Social Health Insurance in Centralia: 1 A Case Study

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1 Social Health Insurance in Centralia: 1 A Case Study Background: Dra. Isabel Ruiz, Director of Planning at Centralia s Ministry of Health, sighed as she hung up the phone. She had been talking to her friend, Dr. Miguel Rosa of the Autonomous University, about the upcoming Health Sector Reform Technical Advisory Group (TAG) Meeting. Last month s gathering was well-attended and discussions had been very lively. However, while everyone agreed that changes to the health system were necessary, there was no consensus about what the specific changes should be, or what steps could be taken to achieve the country s main goals. One such goal was some type of national health insurance system so that all members of Centralia s population would have health coverage. One major obstacle to achieving this goal was that the current Ministry of Health (MOH) budget was barely sufficient to cover the costs of providing a basic level of services to the entire population. A more comprehensive package of services seemed an impossible target. Dra. Ruiz wanted very much to work together with the other TAG members to find an equitable solution, but she wasn t sure how today s follow-up meeting would go. The group seemed so far from consensus last month that it was hard to imagine how they might progress today. She and her staff had prepared a presentation for the meeting; she looked forward to sharing it with the others, as well as learning about the results of the research that they had done. The Technical Advisory Group was trying to answer the following questions: How are funds generated to finance social insurance? Is it necessary to modify the way funds are generated? What are current policies and regulations that have an impact on social insurance coverage? Do we anticipate any changes in these policies and regulations, and are there any impending ones that we should consider? Currently, which institution(s) assume the function of combining and managing funds to finance social insurance? Will the current arrangement need to change? Which institution(s) currently assume the financial risk of providing a defined package of benefits to a defined covered population? Will the current arrangement need to change? How are providers organized and compensated currently? Will the current arrangement need to change? Who is covered by the social insurance, and how much voice do the users of the system have currently? If the current arrangement changes, who will be covered in future, and how much voice will users have then? Dra. Ruiz hoped that at least some of the answers would become clearer after today s meeting. The meeting: Dr. Angel González of the Colegio Médico called the meeting to order. 1 Centralia is a fictitious country, as are the people mentioned in the case. All data are fictitious as well, but are based upon real situations in other countries. When other countries are referred to by name and data cited, those data are actual numbers. Centralia case study, page 1

2 I would like to thank each of you for your ongoing efforts on behalf of the Technical Advisory Group. Last week I had the opportunity to meet with some representatives from the Senate, and I briefed them on our progress so far, as well as the strength and diversity of opinion on the options that seem to be available to us. They look forward to hearing the results from today s meeting, but they expressed some concern about the length of time spent by the TAG in getting to this point. Evidently they are feeling some political pressure to make a decision quickly, no doubt in part because the elections are happening early next year. If you are all in agreement, I d like to suggest that each of you make your presentation without interruption. When you have finished, we will have a short question-and-answer period to debate, clarify points, and so forth. Then we will proceed to the next presentation and begin the process again. I think this is the most equitable way to cover all the material you have; otherwise we risk getting trapped in a heated debate and not having the chance to see all the pieces of this puzzle that we call health reform. Dra. Ruiz, would you like to begin? Isabel Ruiz thanked Dr. González and greeted the group. In addition to these two and Dr. Rosa, other members of the TAG included Lic. Fernando Cruz, a representative of the Health Workers Union (HWU); Lic. Gabriela Herrera, Deputy Minister of Finance; Lic. Antonio García of the Fundación Compartir, a private-sector group working to foster collaboration between the public and private sectors; Doña Ana Delgado, a community health volunteer from Norte Province; Lic. José Padilla, Director of Special Projects, Centralia Social Security Institute (CSSI); Lic. Mayra Sánchez, an attorney who specialized in employment law; and Sister Mercedes Campos of Hospital San Rafael, a mission hospital. The figure below shows the members of the TAG. Members of Centralia Health Sector Reform Technical Advisory Group (TAG) Dra. Isabel Ruiz Ministry of Health Lic. Gabriela Herrera Ministry of Finance Lic. José Padilla CSSI (Social Security) Dr. Miguel Rosa Autonomous University Dr. Angel González Colegio Médico Lic. Fernando Cruz Health Workers Union Lic. Antonio García Fundación Compartir Doña Ana Delgado Community Health Volunteer Lic. Mayra Sánchez Attorney (health law) Sister Mercedes Campos Hospital San Rafael Centralia case study, page 2

