and Policy Implications

3. Uninsured Individuals Pay User fees Source: Rwanda Household and Living Condition Survey 1999/2001

4. Alternative Micro-Health Insurance

5. MHI Enrollment (6/2000 and 6/2003) 8% Source: MHI routine data and PHR reports 19% Enrollment is independent of SEG

6. Methods  Compare Impact of health spending under MHI and UF on service use and hh income  Indirect standardization  to examine horizontal inequity (HI) in utilization of care: equal use for equal need?  Minimum standard approach  to quantify the extent to which user fees compared to MHI protect household income against dropping below the poverty line (PL)  Household survey data collected in Sept/00

7. Horizontal Inequity (HI) In Utilization  Equal use for equal need?  Method: Indirect standardization  Concentration Indices (CI) for:  actual use  need-adjusted (expected) use  CI = 0: equal use across soc-econ groups  HI = CI (need-adjusted use) – CI (actual use)  HI = 0: equal use for equal need  Need-adjusted (expected) use:  Pr(need-visit) = F[SAH, age, gen, preg, bed]

8. Sick MHI Members Have Significantly Higher Actual Visit Rates Across SEG Source: PHR household survey 2000 User fees: Pro-rich visit distribution

9. Equal Need Across Income Source: PHR household survey Equal need distribution

10. Horizontal Equity in Utilization of Care for MHI Members User fees: Pro-rich visit distribution even when visit adjusted by need Source: PHR household survey 2000 Equal visit distribution expected User fees: Pro-rich distribution of actual visit

11. Minimum Standard Approach Poverty Impact of Health Payments Income before health Income after health payment Income PL Cumul % of pop ranked by income ABC H1 Ho

12. Poverty Measures  Headcount ratio:  % of households below poverty line before and after out-of-pocket health payments  from Ho to H1  Poverty gap:  average shortfall of income < PL  sum of all shortfalls, divided by population, and expressed in % of PL  A+B+C

13. Similar Poverty Impact Under MHI and User Fees but at Different Use Levels Source: PHR household survey 2000

14. Conclusions  Equal MHI enrollment across SEG :  But the poor may have endured economic hardship to pay annual premium  Health service use:  Uninsured report significantly fewer visits  User fees: Utilization is independent of need but depends of SEG  MHI: Horizontal equity in utilization  OOP health spending:  Similar low impact on headcount and poverty gap if uninsured don’t seek care

15. Recommendations for Policy Makers Expansion: MHI to other districts Current MHI benefit package to full district coverage Demand-side subsidies of premium:  MHI enrollment should be associated with targeted measures to ensure that the poorest enroll in MHI