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Noubiap JJN, Joko WYA, Obama JMN, Bigna JJR. Community-based health insurance knowledge, concern, preferences, and financial planning for health care among informal sector workers in a health district of Douala, Cameroon. Pan Afr Med J 2013; 16:17. [PMID: 24498466 PMCID: PMC3909694 DOI: 10.11604/pamj.2013.16.17.2279] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Accepted: 07/04/2013] [Indexed: 11/11/2022] Open
Abstract
Introduction For the last two decades, promoted by many governments and international number in sub-Saharan Africa. In 2005 in Cameroon, there were only 60 Community-based health insurance (CBHI) schemes nationwide, covering less than 1% of the population. In 2006, the Cameroon government adopted a national strategy aimed at creating at least one CBHI scheme in each health district and covering at least 40% of the population with CBHI schemes by 2015. Unfortunately, there is almost no published data on the awareness and the implementation of CBHI schemes in Cameroon. Methods Structured interviews were conducted in January 2010 with 160 informal sectors workers in the Bonassama health district (BHD) of Douala, aiming at evaluating their knowledge, concern and preferences on CBHI schemes and their financial plan to cover health costs. Results The awareness on the existence of CHBI schemes was poor awareness schemes among these informal workers. Awareness of CBHI schemes was significantly associated with a high level of education (p = 0.0001). Only 4.4% of respondents had health insurance, and specifically 1.2% were involved in a CBHI scheme. However, 128 (86.2%) respondents thought that belonging to a CBHI scheme could facilitate their access to adequate health care, and were thus willing to be involved in CBHI schemes. Our respondents would have preferred CBHI schemes run by missionaries to CBHI schemes run by the government or people of the same ethnic group (p). Conclusion There is a very low participation in CBHI schemes among the informal sector workers of the BHD. This is mainly due to the lack of awareness and limited knowledge on the basic concepts of a CBHI by this target population. Solidarity based community associations to which the vast majority of this target population belong are prime areas for sensitization on CBHI schemes. Hence these associations could possibly federalize to create CBHI schemes.
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Affiliation(s)
- Jean Jacques N Noubiap
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Cameroon ; Edea Regional Hospital, Edea, Cameroon
| | - Walburga Yvonne A Joko
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Cameroon ; Douala General Hospital, Douala, Cameroon
| | - Joel Marie N Obama
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Cameroon ; Bertoua Regional Hospital, Bertoua, Cameroon
| | - Jean Joel R Bigna
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Cameroon ; Goulfey District Hospital, Goulfey, Cameroon
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Adhikari SR, Supakankunti S, Khan MM. Decision-making process of Kala Azar care: results from a qualitative study carried out in disease endemic areas of Nepal. Infect Dis Poverty 2013; 2:14. [PMID: 23849617 PMCID: PMC3717077 DOI: 10.1186/2049-9957-2-14] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Accepted: 07/11/2013] [Indexed: 11/16/2022] Open
Abstract
Background Analysis of consumer decision making in the health sector is a complex process of comparing feasible alternatives and evaluating the levels of satisfaction associated with the relevant options. This paper makes an attempt to understand how and why consumers make specific decisions, what motivates them to adopt a specific health intervention, and what features they find attractive in each of the options. Method The study used a descriptive-explanatory design to analyze the factors determining the choices of healthcare providers. Information was collected through focus group discussions and in-depth interviews. Results The results suggest that the decision making related to seeking healthcare for Kala Azar (KA) treatment is a complex, interactive process. Patients and family members follow a well-defined road map for decision making. The process of decision making starts from the recognition of healthcare needs and is then modified by a number of other factors, such as indigenous knowledge, healthcare alternatives, and available resources. Household and individual characteristics also play important roles in facilitating the process of decision making. The results from the group discussions and in-depth interviews are consistent with the idea that KA patients and family members follow the rational approach of weighing the costs against the benefits of using specific types of medical care. Conclusion The process of decision making related to seeking healthcare follows a complex set of steps and many of the potential factors affect the decision making in a non-linear fashion. Our analysis suggests that it is possible to derive a generalized road map of the decision-making process starting from the recognition of healthcare needs, and then modifying it to show the influences of indigenous knowledge, healthcare alternatives, and available resources.
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Affiliation(s)
- Shiva Raj Adhikari
- Department of Economics, Patan Multiple Campus, Tribhuvan University, Kathmandu, Nepal.
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Boateng D, Awunyor-Vitor D. Health insurance in Ghana: evaluation of policy holders' perceptions and factors influencing policy renewal in the Volta region. Int J Equity Health 2013; 12:50. [PMID: 23822579 PMCID: PMC3716631 DOI: 10.1186/1475-9276-12-50] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Accepted: 06/30/2013] [Indexed: 11/26/2022] Open
Abstract
Background Health insurance is an important mechanism that succors individuals, states and the nation at large. The purpose of this study was to assess individual’s attitude towards health insurance policy and the factors that influence respondents’ decision to renew their health insurance policy when it expires. Methods This cross sectional study was conducted in the Volta region of Ghana. A total of 300 respondents were randomly sampled and interviewed for the study. Data was collected at the household level and analyzed with STATA software. Descriptive statistics was used to assess the demographic characteristics of the respondents while Logistic regression model was used to assess factors that influence respondents’ decision to take up health insurance policy and renew it. Results The study results indicate that 61.1% of respondents are currently being enrolled in the NHIS, 23.9% had not renewed their insurance after enrollment and 15% had never enrolled. Reasons cited for non-renewal of insurance included poor service quality (58%), lack of money (49%) and taste of other sources of care (23%). The gender, marital status, religion and perception of health status of respondents significantly influenced their decision to enroll and remain in NHIS. Conclusion NHIS has come to stay with clients testifying to its benefits in keeping them strong and healthy. Efforts therefore must be put in by all stakeholders including the community to educate the individuals on the benefits of health insurance to ensure all have optimal access.
