HEALTH - Annex SHI Feasibility Study Lesotho

8/13/2019 HEALTH - Annex SHI Feasibility Study Lesotho

1/23

Annex

Report on the technical support mission for the

Feasibility assessment and

financial projection results

for a

Social Health Insurance Scheme in Lesotho

Exploring Possible Options

Revised DRAFT for discussion with the MOHSW and SHI TWG

- Not for distribution -

WHO, September 2007


2/23

1

Annex 1:

Terms of Reference

Feasibility Assessment and Actuarial Analysisof the Proposed Social Health Insurance Scheme in Lesotho

I. Background

Lesotho is a small country in Southern Africa. It consists of 10 districts, with a populationof about 2 million people. Its territory is completely enclosed by South Africa. Indeed,some of the health care needs of its population are met through medical referrals to SouthAfrica, a problem that has motivated government decisions on two key areas:

The upgrading of the Queen Elizabeth II Hospital (QEII) into a referral-carefacility. This is being done under a public/private partnership arrangement using

build-operate-transfer long-term concession. This initiative is being led by theInternational Finance Corporation with support from the World Bank.

The formulation of a social health insurance (SHI) program initially to coverpublic servants under a medical aid scheme (MAS). To spearhead the effort offormulating the SHI, the MOHSW is organizing a Technical Working Group(TWG) on social health insurance consisting of representatives from relevantministries (e.g., Finance, Health, Public Service, and Labor) and otherstakeholders. From July 11-13, 2006, the government with support from the

World Bank, USAID/East Africa, and the Tanzania National Health InsuranceFund, also organized an SHI orientation and planning workshop which attractedabout 30 participants from MOHSW, the Ministry of Finance, and the Ministry ofPublic Service.

II. Objective of the Undertaking

The objective of this undertaking is to provide technical support to the SHI TWGrevolving around the area of actuarial analysis of the planned SHI. This undertakingcomplements a parallel effort, the "Omnibus Study on Health Care Financing in Lesotho"which is aimed to generate basic data on public and private providers, their unit cost

structures, and the utilization of health services, most of which will be used as inputs inthe actuarial analysis. For this analysis, the Consulting Team is expected to be in

possession of, or have access to, an actuarial software model that could be used for thestudy. This undertaking does not fund the development of such an actuarial softwaremodel.

III. Components of the Undertaking

This undertaking consists of three parts: (a) Stakeholder consultations to generateadditional information to formulate appropriate assumptions for the actuarial model. Thestakeholder consultations are also meant as an opportunity to educate would-be members,

providers, and supporters of the SHI. (b) Actuarial analysis of the proposed SHI program.(c) Local staff training on the actuarial model, and institutionalization plan.


3/23

2

A. Stakeholder Consultations and Feasibility Assessment

The purpose of this component is to undertake a series of stakeholder consultations onvarious aspects of SHI design and operations so as to inform and educate would-be

beneficiaries and providers, to advocate for their support, and to elicit information fromthem that could be used as data for the actuarial model. The tasks of this part of theundertaking are as follows:

1. Assist the SHI TWG undertake beneficiary consultations using an appropriateapproach (e.g., focus group discussions, simple surveys). In undertaking theseconsultations, the Consulting Team should ensure that a representative sample of

beneficiaries from different age groups, ministries, offices, and geographic areasare consulted. The Team should also consult with unions and civil servants'associations. The beneficiary consultations should cover the following areas:

Perceived risks and benefits of participating in the SHI as members; Desire to participate in the SHI; voluntary vs. mandatory contributions; Willingness to contribute, contribution rates, and appropriate ceiling on

contribution rates;

Preferred health service benefits to be covered under the SHI; Domestic vs. external (South Africa) referrals, and implications of personal

preferences on contribution rates;

Rules and procedures for entitlement; Concerns of potential members from rural or outlying areas with constrained

access to providers;

Other programmatic issues from beneficiary's perspective that impinges on thedesign of the SHI.2. Assist the SHI TWG undertake provider consultations using an appropriate

approach (e.g., focus group discussions, simple surveys). In undertaking theseconsultations, the Consulting Team should ensure that a representative sample of

providers from government and private (nonprofit and for-profit) sectors areconsulted. The provider consultations should cover the following areas:

Perceived risks and benefits of participating in SHI as provider; Desire to be accredited as provider of services and to receive payments from SHI

for services rendered; Licensing and accreditation standards and phasing in of those standards; Quality assurance and utilization review; Preferred provider payment system; Fee rates; Administrative issues including medical records and claims payment; Regulatory issues; Other programmatic issues from providers' perspective that impinges on the design

of the SHI.