3 Dra. Ruiz s presentation: As requested, my team and I have gathered more detailed information regarding the MOH budget allocation. First, permit me to refresh your memory on some basic statistics. As you can see from the chart, the year 2000 population estimates show a population of about 3.5 million, with over a third located in the capital. Apart from San Lucas, the most-populated province is Oriente and the least populated is Sur. However, Oriente province also encompasses the most territory, so the average population density is quite small. As you can imagine, this presents special challenges to us when trying to reach the population with adequate health services. We were also able to locate figures on poverty, estimated from the most recent Demographic and Health Survey. Overall, we are a poor country, with more than half of the population categorized as relatively or extremely poor. Norte province is suffering the most; over 80% of its population is considered poor. These figures may surprise some of you; while poverty rates have been dropping in general, we all know how hard-hit a few of our provinces were during the hurricane a few years ago. Centralia: estimated 2000 population distribution by province Province Population Area (sq km) Pop/ sq km % extreme poor % relative poor % total poor Docs/ 1000 hab. Doctors San Lucas/capital 1,217, , % 28% 35% ,683 Norte 614,831 7, % 28% 81% Occidental 528,443 2, % 25% 72% Oriental 759,637 11, % 21% 53% Sur 435,653 1, % 28% 47% Total 3,556,115 23, % 26% 54% ,132 In terms of resources, we have come up with a few measures. One is how doctors are distributed. As you can see, they are heavily concentrated in the capital area. Even taking per-capita rates into account, there are more doctors per 1,000 population in the capital than in any of the other provinces. Another way to examine resource distribution is by comparing the population distribution to the budgetary allocation of the MOH. The following chart shows percentage of population (blue bars) and MOH budget (maroon bars) by province. It is clear that the capital has more than its share of the MOH budget if we use population distribution as our criterion. Areas that receive less than their share include Norte, Occidental, and Sur provinces. Centralia case study, page 3

4 Centralia: Population and MOH budget by province Sur Oriental % of MOH budget by province % of population by province Occidental Norte San Lucas/ capital 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% If we look at our budget by level of service, about 20% is going to primary care, 41% to secondary care, and 39% to tertiary care. My concern here is that many of our poorest citizens need basic care for problems such as respiratory infections and diarrheal diseases, but many of our resources are going to support the hospitals and other specialized care. MOH budget by level of service Primary 19.8% Tertiary 38.9% Secondary 41.3% Finally, the latest data we found showed that overall health sector spending is about 6.5% of GDP for Centralia; this is lower than the Latin American average of just over 7% of GDP. The MOH s budget allocation is approximately 1,359 Centralia case study, page 4

5 million pesos, or about 1.9% of projected GDP for this year. This means that MOH spending represents about 29% of the country s total spending on health. We at the MOH realized the importance of health, but we also know that it is not Centralia s only pressing issue. One of our major concerns is how we will provide more health services, given our current budgetary constraints. We were discussing the feasibility of setting a sliding fee scale, depending on people s Dr. González looked alarmed, as did a few other members of the TAG. I thought we had agreed that the public outcry to user fees would be too negative. People believe that health care is their constitutional right. But anyone who can afford it goes to private physicians; they are paying for their health care anyway, responded Lic. García. If those who can afford it are paying out-of-pocket, why couldn t they contribute to a social health insurance system? Dra. Ruiz replied, I believe that most people at the MOH are doing their best, given current conditions, but there is still a perception that the public sector does not provide good-quality services. People who can afford it generally do not come to our hospitals or health centers. It doesn t bother me so much that well-to-do citizens are paying separately for their health care, but it does bother me that the poor who we are supposed to serve are also paying money that they really cannot afford in order to seek health care. Delgado spoke up. In the area of Norte province where I work, most people are poor. Many of them have sold land or farm animals so that they could pay for some health expense. In fact, we took a survey recently, and over one-third of those who had sold land or animals did so to pay health-related expenses. These people are struggling to feed their families, and yet they are selling the very things that help them to earn a living. They are desperate. Dra. Ruiz nodded. I just have one final comment. My presentation covered many of our current challenges. But there has also been discussion in the past on a possible change in the MOH s role, where we would have more oversight and coordination responsibility. Perhaps we would contract with others to actually provide services, and we would monitor these providers to ensure that the patients are being treated well and receiving good services. This is a major departure from our long-standing role, and I m not sure how or if we could implement it. Dr. González cleared his throat. Dra. Ruiz, thank you for your presentation. I can see we have a lot to talk about, but I d like to hold further discussion until we have a chance to hear some of the others. Lic. Herrera, would you like to go next? Thank you, Dr. González. As you know, our group at the Ministry of Finance was charged with looking more closely at how we might finance social health insurance. Many initiatives are financed with funds collected as part of general tax revenues. In some ways, this is an equitable system; those who earn more contribute proportionally more, and those who earn less have a much smaller burden placed upon them. Centralia case study, page 5