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Affiliation(s)
- Daniel Boateng
- Department of Community Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
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Majaj L, Nassar M, De Allegri M. "It's not easy to acknowledge that I'm ill": a qualitative investigation into the health seeking behavior of rural Palestinian women. BMC Womens Health 2013; 13:26. [PMID: 23705933 PMCID: PMC3679862 DOI: 10.1186/1472-6874-13-26] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Accepted: 04/05/2013] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND This qualitative study sets to fill a gap in knowledge by exploring the health seeking behaviour of rural women living in the occupied Palestinian territories (oPt). The existing literature on the oPt has so far focused on unravelling the country's epidemiological and health system profile, but has largely neglected the assessment of factors shaping people's decisions on health care use. METHODS Based on a conceptual framework rooted in the Anderson behavioural model, we conducted 30 semi-structured interviews with purposely selected women and seven key informant interviews in three purposely selected villages in Ramallah district. RESULTS Our findings indicate that women delay seeking professional care, use self-prescribed medications and home treatment, and do not use preventive and educational health services. Their health seeking behaviour is the result of the interplay of several factors: their gendered socio-cultural role; their health beliefs; financial affordability and geographical accessibility; their perceptions of the quality of care; and their perceived health needs. CONCLUSIONS Findings are discussed in the light of their policy implications, suggesting that adequate health policy planning ought to take into considerations socio-cultural dimensions beyond those directly pertinent to the health care system.
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Affiliation(s)
- Linda Majaj
- UNICEF Bethlehem, West Bank occupied Palestinian territory, Heidelberg, Germany
| | - Majed Nassar
- Medical Aid for Palestinians Ramallah West Bank occupied Palestinian territory, Bethlehem, West Bank
| | - Manuela De Allegri
- Institute of Public Health, University of Heidelberg, Heidelberg, Germany
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Robyn PJ, Bärnighausen T, Souares A, Savadogo G, Bicaba B, Sié A, Sauerborn R. Does enrollment status in community-based insurance lead to poorer quality of care? Evidence from Burkina Faso. Int J Equity Health 2013; 12:31. [PMID: 23680066 PMCID: PMC3665463 DOI: 10.1186/1475-9276-12-31] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2012] [Accepted: 05/03/2013] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION In 2004, a community-based health insurance (CBI) scheme was introduced in Nouna health district, Burkina Faso, with the objective of improving financial access to high quality health services. We investigate the role of CBI enrollment in the quality of care provided at primary-care facilities in Nouna district, and measure differences in objective and perceived quality of care and patient satisfaction between enrolled and non-enrolled populations who visit the facilities. METHODS We interviewed a systematic random sample of 398 patients after their visit to one of the thirteen primary-care facilities contracted with the scheme; 34% (n = 135) of the patients were currently enrolled in the CBI scheme. We assessed objective quality of care as consultation, diagnostic and counselling tasks performed by providers during outpatient visits, perceived quality of care as patient evaluations of the structures and processes of service delivery, and overall patient satisfaction. Two-sample t-tests were performed for group comparison and ordinal logistic regression (OLR) analysis was used to estimate the association between CBI enrollment and overall patient satisfaction. RESULTS Objective quality of care evaluations show that CBI enrollees received substantially less comprehensive care for outpatient services than non-enrollees. In contrast, CBI enrollment was positively associated with overall patient satisfaction (aOR = 1.51, p = 0.014), controlling for potential confounders such as patient socio-economic status, illness symptoms, history of illness and characteristics of care received. CONCLUSIONS CBI patients perceived better quality of care, while objectively receiving worse quality of care, compared to patients who were not enrolled in CBI. Systematic differences in quality of care expectations between CBI enrollees and non-enrollees may explain this finding. One factor influencing quality of care may be the type of provider payment used by the CBI scheme, which has been identified as a leading factor in reducing provider motivation to deliver high quality care to CBI enrollees in previous studies. Based on this study, it is unlikely that perceived quality of care and patient satisfaction explain the low CBI enrollment rates in this community.
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Affiliation(s)
- Paul Jacob Robyn
- Institute of Public Health, University of Heidelberg, Heidelberg, Germany
- The World Bank, 1818 H Street NW, Washington, DC, USA
| | - Till Bärnighausen
- Department of Global Health and Population, Harvard School of Public Health, Boston, USA
- Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Mtubatuba, South Africa
| | - Aurélia Souares
- Institute of Public Health, University of Heidelberg, Heidelberg, Germany
| | - Germain Savadogo
- Institute of Public Health, University of Heidelberg, Heidelberg, Germany
- Nouna Health Research Centre, Ministry of Health, Nouna, Burkina Faso
| | - Brice Bicaba
- Nouna Health District, Ministry of Health, Ouagadougou, Burkina Faso
| | - Ali Sié
- Nouna Health Research Centre, Ministry of Health, Nouna, Burkina Faso
| | - Rainer Sauerborn
- Institute of Public Health, University of Heidelberg, Heidelberg, Germany
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Almualm Y, Alkaff SE, Aljunid S, Alsagoff SS. Factors influencing support for National Health Insurance among patients attending specialist clinics in Malaysia. Glob J Health Sci 2013; 5:1-10. [PMID: 23985101 PMCID: PMC4776860 DOI: 10.5539/gjhs.v5n5p1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Revised: 04/28/2013] [Accepted: 05/02/2013] [Indexed: 11/23/2022] Open
Abstract
This study was carried out to determine the level of support towards the proposed National Health Insurance scheme among Malaysian patients attending specialist clinics at the National University of Malaysia Medical centre and its influencing factors. The cross sectional study was carried out from July-October 2012. 260 patients were selected using multistage sampling method. 71.2% of respondents supported the proposed National Health insurance scheme. 61.4% of respondents are willing to pay up to RM240 per year to join the National Health Insurance and 76.6% of respondents are of the view that enrollment in NHI should be made compulsory. Knowledge had a positive influence on respondent's support towards National Health Insurance. National Health Insurance when implemented in Malaysia can be used to raise funds for health care financing, increase access to health services and achieve the desired health status. More efforts should be taken to promote the scheme and educate the public in order to achieve higher support towards the proposed National Health Insurance. The cost to enroll in NHI as well as services to be included under the scheme should be duly considered.