3. Assist the SHI TWG undertake appropriate consultations among key ministriesand other stakeholder groups, including but not limited to:


4/23

3

The MOHSW as steward, provider, and regulator of health services; The Ministry of Finance; The Ministry of Public Services; The Ministry of Labor; The Christian Hospital Association of Lesotho (CHAL); The Central Bank as regulator of the fiduciary aspects of health insurance in

Lesotho;

Professional societies/bodies; Other organized groups that may be relevant.These consultations should cover the following areas:

Perceived roles of each agency in the SHI; Regulatory issues, both for fiduciary and service quality areas; Governance, administration, and management of the SHI, including oversightstructure and monitoring and reporting; Legal requirements; Administrative costs, and the feasibility (pros and cons) of contracting out some or

all of the SHI administrative functions to a Third-Party Administrator (TPA) underan administrative services only (ASO) arrangement;

Other programmatic areas that impinge on the design of the SHI.B. Actuarial Analysis of the Proposed Lesotho SHI

The purposes of this component of the undertaking are: (a) To generate appropriate

actuarial assumptions on the proposed SHI which the actuary will use in calculating theexpected costs and revenues of the health insurance plan, including but not limited to:utilization rates, age and sex mix of enrollees, and costs of medical services. (b) To run theactuarial model using alternative scenarios on costs and revenues, administrativearrangements, and legal reserve requirements. The tasks of this component are:

1. Generate appropriate assumptions on the contribution revenues of SHI, based onthe results of the consultations with beneficiaries and relevant ministries, thecompanion undertaking on "Omnibus Study on Health Care Financing in Lesotho,"and other data sources:

Number of potential contributing members, labor force participation rates, andforecasts of economic and demographic growth;

Contribution rates and any appropriate ceilings on contributions; Government subsidies to the proposed SHI; Legal reserve requirements and investment policies of the SHI fund; Inflation rates.2. Generate appropriate assumptions on costs of health services, based on the results

of the provider consultations as well as the companion undertaking on "OmnibusStudy on Health Care Financing in Lesotho":

Benefit package and entitlement to benefits; Utilization rates for various health services; Provider payment system to be adopted;


5/23

4

Unit costs of health services and payment rates for providers; Inflation rates.3. Generate appropriate assumptions on the administrative costs of the SHI program,

based on the results of consultations with key ministries:

Assumed percentage of contribution revenues that will be used for administration; Estimation of the likely administrative costs of an SHI program of the size being

envisioned for Lesotho; for this sub-task, it is useful to know the actual costs ofsimilar SHI or other health insurance programs;

Choice to be made whether the administrative functions will be performed in-house, or will be contracted out fully or partially to a TPA under an ASOarrangement.

4. Run the actuarial model, analyse results, perform sensitivity analyses andalternative scenarios of costs and revenues, and discuss the findings with the SHITWG. The sensitivity analyses/alternative scenarios could be:

Alternative assumptions about the number of members and dependents; Changes in contribution rates and ceiling rates; Presence or absence of government subsidy; Alternative assumptions about the benefit package, especially pertaining to access

to tertiary care and South African referral services;

Alternative assumptions about utilization rates and provider payments; Phased roll-out of membership coverage and benefits; Other assumptions that the SHI TWG may want to explore.5. Perform sensitivity analyses under alternative assumptions of administration of the

SHI, and discuss findings with the SHI TWG.

Scenario A, in-house administration; Scenario B, assuming ASO arrangement with TPA.

C. Local Staff Training and Institutionalization of the Actuarial Model

1. Train at least 5 local staff on the actuarial model.2. Assist the MOHSW and the SHI TWG think up ways of how to institutionalize

actuarial analysis in the proposed SHI program.

IV. Level of Effort and Skills Needed

The undertaking requires a Consulting Team consisting of the following illustrative skill-mix:

Health insurance actuary; Health systems specialist and/or health economist; Workshop facilitator.


6/23

5

A total of __ consulting days are expected to be rendered for this undertaking, apportionedillustratively as follows:

Component A: __ person-days Component B: __ person-days Component C: __ person days

V. Deliverables and Schedule

The Consulting Team is expected to deliver the following outputs:

Final report on the stakeholder consultations and feasibility assessment, to bedelivered by _________________________.

