Professional Documents
Culture Documents
gtz
1
A public expenditure review of the health and population sectors, September 1995
2.
An analysis of recurrent costs in GOB health and population facilities, July 1995
3.
Balancing future resources and expenditures in the GOB health and population sectors,
January 1996
4.
Mobilising resources through hospital user fees in Bangladesh: a report on quality and
ability to pay, August 1996
5.
An assessment of the flow of funds in the health and population sector in Bangladesh,
January 1997
Myemensingh Medical College Hospital: financial analysis (FY1994 -5), July 1997
6.
7.
8.
9.
10.
11a
11b.
12.
13.
14.
Cost analysis of caesarean section deliveries in public, private and NGO facilities in
Bangladesh, March 1998
Cost-effectiveness analysis of caesarean section deliveries in public, private and NGO
facilities, April 1998
Resource envelope for the 5th health and population project: preliminary estimates, May
1997
Unofficial fees at health care facilities in Bangladesh: price, equity and institutional
issues, September 1997
Cost benefit analysis of reducing lead emissions from vehicles in Bangladesh, January
1998.
Health and technical cost benefit analysis of options for reducing lead emissions from
motor vehicles in Bangladesh, January 1998
Economic aspects of human resource development in Health and Family Planning: flow
of funds, September 1998
Economic aspects of human resource development in Health and Family Planning: dual
job holding practitioners, September 1998
15.
Economic aspects of human resource development in Health and Family Planning: Costs
of Education and Training, September 1998.
A survey of private medical clinics in Bangladesh, September 1998.
16.
17.
18.
19.
20.
21.
Calculation of total unit cost for diarrhoeal management at district hospital and thana
Geographic resource allocation in Bangladesh, March 2001.
23.
Financing the health and population sector resource projections, May 2001.
24.
25
Funding health care in Bangladesh assessing the impact of new and existing financing,
May 2001
The current costs of essential health services - a study of government facilities, June 2001.
26.
27.
28.
30.
Study on Public and Private Hospital Provision of the ESP and Non-ESP Services
Efficiency, June 2002
Public Expenditure Review (2000/01) of the Health and Population Sector Programme,
October 2001.
Public Health Services Utilisation Study, November 2003
31.
32.
Public Expenditure Review (PER) 2003-04 Health Nutrition and Population Sector
Program, June 2006.
29
Research Notes
Research notes are prepared by staff of the Health Economics Unit or other collaborating units. The
objective is to raise important research questions that might later be researched in more depth. The series
includes research concept notes, structured literature reviews and surveys of current research in a particular
area.
3.
4.
5.
6.
7.
8.
Draft terms of reference and background briefing document: a pilot programme for
resource mobilization through user fees in the MOFHW, Bangladesh, September 1995
Key issues in costing an essential package of health services for Bangladesh, May
1996
User fees, self-selection and the poor in Bangladesh, August 1996
An agenda for health economics research concerning antibiotics usage standards in
developing countries: the case of Bangladesh, July 1996
Experiences with resource mobilisation in Bangladesh: issues and options, June 1997
10.
11.
12.
13.
14.
9.
Costing the ESP: overview of previous studies and current research needs, December
1999.
Economic indicators for monitoring the HPSP, February 2000
The public-private mix in health care in Bangladesh, May 2000
Covering the population: extending health insurance in Bangladesh
Health insurance in South-East Asia and lessons for Bangladesh, July 2000
Strategies for developing health insurance in Bangladesh, October 2000
Towards a poverty strategy for the health sector, February 2001
Proposal to Ministry of Finance for local utilisation of user fee revenue on a pilot
basis within HPSP, November 2000
Contents
Contents .......................................................................................................................... 1
Abstract ........................................................................................................................... 8
Introduction..................................................................................................................... 9
The insurance function.................................................................................................... 9
International priorities in low income countries ........................................................... 10
Assessing the potential of financing systems to provide risk-protection...................... 12
Discussion: a way forward............................................................................................ 19
References..................................................................................................................... 20
Abbreviations
APIR
APR
ESD
ESP
GOBI-FFF
HNPSP
HPSP
HEU
IMCI
MOHFW
NGO
OECD
PER
STI
Abstract
Although mentioned as an objective of HNPSP, funding for catastrophic health care risks
remains extremely low in Bangladesh. Public funding focuses predominantly on primary
care led essential services delivery. At the same time there remains considerable interest
in alternative financing mechanisms such as vouchers and other demand side mechanisms
although these are largely not suited to the financing of uncertain, catastrophic services.