6 We reviewed an in-depth comparative study of the tax burden in Central America that is, what percentage of GDP is typically collected in the form of general taxes? As you can see, some countries have a better tax collection rate than others. As of 1998, Guatemala had the lowest rate of tax collection, while Nicaragua had the highest. I ve added in the corresponding figures for Centralia. We are doing better than some countries, but worse than others. In 1998, we collected about 11.3% of GDP in taxes. TAX BURDEN IN CENTRAL AMERICA (for the period ) Centralia Costa Rica El Salvador Guatemala Honduras n.a. Nicaragua Panama Source (for Central American country data): United Nations, CEPAL, Series Macroeconómicas del Istmo Centroamericano. If we plan to finance social health insurance through an increase in taxes, we have to remember that our tax collection rate is relatively low. We cannot, for example, raise the tax rates and automatically expect to see the extra revenue coming into the system. For one thing, many of our people are subsistence farmers in rural areas. We don t have a very large percentage of the population in the formal sector, especially outside of San Lucas and the other major urban areas. For another, we would need more staff to track down potential cases of tax evasion. This takes time and money, and I don t think we d see results immediately. Certainly, we can aim to improve tax collection as a longer-term goal. But it doesn t solve our immediate problem of how to finance social health insurance. If we think of health as a public good, then we might wish to reshape our current system, and use public funds those currently allocated for the MOH and CSSI when trying to decide what we might have available to spend on social health insurance. Lic. García commented, We may be able to pool the resources of these two public institutions to serve more of the population more efficiently, but that raises an issue that we ve already touched upon. If people are going elsewhere for care because of perceived problems with quality, medicines being out of stock, or any number of other reasons, how will we convince them to take advantage of their social insurance coverage? What will stop them from continuing to patronize private-sector health clinics, and will they resent having to pay for a system that they do not want to use? Centralia case study, page 6

7 Perhaps this isn t the best time to bring this up, began Lic. Cruz, but I see another related issue. We keep talking about health in terms of people seeking health care, but I believe health encompasses much more than that. We also need to work to reduce or eliminate some underlying causes of ill health, especially in the poorer regions. Why is it that more people do not have access to a safe water supply? And with all the tourist revenue coming in, why do we let the developers and others who profit from the tourist trade continue to flout the laws, pollute the environment, and not worry about the consequences? Dra. Ruiz reminded us that many Centralians suffer from diarrheal diseases and respiratory infections. This places a double burden on the poor. Many of them are paying something out-of-pocket for health care; at the same time, they cannot work while they are sick. So how can they support themselves and their families? Furthermore, those with a steady job risk losing it if they miss too many work days due to illness. Why can t we stem the problems at their source by cutting down on pollution and improving access to safe water? Wouldn t this be less expensive in the long run? We see people all the time who are trying to make a decent living, but it s heartbreaking to see the conditions Dr. Rosa joined the conversation. Your point is well-taken, Fernando. Perhaps we could frame the discussion in terms of what we can do now or in the short term, and what we need to begin now in order to see results in the medium to long term. These problems have taken a long time to reach the current stage, and we cannot expect them to disappear overnight. It would be like asking someone who just discovered that he is diabetic to change his diet and exercise patterns tomorrow. It doesn t work that way. We need to set attainable goals. What can we ourselves change, and what do we need help to change? What sort of timeline do we anticipate? It s funny; progress in this TAG reminds me of the Medical School at times. Often, we doctors are so accustomed to treating symptoms that we do not take the longer or broader view, but we are trying to change our curriculum at the Medical School to encourage a more holistic approach. I think a similar approach could benefit the TAG. You have all raised critical issues, said Dr. González. Obviously, as Dr. Rosa has noted, we cannot change everything at once. We need to examine the implications of various choices; no matter what recommendations we offer, there will be trade-offs to consider. For now, though, I d like to continue with the presentations. Lic. Padilla, please share with us your findings about Lic. Padilla s presentation: Thank you. We have a more in-depth analysis of the CSSI. As you can see from the accompanying chart, we estimate that current coverage is 524,950 people, or about 14.8% of the population of Centralia. The San Lucas/capital region has the most covered workers, pensioners, and dependents, with just over 30% coverage. At the other extreme, only about 4% of the population in Norte province is covered not surprising, given that the vast majority are in the informal sector. Our budget for this year is 940 million pesos, which works out to roughly 1,800 pesos per covered person. This represents about 1.3% of estimated GDP for the year, and about 20% of total estimated spending on health. Nearly 72% of the budget is concentrated in San Lucas, but again this is not surprising if you compare the number of enrollees in San Lucas to those in the other regions. Centralia case study, page 7

