Financial Sustainability of a Health Insurance Fund for Kosovo
Content... Current situation Draft law on health insurance Health sector financing methods Proposed approach Assumptions used and possible scenarios Effects of HIF on the labour market Conclusions 11/05/2012 2
Current situation... In a dire state: Deficit of financing Underinvestment Poor health infrastructure Mismanagement of health resources Low compensation of health workers Decrease in moral of healthcare workers Increase in incidence of informal payments Typical of developing countries 11/05/2012 3
Current situation...continued No risk pooling Higher incidence of catastrophic expenditures Intransparent tariffs in the private provision of health services Intransparent copayments Failure by ministers of health to reform the healthcare system Unfavourable health indicators 11/05/2012 4
Draft law on health insurance... Developed by MoH (to be submitted to the assembly in the following months): Basic provisions for creating a HIF Categories of citizens defined very generally (including those with free access) Defines health services to be offered Describes the process of managing the revenues collected in HIF 5% ceiling for administrative costs 5% financial reserve 11/05/2012 5
Draft law on health insurance... continued Shortcomings of the draft law: Categories of citizens defined too loosely no provisions for those living abroad Listing all health services covered excludes all other health services No provisions for patients who are mid-way through treatment for discontinued services Flat rate premiums on annual average earnings no room for contributor solidarity Article 26 describes HIF as a public institution with legal autonomy, but art. 30 allows for direct political interference through governing body 11/05/2012 6
Health sector financing methods... Kosovo s healthcare financing (3% of GDP) comes from: Taxation, Copayments, Direct out-of-pocket payments, Donations Health sector is financed as a mixture of above instruments and insurance contributions. Financing options can take several forms depending on circumstances 11/05/2012 7
Proposed approach... Lack of data in Kosovo in general, so estimates are used when no actual data available Despite lack of data we can still make some comparisons with neighbouring countries, and Kosovo lags behind in a range of factors: Total health spending as percentage of GDP Number of doctors per 100,000 inhabitants Mortality statistics for infants and children under 5 etc 11/05/2012 8
Assumptions used and possible scenarios... Average wages and cost of health care packages grow in line with GDP (4.7bn Euros for 2011, MTEF 2012-2014) Public and private sectors have equal productivity growth Population of Kosovo is 1.8 million (2011 Census), and grows 1.18% per year Total number of employed persons is estimated at 270,000 (figure from KPST + 15% estimate of noncontributors) Public sector employees are 78,695 (Republic of Kosovo Budget 2011), with a growth rate of either 1% per year or remain static 11/05/2012 9
Assumptions used and possible scenarios... continued Average monthly wages is 290 Euros (Ministry of Finance and Economics) Cost of family health package is estimated at 245 Euros per year. Covered persons multiplier (CPM) 20% of all employed persons have another family member employed Therefore, 80% of employed persons families are covered Household size is 5.88 (2011 Census) Therefore, CPM = 4.7 11/05/2012 10