The extent of social and micro/community insurance remains small. Although there are
an increasing number of micro-insurance schemes, the proportion of the population
covered remains low. Social insurance has largely not developed although more rapid
growth and an increased industrial sector means that there may be some potential for
exploring ways of extending more risk protection to the formal sector using such
mechanisms. In considering ways of increasing the level of financial pooling it is
worthwhile also examining how the existing public sector might be enhanced to provide a
greater level of protection from catastrophic costs. The hospital sector in Bangladesh
remains small and largely unrelated to population need. The policy agenda for financing
of the sector should explore how resource allocation, management and investment in this
sector could be enhanced to provide for a greater proportion of catastrophic needs.
Keywords: health insurance, catastrophic risk, financing, risk pooling
Introduction
The aim of this note is to stimulate the debate about what type of risk pooling could and
should be used to reduce the consequences of catastrophic spending due to ill health in
Bangladesh. The note is written in full knowledge that this question has been asked many
times over the last 10 or more years including by the HEU; see (Ensor & Dave Sen, 2000;
HEU, 1997, , 1998, , 2000; Hoque, 2005; K.M. Mortuza Ali, 2005). Debating whether
current health financing mechanisms are adequate is a natural part of the long term policy
cycle. Bangladeshi economic growth rates are quite high, there are projections of
considerable urbanisation of over the next 20 years and the formal sector is expanding. In
addition it may be helpful to view the issue not solely from the perspective of
mechanisms how can the country encourage the extension of insurance systems? - and
more from the side of the risk-reducing function. Taking this perspective forces us to
consider how this risk-reducing function might be enhanced within the existing publicly
financed system as well as by developing new mechanisms for risk reduction.
Insurance of any time is principally required in order to mitigate the negative financial
consequences of uncertainty. Ultimately these financial consequences may affect a
households ability to secure good education, health and lifestyle for its members or
require it to take action to secure additional resources such as selling productive assets
or taking out loans that in themselves can increase the likelihood of future
impoverishment. It follows from this that adequate insurance is associated with several
financing functions. A fundamental principle of risk mitigation is that contributions
collected from members are pooled so that when individuals require benefits that exceed
their individual means they can draw from this pool to finance their own care. Adequate
resource generation obtained at low administrative cost is also important community
insurance systems are often criticised for taking too large a slice of income for
Growth monitoring, ORS, breast feeding, immunization (GOBI) food production, female literacy, family
planning (FFF) package Introduced by UNICEF.
10
http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTHEALTHNUTRITIONANDPOPULATIO
N/EXTPAH/0,,contentMDK:20216946~menuPK:400482~pagePK:148956~piPK:216618~theSitePK:4004
76,00.html
11
Expenditure/year
Post expenditure
Poverty level
4.0
Higher
income
3.0
2.0
Poverty level
1.0
92
10
5
11
8
13
1
14
4
15
7
17
0
18
3
19
6
20
9
22
2
23
5
79
66
53
40
27
0.0
1
14
5.0
-1.0
Cases (poorest to richest)
12
13
Pooling
Targeting
Type of services
Social insurance
(payroll taxes)
Pooling restricted
to those
contributing usually the formal
sector.
Entitlement is based
on contribution but
since these are income
related poorer
employees can benefit
disproportionately.
Community or
Micro insurance
Extent of pooling
is restricted by
the need to
ensure that
members remain
in the scheme.
14
Pooling
Targeting
Type of services
Private insurance
Limted to those
volunatarily buying
insurance.
Medical savings
accounts
Pooling is
restricted to those
choosing to
contribute mostly the
relatively wealthy.