8 As you are probably aware, we cover workers in the formal sector, retirees, and their dependents, with some limitations. For example, we currently cover dependent children only up to the age of five, since they are considered one of the vulnerable groups. For example, we try to ensure that they are fully immunized before they begin school. Because we cover employees and their spouses, we are serving another key group of users of health services: women of reproductive age. Our facilities provide a full range of services, including outpatient care and hospitalization if necessary. We also have the advantage of knowing exactly who our covered population is, since the employers can get these data from their employees. We know how many males and females are covered, and in which age ranges. This helps us to plan better for the services that we offer. Centralia: CSSI budget, FY 2000 Workers, pensionados, beneficiaries covered % of population covered by CSSI CSSI budget (million pesos) % of CSSI budget by province Province Population San Lucas/ capital 1,217, , % % Norte 614,831 24, % % Occidental 528,443 23, % % Oriental 759,637 46, % % Sur 435,653 60, % % Total 3,556, , % % GDP in pesos (est.) 73,142,173,320 As % of GDP CSSI budget in pesos 940,220, % Average CSSI budget/ covered person 1,791 We have been talking with various employer groups and unions to examine the feasibility of extending coverage to a wider group of people. For example, we have many laborers involved in fairly steady construction work due to the tourism boom that Lic. Cruz mentioned. However, day laborers are often paid in cash. The administrative burden to track payments and contributions might be excessive for some of these people. We also have to be very careful for another reason: some of these potential new groups almost certainly have worse health status than our current covered population, given their living conditions. We would expect them to need and use more services, and that will have a financial impact on us. We don t want to be put in the position of offering services, only to bankrupt ourselves and not be able to cover everyone who has been paying into the system for years. We need to ensure that we are setting the payroll deduction and employer contribution rates appropriately. Lic. García took out his laptop computer. If it s all right with you, I d like to start putting some of these numbers into a spreadsheet. I assure you that I am paying attention; I just want to construct a simple model and test some assumptions that might help to inform our discussion. Please let me know if I am bothering you, and I will stop. After a short discussion, the group reassured him that his typing would not disturb them; by now they were accustomed to this habit Centralia case study, page 8

