Are adolescents financially protected under government health schemes?

Dr. Joel Shyam Klinton
Key Insights
  • Though adolescent health financing schemes appear to be more prevalent in high income countries, a growing number of upper and lower middle-income countries have started to invest in adolescent health.
  • Despite WHO’s definition of adolescents as individuals between 10 to 19 years of age, 18 years seems to be the common cap for non-specific health services for adolescents.
  • Considering the importance of self-care for adolescents in the areas of contraception and mental health, only 1 country in the sample covers psychological care for adolescents.
  • Most countries require adolescents to make some out-of-pocket expenditures which may deter them from seeking care.

 

Adolescence is a critical phase of life with unique health issues that require specific interventions. While some may doubt the worthiness of covering healthcare for generally healthy adolescents, investment has shown benefits of nearly ten times its cost. [1] As countries gear up to achieve Universal Health Coverage (UHC), it is useful to understand what is being done globally to ensure financial protection for adolescents.

Impact for Health identified 18 countries through WHO’s online tool, ‘Health for the world’s adolescents’ [2] and a purposeful analysis of the grey literature. After grouping countries based on their income status using the World Bank’s database [3], the financing schemes were analysed according to the WHO’s health financing cube [4] which addresses three dimensions; who is covered, which services are covered and what proportion of the costs are covered. The findings are outlined below.

What type of countries are financing programs for adolescent health?  Though adolescent health financing schemes appear to be more prevalent in high income countries, a growing number of middle-income countries have started to invest in adolescent health.

Graphic 1 illustrates that no examples of nation-wide government-sponsored financing schemes for adolescents in low income countries were found. However, efforts have been taken by some of these countries to support adolescent health by either focusing on single issues (such as the national adolescent sexual and reproductive health programme in Nepal), or by integrating with school health programmes (as practiced in Rwanda). [5] There is also very little documented information on the efforts taken by middle income countries like Argentina, Costa Rica or Kenya which recently tried to extend the National Hospital Insurance fund (NHIF) to cover students in public secondary schools. [6] In some countries such as India, there are programs which cover adolescent health through state sponsored insurance schemes (Kalaiagnar scheme, Rajiv Aarogyasri, etc.).  

Which adolescents are covered by these financing programs?  Despite WHO’s definition of adolescents as individuals between 10 to 19 years of age, 18 years seems to be the common cap for non-specific health services for adolescents.

While countries like Armenia, France, United Kingdom and Vietnam have multiple eligibility criteria, age emerges as the most common criteria to assess eligibility for these prepaid pooling arrangements with a common cap of 18 years. These health systems cover young adolescents of school-age but restrict coverage for older adolescents who are significantly vulnerable due to limited access to money and greater need for confidentiality.

Which services are covered? Considering the importance of self-care for adolescents in the areas of contraception and mental health, only 1 country covers psychological care for adolescents.

As most programs are linked to government health insurance scheme, the basic benefits package (BBP) is likely to be the service that is covered. The BBP is specific to each health system and usually includes primary care, maternity services, emergency services, counselling services, epidemiological services and inpatient treatment for specific diseases. The BBPs are not always aligned with the requirements for adolescents. [5] For instance, the package may cover sexual health counselling or mental health counselling, but not long term contraceptives, abortion, HPV vaccine or psychiatric medications. Though certain countries cover dental and pharmacy care, Norway appears to be the only country to cover psychological care which may be critical as adolescents can be vulnerable to mental illness.

What proportion of the costs are covered? Most services require adolescents to make some out-of-pocket expenditures which may deter care seeking. 

Since the overall picture is highly variable, Table 1 below outlines a detailed outlook of the services to which adolescents are entitled in the 18 countries and the proportion of the cost covered.

In general, adolescents in the financing systems reviewed are entitled to at least one service that is exempted from copay either through adolescent specific programs or national programs that cover all eligible citizens. 15 countries offer full exemption to adolescents for BBP. The Czech Republic and Switzerland offer a subsidized BBP rate, while Egypt and Iceland offer subsidized rates for pharmacy coverage. An outlier, France does not cover the basic benefit package, but does exempt adolescents from paying for medicines along with four other health systems.

National health systems that are commonly designed for young children or adults need to focus on delivering for adolescents as well. The transition of countries from foreign aid to self reliance urges the government health systems to ensure coverage for all its citizens and leave no one behind, including adolescents. The 18 countries could serve as a learning tool as governments reshape their health systems to advance towards UHC.

These health financing programs need to be analyzed further to serve as a learning tool for countries that our grappling with financing for adolescent health. Questions for further analysis include: 

  1. How can health information systems improve to capture adolescent specific data?
  2. How can the efforts of low- and middle-income countries be supported at a global as well as local level?
  3. How can the coverage expand to include older adolescents who are less likely to be covered by effective government insurance schemes?
  4. How can adolescents be adequately covered for services needed by them?
  5. How can providers be financed effectively to encourage delivery of service to adolescents who may require more time and attention than an average adult?

If you are interested in exploring this issue further with us, please contact hello@impactforhealth.com

References
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