Inter-temporal but
not interpersonal
pooling.
Usually restricted to
those in formal
employment.
Vouchers
A mechanism not a
financing source.
Limited since a
voucher is usually
for a pre-defined
service. May
allow pooling
within treatment
groups (e.g.
delivery care).
Can be targeted at a
group or area as
required.
Conditional cash
transfers
An allocation mechanism
not a financing source.
Not a pooling
system
Can be targeted at a
group or area as
required.
Consolidated tax
funding
Pooled funding
from taxation.
Entitlement based on
citizenship or
residency.
User fees
Although private
payments are ubiquitous,
official collection in
private facilities can be
administratively
expensive.
Not a pooling
system
Exemptions may
reduce impact on the
poor
15
16
17
For example Sri Lanka has 3.08 per 1000 population while Bangladesh has 0.24.
18
19
References
Ahmed, M.U., Islam, S.K., Quashem, M.A., & Ahmed, N. (2006). Health Microinsurance
A Comparative Study of Three
Examples in Bangladesh. Geneva: CGAP Working Group on Microinsurance, Good and
Bad Practices, Case Study No. 13, ILO.
Al-Sabir, A., Sultana, S., Bhadra, S.K., & Rahman, M. (2006). Utilization of Essential
Service Delivery (UESD) Survey 2006 (p. 33). Dhaka: National Institute of
Population Research and Training (NIPORT) &Institute of Epidemiology,
Disease Control and Research (IEDCR).
Barkat, A., & Sabina, N. (2006). Barriers in poor people's access to public health
facilities in Bangladesh. Dhaka: Human Development Research Centre, prepared
for ActionAid Bangladesh.
Bitran, R., & Giedion, U. (2003). Waivers and exemptions for health services in
developing countries (p. 88). Washington DC.: World Bank, Social Protection
Unit.
Carrin, G., Hollmeyer, H., Jones, J., Everard, M., Ron, A., Savioli, L., & Sen-Hai, Y.
(1999). School health insurance as a vehicle for Health-Promoting Schools:
Recent Experience in Vietnam. Geneva: World Health Organisation.
Castro-Leal, F., Dayton, J., Demery, L., & Mehra, K. (1999). Public Social Spending in
Africa: Do the Poor Benefit? The World Bank Research Observer, 14(1), 49-72.
Data International (2003). Bangladesh National Health Accounts 1999-2001. Dhaka:
Health Economics Unit (HEU) Ministry of Health and Family Welfare,
Government of the Peoples Republic of Bangladesh.
Demery, L. (2000). Benefits incidence: a practitioner's guide. Washington: World Bank.
Desmet, M., Chowdhury, A.Q., & Islam, M.K. (1999). The potential for social
mobilisation in Bangladesh: the organisation and functioning of two health
insurance schemes. Social Science & Medicine, 48(7), 925-938.
Ensor, T. (1995). Introducing Health-Insurance in Vietnam. Health Policy and Planning,
10(2), 154-163.
Ensor, T., & Dave Sen, P. (2000). Strategies for developing health insurance in
Bangladesh. Dhaka: Research Note 20, Health Economics Unit.
Ensor, T. (2004). Consumer-led demand side financing in health and education and its
relevance for low and middle income countries. International Journal of Health
and Planning Management, 19, 267-285.
Ensor, T., & Cooper, S. (2004). Overcoming barriers to health service access: influencing
the demand side. Health Policy Planning, 19(2), 69-79.
Ensor, T., Hossain, A., Sen, P.D., Ali, L., Begum, S.A., & Moral, H. (2004). Geographic
Resource Allocation in Bangladesh, Chapter 5. In A. Yazbeck, & D. Peters (Eds.),
Health Policy Research in South Asia: Building Capacity for Reform.
Washington: World Bank.
Gertler, P. (2000). The impact of Progresa on health: Final Report. Washington:
International Food Policy Research Institute.
GOB (1998). Project Implementation Plan, Health and Population Sector Programme
Government of the People's Republic of Bangladesh.
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