Impact evaluation of India's 'Yeshasvini' community-based health insurance programme

Value for solidarity: a proxy for community understanding and acceptance of the basic principles of community-based health insurance in rural Ethiopia

BACKGROUND

Solidarity is an aspect of human association that gives emphasis to the cohesive social bond that holds a group together and is valued and understood by all members of the group. A lack of understanding of the solidarity principle is one of the main reasons for low population coverage in microhealth insurance schemes. This study aimed to examine the extent to which people value solidarity and the factors that explain the differences.

METHODS

A community-based cross-sectional study was carried out in two districts of northeast Ethiopia among 1232 randomly selected households which have ever been registered in a community-based health insurance scheme. Face-to-face interviews were conducted with household heads using a standardized questionnaire deployed to an electronic data collection platform. Solidarity was measured using three dimensions: income solidarity, risk solidarity, and cost coverage. Principal component analysis was used to construct composite variables, and the reliability of the tools was checked using Cronbach's alpha. A multivariable analysis was performed using the partial proportional odds model to determine the associations between variables. The degree of association was assessed using the odds ratio, and statistical significance was determined at 95% confidence interval.

RESULTS

Three-quarters (75%) of the respondents rated risk solidarity as high, while 70% and 63% rated income solidarity and cost coverage as high, respectively. Place of residence (AOR = 2.23; 95% CI: 1.68, 2.94), wealth index (AOR = 1.51; 95% CI: 1.07, 2.12), self-rated health status (AOR = 1.64; 95% CI: 1.12, 2.40), trust in insurance schemes (AOR = 1.68; 95% CI: 1.22, 2.30), perceived quality of care (AOR = 1.75; 95% CI: 1.33, 2.31) and frequency of outpatient visits (AOR = 2.05; 95% CI: 1.30, 3.24) were significant predictors of value for solidarity.

CONCLUSIONS

The community placed greater value for solidarity, indicating community understanding and acceptance of the core principles of microhealth insurance. Administrators of the insurance scheme, health authorities, and other actors should strive to create a transparent management system and improve access to high-quality health care, which will facilitate community acceptance of the insurance scheme and its guiding principles.

Measurements of Impoverishing and Catastrophic Surgical Health Expenditures in Low- and Middle-Income Countries and Reduction Interventions in the Last 30 Years: A Systematic Review

INTRODUCTION

Approximately 33 million people suffer catastrophic health expenditure (CHE) from surgery and/or anesthesia costs. The aim of this systematic review is to evaluate catastrophic and impoverishing expenditure associated with surgery and anesthesia in low- and middle-income countries (LMICs).

METHODS

We performed a systematic review of all studies from 1990 to 2021 that reported CHE in LMICs for treatment of a condition requiring surgical intervention, including cesarean section, trauma care, and other surgery.

RESULTS

77 studies met inclusion criteria. Tertiary facilities (23.4%) were the most frequently studied facility type. Only 11.7% of studies were conducted in exclusively rural health-care settings. Almost 60% of studies were retrospective in nature. The cost of procedures ranged widely, from $26 USD for a cesarean section in Mauritania in 2020 to $74,420 for a pancreaticoduodenectomy in India in 2018. GDP per capita had a narrower range from $315 USD in Malawi in 2019 to $9955 USD in Malaysia in 2015 (Median = $1605.50, interquartile range = $1208.74). 35 studies discussed interventions to reduce cost and catastrophic expenditure. Four of those studies stated that their intervention was not successful, 18 had an unknown or equivocal effect on cost and CHE, and 13 concluded that their intervention did help reduce cost and CHE.

CONCLUSIONS

CHE from surgery is a worldwide problem that most acutely affects vulnerable patients in LMICs. Existing efforts are insufficient to meet the true need for affordable surgical care unless assistance for ancillary costs is given to patients and families most at risk from CHE.

Health insurance and child mortality: Evidence from India

Although less than a third of the population in developing countries is covered by health insurance, the number has been on the rise. Many countries have implemented national insurance policies in the past decade. However, there is limited evidence on their impact on child mortality in low- and middle-income contexts. Here we document the child mortality reducing effects of an at-scale national level health insurance policy in India. The Rashtriya Swasthya Bima Yojana (RSBY), was rolled out across India between 2008 and 2013. Leveraging the temporal and spatial variation in program implementation, we demonstrate that it lowered infant mortality by 6% and child under five mortality by 5%. The effects are largely concentrated among urban poor households. In terms of mechanisms, we find that the program effects seem to be driven by increased usage of reproductive health services by mothers. We also demonstrate a rise in usage of complementary health services that were were not covered under the policy (such as child immunizations), which suggests that RSBY had significant positive spillover effects on health care usage.