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Turcotte-Tremblay AM, Haddad S, Yacoubou I, Fournier P. Mapping of initiatives to increase membership in mutual health organizations in Benin. Int J Equity Health 2012; 11:74. [PMID: 23217438 PMCID: PMC3541096 DOI: 10.1186/1475-9276-11-74] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2012] [Accepted: 11/11/2012] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Mutual health organizations (MHO) have been implemented across Africa to increase access to healthcare and improve financial protection. Despite efforts to develop MHOs, low levels of both initial enrolment and membership renewals continue to threaten their financial viability. The purpose of this study was to map initiatives implemented to increase the pool of MHO members in Benin. METHODS A multiple case study was conducted to assess MHOs supported by five major promoters in Benin. Three months of fieldwork resulted in 23 semi-structured interviews and two focus groups with MHO promoters, technicians, elected members, and health professionals affiliated with the MHOs. Fifteen non-structured interviews provided additional information and a valuable source of triangulation. RESULTS MHOs have adopted a wide range of initiatives targeting different entry points and involving a variety of stakeholders. Initiatives have included new types of collective health insurance packages and efforts to raise awareness by going door-to-door and organizing health education workshops. Different types of partnerships have been established to strengthen relationships with healthcare professionals and political leaders. However, the selection and implementation of these initiatives have been limited by insufficient financial and human resources. CONCLUSIONS The study highlights the importance of prioritizing sustainable strategies to increase MHO membership. No single MHO initiative has been able to resolve the issue of low membership on its own. If combined, existing initiatives could provide a comprehensive and inclusive approach that would target all entry points and include key stakeholders such as household decision-makers, MHO elected members, healthcare professionals, community leaders, governmental authorities, medical advisors, and promoters. There is a need to evaluate empirically the implementation of these interventions. Mechanisms to promote dialogue between MHO stakeholders would be useful to devise innovative strategies, avoid repeating unsuccessful ones, and develop a coordinated plan to promote MHOs.
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Affiliation(s)
- Anne-Marie Turcotte-Tremblay
- University of Montreal Hospital Research Centre, 3875 Saint-Urbain Street, Room 5-01, Montreal, Quebec, H2W 1V1, CANADA
| | - Slim Haddad
- University of Montreal Hospital Research Centre, 3875 Saint-Urbain Street, Room 5-01, Montreal, Quebec, H2W 1V1, CANADA
- Department of Social and Preventive Medicine, Faculty of Medicine, University of Montreal, 1420 Mont-Royal Boulevard, Montreal, Quebec, H2V 4P3, CANADA
| | - Ismaïlou Yacoubou
- Centre d'étude et d'Appui Technique aux Institutions de Micro assurance Santé (A.I.M.S.), Parakou, 02BP866, Republic of Benin
| | - Pierre Fournier
- University of Montreal Hospital Research Centre, 3875 Saint-Urbain Street, Room 5-01, Montreal, Quebec, H2W 1V1, CANADA
- Department of Social and Preventive Medicine, Faculty of Medicine, University of Montreal, 1420 Mont-Royal Boulevard, Montreal, Quebec, H2V 4P3, CANADA
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Ma Y, Zhang L, Chen Q. China's new cooperative medical scheme for rural residents: popularity of broad coverage poses challenges for costs. Health Aff (Millwood) 2012; 31:1058-64. [PMID: 22566447 DOI: 10.1377/hlthaff.2009.0808] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
One of the components in China's massive health reform effort is the New Cooperative Medical Scheme, which is intended to provide affordable health insurance, especially to the rural poor. This program offers three options with different benefits and costs to county health officials, who select one of the options to make available to local residents. Data were obtained from the New Cooperative Medical Scheme survey conducted by the Chinese Ministry of Health and the World Bank in 2005, which covered more than 47,000 people living in twenty-seven counties, to determine participation levels, identify which option was most attractive, and characterize the impact that each option had on care and costs. Our study found that those participants with the most limited coverage might have delayed seeking care, while the broadest coverage--the "Cadillac option"--was the most popular. Yet if this generous package were to be broadly offered, health costs would become unsustainable. Therefore, the Chinese government must consider which costs to cover for people in economically depressed rural areas.
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Affiliation(s)
- Yuqin Ma
- Institute of Military Health Management, Second Military Medical University, Shanghai, China.
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Dalinjong PA, Laar AS. The national health insurance scheme: perceptions and experiences of health care providers and clients in two districts of Ghana. HEALTH ECONOMICS REVIEW 2012; 2:13. [PMID: 22828034 PMCID: PMC3505458 DOI: 10.1186/2191-1991-2-13] [Citation(s) in RCA: 103] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Accepted: 06/28/2012] [Indexed: 06/01/2023]
Abstract
UNLABELLED BACKGROUND Prepayments and risk pooling through social health insurance has been advocated by international development organizations. Social health insurance is seen as a mechanism that helps mobilize resources for health, pool risk, and provide more access to health care services for the poor. Hence Ghana implemented the National Health Insurance Scheme (NHIS) to help promote access to health care services for Ghanaians. The study examined the influence of the NHIS on the behavior of health care providers in their treatment of insured and uninsured clients. METHODS The study took place in Bolgatanga (urban) and Builsa (rural) districts in Ghana. Data was collected through exit survey with 200 insured and uninsured clients, 15 in-depth interviews with health care providers and health insurance managers, and 8 focus group discussions with insured and uninsured community members. RESULTS The NHIS promoted access for insured and mobilized revenue for health care providers. Both insured and uninsured were satisfied with care (survey finding). However, increased utilization of health care services by the insured leading to increased workloads for providers influenced their behavior towards the insured. Most of the insured perceived and experienced long waiting times, verbal abuse, not being physically examined and discrimination in favor of the affluent and uninsured. The insured attributed their experience to the fact that they were not making immediate payments for services. A core challenge of the NHIS was a delay in reimbursement which affected the operations of health facilities and hence influenced providers' behavior as well. Providers preferred clients who would make instant payments for health care services. Few of the uninsured were utilizing health facilities and visit only in critical conditions. This is due to the increased cost of health care services under the NHIS. CONCLUSION The perceived opportunistic behavior of the insured by providers was responsible for the difference in the behavior of providers favoring the uninsured. Besides, the delay in reimbursement also accounted for providers' negative attitude towards the insured. There is urgent need to address these issues in order to promote confidence in the NHIS, as well as its sustainability for the achievement of universal coverage.
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Affiliation(s)
| | - Alexander Suuk Laar
- National Health Insurance Authority (Operations), Greater Accra Region, Accra, Ghana
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Parmar D, Souares A, de Allegri M, Savadogo G, Sauerborn R. Adverse selection in a community-based health insurance scheme in rural Africa: implications for introducing targeted subsidies. BMC Health Serv Res 2012; 12:181. [PMID: 22741549 PMCID: PMC3457900 DOI: 10.1186/1472-6963-12-181] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Accepted: 06/15/2012] [Indexed: 11/24/2022] Open
Abstract
Background Although most community-based health insurance (CBHI) schemes are voluntary, problem of adverse selection is hardly studied. Evidence on the impact of targeted subsidies on adverse selection is completely missing. This paper investigates adverse selection in a CBHI scheme in Burkina Faso. First, we studied the change in adverse selection over a period of 4 years. Second, we studied the effect of targeted subsidies on adverse selection. Methods The study area, covering 41 villages and 1 town, was divided into 33 clusters and CBHI was randomly offered to these clusters during 2004–06. In 2007, premium subsidies were offered to the poor households. The data was collected by a household panel survey 2004–2007 from randomly selected households in these 33 clusters (n = 6795). We applied fixed effect models. Results We found weak evidence of adverse selection before the implementation of subsidies. Adverse selection significantly increased the next year and targeted subsidies largely explained this increase. Conclusions Adverse selection is an important concern for any voluntary health insurance scheme. Targeted subsidies are often used as a tool to pursue the vision of universal coverage. At the same time targeted subsidies are also associated with increased adverse selection as found in this study. Therefore, it’s essential that targeted subsidies for poor (or other high-risk groups) must be accompanied with a sound plan to bridge the financial gap due to adverse selection so that these schemes can continue to serve these populations.