9 of his, and they knew that he was able to think better when he could take an abstract theory and apply it, using actual data whenever possible. Lic. Sánchez spoke up for the first time. I like your idea of extending coverage using an existing system, José. I think you make several excellent points. We know that the current system has to change, but you remind us that there are administrative (and other) costs involved in any type of change. How much can we work within the existing system, and where do we need to begin from the beginning, as it were? Who will be covered under a new social insurance scheme, and how do we collect the funds for such a scheme? You have mentioned only a few obstacles involved, given our situation. I ll hold the rest of my comments until it s my turn to present, but I have some information that relates directly to the issues that you have raised. Dr. González looked around the room. Does anyone else wish to comment on Lic. Padilla s presentation? If not, we could have Lic. Sánchez do her presentation now, especially if it builds on Lic. Padilla s information. Hearing no objection, he motioned Lic. Sánchez to begin. Lic. Sánchez s presentation: Thank you, Dr. González. As you know, my specialty is employment law. With the formal sector, our work is pretty straightforward. In most cases, it s not difficult to tell if an employer is complying with the law or not. For example, we know the CSSI contribution rates; if a worker comes to us and complains that she is getting deductions made from her paycheck, but the CSSI clinic tells her that she is not on its list of covered employees, we can usually find out quickly if there is an administrative error or if the employer is not reporting contributions to the CSSI properly. With the informal sector it s much more difficult. Let s take José s example of the day laborers. If they work more than a certain number of days, they should be put on the regular payroll, even if it s in the temporary worker category. But if they start out getting paid by the day, it s hard for us to track compliance. Exactly when should the transition take place? Often, they don t remember the specific date that they started to work; furthermore, many of them have come from the more rural areas and may not be aware of the laws. Even if they know the law, they are often grateful to have the work and do not complain about something that might be unfair, simply because they don t want to risk their jobs. And since they have typically not had health coverage before, some of them are resistant to the idea of having money deducted from their pay in case they get sick in the future; they aren t accustomed to the concept of risksharing in this way. They worry about paying the doctor when they get sick, not when they are healthy and able to work. One strategy that has been somewhat effective is to explain it as an approach similar to the community cooperatives. Where I grew up, neighbors helped one another in times of crisis, because we all knew that it could be our family with the next problem. We lose that sense of community when we move to the city, but I tell my clients that they can think of payroll deductions for insurance as a very large community cooperative! Another area we are beginning to study is incentives. I know Lic. García is going to update us on his research, but for now I ll say that many of my public- Centralia case study, page 9

10 sector clients working in the health arena do not feel motivated at work. They feel that their pay is low, and that the system is very hierarchical. They are not allowed to take part in decision-making, and those in traditional supporting roles think it s very unfair that they work a full day while some of the doctors come in for only a few hours and spend the remainder of the day seeing private patients. We have to balance this perspective with what we know about civil service laws. In Centralia, as in many countries, civil servants in the health sector are paid a flat salary, regardless of how many patients they see or how many improvements they suggest and implement. I think I might lose some motivation, too, if nobody praised me for a job well done, or indicated to me how I might improve my performance. Lic. García nodded. We cannot underestimate the importance of incentives, good or bad. Their impact can be quite dramatic; we have found statistically significant differences in our research comparing performance, morale, and so on, under different incentive systems. Dr. González replied, But your work has focused primarily on the private sector. We are talking about a public-sector initiative here, and I am not sure that the situations are analogous. You know that there is entrenched resistance to privatizing health care, and with good reason; everything we are discussing here is a public health issue, and I believe that the solution must also be part of the public sector. We cannot depend on any private company to look out for the good of our citizens when its main concern is making a profit. Lic. García sighed. Dr. González, I know we have discussed this point of contention before. And I must repeat what I said before: I don t think that everything about the public sector is bad, or that everything about the private sector is good. There are several fine examples right in this room of public servants who are dedicated, who really care about what they are doing, why they do it, and for whom. Similarly, I have seen plenty of examples in the private sector where people are motivated solely by greed, and all they care about is the bottom line, regardless of who gets destroyed along the way. But I don t believe that we can ignore the mounting body of research that shows how sound business concepts and principles are being applied successfully in the public sector. If you want to reduce absenteeism, get people interested in their jobs, improve productivity, solicit employees feedback on ways to improve quality or other aspects of their work, and bring your costs down just to name a few you need to show employees that they are valued, and structure various systems accordingly. How are employees reviewed? How are they paid? What are the consequences if they exceed expectations, or if they fall below expectations? He stopped suddenly. I m getting ahead of myself. I have to save something for my presentation to the group! The others chuckled. If I may comment, began Sister Mercedes, I would like to remind Dr. private institutions are for-profit. I would hope that our hospital even though it is not a public institution aspires to many of the same ideals that the public hospitals do. And I agree with much of what Lic. García and Lic. Sánchez have said. I know that the public institutions receive funding from the Treasury, or from employer and employee contributions. We do not; we rely entirely on support from the church, both here in Centralia and overseas, as well as the fees we charge those who can afford to pay. And a few years ago we were struggling. As Dra. Ruiz already mentioned, some areas were harder hit by the hurricane than others. Fortunately, our hospital did not sustain much damage. But many of our supporters some of whom had lost Centralia case study, page 10

