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Promoting universal financial protection: evidence from seven low- and middle-income countries on factors facilitating or hindering progress
Although universal health coverage (UHC) is a global health policy priority, there remains limited evidence on UHC reforms in low- and middle-income countries (LMICs). This paper provides an overview of key insights from case studies in this thematic series, undertaken in seven LMICs (Costa Rica, Georgia, India, Malawi, Nigeria, Tanzania, and Thailand) at very different stages in the transition to UHC.
These studies highlight the importance of increasing pre-payment funding through tax funding and sometimes mandatory insurance contributions when trying to improve financial protection by reducing out-of-pocket payments. Increased tax funding is particularly important if efforts are being made to extend financial protection to those outside formal-sector employment, raising questions about the value of pursuing contributory insurance schemes for this group. The prioritisation of insurance scheme coverage for civil servants in the first instance in some LMICs also raises questions about the most appropriate use of limited government funds.
The diverse reforms in these countries provide some insights into experiences with policies targeted at the poor compared with universalist reform approaches. Countries that have made the greatest progress to UHC, such as Costa Rica and Thailand, made an explicit commitment to ensuring financial protection and access to needed care for the entire population as soon as possible, while this was not necessarily the case in countries adopting targeted reforms. There also tends to be less fragmentation in funding pools in countries adopting a universalist rather than targeting approach. Apart from limiting cross-subsidies, fragmentation of pools has contributed to differential benefit packages, leading to inequities in access to needed care and financial protection across population groups; once such differentials are entrenched, they are difficult to overcome. Capacity constraints, particularly in purchasing organisations, are a pervasive problem in LMICs. The case studies also highlighted the critical role of high-level political leadership in pursuing UHC policies and citizen support in sustaining these policies.
This series demonstrates the value of promoting greater sharing of experiences on UHC reforms across LMICs. It also identifies key areas of future research on health care financing in LMICs that would support progress towards UHC.
Journal Article
Financial cybersecurity risk management : leadership perspectives and guidance for systems and institutions
Financial cybersecurity is a complex, systemic risk challenge that includes technological and operational elements. The interconnectedness of financial systems and markets creates dynamic, high-risk environments where organizational security is greatly impacted by the level of security effectiveness of partners, counterparties, and other external organizations. The result is a high-risk environment with a growing need for cooperation between enterprises that are otherwise direct competitors. There is a new normal of continuous attack pressures that produce enterprise threats that must be met with an array of countermeasures. This book explores a range of cybersecurity topics impacting financial enterprises, including the threat and vulnerability landscape confronting the financial sector, risk assessment practices and methodologies, and cybersecurity data analytics. Governance perspectives, including executive and board considerations, are analyzed as are the appropriate control measures and executive risk reporting.-- From publisher's description.
Book
Promoting universal financial protection: evidence from the Rashtriya Swasthya Bima Yojana (RSBY) in Gujarat, India
Background
India’s health expenditure is met mostly by households through out-of-pocket (OOP) payments at the time of illness. To protect poor families, the Indian government launched a national health insurance scheme (RSBY). Those below the national poverty line (BPL) are eligible to join the RSBY. The premium is heavily subsidised by the government. The enrolled members receive a card and can avail of free hospitalisation care up to a maximum of US$ 600 per family per year. The hospitals are reimbursed by the insurance companies. The objective of our study was to analyse the extent to which RSBY contributes to universal health coverage by protecting families from making OOP payments.
Methods
A two-stage stratified sampling technique was used to identify eligible BPL families in Patan district of Gujarat, India. Initially, all 517 villages were listed and 78 were selected randomly. From each of these villages, 40 BPL households were randomly selected and a structured questionnaire was administered. Interviews and discussions were also conducted among key stakeholders.
Results
Our sample contained 2,920 households who had enrolled in the RSBY; most were from the poorer sections of society. The average hospital admission rate for the period 2010–2011 was 40/1,000 enrolled. Women, elderly and those belonging to the lowest caste had a higher hospitalisation rate. Forty four per cent of patients who had enrolled in RSBY and had used the RSBY card still faced OOP payments at the time of hospitalisation. The median OOP payment for the above patients was US$ 80 (interquartile range, $16–$200) and was similar in both government and private hospitals. Patients incurred OOP payments mainly because they were asked to purchase medicines and diagnostics, though the same were included in the benefit package.