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Affiliation(s)
- Divya Parmar
- Institute of Public Health, INF 324, University of Heidelberg, Heidelberg 69120, Germany.
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Robyn PJ, Bärnighausen T, Souares A, Savadogo G, Bicaba B, Sié A, Sauerborn R. Health worker preferences for community-based health insurance payment mechanisms: a discrete choice experiment. BMC Health Serv Res 2012; 12:159. [PMID: 22697498 PMCID: PMC3476436 DOI: 10.1186/1472-6963-12-159] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2012] [Accepted: 06/14/2012] [Indexed: 01/09/2023] Open
Abstract
Background In 2004, a community-based health insurance scheme (CBI) was introduced in Nouna health district, Burkina Faso. Since its inception, coverage has remained low and dropout rates high. One important reason for low coverage and high dropout is that health workers do not support the CBI scheme because they are dissatisfied with the provider payment mechanism of the CBI. Methods A discrete choice experiment (DCE) was used to examine CBI provider payment attributes that influence health workers’ stated preferences for payment mechanisms. The DCE was conducted among 176 health workers employed at one of the 34 primary care facilities or the district hospital in Nouna health district. Conditional logit models with main effects and interactions terms were used for analysis. Results Reimbursement of service fees (adjusted odds ratio (aOR) 1.49, p < 0.001) and CBI contributions for medical supplies and equipment (aOR 1.47, p < 0.001) had the strongest effect on whether the health workers chose a given provider payment mechanism. The odds of selecting a payment mechanism decreased significantly if the mechanism included (i) results-based financing (RBF) payments made through the local health management team (instead of directly to the health workers (aOR 0.86, p < 0.001)) or (ii) RBF payments based on CBI coverage achieved in the health worker’s facility relative to the coverage achieved at other facilities (instead of payments based on the numbers of individuals or households enrolled at the health worker’s facility (aOR 0.86, p < 0.001)). Conclusions Provider payment mechanisms can crucially determine CBI performance. Based on the results from this DCE, revised CBI payment mechanisms were introduced in Nouna health district in January 2011, taking into consideration health worker preferences on how they are paid.
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Affiliation(s)
- Paul Jacob Robyn
- University of Heidelberg, Institute of Public Health, Heidelberg, Germany.
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Robyn PJ, Sauerborn R, Bärnighausen T. Provider payment in community-based health insurance schemes in developing countries: a systematic review. Health Policy Plan 2012; 28:111-22. [PMID: 22522770 PMCID: PMC3584992 DOI: 10.1093/heapol/czs034] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Objectives Community-based health insurance (CBI) is a common mechanism to generate financial resources for health care in developing countries. We review for the first time provider payment methods used in CBI in developing countries and their impact on CBI performance. Methods We conducted a systematic review of the literature on provider payment methods used by CBI in developing countries published up to January 2010. Results Information on provider payment was available for a total of 32 CBI schemes in 34 reviewed publications: 17 schemes in South Asia, 10 in sub-Saharan Africa, 4 in East Asia and 1 in Latin America. Various types of provider payment were applied by the CBI schemes: 17 used fee-for-service, 12 used salaries, 9 applied a coverage ceiling, 7 used capitation and 6 applied a co-insurance. The evidence suggests that provider payment impacts CBI performance through provider participation and support for CBI, population enrolment and patient satisfaction with CBI, quantity and quality of services provided and provider and patient retention. Lack of provider participation in designing and choosing a CBI payment method can lead to reduced provider support for the scheme. Conclusion CBI schemes in developing countries have used a wide range of provider payment methods. The existing evidence suggests that payment methods are a key determinant of CBI performance and sustainability, but the strength of this evidence is limited since it is largely based on observational studies rather than on trials or on quasi-experimental research. According to the evidence, provider payment can affect provider participation, satisfaction and retention in CBI; the quantity and quality of services provided to CBI patients; patient demand of CBI services; and population enrollment, risk pooling and financial sustainability of CBI. CBI schemes should carefully consider how their current payment methods influence their performance, how changes in the methods could improve performance, and how such effects could be assessed with scientific rigour to increase the strength of evidence on this topic.
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Affiliation(s)
- Paul Jacob Robyn
- Institute of Public Health, University of Heidelberg, Im Neuenheimer Feld 324, 69120 Heidelberg, Germany.
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Determinants for participation in a public health insurance program among residents of urban slums in Nairobi, Kenya: results from a cross-sectional survey. BMC Health Serv Res 2012; 12:66. [PMID: 22424445 PMCID: PMC3317843 DOI: 10.1186/1472-6963-12-66] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2010] [Accepted: 03/19/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The government of Kenya is making plans to implement a social health insurance program by transforming the National Hospital Insurance Fund (NHIF) into a universal health coverage program. This paper examines the determinants associated with participation in the NHIF among residents of urban slums in Nairobi city. METHODS The study used data from the Nairobi Urban Health and Demographic Surveillance System in two slums in Nairobi city, where a total of about 60,000 individuals living in approximately 23,000 households are under surveillance. Descriptive statistics and multivariate logistic regression analysis were used to describe the characteristics of the sample and to identify factors associated with participation in the NHIF program. RESULTS Only 10% of the respondents were participating in the NHIF program, while less than 1% (0.8%) had private insurance coverage. The majority of the respondents (89%) did not have any type of insurance coverage. Females were more likely to participate in the NHIF program (OR = 2.4; p < 0.001), while respondents who were formerly in a union (OR = 0.5; p < 0.05) and who were never in a union (OR = 0.6; p < 0.05) were less likely to have public insurance coverage. Respondents working in the formal employment sector (OR = 4.1; p < 0.001) were more likely to be enrolled in the NHIF program compared to those in the informal sector. Membership in microfinance institutions such as savings and credit cooperative organizations (SACCOs) and community-based savings and credit groups were important determinants of access to health insurance. CONCLUSIONS The proportion of slum residents without any type of insurance is high, which underscores the need for a social health insurance program to ensure equitable access to health care among the poor and vulnerable segments of the population. As the Kenyan government moves toward transforming the NHIF into a universal health program, it is important to harness the unique opportunities offered by both the formal and informal microfinance institutions in improving health care capacity by considering them as viable financing options within a comprehensive national health financing policy framework.