11 their crops or their homes could no longer afford to give us funding, or they had to reduce the amount they could give. Not only that, the branches of the church overseas support other locations around the globe besides our hospital. We are not the only ones who are suffering. So we had to look long and hard at how we were running the hospital, and how we could improve management to reduce costs and improve quality and efficiency. For instance, we introduced a performance-based incentive system at our outreach clinics, and we have been amazed by the results. They are actually making money now, which means that we can use the additional revenue to do additional outreach, or to waive our fees for our poor clients. If you had told me three years ago that I would be helping to run our hospital like a business, I would have laughed at the notion. But now we do. If we hadn t made some major changes, we might have had to close the hospital, and then there would be nobody in our area to serve the people who need health care. Being efficient has kept us alive, and I would go so far as to say that we are beginning to thrive. Dr. González nodded. I did not mean to imply that the entire private sector was bad. But I still think public health falls within the purview of the public sector, and we need to ensure that our recommendations when we have them are geared toward a system that will serve our people well. He paused for a moment, and then asked Lic. García if he was ready to present. Lic. García s presentation: Thank you, Dr. González. I ve already shared some of my presentation with you in my earlier comments. I d like to build on what I said previously, and I think Sister Mercedes just gave us a very clear example of how incentives can work. Let s consider a typical public sector health employee at a Ministry of Health facility. This person gets paid a flat salary, whether he or she attends 50 patients in a day or one patient; whether he or she treats the patient with courtesy or with rudeness; whether he or she comes to work for two hours or ten. I think we would all agree that the incentive to change, to improve, or to make suggestions about how work flow might be made easier is lacking. At a higher level, where is the incentive to reform the current system? If a facility does well at keeping its costs down by running efficiently, it is penalized. How? The budget for the following year is based on current year spending, with some allowance made for price inflation. So a facility that comes in under budget may have its budget reduced the following year. Conversely, a facility that overspends because it is inefficient may have its budget increased for the next year. I don t think that s appropriate. Here s another example. I know we are not talking about decentralization per se, but since the reform process has begun, it is something that we will need to address as we consider the implications of a nationwide social health insurance system. Currently, people at the central Ministry of Health are accustomed to the centralized system. Where is the incentive to decentralize? They will lose power and control. From their perspective, they get nothing in return. How can we change that? If decentralization is implemented properly, some key decisions will be made at the provincial or municipality level, where the MOH staff are much closer to the people they serve. They will be able to report changes in health status, utilization, and so on much more rapidly. Provided the information flows Centralia case study, page 11

12 back to the central MOH, the central-level staff can take more of a leadership role, overseeing and coordinating, and will be able to do so with much better information at their fingertips. We have done some of our own research, and have studied findings from other settings, and I believe there is real potential for changing incentives, even working within the constraints of the current laws and regulations. For example, if we cannot change the regulations about civil servants getting paid a flat salary, we may be able to institute a bonus program payments in addition to salary if certain indicators or performance targets are met. Whatever we do, though, we need to proceed with caution. I think Dr. and I are in total agreement on that point. We could institute non-salary incentives that would still have a negative effect; for example, if we reward health providers for seeing a certain number of patients, they may have an incentive to perform too many procedures, or to have patients come for follow-up appointments that are not really necessary. We need to find the correct balance of incentives, given our current situation and where we hope to be in a few years, or five years, or 10 years from now. Dr. Rosa was correct when he brought up the necessity of taking the long view. Perhaps we cannot reach our goal in one year or a few years. But we can begin the change process now, knowing that we are working toward something very different, something better for our people. Lic. García paused. The group was silent, mulling over his words. After a few moments, he continued. I d like to share with you now what I was working on just now. I took Dra. Ruiz s figures on population, poverty rates, and so on, and estimated from them the numbers of poor people in each province a relatively simple matter, multiplying the population for each province by the estimated percentage of people living in poverty in that province. Then I took the MOH budget figures for each province and added them to my spreadsheet. Finally, I used a copy of the population distribution by age group both rural and urban to estimate the numbers of people falling into certain categories that have been brought up in our discussions: women of reproductive age (WRA) and children under the age of five. These numbers may not be entirely accurate, but I think they will do for my purposes here. We have talked about several social insurance options, from very basic coverage to more comprehensive coverage. I wanted to get an idea of the costs involved in doing this. For the basic coverage (maternal and child health, reproductive health, well-baby and child care, health education, dentistry, and preventive and curative outpatient services for adults), I know from my research and other country studies that many estimates fall within the range of US $20 to US $30. Obviously, this will differ from country to country, and even facility to facility. Much of it depends on the cost of labor and supplies, as well as on how efficient a facility is. For now, let s say the cost would be around US $25. At the current exchange rate, that s about 300 pesos. So if we multiply this figure by the population estimates, we can begin to get a feel for how much it would cost to provide basic services to the population. Here s a chart showing the percentages of the current MOH budget that would be necessary to provide a basic basket to the extreme poor, total poor, and the entire population. Centralia case study, page 12

