2011年-世界发展银行全球_Social_Protection_in_Health___What_Are_the_Options_for_Pakistan__13页_649kb

报告摘要

Pakistan Social Protection Policy Notes: Social Protection in Health

Core Content

This document is part of the World Bank's Pakistan Programmatic Social Protection Policy Notes, initiated in 2009 to support the design and implementation of the Benazir Income Support Program (BISP) health insurance initiatives. The primary goal is to guide the Government of Pakistan (GOP) in developing an effective health insurance system for the poor and vulnerable, with a focus on financial protection and improved health outcomes.

The report outlines the three core functions of a health insurance program: revenue collection, risk pooling, and purchasing. These functions are interlinked and require careful planning to ensure that health services are accessible, of good quality, and efficiently delivered. It also highlights the major planning issues that need to be addressed before the implementation of a health insurance scheme, including population coverage, benefit package design, engagement with healthcare providers, regulatory structure, operational issues, and monitoring and evaluation.

Main Objectives

To provide financial protection to poor households against catastrophic health expenditures.
To improve health outcomes among vulnerable populations.
To guide the GOP in designing and implementing a national health insurance system that is both effective and sustainable.

Key Issues in Planning

Population Coverage: Define the target population, understand the pros and cons of targeting specific groups, and identify eligible beneficiaries.
Benefit Package Design: Determine the scope of services (e.g., inpatient care, preventive care, outpatient services) and their cost implications.
Healthcare Provider Engagement: Select and contract providers, design payment systems, and ensure quality and efficiency in service delivery.
Regulatory and Organizational Structure: Establish a legislative framework and institutional capacity for managing the health insurance system.
Operational Issues: Develop information systems, accountability mechanisms, financial management, and claims administration.
Monitoring and Evaluation: Create a robust framework to assess the effectiveness and impact of the health insurance scheme.

Options for Extending Social Protection in Health

The document presents three main options for extending health insurance coverage in Pakistan:

1. Catastrophic Insurance for Inpatient Services

Scope: Covers surgeries and inpatient services.
Financing: Tax-based or from the federal budget.
Implementation: BISP may contract with public or private hospitals, either directly or through a parastatal institution.
Challenges: Requires coordination between federal and provincial governments, and may face issues with provider capacity and insurance market competitiveness.
Governance: Needs a clear governance structure, including oversight, audits, and monitoring mechanisms.

2. Demand Side Subsidies

Scope: Incentivizes the use of essential health services by reducing out-of-pocket costs.
Implementation: Can include vouchers or conditional cash transfers.
Benefits: Proven to be cost-effective in improving maternal and child health outcomes.
Challenges: Requires mechanisms for verifying conditions, managing cash transfers, and ensuring access to services.

3. Output-Based Financing for Essential Health Services

Scope: Payment is based on the delivery of an essential package of services to a targeted population.
Implementation: Can be directed to public or private institutions.
Benefits: Encourages service delivery and accountability.
Challenges: Requires strong contract and monitoring systems, and may be difficult to implement due to supply-side constraints.

Key Risks and Benefits

Potential Benefits	Potential Risks
Generate stable resources for health	Governments may reallocate budget away from public health inputs
Improve access to priority health services	Benefits may favor better-off groups, neglecting primary and preventive care
Protect households from impoverishment	Risk of corruption in insurance funds
Increase utilization of preventive services	Lack of institutional capacity for implementation
Encourage private sector participation	Exclusion of public providers may limit coverage
Influence quality and efficiency of care	Poor provider payment methods may hinder quality
Build on existing community-based schemes	Premature replacement may lose existing benefits
Address socio-economic and geographic inequities	High-cost, unsustainable benefit packages may raise expectations but fail to deliver

Actions to Be Taken

Define the Benefit Package: Decide whether to include inpatient, preventive, and outpatient services, or a subset thereof.
Establish a Technical Working Group: Include representatives from BISP, the Ministry of Finance, the Ministry of Health, and Provincial Governments to review the design and develop an implementation plan.
Develop Institutional Arrangements: Ensure that the necessary regulatory, financial, and operational structures are in place.
Implement Monitoring and Evaluation: Create a system to track the performance and impact of the health insurance program.
Explore Financing Mechanisms: Consider tax-based funding, direct federal budget support, or contributions from enrolled families and local governments.

Conclusion

The document emphasizes that the success of the health insurance component of BISP depends on careful planning and decision-making around the benefit package, provider engagement, and institutional capacity. It encourages the GOP to engage with relevant stakeholders and leverage the World Bank's expertise to ensure an effective and sustainable health insurance system for the poor and vulnerable.

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