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Dixon J, Tenkorang EY, Luginaah I. Ghana's National Health Insurance Scheme: Helping the Poor or Leaving Them Behind? ACTA ACUST UNITED AC 2011. [DOI: 10.1068/c1119r] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
We present findings on the determinants of enrolment for Ghana's National Health Insurance Scheme (NHIS). With this study we contribute to the literature by providing one of the few quantitative analyses on a nationwide survey. Using data from the 2008 Ghana Demographic and Health Survey, we find that those from the poorest households remain significantly less likely to enrol in the NHIS compared with respondents from wealthy households, even after controlling for theoretically relevant variables. However, our analysis also shows that respondents in Northern Ghana, considered the poorest part of the country, are more likely to be enroled than those in Southern Ghana. The findings present a clear challenge to the original mandate of the NHIS as a propoor policy and suggest that health policy makers should consider expanding and clarifying the criteria for declaring a person as indigent and that the scheme be further evaluated for obstacles that may be hindering enrolment.
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Affiliation(s)
- Jenna Dixon
- Department of Geography, University of Western Ontario, 1151 Richmond Street, London, ON N6A 5C2, Canada
| | - Eric Y Tenkorang
- Department of Sociology, Memorial University of Newfoundland, St John's Newfoundland, A1C 5S7, Canada
| | - Isaac Luginaah
- Department of Geography, University of Western Ontario, 1151 Richmond Street, London, ON N6A 5C2, Canada
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Parmar D, Reinhold S, Souares A, Savadogo G, Sauerborn R. Does community-based health insurance protect household assets? Evidence from rural Africa. Health Serv Res 2011; 47:819-39. [PMID: 22091950 DOI: 10.1111/j.1475-6773.2011.01321.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To evaluate whether community-based health insurance (CBHI) protects household assets in rural Burkina Faso, Africa. DATA SOURCES Data were used from a household panel survey that collected primary data from randomly selected households, covering 41 villages and one town, during 2004-2007(n = 890). STUDY DESIGN The study area was divided into 33 clusters and CBHI was randomly offered to these clusters during 2004-2006. We applied different strategies to control for selection bias-ordinary least squares with covariates, two-stage least squares with instrumental variable, and fixed-effects models. DATA COLLECTION Household members were interviewed in their local language every year, and information was collected on demographic and socio-economic indicators including ownership of assets, and on self-reported morbidity. PRINCIPAL FINDINGS Fixed-effects and ordinary least squares models showed that CBHI protected household assets during 2004-2007. The two-stage least squares with instrumental variable model showed that CBHI increased household assets during 2004-2005. CONCLUSIONS In this study, we found that CBHI has the potential to not only protect household assets but also increase household assets. However, similar studies from developing countries that evaluate the impact of health insurance on household economic indicators are needed to benchmark these results with other settings.
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Affiliation(s)
- Divya Parmar
- Institute of Public Health, INF 324, Heidelberg University, Heidelberg, Germany.
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Jehu-Appiah C, Aryeetey G, Agyepong I, Spaan E, Baltussen R. Household perceptions and their implications for enrollment in the National Health Insurance Scheme in Ghana. Health Policy Plan 2011; 27:222-33. [PMID: 21504981 DOI: 10.1093/heapol/czr032] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE This paper identifies, ranks and compares perceptions of insured and uninsured households in Ghana on health care providers (quality of care, service delivery adequacy, staff attitudes), health insurance schemes (price, benefits and convenience) and community attributes (health 'beliefs and attitudes' and peer pressure). In addition, it explores the association of these perceptions with household decisions to voluntarily enroll and remain in insurance schemes. METHODS First, data from a household survey of 3301 households and 13,865 individuals were analysed using principal component analysis to evaluate respondents' perceptions. Second, percentages of maximum attainable scores were computed for each cluster of perception factors to rank them according to their relative importance. Third, a multinomial logistic regression was run to determine the association of identified perceptions on enrollment. RESULTS Our study demonstrates that scheme factors have the strongest association with voluntary enrollment and retention decisions in the National Health Insurance Scheme (NHIS). Specifically these relate to benefits, convenience and price of NHIS. At the same time, while households had positive perceptions with regards to technical quality of care, benefits of NHIS, convenience of NHIS administration and had appropriate community health beliefs and attitudes, they were negative about the price of NHIS, provider attitudes and peer pressure. The uninsured were more negative than the insured about benefits, convenience and price of NHIS. CONCLUSIONS Perceptions related to providers, schemes and community attributes play an important role, albeit to a varying extent in household decisions to voluntarily enroll and remain enrolled in insurance schemes. Scheme factors are of key importance. Policy makers need to recognize household perceptions as potential barriers or enablers to enrollment and invest in understanding them in their design of interventions to stimulate enrollment.
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Affiliation(s)
- Caroline Jehu-Appiah
- Department of Primary and Community Care, Radboud University Nijmegen Medical Center, PO Box 9101, 6500HB Nijmegen, The Netherlands.
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Robyn PJ, Hill A, Liu Y, Souares A, Savadogo G, Sié A, Sauerborn R. Econometric analysis to evaluate the effect of community-based health insurance on reducing informal self-care in Burkina Faso. Health Policy Plan 2011; 27:156-65. [PMID: 21414993 PMCID: PMC3291875 DOI: 10.1093/heapol/czr019] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE This study examines the role of community-based health insurance (CBHI) in influencing health-seeking behaviour in Burkina Faso, West Africa. Community-based health insurance was introduced in Nouna district, Burkina Faso, in 2004 with the goal to improve access to contracted providers based at primary- and secondary-level facilities. The paper specifically examines the effect of CBHI enrolment on reducing the prevalence of seeking modern and traditional methods of self-treatment as the first choice in care among the insured population. METHODS Three stages of analysis were adopted to measure this effect. First, propensity score matching was used to minimize the observed baseline differences between the insured and uninsured populations. Second, through matching the average treatment effect on the treated, the effect of insurance enrolment on health-seeking behaviour was estimated. Finally, multinomial logistic regression was applied to model demand for available health care options, including no treatment, traditional self-treatment, modern self-treatment, traditional healers and facility-based care. RESULTS For the first choice in care sought, there was no significant difference in the prevalence of self-treatment among the insured and uninsured populations, reaching over 55% for each group. When comparing the alternative option of no treatment, CBHI played no significant role in reducing the demand for self-care (either traditional or modern) or utilization of traditional healers, while it did significantly increase consumption of facility-based care. The average treatment effect on the treated was insignificant for traditional self-care, modern self-care and traditional healer, but was significant with a positive effect for use of facility care. DISCUSSION While CBHI does have a positive impact on facility care utilization, its effect on reducing the prevalence of self-care is limited. The policy recommendations for improving the CBHI scheme's responsiveness to population health care demand should incorporate community-based initiatives that offer attractive and appropriate alternatives to self-care.