Scenario 1...low economic growth (3%), Family insurance, Public Employment with 1% Annual Increase Year Population GDP Average Wage Cost of health package Employment Covered Persons Total Cost % from private sector % of average wage Non - Contributors Cost for Non- Contributors 2011 1,800,000 4.7000 3,480 245.00 270,000 1,270,080 66,150,000 71% 7.0% 529,920 79,488,000 2012 1,821,240 4.8410 3,584 252.35 278,100 1,308,182 70,178,535 71% 7.0% 513,058 79,267,399 2013 1,842,731 4.9862 3,692 259.92 286,443 1,347,428 74,452,408 72% 7.0% 495,303 78,820,005 2014 1,864,475 5.1358 3,803 267.72 295,036 1,387,851 78,986,559 73% 7.0% 476,624 78,123,011 2015 1,886,476 5.2899 3,917 275.75 303,887 1,429,486 83,796,841 73% 7.0% 456,989 77,151,844 2016 1,908,736 5.4486 4,034 284.02 313,004 1,472,371 88,900,068 74% 7.0% 436,365 75,880,039 2017 1,931,259 5.6120 4,155 292.54 322,394 1,516,542 94,314,083 74% 7.0% 414,717 74,279,106 2018 1,954,048 5.7804 4,280 301.32 332,066 1,562,038 100,057,810 75% 7.0% 392,010 72,318,394 2019 1,977,106 5.9538 4,408 310.36 342,028 1,608,899 106,151,331 75% 7.0% 368,206 69,964,934 2020 2,000,436 6.1324 4,541 319.67 352,289 1,657,166 112,615,947 76% 7.0% 343,269 67,183,287 2021 2,024,041 6.3164 4,677 329.26 362,857 1,706,881 119,474,258 76% 7.0% 317,159 63,935,368 11/05/2012 11
Scenario 2...optimistic economic growth (5%), Family insurance, Public Employment with 1% Annual Increase Year Population GDP Average Wage Cost of health package Employment Covered Persons Total Cost % from private sector % of average wage Non - Contributors Cost for Non- Contributors 2011 1,800,000 4.7000 3,480 245.00 270,000 1,270,080 66,150,000 71% 7.0% 529,920 79,488,000 2012 1,821,240 4.9350 3,654 257.25 278,100 1,308,182 71,541,225 71% 7.0% 513,058 80,806,572 2013 1,842,731 5.1818 3,837 270.11 286,443 1,347,428 77,371,835 72% 7.0% 495,303 81,910,694 2014 1,864,475 5.4408 4,029 283.62 295,036 1,387,851 83,677,639 73% 7.0% 476,624 82,762,804 2015 1,886,476 5.7129 4,230 297.80 303,887 1,429,486 90,497,367 73% 7.0% 456,989 83,321,026 2016 1,908,736 5.9985 4,441 312.69 313,004 1,472,371 97,872,902 74% 7.0% 436,365 83,538,739 2017 1,931,259 6.2984 4,664 328.32 322,394 1,516,542 105,849,544 74% 7.0% 414,717 83,364,110 2018 1,954,048 6.6134 4,897 344.74 332,066 1,562,038 114,476,282 75% 7.0% 392,010 82,739,576 2019 1,977,106 6.9440 5,142 361.98 342,028 1,608,899 123,806,099 75% 7.0% 368,206 81,601,290 2020 2,000,436 7.2912 5,399 380.08 352,289 1,657,166 133,896,296 76% 7.0% 343,269 79,878,503 2021 2,024,041 7.6558 5,669 399.08 362,857 1,706,881 144,808,844 76% 7.0% 317,159 77,492,899 11/05/2012 12
Effects of HIF on the labour market... Economic theory: increase in labour costs could affect employment demand and supply Demand: equivalent to lowering of marginal productivity Supply: any form of taxation favours leisure versus work lowering work effort and increasing incentives for overtime. Empirical findings show that in developing countries, income effect could dominate substitution effect. 11/05/2012 13
Effects of HIF on the labour market... for Kosovo Health spending very small and very high unemployment (38 45%) Lower reservation wage jobseekers willing to work even at lower wages Therefore, a proposed contribution rate of 7% (3.5% + 3.5%) not expected to have an impact on the labour market Private sector: employers may compensate through price increases or lowering of net pay, but effects are expected to be minimal 11/05/2012 14
Conclusions... Kosovo health sector is in deep crisis, and MoH and international donors started work on system reform, including the setting up of HIF This paper contributes in the same direction We analyse a number of scenarios and two presented here have been flagged as more relevant, with both leading to an increase in health spending, so support HIF A contribution rate of 3.5% + 3.5% (employer and employee) should be set This rate together with the current tax burden (including pensions contributions) does not exceed 16% of gross wage and not expected to effect the labour market 7% contribution rate is for a restrictive healthcare package if the government wants to improve the situation more and reduce the incidence of catastrophic risks, a higher pooling of risks would be necessary 11/05/2012 15