Final report on the results of the actuarial analysis, including sensitivity analysesand alternative scenarios, to be delivered by _____________________.

Training of at least 5 staff on the actuarial model, to be completed by________________________.

VI. Reporting Requirements

The Consulting Team is required to report and make briefings to the following:

The Technical Working Group on Social Health Insurance; and The head of the Planning Department of the MOHSW.

The Consulting Team may also be asked to make briefings to the Lesotho Cabinet, theMinistry of Finance, the MOHSW, donors supporting the SHI, and other stakeholders.


7/23

6

Annex 2:

Data Sources, Assumptions and Explanations for SimIns FinancialProjections

Annex 2 explains each figure input into the SimIns Model. The SimIns Model consists of6 different modules for data input. The section numbering corresponds to these 6 modules;sub-section numbers refer to the input cells in each of these modules from top to bottom.Ideally, this section is read with the SimIns files opened in front of you on the screen.

Annex 2.1:

Scenario A: "SHI for All"

1. Introduction

1.1. Name of this simulation:Lesotho National Social Health Insurance (or Scenario A)

1.2. Short description of this simulation:See Main Report, Chapter 6.1.1

1.3. Base year:2008

1.4. Type of health insurance analysed:Social health insurance for Lesotho

1.5.

Health Service Categories:The following health service categories are covered by the social health insurancescheme:- GOL health centre (outpatient, OP)- CHAL health centre (OP)- GOL district hospital (OP)- CHAL district hospital (OP)- GOL hospital (inpatient, IP)- CHAL hospital (IP)- Queen Elizabeth II (OP)- Queen Elizabeth II (IP)- Private (OP)- RSA referrals (IP)

1.6. Government entities:No other health relevant government entity is included in this scenario.

2. Population Structure

2.1. Demography2.1.1. Total population (thousands):

Population and growth rate taken from United Nations, Department of Economic

and Social Affairs (UN 2006). Data interpolated for yearly figures.For details, see file UNPop-LES.xls(See the attached Excel-folder)


8/23

7

2.1.2. Growth rate:same source as 2.1.1

2.1.3. Percentage of dependants:same source as 2.1.1

2.1.4. Of which children:same source as 2.1.12.2. Workforce, wages and pensions2.2.1. Structure of workforce & pensioners (non-dependants):

The workforce is defined as non-dependants from population figures. The numberof government employees was taken from the Cabinet Memo on SHI/MAS, theformal sector size is estimated in the QEII referral study (Bicknell et al. 2002),

p165. Pensioners assumed to be 1% of the workforce (but more precise data isrequired). The rest of the population is part of the informal sector; in SimIns this

population group is called "self-employed".

For details, see file SimIns-data.xls> Population (worksheet)2.2.2. Average annual wage and pension:

For civil servants, data on salary adjustments and number of posts provided by theMinistry of Public Service (see file SimIns-data.xls> Gov emp 2). For teachers,the salary data was from the same source and the number of teachers were

provided by the Ministry of Education. The average was calculated based on abovesources (see file teachers.xls).The average formal sector wage is based on garment factory worker salaries asdescribed in the Garment Industry study (Salm et al. 2002). The figure from thatstudy is inflation adjusted.

Pensions are assumed to be M10,000 a year, but more precise data is required.2.2.3. Nominal growth rate:

GDP deflator figure used (see 3.1.2)

3. Macroeconomy

3.1. Gross domestic product (GDP):Figures are taken from the Lesotho Bureau of Statistics. Data for 2005 were

projected to 2008 by using the average annual % change over the 5 year prior.See file SimIns-data.xls> GDP

3.1.1. Growth rate:Same source and calculation as 3.1 GDP

3.1.2. Percentage change in GDP deflator:Same source and calculation as 3.1 GDP.

3.2. External price index:Economist Intelligence Unit (EIU) forecast for US$ GDP deflator used(www.eiu.com)

3.2.1. Interest rate:Source: EIU forecast. See file SimIns-data.xls> Exchange rate

3.3. Exchange rate (NCU (National Currency Units) per US$):Source: EIU forecast. See file SimIns-data.xls> Exchange rate


9/23

8

3.3.1. Purchasing Power Parity (PPP):In the absence of better data, PPP is being used.

3.4. Utilization of resources (national accounts)3.4.1. Household & government consumption, gross fixed capital formation, exports &

imports of goods and services:Source: International Monetary Fund (IMF) International Financial Statistics: 2005figures used. GDP change and deflator applied to estimate 2008 figures.