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Affiliation(s)
- Paul Jacob Robyn
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA.
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Jehu-Appiah C, Aryeetey G, Spaan E, de Hoop T, Agyepong I, Baltussen R. Equity aspects of the National Health Insurance Scheme in Ghana: Who is enrolling, who is not and why? Soc Sci Med 2010; 72:157-65. [PMID: 21145152 DOI: 10.1016/j.socscimed.2010.10.025] [Citation(s) in RCA: 167] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2010] [Revised: 09/22/2010] [Accepted: 10/20/2010] [Indexed: 11/30/2022]
Abstract
To improve equity in the provision of health care and provide risk protection to poor households, low-income countries are increasingly moving to social health insurance. Using data from a household survey of 3301 households conducted in 2009 this study aims to evaluate equity in enrollment in the National Health Insurance Scheme (NHIS) in Ghana and assess determinants of demand across socio-economic groups. Specifically by looking at how different predisposing (age, gender, education, occupation, family size, marital status, peer pressure and health beliefs etc) enabling (income, place of residence) need (health status) and social factors (perceptions) affect household decision to enrol and remain in the NHIS. Equity in enrollment is assessed by comparing enrollment between consumption quintiles. Determinants of enrolling in and dropping out from NHIS are assessed using a multinomial logit model after using PCA to evaluate respondent's perceptions relating to schemes, providers and community health 'beliefs and attitudes'. We find evidence of inequity in enrollment in the NHIS and significant differences in determinants of current and previous enrollment across socio-economic quintiles. Both current and previous enrollment is influenced by predisposing, enabling and social factors. There are, however, clear differences in determinants of enrollment between the rich and the poor. Policy makers need to recognize that extending enrollment will require recognition of all these complex factors in their design of interventions to stimulate enrollment.
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Affiliation(s)
- Caroline Jehu-Appiah
- Department of Primary and Community Care, Radboud University Nijmegen Medical Center, The Netherlands.
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Sié A, Louis VR, Gbangou A, Müller O, Niamba L, Stieglbauer G, Yé M, Kouyaté B, Sauerborn R, Becher H. The Health and Demographic Surveillance System (HDSS) in Nouna, Burkina Faso, 1993-2007. Glob Health Action 2010; 3. [PMID: 20847837 PMCID: PMC2940452 DOI: 10.3402/gha.v3i0.5284] [Citation(s) in RCA: 121] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2010] [Revised: 08/19/2010] [Accepted: 08/20/2010] [Indexed: 11/16/2022] Open
Abstract
The Nouna Health and Demographic Surveillance System (HDSS) is located in rural Burkina Faso and has existed since 1992. Currently, it has about 78,000 inhabitants. It is a member of the International Network for the Demographic Evaluation of Populations and Their Health in Developing Countries (INDEPTH), a global network of members who conducts longitudinal health and demographic evaluation of populations in low- and middle-income countries. The health facilities consist of one hospital and 13 basic health centres (locally known as CSPS). The Nouna HDSS has been used as a sampling frame for numerous studies in the fields of clinical research, epidemiology, health economics, and health systems research. In this paper we review some of the main findings, and we describe the effects that almost 20 years of health research activities have shown in the population in general and in terms of the perception, economic implications, and other indicators. Longitudinal data analyses show that childhood, as well as overall mortality, has significantly decreased over the observation period 1993–2007. The under-five mortality rate dropped from about 40 per 1,000 person-years in the mid-1990s to below 30 per 1,000 in 2007. Further efforts are needed to meet goal four of the Millennium Development Goals, which is to reduce the under-five mortality rate by two-thirds between 1990 and 2015.
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Affiliation(s)
- Ali Sié
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
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Exploratory study of the impacts of Mutual Health Organizations on social dynamics in Benin. Soc Sci Med 2010; 71:467-474. [PMID: 20580857 DOI: 10.1016/j.socscimed.2010.03.047] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2009] [Revised: 03/25/2010] [Accepted: 03/30/2010] [Indexed: 11/22/2022]
Abstract
The primary aim of Mutual Health Organizations (MHOs) is the financial protection of their members. However, given their community-based, participative and voluntary nature, it is conceivable that MHOs, as social organizations, would affect social dynamics. In an exploratory study in Benin, we studied social dynamics related to mutual aid, relationships of trust, and empowerment. Four MHOs, as contrasted cases, were selected from among the 11 in the region. Focus groups (n = 20) and individual interviews (n = 29) were conducted with members, non-members, and elected leaders of the four MHOs, and with professionals from the health facilities concerned. We carried out a qualitative thematic analysis of the content. Mutual aid practices, which pre-date MHOs, can be mobilized to promote MHO membership. Mutual aid practices are based on relationships of trust. The primary reason for joining an MHO is to improve financial accessibility to health services. Non-members see that members have a strong sense of empowerment in this regard, based on a high level of trust in MHOs and their elected leaders, even if their trust in health professionals is not as strong. Non-members share these feelings of confidence in MHOs and their leadership, although they trust health professionals somewhat less than do the members. The MHOs' low penetration rate therefore cannot be explained by lack of trust, as this study shows that, even with some distrust of the professionals, the overall level of trust in MHOs is high and MHOs and their leaders function as intermediaries with health professionals. Other explanatory factors are the lack of information available to villagers and, most especially, the problems they face in being able to pay the MHO premiums.