Conclusions
While the RSBY has managed to include the poor under its umbrella, it has provided only partial financial coverage. Nearly 60% of insured and admitted patients made OOP payments. We plea for better monitoring of the scheme and speculate that it is possible to enhance effective financial coverage of the RSBY if the nodal agency at state level would strengthen its stewardship and oversight functions.
Journal Article
Strategies for financial protection for patients with cancer or special diseases in the health system: A scoping review
Background
Financial protection refers to the health system’s ability to protect the population from the financial risk of ill health. Patients with cancer or special diseases are particularly vulnerable to catastrophic health spending and impoverishment, highlighting the urgent need for targeted financial protection strategies. Diseases such as haemophilia, thalassemia, dialysis, renal replacement therapy and multiple sclerosis (MS) are among the list of special diseases in Iran. This scoping review aims to identify existing strategies for financial protection for patients with cancer or special diseases in health systems.
Methods
This scoping review utilized the Arksey and O’Malley framework and used the population–context–concept model to review publications related to financial protection for patients with cancer or special diseases from 2000 to 2024. The data were collected from three databases (PubMed, Institute for Scientific Information (ISI) Web of Science and Scopus) and two search engines (Google and Google Scholar). The keywords included “financial protection,” “financial risk protection,” “health insurance coverage,” “poor people” and “health services.”
Results
A total of 4625 articles were found, 17 of which were ultimately included in the final analysis. We identified seven main types of strategies for financial protection in health systems, including purchasing, prepaid mechanisms, financial support, benefits packages, infrastructure and facilities, intersectoral collaboration and economic support.
Conclusion
Prepaid mechanisms are the most widely used main component of financial protection for patients with cancer and special diseases. Policy-makers and healthcare stakeholders must prioritize adaptable and context-specific solutions that account for local economic, social and healthcare realities.
Journal Article
Financial justice : the people's campaign to stop lender abuse
This provocative and accessible narrative recounts the inside story of how a broad-based people's campaign was mobilized and subsequently succeeded in pushing Congress to create a consumer financial regulator with clout. What would Congress do—if anything—to tame Wall Street and the nation's lenders following the financial meltdown of 2008? This book tells the true story of how an alliance of consumer, civil rights, labor, fair lending, and other progressive groups emerged to effectively challenge Wall Street and its official protectors and to win substantial new legislative reforms—actions that resulted in the Dodd-Frank Act and its path-breaking Consumer Financial Protection Bureau (CFPB). Based largely on in-depth interviews with the leading activists involved in the campaign, Financial Justice: The People's Campaign to Stop Lender Abuse taps into the world of contemporary citizen movements to present evidence into the conditions that determine the success and failure of social movement campaigns. It goes well beyond general, global variables, such as \"effective management, \" to show how the formal and informal rules adopted by a campaign can serve to preclude fragmentation and incoherence.
eBook
Promoting universal financial protection: health insurance for the poor in Georgia – a case study
Background
The present study focuses on the program “Medical Insurance for the Poor (MIP)” in Georgia. Under this program, the government purchased coverage from private insurance companies for vulnerable households identified through a means testing system, targeting up to 23% of the total population. The benefit package included outpatient and inpatient services with no co-payments, but had only limited outpatient drug benefits. This paper presents the results of the study on the impact of MIP on access to health services and financial protection of the MIP-targeted and general population.
Methods
With a holistic case study design, the study employed a range of quantitative and qualitative methods. The methods included document review and secondary analysis of the data obtained through the nationwide household health expenditure and utilisation surveys 2007–2010 using the difference-in-differences method.
Results
The study findings showed that MIP had a positive impact in terms of reduced expenditure for inpatient services and total household health care costs, and there was a higher probability of receiving free outpatient benefits among the MIP-insured. However, MIP insurance had almost no effect on health services utilisation and the households’ expenditure on outpatient drugs, including for those with MIP insurance, due to limited drug benefits in the package and a low claims ratio. In summary, the extended MIP coverage and increased financial access provided by the program, most likely due to the exclusion of outpatient drug coverage from the benefit package and possibly due to improper utilisation management by private insurance companies, were not able to reverse adverse effects of economic slow-down and escalating health expenditure. MIP has only cushioned the negative impact for the poorest by decreasing the poor/rich gradient in the rates of catastrophic health expenditure.