4. Health care costs

4.1.For base year:All health centre and district hospital costs are based on a step-down costs analysis(Boston Medical Center 2006). Average costs calculated from the study are used. QEII OP costs are assumed to be double the outpatient costs of a health centre. QE II IPcosts are based on the figures reported in the QEII referral study (Bicknell et al. 2002).Private OP costs are assumed to be twice those of health centres. RSA referrals areagain based on the figures reported in the QE II referral study (Bicknett et al. 2002).

See file SimIns-data.xls> Unit costs

4.2.For year-on changes:For this simulation the costs are assumed to increase by 50% over 10 years, i.e.current costs (100%) at base year to 150% of those costs in year 10 (all in constant

prices). This is to simulate a quality improvement in services. There are 2 exceptions:private OP costs are increased by 13%, since unit costs were set at a much higher ratefrom the outset at which it is assumed that private providers will be willing to offercare. Also, there is not such a large need for improved quality. RSA referral costs arenot increased, as the stated aim is to limit such referrals.

5. Utilization rate

5.1.All utilization rates for public sector health services are calculated from MOHSWHealth Statistical Tables (2005). As co-payments (see Section 6.4, copayment rates)in the SHI scheme and user fees for the non-insured are simulated to be lower thancurrent user fee levels (in line with plans of the MOHSW to lower user fees), newutilization rates under the SHI scheme are assumed to increase for both the insuredand the non-insured.. The increase in utilization rates is calculated assuming a price

elasticity of demand of -0.32. This figures is an estimate for Swaziland (Yoder 1989) which is the geographically closest available figure.Private OP utilization rates are calculated using information from interviews duringthe first mission. These interviews yielded an estimate of total patient contacts at

private facilities. We then assumed that two thirds of these contacts are by the formalsector (govt employees, formal employees, pensioners, and dependants of these), andcalculated the respective average utilization rates for this group based on thisassumption. Utilization rates for private OP for the uninsured are lower as theuninsured do not benefit from the drop in co-payments. Utilization for RSA referralsare based on the QEII referral study (Bicknell et al. 2002, p.2).See file MOH stats util&cost.xls


10/23

9

6. Health insurance

6.1.Health insurance coverage (percentage insured, exempted included):This scenario simulates a rapid increase in coverage. The government sector iscovered 100% immediately. The formal sector is covered by half (e.g. the garmentindustry) in the first year. Coverage is then extended to 100% over two more years.Pensioners are assumed to be covered at the same rate as the formal sector. Coverageof the self-employed is extended across the country by one district per year, thusreaching universal coverage in the last year of the projection period.See file SimIns-data.xls> Coverage

6.1.1. Percentage insured that are exempted:Using poverty figures from the Lesotho Household Budget Survey (KOL 2006a /Table 6.2.7.1, p.65), the districts were classified into three levels of poverty.Informal sector exemption rates were then applied according to poverty level ofeither 70%, 83.6 or 90%. Relative to the total population, this results in anexemption rate of just over 50% of the total population at universal coverage.

See file SimIns-data.xls> Poverty & exemptions

6.2.Health insurance contributions6.2.1. Insurance contribution rate as a percentage of the wage and pension (%):

5% was chosen as a contribution rate for the formal sector. This is within the rangeof what the stakeholder consultations revealed as an acceptable contribution ratefor the formal sector (see Main report, Chapter 5.1.).Pensioners, earning less than the employees of the formal sector, are assumed to

pay a lower contribution: 3%.

6.2.2. Average contribution rates per self-employed adult:Half of the current average health expenditure per household (see the HouseholdBudget Survey, KOL 2006a) was chosen as the flat contribution rate forhouseholds from the informal sector (in SimIns, for what is called the "self-employed"). The given figure for 2003 was inflation adjusted to arrive at a 2008rate.

See file SimIns-data.xls> Poverty & exemptions

6.2.3. Average contribution rate per adult dependant in self-employed category:This simulation assumes that dependants are included for no extra contribution, i.e.it is a family insurance. Therefore this figure is at zero.

6.2.4. Average contribution rate per child in self-employed category:This simulation assumes that dependants are included for no extra contribution, i.e.it is a family insurance. Therefore this figure is at zero.

6.3.Government subsidies:The initial scenario calculates results before any extra government subsidy. The Mainreport (Chapter 6) provides further explanations.