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Castleden H, Crooks VA, Schuurman N, Hanlon N. “It’s not necessarily the distance on the map…”: Using place as an analytic tool to elucidate geographic issues central to rural palliative care. Health Place 2010; 16:284-90. [DOI: 10.1016/j.healthplace.2009.10.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2009] [Revised: 10/13/2009] [Accepted: 10/13/2009] [Indexed: 10/20/2022]
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Pokhrel S, De Allegri M, Gbangou A, Sauerborn R. Illness reporting and demand for medical care in rural Burkina Faso. Soc Sci Med 2010; 70:1693-700. [PMID: 20299143 DOI: 10.1016/j.socscimed.2010.02.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2009] [Revised: 12/15/2009] [Accepted: 02/03/2010] [Indexed: 11/16/2022]
Abstract
The issue of illness reporting in modelling demand for health care in low- and middle-income countries can be handled according to either of two conceptually-different constructs: (a) considering illness reporting behaviour as endogenous to demand; or (b) considering demand itself as the outcome of a sample selection phenomenon. In this paper, we take the second viewpoint and estimate the demand for medical care with an estimator that uses Heckman-type. Empirical estimates based on household survey data from rural Burkina Faso suggest that there are some implications of illness reporting behaviour for modelling the demand for medical care.
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Affiliation(s)
- Subhash Pokhrel
- Brunel University, Health Economics Research Group, Uxbridge UB8 3PH, United Kingdom.
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Morrison J, Thapa R, Sen A, Neupane R, Borghi J, Tumbahangphe KM, Osrin D, Manandhar D, Costello A. Utilization and management of maternal and child health funds in rural Nepal. COMMUNITY DEVELOPMENT JOURNAL 2010; 45:75-89. [PMID: 28824196 PMCID: PMC5562271 DOI: 10.1093/cdj/bsn029] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Maternal and neonatal mortality rates are highest in the poorest countries, and financial barriers impede access to health care. Community loan funds can increase access to cash in rural areas, thereby reducing delays in care seeking. As part of a participatory intervention in rural Nepal, community women's groups initiated and managed local funds. We explore the factors affecting utilization and management of these funds and the role of the funds in the success of the women's group intervention. We conducted a qualitative study using focus group discussions, group interviews and unstructured observations. Funds may increase access to care for members of trusted 'insider' families adjudged as able to repay loans. Sustainability and sufficiency of funds was a concern but funds increased women's independence and enabled timely care seeking. Conversely, the perceived necessity to contribute may have deterred poorer women. While funds were integral to group success and increased women's autonomy, they may not be the most effective way of supporting the poorest, as the risk pool is too small to allow for repayment default.
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Affiliation(s)
- Joanna Morrison
- Centre for International Health and Development, Institute of Child Health, University College London, UK
| | - Rita Thapa
- Mother and Infant Research Activities (MIRA), Kathmandu, Nepal
| | - Aman Sen
- Mother and Infant Research Activities (MIRA), Kathmandu, Nepal
| | - Rishi Neupane
- Mother and Infant Research Activities (MIRA), Kathmandu, Nepal
| | - Jo Borghi
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - David Osrin
- Centre for International Health and Development, Institute of Child Health, University College London, UK
| | | | - Anthony Costello
- Centre for International Health and Development, Institute of Child Health, University College London, UK
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Dong H, De Allegri M, Gnawali D, Souares A, Sauerborn R. Drop-out analysis of community-based health insurance membership at Nouna, Burkina Faso. Health Policy 2009; 92:174-9. [DOI: 10.1016/j.healthpol.2009.03.013] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2008] [Revised: 03/16/2009] [Accepted: 03/23/2009] [Indexed: 10/20/2022]
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Vialle-Valentin CE, Ross-Degnan D, Ntaganira J, Wagner AK. Medicines coverage and community-based health insurance in low-income countries. Health Res Policy Syst 2008; 6:11. [PMID: 18973675 PMCID: PMC2584623 DOI: 10.1186/1478-4505-6-11] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2007] [Accepted: 10/30/2008] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES The 2004 International Conference on Improving Use of Medicines recommended that emerging and expanding health insurances in low-income countries focus on improving access to and use of medicines. In recent years, Community-based Health Insurance (CHI) schemes have multiplied, with mounting evidence of their positive effects on financial protection and resource mobilization for healthcare in poor settings. Using literature review and qualitative interviews, this paper investigates whether and how CHI expands access to medicines in low-income countries. METHODS We used three complementary data collection approaches: (1) analysis of WHO National Health Accounts (NHA) and available results from the World Health Survey (WHS); (2) review of peer-reviewed articles published since 2002 and documents posted online by national insurance programs and international organizations; (3) structured interviews of CHI managers about key issues related to medicines benefit packages in Lao PDR and Rwanda. RESULTS In low-income countries, only two percent of WHS respondents with voluntary insurance belong to the lowest income quintile, suggesting very low CHI penetration among the poor. Yet according to the WHS, medicines are the largest reported component of out-of-pocket payments for healthcare in these countries (median 41.7%) and this proportion is inversely associated with income quintile. Publications have mentioned over a thousand CHI schemes in 19 low-income countries, usually without in-depth description of the type, extent, or adequacy of medicines coverage. Evidence from the literature is scarce about how coverage affects medicines utilization or how schemes use cost-containment tools like co-payments and formularies. On the other hand, interviews found that medicines may represent up to 80% of CHI expenditures. CONCLUSION This paper highlights the paucity of evidence about medicines coverage in CHI. Given the policy commitment to expand CHI in several countries (e.g. Rwanda, Lao PDR) and the potential of CHI to improve medicines access and use, systematic research is needed on medicine benefits and their performance, including the impacts of CHI on access to, affordability, and use of medicines at the household level.
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Affiliation(s)
- Catherine E Vialle-Valentin
- WHO Collaborating Center on Pharmaceutical Policy, Harvard Medical School and Harvard Pilgrim Health Care, Boston, MA, USA.
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De Allegri M, Pokhrel S, Becher H, Dong H, Mansmann U, Kouyaté B, Kynast-Wolf G, Gbangou A, Sanon M, Bridges J, Sauerborn R. Step-wedge cluster-randomised community-based trials: an application to the study of the impact of community health insurance. Health Res Policy Syst 2008; 6:10. [PMID: 18945332 PMCID: PMC2583992 DOI: 10.1186/1478-4505-6-10] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2007] [Accepted: 10/22/2008] [Indexed: 11/26/2022] Open
Abstract
Background We describe a step-wedge cluster-randomised community-based trial which has been conducted since 2003 to accompany the implementation of a community health insurance (CHI) scheme in West Africa. The trial aims at overcoming the paucity of evidence-based information on the impact of CHI. Impact is defined in terms of changes in health service utilisation and household protection against the cost of illness. Our exclusive focus on the description and discussion of the methods is justified by the fact that the study relies on a methodology previously applied in the field of disease control, but never in the field of health financing. Methods First, we clarify how clusters were defined both in respect of statistical considerations and of local geographical and socio-cultural concerns. Second, we illustrate how households within clusters were sampled. Third, we expound the data collection process and the survey instruments. Finally, we outline the statistical tools to be applied to estimate the impact of CHI. Conclusion We discuss all design choices both in relation to methodological considerations and to specific ethical and organisational concerns faced in the field. On the basis of the appraisal of our experience, we postulate that conducting relatively sophisticated trials (such as our step-wedge cluster-randomised community-based trial) aimed at generating sound public health evidence, is both feasible and valuable also in low income settings. Our work shows that if accurately designed in conjunction with local health authorities, such trials have the potential to generate sound scientific evidence and do not hinder, but at times even facilitate, the implementation of complex health interventions such as CHI.
