NGOs in community health insurance schemes: examples from Guatemala and the Philippines

Abstract

In poor rural communities, access to basic health care is often severely limited by inadequate supply as well as financial barriers to seeking care. National policies may introduce social health insurance, but these are likely to begin with the salaried public and private sector workers while the informal sector population may be the last to be covered. Community initiatives to generate health care financing require a complex development process. This paper covers attempts to develop such schemes in rural populations in Guatemala and the Philippines through non-government organizations and notes the major factors which have contributed to unequal progress in the two schemes. The scheme of the Association por Salud de Barillas (ASSABA) in Guatemala was not sufficiently established as an administrative body at the conceptual stage and there was no clear national policy on health care financing. By the time the necessary action was taken, local conflicts hindered progress. In the Philippines, the ORT Health Plus Scheme (OHPS) was implemented during the period of legislation of a national health insurance act. The appraisal after three years of operation shows that OPHS has made health care affordable and accessible to the target population, composed mainly of low and often unstable income families in rural areas. The major success factors are probably the administrative structure provided by a cooperative and controls in the delivery system and in expenditures, through the salaried primary health care team, referral process and the capitation agreement for hospital-based services. The proliferation of such schemes could benefit from national guidelines, a formal accreditation process and an umbrella organization to provide assistance in design, training and information services, involving government, non-government and academic institutions as an integral part of the development process.

Introduction

In poor rural communities, access to basic health care is often severely limited by inadequate supply, mainly of sparsely distributed government health centres and hospitals. Access may be further hampered when government funding for health care is reduced and new public financing policies lead to the introduction of user charges in these public health care facilities (Waddington and Enyimayew, 1990; Abel-Smith and Dua, 1998). The financial barriers to access may become even greater when private for-profit services located in nearby towns are the major or only source of care.

National policies may introduce social health insurance, as part of a broad social security system or as a separate programme. However, such schemes are usually implemented in stages, with salaried workers covered first. In many developing countries, the vast majority of the population will not fit into that group, even when the schemes cover both public and private sector employees and when family members are included. Private for-profit health insurance is not likely to cover more than a very small proportion of the population, as the premiums and costs in these schemes are usually far above the average per capita expenditure on health care in the country.

Community initiatives to generate health care financing through voluntary prepayment schemes are an option, but may require a complex development process. An underlying assumption is that the local community sees advantages in taking direct responsibility for the financial stability of their personal health care services. Another assumption is that if the local community members will themselves contribute on a regular basis to create this financing mechanism, the government will give due recognition to these efforts as a form of cost-sharing. In that case, the government will not decrease its current level of funding and will continue to guarantee and improve the provision of public health services. These assumptions are not generally in the forefront in the process of obtaining health care in low-income rural communities and the development of appropriate health care financing mechanisms becomes more complex.

Even if the members of these communities are prepared to take action to assure access to health care on a regular basis, they may have very limited understanding of insurance or prepayment mechanisms. The lack of experience with insurance is even more significant when we consider that illness is a contingency which may not have entailed significant out-of-pocket expenditure for the necessary services in the past. At the household level, it may in fact be easier to `sell' insurance for a new utility, such as a costly appliance or farm machine, than for health care. The marketing of voluntary insurance is further complicated when we expect people to understand and accept solidarity among a large population of community members, beyond their own family.

Once user charges for health care are introduced, the household health care expenditure patterns may change. The application of user charges at the time of illness, when earnings may be reduced, can lead to irrational behaviour, such as delays in seeking care, decisions of which family member should have priority and what services to purchase beyond the initial consultant. Prepayment schemes obviously can rationalize health care behaviour as the financial barrier to seeking care at the time of illness is essentially removed, payments are made throughout the year and not at the time of illness and each insured individual is entitled to benefits in his or her own right.

Understanding of the prepayment/insurance and solidarity concepts are still not enough to launch community health care financing systems using these mechanisms. In the communities we are dealing with, that is, generally low and sometimes unstable income families in rural areas, we may have difficulty in finding the administrative structures we need for efficient registration, premium collection, health care and human resource mobilization as well as financial control systems to operate viable health insurance schemes.

This paper covers attempts to develop such community health care financing schemes in rural populations in two countries: Guatemala and the Philippines. The activities began in the same year (1994) but subsequent development has been very different. The paper will therefore deal with the major factors which have contributed to this unequal progress, as well as other issues that emerge as critical in community health insurance scheme development and sustainability.

In Guatemala and the Philippines, we find similarities in access to basic health care in poor rural areas, as government community health centres are the basic unit for primary health care, including preventive services. In both countries, such basic health services have not yet been established in many rural communities. Recent decisions allow government health care facilities to apply user charges (Nanagas et al., 1995) for all levels of curative care. District and regional hospitals still provide some basic services free of charge, but have recently introduced user charges, starting with fees for diagnostic X-ray and laboratory services.

Over the past two decades, the growth of small private hospitals has spread to many provincial capitals and towns. In the Philippines, these hospitals are mainly for profit, while in Guatemala, many private hospitals in rural areas are nonprofit charitable institutions but charge significant fees. Neither the government nor private hospitals can undertake the primary health care function for dispersed rural populations.

Some protection exists for salaried workers through the social security health insurance systems, but this applies to a very small percentage of the rural populations accounted for by civil servants (such as local government staff and teachers) and salaried employees of national companies. Coverage by commercial for-profit health insurance has been growing in both countries, but is concentrated in urban areas.

In Guatemala there is a clear policy to extend coverage of the social security health insurance programme, but the target beneficiaries of this policy are dependants of the salaried workers now covered and additional labour sectors, such as domestic workers and seasonal workers. In the Philippines, the National Health Insurance Law passed in February 1995 is aimed at providing universal coverage for a comprehensive range of health care benefits (Republic of the Philippines, 1995). However, universal coverage, to include all rural communities, is likely to take at least 15 years. In the meantime, community initiatives to develop health insurance schemes, within the basic guidelines of the National Health Insurance Law, are encouraged.

The following sections will cover the framework, design and current situation of a community health insurance scheme in each of the two countries. The last section will look at success and failure factors relating to the development of both schemes and attempt to reach some general conclusions on community health insurance.