Conditional Cash Transfer PATH - Jamaica World Bank s s Human Development Forum

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1 Conditional Cash Transfer PATH - Jamaica World Bank s s Human Development Forum Dr. Sheila Campbell-Forrester Chief Medical Officer Ministry of Health, Jamaica 2006 October 30 Jamaica

2 Objectives for PATH (Program for the Advancement Through Health and Education) To implement a single system of benefits, fiscally sound and more efficient; also to provide better and more cost-effective social assistance to the extreme poor with outcomes of: Increased education attainment Improved health outcomes Reduced child labor Reduced poverty Serve as a safety net for poor families Jamaica

3 Expected Outcomes for (PATH) The expected results are to break the cycle of poverty by increasing the access of poor children to education, and to improve health status, productivity and longevity of the poor.

4 Demographic Profile of Jamaica Population Million Children < 1 year - 47,500 Children up to age 18 - ~ 45% of population Population >60 years - 10% Population Growth rate - 0.6% Age dependency ratio %

5 Jamaica Poverty rate - Social indicators Range 10% - 24% Children < 18 - ½ the poor Elderly - 10% Female headed households - 66% Literacy rate 15 years & over - 88% School Drop Out Rate - ~ 20%

6 INCIDENCE OF POVERTY BY REGION, Percentages Years KMA Other Tow ns Rural Areas Jamaica

7 The Poor Have more protracted illnesses Have more days of illness Have more days of impairment Are less likely to seek care and demand services Make greater use of public facilities and medical care

8 Health Expenditure Indicators Total Health Expenditure as a % of GDP Private Health Expenditure as a % of Total Health Expenditure Public Health Expenditure as a % of Total Health Expenditure Out of Pocket Expenditure as a % of Total Health Expenditure Jamaica

9 Target Population The population targeted for CCT are the most vulnerable groups among the poor, and stands at 236, ,000 children 11,000 pregnant and lactating women 33,000 elderly poor 19,000 disabled persons 5,000 indigent persons. Targeting is based on a proxy means test.

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

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

12 Health Centre Service Mix Health Centre Type Type 1 Type 2 Level of Personnel Midwife, Community Health Aide Public Health Nurse, registered Nurse, Public health Inspector, Doctor and Visiting Dentist Services Provided Maternal & Child Health and Home visits Maternal & Child Health, Dental care, Curative, Environmental Preventative and Promotive. Type 3 Doctor, Dentist, Nurse Practitioner, Public Health Nurse, Public Health Inspector, Registered Nurse Maternal & Child Health, Dental Care, Curative, Preventative and Promotive. Type 4 Doctor, Dentist, Nurse Practitioner, Public Health Nurse, Public Health Inspector, Registered Nurse Maternal & Child Health, Dental Care, Curative, Preventative and Promotive Type 5 Doctor, Dentist, Nurse Practitioner, Public Health Nurse, Public Health Inspector, Registered Nurse Maternal & Child Health, Dental Care, Curative, Environmental Health Preventative and Promotive and Specialist services

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

14 Achievements and Challenges Achievements 38% increase in health centre visits of children age years Challenges Non-Compliance has been a major challenge for beneficiaries aged years. Some clients not aware of the compliance requirements. Compliance requirements were not in sync with the immunization schedule

15 Advantages and Disadvantages Advantages PATH has helped to boost immunization among children who are most vulnerable. Disadvantages Due to urban rural population shift in some areas and increasing informal settlements, CHA s are not always assigned to some areas to follow up cases

16 Institutional Achievements and Challenges Achievements Community Health Aides seek out non compliant families and ensure that children are tracked for immunization a flagship priority of the Ministry of Health Majority of beneficiaries use health facilities Challenges Shortage of Human resources in some health facilities mainly due to migration Access to health service delivery vis... Services not offered on a daily basis at some facilities. Beneficiaries whose names were listed on compliance listing but they choose not attend their assigned health centre

17 Human Resources in Primary Health Care Category % Vacancy Public Health Nurses Range 28% - 46% Midwives 40%

18 Managing the increase demand on service delivery The reduced capacity to achieve service delivery targets lead to the revision of the conditionalties for children vis: Age Group Original target Revised target 0-12 months 6 visits for 12 month period 4 visits for 12 month period

19 Managing the increase demand on service delivery Innovative approaches for accommodating PATH beneficiaries implemented such as special clinic days specifically for beneficiaries which contribute to reducing the waiting and turn around times for beneficiaries.

20 Mechanisms of Inter-Agency Linkages Improvement in communication between ministries. Liaison Officer placed in the Ministry of Health who works across Ministries Sensitization parish staff to policies and protocols of the different agencies.

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

22 Financial Challenges More vulnerable are exempted from user fees and are able to access care and health information. This program is a public good which benefits the poor Cost of providing goods and services not reimbursable and this creates an additional burden on limited budget. Exemptions not reflected in budget. Impact of catastrophic events on the health services

23 Operational Challenges Achievements Level of coverage significant Challenges Provision of health cards to beneficiaries. Manual information management system and Need for an electronic health information system that links with the Ministry of Labour and Social Security database Compliance recording and timely reporting.

24 Conclusions PATH is contributing to meeting the Millennium Development Goals 4 and 6 reducing childhood mortality and maternal mortality The program has contributed to the health and wellbeing of the most vulnerable. Some results: Jamaica increase in immunization coverage Increased school attendance Reduced leakage among income transfer program consequent of better targeting Poverty reduction A Benefits Information study is presently being done to improve the proxy means test. The greatest challenge is the impact on financial, human and material resources

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

26 The world of ideas and the world of action are not separate, as some would have us think, but inseparable parts of each other. Ideas, in particular, are truly potent forces that shape the tangible world. - A. Donabedian

27 End of Presentation Thank you.

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