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Affiliation(s)
- Manuela De Allegri
- Department of Tropical Hygiene and Public Health, University of Heidelberg, Germany.
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Basaza R, Criel B, Van der Stuyft P. Community health insurance in Uganda: why does enrolment remain low? A view from beneath. Health Policy 2008; 87:172-84. [PMID: 18280608 DOI: 10.1016/j.healthpol.2007.12.008] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2007] [Revised: 12/13/2007] [Accepted: 12/17/2007] [Indexed: 11/19/2022]
Abstract
Community Health Insurance (CHI) in Uganda faces low enrolment despite interest by the Ugandan health sector to have CHI as an elaborate health sector financing mechanism. User fees have been abolished in all government facilities and CHI in Uganda is limited to the private not for profit sub-sector, mainly church-related rural hospitals. In this study, the reasons for the low enrolment are investigated in two different models of CHI. Focus group discussions and in-depth interviews were carried out with members and non-members of CHI schemes in order to acquire more insight and understanding in people's perception of CHI, in their reasons for joining and not joining and in the possibilities they see to increase enrolment. This study, which is unprecedented in East Africa, clearly points to a mixed understanding on the basic principles of CHI and on the routine functioning of the schemes. The lack of good information is mentioned by many. Problems in ability to pay the premium, poor quality of health care, the rigid design in terms of enrolment requirements and problems of trust are other important reasons for people not to join. Our findings are grossly in line with the results of similar studies conducted in West Africa even if a number of context-specific issues have been identified. The study provides relevant elements for the design of a national policy on CHI in Uganda and other sub-Saharan countries.
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Affiliation(s)
- Robert Basaza
- Ministry of Health Uganda, P.O. Box 27450, Kampala, Uganda.
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Basaza R, Criel B, Van der Stuyft P. Low enrollment in Ugandan Community Health Insurance schemes: underlying causes and policy implications. BMC Health Serv Res 2007; 7:105. [PMID: 17620138 PMCID: PMC1940250 DOI: 10.1186/1472-6963-7-105] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2006] [Accepted: 07/09/2007] [Indexed: 11/18/2022] Open
Abstract
Background Despite the promotion of Community Health Insurance (CHI) in Uganda in the second half of the 90's, mainly under the impetus of external aid organisations, overall membership has remained low. Today, some 30,000 persons are enrolled in about a dozen different schemes located in Central and Southern Uganda. Moreover, most of these schemes were created some 10 years ago but since then, only one or two new schemes have been launched. The dynamic of CHI has apparently come to a halt. Methods A case study evaluation was carried out on two selected CHI schemes: the Ishaka and the Save for Health Uganda (SHU) schemes. The objective of this evaluation was to explore the reasons for the limited success of CHI. The evaluation involved review of the schemes' records, key informant interviews and exit polls with both insured and non-insured patients. Results Our research points to a series of not mutually exclusive explanations for this under-achievement at both the demand and the supply side of health care delivery. On the demand side, the following elements have been identified: lack of basic information on the scheme's design and operation, limited understanding of the principles underlying CHI, limited community involvement and lack of trust in the management of the schemes, and, last but not least, problems in people's ability to pay the insurance premiums. On the supply-side, we have identified the following explanations: limited interest and knowledge of health care providers and managers of CHI, and the absence of a coherent policy framework for the development of CHI. Conclusion The policy implications of this study refer to the need for the government to provide the necessary legislative, technical and regulative support to CHI development. The main policy challenge however is the need to reconcile the government of Uganda's interest in promoting CHI with the current policy of abolition of user fees in public facilities.
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Affiliation(s)
- Robert Basaza
- Ministry of Health Uganda, PO Box 27450, Kampala Uganda
- Department of Public Health, Institute of Tropical Medicine Nationalestraat 155, B-2000 Antwerp, Belgium
| | - Bart Criel
- Department of Public Health, Institute of Tropical Medicine Nationalestraat 155, B-2000 Antwerp, Belgium
| | - Patrick Van der Stuyft
- Department of Public Health, Institute of Tropical Medicine Nationalestraat 155, B-2000 Antwerp, Belgium
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Abstract
Removing financial barriers is only the first step towards better access to care for poor people
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80
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Pokhrel S. Scaling up health interventions in resource-poor countries: what role does research in stated-preference framework play? Health Res Policy Syst 2006; 4:4. [PMID: 16573821 PMCID: PMC1448195 DOI: 10.1186/1478-4505-4-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2005] [Accepted: 03/30/2006] [Indexed: 11/17/2022] Open
Abstract
Despite improved supply of health care services in low-income countries in the recent past, their uptake continues to be lower than anticipated. This has made it difficult to scale-up those interventions which are not only cost-effective from supply perspectives but that might have substantial impacts on improving the health status of these countries. Understanding demand-side barriers is therefore critically important. With the help of a case study from Nepal, this commentary argues that more research on demand-side barriers needs to be carried out and that the stated-preference (SP) approach to such research might be helpful. Since SP techniques place service users' preferences at the centre of the analysis, and because preferences reflect individual or social welfare, SP techniques are likely to be helpful in devising policies to increase social welfare (e.g. improved service coverage). Moreover, the SP data are collected in a controlled environment which allows straightforward identification of effects (e.g. that of process attributes of care) and large quantities of relevant data can be collected at moderate cost. In addition to providing insights into current preferences, SP data also provide insights into how preferences are likely to respond to a proposed change in resource allocation (e.g. changing service delivery strategy). Finally, the SP-based techniques have been used widely in resource-rich countries and their experience can be valuable in conducting scaling-up research in low-income countries.
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Affiliation(s)
- Subhash Pokhrel
- School of Health Sciences and Social Care, Brunel University Osterley Campus, Borough Road, Isleworth, Middlesex, TW7 5DU, UK.
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