13 Percentage of MOH budget to provide basic basket to... Total Sur Oriental Occidental Total poor Extreme poor Entire population Norte San Lucas/capital 0% 20% 40% 60% 80% 100% 120% As you can see, given the estimates I ve outlined above, it would take close to 80% of the current MOH budget to provide just basic services to the entire population. Keep in mind that this does not include hospitalization or any catastrophic services, and then take a look at how the MOH budget is allocated. Only about 20% is currently earmarked for primary care. Here s a similar chart, showing the percentage of the MOH budget needed to provide a basic basket to the relative poor, women of reproductive age and children under the age of five, and a subset of that group poor WRA and poor children under the age of five. Centralia case study, page 13

14 Percentage of MOH budget to provide basic basket to... Total Sur Oriental Occidental Poor (WRA & children <5) WRA and children <5 Relative poor Norte San Lucas/capital 0% 20% 40% 60% 80% 100% Now, what about a comprehensive basket of services? There are many fewer estimates of what comprehensive care would cost, so I used Lic. Padilla s figure of the average amount of the CSSI budget per covered person, or 1,800 pesos. What happens when we use 1,800 pesos instead of 300 pesos as the cost per person in the model? Percentage of MOH budget to provide comprehensive basket to... Total Sur Oriental Occidental Total poor Extreme poor Entire population Norte San Lucas/capital 0% 100% 200% 300% 400% 500% 600% 700% Centralia case study, page 14

15 It would take nearly 500% of the MOH s current budget to provide comprehensive services to the entire population, and about 130% of the budget to provide these services to the extreme poor. The next chart shows the estimated cost for providing the comprehensive basket of services to the relative poor, WRA and children under five, and poor WRA and children under five. It would take practically all of the current MOH budget to provide comprehensive services just to poor women and young children. Percentage of MOH budget to provide comprehensive basket to... Total Sur Oriental Occidental Poor (WRA & children <5) WRA and children <5 Relative poor Norte San Lucas/capital 0% 100% 200% 300% 400% 500% 600% 700% Here s something else to think about. We know the MOH budget is about 1.9% of estimated GDP for this year. What is the cost for these various scenarios in terms of GDP? To provide the basic basket to the entire population, the cost would be about 1.5% of GDP. Province MOH budget Entire (million pesos) population Cost (in millions of pesos) to provide basic basket to: WRA and Extreme Relative Total children poor poor poor <5 Centralia case study, page 15 Poor (WRA & children <5) San Lucas/capital Norte Occidental Oriental Sur Total 1, , Percentage of GDP: 1.9% 1.5% 0.4% 0.4% 0.8% 0.5% 0.3% Look at this next chart. To provide the comprehensive basket to the entire population, the cost would be about 8.8% of GDP. Providing the comprehensive basket to the total poor would cost about 4.7% of GDP. Now contrast these percentages with what we have learned from Lic. Herrera about tax collection patterns in Centralia. We ve hovered around a rate of 11% of GDP for a number of years. If we need additional resources for this social health insurance program,