6.4.Co-payment rates (%)6.4.1. in government facilities:

Scenario A simulates the currently envisaged flat GOL user charges, which arelower (mostly half) than currently applied user charge. With the agreed

harmonization of user fees and government subsidies between GOL and CHAL


11/23

10

facilities, the same figures are used for both. The average length of stay forinpatient visits is assumed to be 6 days. See file MOH stats util&cost.xls):- Health centre OP (GOL & CHAL): Maloti 0- District hospital OP (GOL & CHAL): M 5- District hospital IP (GOL & CHAL): M 10 per day or M 60 per stay- Queen Elizabeth II OP: M 10- Queen Elizabeth II IP: M 20 per day or M 120 per stayFor SimIns calculation requirements, CHAL facilities are treated and categorisedas government facilities.1This is because they receive a large amount of theirrevenues from government budgets.

6.4.2. in non-government facilities:Private outpatient treatment is assumed to be subject to a 30M co-payment inscenario A.RSA referrals incur no co-payment, however their utilization is strictly controlledas a referral has to be initiated by QE II hospital.

6.5.Reserves, administrative costs and other non-health care costs6.5.1. Reserves (%):

This simulation uses a 5% reserve rate (calculated as a percentage of health carecosts to the insurance).2

6.5.2. Administrative costs (%):This simulation uses a 15% administrative cost rate (calculated as a percentage ofhealth care costs to the insurance).3

6.5.3. Other non-health care costs (%):None specified.

7. Governments share in financing and provision of health care

7.1.1. Government-funded share of average cost per health service (%):Scenario A simulates that current budgets from the MOHSW are maintained atcurrent levels (in constant prices) for the simulation period, and that they continueto be used to fund or subsidize the provision of services. Thus, as a percentage ofhealth care costs, the government funded share is between 90 and 97% in the firstyear of the financial projection (2008), the remaining difference to 100%consisting of co-payments / user fees, which differ across the health servicecategories. With increasing unit costs (by 50%) that reflect improved quality and

the same level of government funding, this government share then decreases as apercentage of the overall health care costs to about 66%. In essence the SHI fundsthe cost (and quality) increase whereas the MOHSW budgets to GOL and CHALfacilities is maintained at its current level. With the agreed harmonization of userfees and government subsidies between GOL and CHAL facilities, the samefigures are used for both GOL and CHAL.

For SimIns calculation requirements, note again that CHAL facilities are treated asgovernment facilities. This is because they receive a large amount of their revenues

1This categorization merely serves to ensure that SimIns can correctly calculate health care costs catered by

the Social Health Insurance.2The reserves amount to 4% in terms of total SHI expenditure.

3The administration costs amount to 12.5% in terms of total SHI expenditure.


12/23

11

from government budgets. Hence, the share of MOHSW funding in total healthcare expenditure, as presented in the SimIns graphs and output section, includesthe funding that CHAL is supposed to collect from their own donors.See file MOH stats util&cost.xls

7.2.Estimated share of total services provided by government facilities (%):As GOL services are provided 100% by government, and as CHAL services are

provided 100% by CHAL, yet given that CHAL are treated as government servicesfor purposes of SimIns calculation steps, we enter 100% government provision.Private and RSA referrals are classified as private services. The latter could haveequally been classified as a government services, but since the costs incurred throughreferrals are fully assumed by the SHI, the financial projection results do not change.

7.3.Timeline and extent for financial autonomy of government facilities (%):As Scenario A assumes that the current government spending on services ismaintained, this figures stays at 0 throughout.

8. Public finance

8.1.General government revenue8.1.1. Taxes on income, profits, and capital gains, on goods and services, on international

trade and transactions, other fiscal revenues, non-fiscal revenues, grants:Source: IMF Government Finance Statistics Yearbook. 2008 figures are based onthe provided figures for 2004 and then projected with GDP change and deflatordata. See file SimIns-data.xls> Public finance

8.2.General government expenditure8.2.1. General public services, defence, public order and safety, economic affairs,education, social protection, and other functions:

Source: IMF Government Finance Statistics Yearbook. 2008 figures are based onthe provided figures for 2004 and then projected with GDP change and deflatordata. See file SimIns-data.xls> Public finance

9. Ministry of health expenditure

9.1.1. Inpatient, outpatient and other personal care, prevention and public health services,health administration and health-related functions:As this detailed data is not available in the Lesotho National Health Accountsestimations, the full figure for MOHSW health expenditure is entered as Other

personal care. See file SimIns-data.xls> NHA

9.1.2. Growth rate:GDP growth rate is used.

9.2.Other general government health expenditure:No entities entered.