Conclusions
The recent governmental decision on major expansion of MIP coverage and inclusion of additional drug benefit will most likely significantly enhance the overall MIP impact and its potential as a viable policy instrument for achieving universal coverage. The Georgian experience presented in this paper may be useful for other low- and middle-income countries that are contemplating ways to ensure universal coverage for their populations.
Journal Article
The health sector in ghana
Ghana has committed politically, legislatively, and fiscally to providing universal health insurance coverage for its population with the intent of reducing financial barriers to utilization of health care.. However, under current cost and enrollment projections the system will not be financially sustainable in the long term, so there is more work to do. This book provides an important evidence-based review of the current performance of Ghana's health system and options for reform. As such, it provides an overall picture of the Ghana health sector, how things were and how things have changed, as well as a situational analysis of the performance of the health delivery and health financing systems using the latest available data. Finally, it discusses key reform issues and options in the context of the country's likely fiscal space. An important and valuable contribution of this book is its examination of how Ghana is performing compared to its neighboring countries and compared to other countries with similar incomes and health spending, providing global benchmarks for Ghana's health system performance.
eBook
Effect of health insurance program for the poor on out-of-pocket inpatient care cost in India: evidence from a nationally representative cross-sectional survey
Background
In India, Out-of-pocket expenses accounts for about 62.6% of total health expenditure - one of the highest in the world. Lack of health insurance coverage and inadequate coverage are important reasons for high out-of-pocket health expenditures. There are many Public Health Insurance Programs offered by the Government that cover the cost of hospitalization for the people below poverty line (BPL), but their coverage is still not complete. The objective of this research is to examine the effect of Public Health Insurance Programs for the Poor on hospitalizations and inpatient Out-of-Pocket costs.
Methods
Data from the recent national survey by the National Sample Survey Organization, Social Consumption in Health 2014 are used. Propensity score matching was used to identify comparable non-enrolled individuals for individuals enrolled in health insurance programs. Binary logistic regression model, Tobit model, and a Two-part model were used to study the effects of enrolment under Public Health Insurance Programs for the Poor on the incidence of hospitalizations, length of hospitalization, and Out-of- Pocket payments for inpatient care.
Results
There were 64,270 BPL people in the sample. Individuals enrolled in health insurance for the poor have 1.21 higher odds of incidence of hospitalization compared to matched poor individuals without the health insurance coverage. Enrollment under the poor people health insurance program did not have any effect on length of hospitalization and inpatient Out-of-Pocket health expenditures. Logistic regression model showed that chronic illness, household size, and age of the individual had significant effects on hospitalization incidence. Tobit model results showed that individuals who had chronic illnesses and belonging to other backward social group had significant effects on hospital length of stay. Tobit model showed that days of hospital stay, education and age of patient, using a private hospital for treatment, admission in a paying ward, and having some specific comorbidities had significant positive effect on out-of-pocket costs.
Conclusions
Enrolment in the public health insurance programs for the poor increased the utilization of inpatient health care. Health insurance coverage should be expanded to cover outpatient services to discourage overutilization of inpatient services. To reduce out-of-pocket costs, insurance needs to cover all family members rather than restricting coverage to a specific maximum defined.
Journal Article
ReguLating Buy Now, Pay Later
Recent years have seen the dramatic growth of Buy Now, Pay Later (BNPL), a class of unregulated fintech products that permit consumers to finance purchases by dividing payments into several interest-free installments. BNPL presents novel regulatory challenges because it is primarily marketed to consumers as an interest-free alternative to credit, and its distinctive market structure is characterized by lender-merchant agreements that promote financing at the point of sale. In the American context, the Consumer Financial Protection Bureau (CFPB) has announced plans to analogize treatment of BNPL to existing credit card regulations, which generally emphasize disclosure requirements.
Though undoubtedly an improvement over the unregulated status quo, this regulatory response is hardly a panacea to the industry's risks, as it would not account for the crucial role that merchants play in driving the industry or the fact that consumers often do not even view BNPL as credit in the first place. This Note proposes a novel framework for the regulation of BNPL under the CFPB's rulemaking authority to regulate actions undertaken by both lenders and merchants in promoting BNPL financing to consumers. This approach would provide the CFPB with the flexibility to ensure that regulations continue to stay abreast of developments in the market and the necessary tools to calibrate consumer financial protection to a landscape that is increasingly shaped by fintech.
Journal Article