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Ethiopia’s Urban ‘Cash Plus’ Pilot: Health Insurance System Linkages


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Debebe Barud Dera's (Government of Ethiopia) presentation at the Transfer Project Workshop in Arusha, Tanzania on 4th April 2019.

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Ethiopia’s Urban ‘Cash Plus’ Pilot: Health Insurance System Linkages

  1. 1. URBAN PRODUCTIVE SAFETY NET PROJECT (UPSNP) Ethiopia’s Urban Cash Plus pilot To promote UPSNP and CBHI Linkages: the case of the City Government of Addis Ababa, Ethiopia Debebe Barud Project Coordination Unit, UPSNP Arusha, Tanzania April 2019
  2. 2. CONTENTS o Background to UPSNP  Major components  Objective of the Social Health Insurance Scheme  Linkage Of UPSNP Direct Support Beneficiaries With Social Health Insurance Scheme In A.A  Linkage Of UPSNP Public Works Beneficiaries With Health Insurance Scheme In A.A  Impact Of The Linkages Of Health Insurance Scheme
  3. 3. BACKGROUND TO UPSNP  Ethiopia has a strong record of reducing extreme poverty in recent years; but there was more focus on rural areas  Urbanization is taking place, and as Ethiopia urbanizes, poverty becomes more urban  with a tripling of the urban population expected by 2034, 30% of the Ethiopian population will live in urban areas .  Urban poverty rates in Ethiopia are quite high, particularly in the large cities.  The total national poverty head count in 2011 was 29.6 % (30.4% in rural and 25.7% in urban areas).
  4. 4. BACKGROUND TO UPSNP CONT’D  Poverty rates in Addis Ababa and Dire Dawa were as high as 28.1 percent and 28.3 percent, respectively.  Access to the labor market is a key determinant of poverty in urban areas  The most visible faces of urban poverty are the destitute.  Another clearly identifiable group of the urban poor are the elderly and disabled living in households with no working-age members  However, the largest groups of urban poor are those with little work or those in low-quality employment
  5. 5. BACKGROUND TO UPSNP CONT’D  Expanding development programs to address key challenges to urban poverty reduction is the most critical.  The GoE has developed a 10-year UPSNP strategy, as an element of the Urban Job Creation and Food Security Strategy approved on May 8, 2015  The Government is also committed to implement urban productive Safety Net Programs based on the recently endorsed Social Protection Policy/strategy and successor of Rural Productive Safety Net Program (PSNP).
  6. 6. BACKGROUND TO UPSNP CONT’D  The Program is one of the few large flagship national programs in Africa-and globally. UPSNP constitutes the long term Urban Safety Net strategy of the government aimed at supporting over 4.7 million urban poor living in 972 cities and towns.  The UPSNP also focused on putting in place basic safety net building blocks and reaches 604,000 people in 11major cities, which are Addis Ababa, Mekele, Adama, Dessie,Hawassa, Gamabella, Assosa, Diredewa, Semer/Logia and Jigjiga with the total budgt of 450 Miliion USD, out of which 300 million USD from WB and 150 million USD from the GOE for five years.
  7. 7. BACKGROUND OF UPSNP…CON’D  Poorest 12% of population (55% of those living beneath the poverty line) in the 11 selected cities for the program are the beneficiaries.  Provision of social transfers in combination with livelihood support with the long term aim to graduate people out of their current situation (= beyond food security alone)  Transfers are conditional for people with labor and unconditional for people without labor in hh.  Transfers are meant to temporary smoothen consumption and livelihood support aims to diversify and improve household level income in the long run  The program started from 2017 and goes until 2021
  8. 8. BACK GROUNDS OF UPSNP…CONT’D  Public Work are activities planned to be implemented with able – bodied people who are under poverty line for urban productive safety net transfer  Public works aim to provide community assets and deliver services  Wage rate for Public Works is set below market wage rate to avoid disincentives to search for more permanent income opportunities or continue existing economic activities  Participation in Public Works is not meant to become a full time job but is a condition to access social transfers to temporary increase HHs income and smoothen consumption  Direct support group constitute the elderly, people with disability, the chronically ill and orphans with limited family support  They need sustained financial support through direct transfers.  unconditional transfer of around 215 Birr have been provided per person a month will lift about 60% to 65% of those in this group out of poverty  Attention to people with special needs also have been taken due consideration.
  9. 9. MAJOR COMPONENTS Component one: Safety Net: predictable transfers through participation in Public Works or Direct Support  Public Works including capital expenditure  Direct Support and Special Needs Component two: Livelihood Support : promotion of employability (self- employment, wage employment, skills training) Component three: Institutional Strengthening and Systems Development  Targeting, PMT, Baseline  Capacity Building  Safeguard  Citizen Engagement (Social accountability); and Gender  MIS, M&E  Program management (Financial Management,and Procurement ).