16 do you honestly think that we could raise tax collection rates by five or eight percentage points in order to pay for this program? Province Cost (in millions of pesos) to provide comprehensive basket to: WRA and Entire Extreme Relative Total children population poor poor poor <5 MOH budget (million pesos) Poor (WRA & children <5) San Lucas/capital , Norte , Occidental Oriental , Sur Total 1, , , , , , , Percentage of GDP: 1.9% 8.8% 2.4% 2.3% 4.7% 3.3% 1.8% Now, one last thing before I finish. I do not mean to imply that any of these estimates is the actual amount of what it would cost. We ve discussed a number of factors today that could all have an impact on cost and quality, and none of that takes into account how people s behavior might change under a new system. I realize that this may be overly simplistic. The population estimates could be incorrect. The price of the basic or comprehensive basket could be higher or lower. But the beauty of the model is that it does give us a rough idea, and it allows us to ask some what-if questions: What if the price of the basic or comprehensive basket is higher or lower than the estimate I have used here? What if reforms are instituted and costs rise in the short term, due to reallocation of resources? What if improvements are made and efficiency gains occur, and the prices drop? What if, due to improved quality, we see a marked increase in the number of patients using the program? Increased utilization might lead to higher costs if we need to buy more supplies, hire additional personnel, use more resources to maintain the facilities, and so on. No matter what step we take, changes will ripple throughout the system. This little model is rough, but it does help us begin to quantify some of the implications of the recommendations that we will make. Lic. Cruz commented, I find this all extremely interesting. Instead of focusing on what we cannot do, let s look at what we can do. It looks as if we might actually be able to offer basic services to those who are most desperate, at least on paper. I worry, though, that many of the people who are classified as extreme poor are also in the least accessible rural areas. How will they receive basic services if they are not within a reasonable distance of a health facility? Wouldn t we also need to estimate costs of mobile clinics, setting up health posts, or some such mechanism to ensure that the services are reaching those people for whom the program has been designed? Yes, absolutely, replied Lic. García. That s one of the reasons that this model is overly simplistic. All it will do is tell us country- and province-level estimated costs, given certain assumptions. But since these assumptions are based on past or current experience, they do not take into account additional resources for new facilities, revised staffing patterns, or any number of other changes that might be made. Dr. González interrupted. I m sorry to cut the discussion short, but we have only half an hour left before the meeting is due to end. Let s revisit our list of questions and see where we stand, and then we can continue the discussion to see what recommendations we might make to the Senate Subcommittee on Health Reform. Centralia case study, page 16

17 First, how are funds generated to finance social health insurance? We know that current services at the MOH and CSSI are funded primarily by contributions from Treasury and employers/employees, respectively. We need to decide what to recommend in terms of potential modifications to the status quo. As far as current policies and regulations that have an impact on social insurance coverage, we have learned that civil service laws may impede the process of introducing new initiatives. We also know that it is not likely that we would be able to raise significant additional funds at least not in the short term through taxes. We have learned that current methods of determining budget allocations may not be the most equitable way to distribute resources, nor create incentives for cost control, efficiency, quality, and the like. What recommendations should we make in this area? For the next question, we have not talked explicitly about which institutions assume the function of combining and managing funds to finance social insurance. Perhaps we can go into that in more detail at the next meeting. Which institutions currently assume the financial risk of providing a defined package of benefits to a defined covered population? Well, the CSSI certainly assumes the risk for its enrollees. The MOH provides services, but not to a defined covered population. In theory, the MOH is geared toward providing services for the poor. However, we know that some of the poor seek care elsewhere, and some non-poor seek care at MOH facilities. We need to decide how this will be handled in future. Will we turn people away from facilities if they do not belong to the social insurance plan? Will we charge separate fees for those not covered? What shall we recommend as the basket of services to be covered? Will the system have more than one tier that is, will we provide more comprehensive services to the poor and just basic services to people with more resources? How are providers organized and compensated currently? We have heard from our two major public-sector institutions today, but there are also private providers, some of whom get paid directly and some of whom remit bills to the patient s insurance company for services rendered. The MOH and CSSI are basically separate systems. Will there be attempts to merge the two, or to form a provider network? What will be our recommendations here? Who is covered by social insurance, and how much voice do they have? This is another major decision. Will we cover the extreme poor, or just poor women and children, or will we cover different groups for different services? I think Lic. García s estimates will be quite helpful here. As for how much voice consumers have, I am not sure how to answer. The current system is quite fragmented, and I don t know how much clout people have when seeking health services. Will they have a choice of provider? To whom would they complain to get a problem resolved? Perhaps we can at least outline some rough guidelines to pass along to the Senate. All right. Let s open it up for discussion now. We ve heard all the presentations and we have reviewed the questions. What are we going to recommend to the Senate for Centralia s social health insurance system? Centralia case study, page 17

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