10. Private health expenditure

10.1. Total private health expenditure:National health accounts data used. See file SimIns-data.xls> NHA


13/23

12

10.2. growth rate of residual:This simulation applies no growth rate.


14/23

13

Annex 2.2:

Scenario B: "SHI for formal sector only"

2. Introduction1.1.Name of this simulation:

Formal Sector Insurance (or Scenario B)

1.2.Short description of this simulation:See Main Report, Chapter 6.2.1

1.3.Base year:2008

1.4.Type of health insurance analysed:Social health insurance for Lesotho

1.5.Health Service Categories:identical with Scenario A.

1.6.Government entities:identical with Scenario A.

2. Population Structure

identical with Scenario A.

3. Macroeconomy


4. Health care costs


5. Utilization rate


6. Health insurance

6.1.Health insurance coverage (percentage insured, exempted included):This scenario simulates a rapid increase in coverage of the formal sector. Thegovernment sector is covered 100% immediately. The formal sector is covered by half(e.g. the garment industry) in the first year. Coverage is then extended to 100% overtwo more years. Pensioners are assumed to be covered at the same rate as the formalsector.Coverage by the social health insurance part of the health financing system of the self-

employed remains at zero throughout the projection period.


15/23

14

6.1.1. Percentage insured that are exempted:identical with Scenario A. However, as the self-employed coverage is 0, these

figures have no bearing on the result. (One could equally enter 0 in these cells).

6.2.Health insurance contributions6.2.1. Insurance contribution rate as a percentage of the wage and pension (%):identical with Scenario A.6.2.2. Average contribution rates per self-employed adult:

identical with Scenario A. However, as the self-employed coverage is 0, these


(One could equally enter 0 in these cells).

6.2.3. Average contribution rate per adult dependant in self-employed category:identical with Scenario A. However, as the self-employed coverage is 0, these


6.2.4. Average contribution rate per child in self-employed category:identical with Scenario A. However, as the self-employed coverage is 0, these


6.3.Government subsidies:The initial scenario calculates results before any extra government subsidy. The Mainreport (Chapter 6) provides more explanations on this.

6.4.Co-payment rates (%)identical with Scenario A.

6.5.Reserves, administrative costs and other non-health care costsidentical with Scenario A.

7. Governments share in financing and provision of health care

7.1.1. Government-funded share of average cost per health service (%):Scenario B simulates that current budgets from the MOHSW are continued atcurrent levels (in constant prices) for the simulation period, and that they continueto be used to fund or subsidize the provision of services. However, these fundsare used to pay the costs of health services to the general population that is

not covered by the SHI, i.e. the informal sector.Thus, as a percentage of healthcare costs for the formal sector, the government funded share is zero and remains

so. In essence the SHI is expected to fund the full cost of the health servicesincurred by its members (the formal sector).

7.2.Estimated share of total services provided by government facilities (%):identical with Scenario A.

7.3.Timeline and extent for financial autonomy of government facilities (%):identical with Scenario A.

8. Public finance



16/23

15

9. Ministry of health expenditure


10. Private health expenditure



17/23


18/23

17

Health insurance expenditure and incomeThe following tables show the detailed results for the SHI for each of the above listedvariations. The figures are in Maloti (2008 constant prices / thousands). The incomes andexpenditures listed here are specifically for the SHI.

The line actual required government subsidies lists the amount that would be neededextra for the SHI to break even in those years. This may be a subsidy, but it may alsocome from other sources. Notably, reserves from surplus years can be used to pay fordeficits at least in the initial years. In those columns where this figure is negative, it meansthat the SHI is operating at a surplus, so no extra income (from subsidy, reserves, etc.)would be needed.

A1.1: administration costs low


19/23

18

A1.2: administration costs high

A2.1: health care costs low


20/23

19

A2.2: health care costs high

A3.1: utilization rate low


21/23

20

A3.2: utilization rate high

A4: faster quality increase


22/23


23/23

A7.1: cumulative administration, health care costs and utilization rate low

A7.2: cumulative administration, health care costs and utilization rate high

HEALTH - Annex SHI Feasibility Study Lesotho

Documents

Transcript of HEALTH - Annex SHI Feasibility Study Lesotho