  10. 10. LIVELIHOODS SUPPORT  First year initial guidance and life skills training  Wage-employment package:  MOLSA provide guidance and information about wage employment opportunities and required skills training  Self-employment package  UJCFSA provide guidance and information about self-employment opportunities and direct them to TVET courses on entrepreneurship, business development and financial management.  Livelihood grant  Grant to support livelihood options (e.g. Cost of training or expansion of enterprise) up to Birr 10,000 or approximately USD 500 per family one time transfer.  Part of the livelihood grant will be obtained as matching grant for savings  There is a need to build capacity in MOLSA, UJCFSA and TVET to fulfill these activities.
  12. 12. OBJECTIVE OF THE SOCIAL HEALTH INSURANCE SCHEME  Is ongoing government program meant to provide quality and sustainable universal health care coverage to the citizens through pooling of risks, vulnerability and reducing financial barriers at the point of service delivery of the country by cost sharing.
  13. 13. ETHIOPIA’S URBAN CASH TRANSFER PILOT LINKAGES WITH SHI  It was a kick start as a pilot program in Addis Ababa city government with support of UNICEF fund started from 2018  It is 5 year pilot program implemented in certain selected woredas of Addis Ababa.  The philosophy of the pilot program and linkage behind is that the beneficiaries receive the service with out any cost sharing at the beginning and through continuous sensitization , messaging of the program and voluntary saving public work beneficiaries eventually able to pay the cost by themselves after graduation.  Direct support beneficiaries will get the benefit freely until the end of the program.
  14. 14. Linkage Of UPSNP Direct Support Beneficiaries With Social Health Insurance Scheme In A.A  Beneficiaries were less likely to use the health services and have poorer birth and child nutritional outcomes before this program.  Cash transfers, therefore, address the health services bottlenecks of the beneficiaries in Ethiopian context.  All UPSNP safety net beneficiaries in A.A have been benefiting free health services through the Social Health Insurance Scheme covered by government.  Free health services through the Social Health Insurance Scheme have been delivered for the beneficiaries based on an agreement signed with Health Bureau of City Government. Fig.1: Discussion with the Issue
  15. 15. Table 1: Direct Support and CBHI beneficiaries N o. Sub-Cities Direct Support Clients CBHI Clients Average* Cost/Annum1st Round 2nd Round 1 Yeka 2,246 3,680 5,926 1,605,946.00 2 Kolfe 1,602 3,892 5,494 1,488,874.00 3 Gulele 2,393 3,437 5,830 1,579,930.00 4 Addis Ketema 3,542 4,626 8,168 2,213,528.00 5 Nefas Silk Lafto 1,405 3,363 4,768 1,292,128.00 6 Akaki 1,763 2,561 4,324 1,171,804.00 7 Kirkos 2,319 3,376 5,695 1,543,345.00 8 Arada 1,409 2,516 3,925 1,063,675.00 9 Lideta 3,023 3,421 6,444 1,746,324.00 10 Bole 125 1,128 1,253 339,563.00 Total 19,827 32,000 51,827 14,045,117.00 *the annual cost/person = ETB 271 (covered by city government)
  16. 16. Linkages of UPSNP Public Works clients with the CBHI  For UPSNP Public Works clients in Addis Ababa, 9 sub-cities ensured free CBHI coverage  The CBHI membership has been provided to all Public Works clients in the nine sub- cities, based on a formal agreement signed between the UPSNP and the respective sub-city Health Offices
  17. 17. Table 2: Public Works and CBHI clients in 9 sub-cities of Addis Ababa No. Sub-Cities 1st & 2nd Round PW Beneficiaries Health Insurance Beneficiaries Health Insurance Beneficiaries Average Cost/ Annum*Male Headed Female Headed Total Male Female Total 1 Yeka 31,882 390 1,406 1,796 1,968 2,812 4,780 1,295,380.00 2 Kolfe 29,690 797 1,868 2,665 3,747 4,906 8,653 2,344,965.00 4 Addis Ketema 31,660 150 208 358 485 769 1,254 339,834.00 5 Nefas Silk Lafto 36,247 1,146 5,882 1,594,022.00 6 Kirkos 18,378 10,124 2743604 7 Arada 25,387 359 1,044 1,403 1,826 2,440 4,266 1156086 8 Lideta 26,371 1,247 3,812 5,059 4,887 6,994 11,882 3220022 9 Bole 17711 39 145 184 271 349 620 168020 Total 217,326 2,981 8,483 12,611 19,183 18,270 47,461 12,861,931 *the annual cost/person = ETB 271 (covered by local government)
  18. 18. So far impact of UPSNP/SHI linkages in Addis Ababa  Strengthened multi-sectoral collaboration amongst different stakeholders of Social Protection as well as overall strengthening of both the National UPSNP and the SHI systems  Improved availability, accessibility and delivery of basic health care services for UPSNP clients being the most vulnerable urban groups in Addis Ababa  Enhanced health seeking behavior of UPSNP clients, especially women and children who present more than 70% of USPNP clients  Improved overall health status of UPSNP clients  Strengthened confidence, trust, and interaction of UPSNP clients in their respective communities (general empowerment and reintegration into the communities)  Tendencies to take debts to cover healthcare costs have reduced for UPSNP clients  Longer term benefit is expected regarding overall resilience to shocks of the UPSNP clients  Important lessons have also been drawn from this pilot to be scaled up to other cities of Ethiopia in the near future
  19. 19. SOME INSIGHT…