2001年-世界发展银行全球_Hedging_the_Health_of_the_Poor___The_Case_for_Community_Financing_in_India_32页_712kb

Summary of "Hedging The Health of The Poor: The Case for Community Financing in India"

Core Content

This document is a Health, Nutrition and Population Discussion Paper by Anil Gumber, published in September 2001. It discusses the role of community financing in improving healthcare access and financial protection for the poor in India, particularly for those in the informal sector and rural areas.

The paper is based on a pilot study conducted in Gujarat and is part of the Commission on Macroeconomics and Health (CMH) work, which was chaired by Professor Jeffery D. Sachs and included contributions from Professor Alan Tait and Professor Kwesi Botchewey.

Main Viewpoints

• Health Insurance Coverage in India is Low: Only 9% of the Indian workforce is covered by health insurance schemes, with the majority being in the organized sector. The poor and vulnerable are largely excluded from such schemes.

• Community-Based Financing as a Solution: Community financing schemes, often managed by NGOs and nonprofit organizations, offer a complementary approach to government-led health financing. These schemes aim to improve access to health services, financial protection, and preventive care for low-income populations.

• Key Challenges in Community Financing:

  • Low Revenue Mobilization: Poor communities generate limited funds for health insurance.
  • Exclusion of the Poorest: The very poorest are often not included in such schemes without subsidies.
  • Small Risk Pools: Limited participation restricts the financial protection potential.
  • Weak Management Capacity: Especially in rural areas, the capacity to manage these schemes is limited.
  • Isolation from Formal Systems: Community schemes are isolated from the broader formal health financing systems.

• Role of Community Financing:

  • It helps reduce out-of-pocket expenditure.
  • It mitigates financial burden on poor households.
  • It improves healthcare utilization and preventive care.

• Health Insurance as a Tool for Financial Protection:

  • It can reduce the risk of impoverishment due to health shocks.
  • However, current schemes cover only a fraction of healthcare costs, with most schemes covering only hospitalization and excluding other costs like transport, loss of earnings, and preventive care.

Key Information

• Community financing schemes are typically run by NGOs and nonprofit organizations.
• Microcredit-linked health insurance has emerged as a strategy to support vulnerable groups and break the cycle of poverty.
• SEWA (Self-Employed Women's Association) is a pioneering organization in India that has integrated health insurance with microcredit and community-based health programs.
• The SEWA health insurance program, launched in March 1992, initially covered 7,000 women in Ahmedabad, and later expanded to rural women in nine districts of Gujarat.
• The program includes preventive, curative, and promotional health services, with health education and occupational health support.
• Financial protection is partial, as most schemes cover only hospitalization and exclude other costs.
• Gender bias persists in healthcare access, with women facing greater challenges due to cultural and socioeconomic factors.
• Government health insurance schemes such as ESIS (Employees' State Insurance Scheme) and CGHS (Central Government Health Scheme) are limited in coverage and focus on the formal sector.
• Public health facilities often fail to provide free services, and out-of-pocket expenditure is high, especially for rural and informal sector workers.

Critical Issues Addressed

• Accessibility and Use of Health Services: Poor households, especially in rural and remote areas, face significant barriers to accessing quality healthcare.
• Out-of-Pocket Expenditure: This is a major financial burden for the poor, often leading to debt and poverty.
• Need for Health Insurance: There is a clear need for voluntary and comprehensive health insurance to protect poor households from the impoverishing effects of illness.
• Role of NGOs: NGOs play a crucial role in delivering affordable and accessible health services, but their coverage remains limited.

Policy Recommendations

• Targeted Subsidies: To ensure coverage for the poorest, governments should provide targeted subsidies.
• Reinsurance Mechanisms: To enhance the risk pool, reinsurance can be used to support small-scale schemes.
• Prevention and Case Management: These should be integrated to reduce healthcare costs.
• Technical Support: Local schemes need technical and managerial support to function effectively.
• Integration with Formal Systems: There should be links with formal health financing and provider networks to ensure comprehensiveness and sustainability.

Conclusion

Community financing and health insurance schemes in India, especially those like SEWA, offer partial financial protection and improved access to healthcare for the poor. However, they are not a complete solution and require government support, subsidies, and integration with formal systems to be effective and equitable. The CMH emphasizes that community financing should complement, not replace, government involvement in health financing and risk management.