Determinants of public institutional births in India: An analysis using the National Family Health Survey (NFHS-5) factsheet data

Background

Institutional births ensure deliveries happen under the supervision of skilled healthcare personnel in an enabling environment. For countries like India, with high neonatal and maternal mortalities, achieving 100% coverage of institutional births is a top policy priority. In this respect, public health institutions have a key role, given that they remain the preferred choice by most of the population, owing to the existing barriers to healthcare access. While research in this domain has focused on private health institutions, there are limited studies, especially in the Indian context, that look at the enablers of institutional births in public health facilities. In this study, we look to identify the significant predictors of institutional birth in public health facilities in India.

Method

We rely on the National Family Health Survey (NFHS-5) factsheet data for analysis. Our dependent variable (DV) in this study is the % of institutional births in public health facilities. We first use Welch's t-test to determine if there is any significant difference between urban and rural areas in terms of the DV. We then use multiple linear regression and partial F-test to identify the best-fit model that predicts the variation in the DV. We generate two models in this study and use Akaike's Information Criterion (AIC) and adjusted R2 values to identify the best-fit model.

Results

We find no significant difference between urban and rural areas (P = 0.02, α =0.05) regarding the mean % of institutional births in public health facilities. The best-fit model is an interaction model with a moderate effect size (Adjusted2 = 0.35) and an AIC of 179.93, lower than the competitive model (AIC = 183.56). We find household health insurance (β = -0.29) and homebirth conducted under the supervision of skilled healthcare personnel (β = -0.56) to be significant predictors of institutional births in public facilities in India. Additionally, we observe low body mass index (BMI) and obesity to have a synergistic impact on the DV. Our findings show that the interaction between low BMI and obesity has a strong negative influence (β = -0.61) on institutional births in public health facilities in India.

Conclusion

Providing households with health insurance coverage may not improve the utilisation of public health facilities for deliveries in India, where other barriers to public healthcare access exist. Therefore, it is important to look at interventions that minimise the existing barriers to access. While the ultimate objective from a policy perspective should be achieving 100% coverage of institutional births in the long run, a short-term strategy makes sense in the Indian context, especially to manage the complications arising during births outside an institutional setting.

The impact of basic health insurance participation characteristics on the health of mobile populations: the mediating role of health service utilization behavior

Objectives

It is a pivotal element of China's health system reform to improve the health security of health insurance for the mobile population. Achieving this objective is integral to the success of the reform. The aim of this study was to analyze the impact of different enrollment characteristics of basic health insurance on the health of the mobile population and to investigate the mediating role of health service utilization behavior.

Methods

This cross-sectional study included 135,372 migrants who participated in the 2018 China Migrants Dynamic Survey (CMDS). Two indicators were employed in this study to assess the characteristics of the mobile population's involvement in basic health insurance-namely, whether or not they participated in local health insurance and the type of health insurance in which they participated. The health status of the mobile population was measured using self-assessed health. Health service utilization behavior was divided into public health service utilization and medical service utilization. Multivariate ordered logistic regression was employed to examine the effect of health insurance on the health of the mobile population. Subsequently, the Bootstrap method was applied to analyze the mediating effect of health service utilization behavior in the relationship between health insurance and the health of the mobile population.

Results

Health insurance had a positive impact on health, public health services, and health service utilization among the mobile population. However, enrollment in local health insurance (OR = 1.088, 95% CI = 1.043-1.134) and enrollment in Basic Medical Insurance for Urban Employees (OR = 1.178, 95% CI = 1.090-1.273) were more likely to be associated with higher levels of health and a greater likelihood of receiving health service utilization. The results of the mediating mechanism analysis indicated that health education, health records, family doctor contracting, receiving inpatient services, and being hospitalized locally all played a partially mediating role in the impact of the place of enrollment on health. Regarding the effect of the type of enrollment on health, three types of services-namely, health education, health records, and contracting with a family doctor-played a partially mediating role, while receiving inpatient services and being hospitalized locally did not exhibit a mediating effect. The effect of the type of participation on health is partially mediated.

Conclusion

Based on the impact of the different enrolment characteristics of basic health insurance on the health of the mobile population and the mediating role of health service utilization in this impact, furthermore, improvement of health insurance coverage for the mobile population should focus on improving the accessibility of health services, increasing the level of health insurance coverage, mitigating differences in treatment between the different insurance systems, and simplifying the process of transferring the health insurance relationships.

Dropout rate and associated factors of community-based health insurance beneficiaries in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Ethiopia aims to achieve universal healthcare using health insurance. To do so, it has been implementing community-based health insurance since 2011. However, the retention of members by the scheme has not yet been evaluated nationally. The systematic review and meta-analysis aimed to evaluate the dropout rate and associated factors among the scheme's beneficiaries in Ethiopia.

METHODS

On December 19, 2022, searches were conducted in Scopus, Hinari, PubMed, Semantic Scholar, and Google Scholar. Searches were also conducted on the general web and electronic repositories, including the Ethiopian Health Insurance Service, the International Institute for Primary Health Care-Ethiopia, and various higher education institutions. The Joanna Briggs Institute's tools and the "preferred reporting items for systematic reviews and meta-analyses 2020 statement" were used to evaluate bias and frame the review, respectively. Data were analyzed using Stata 17 and RevMan 5. To assess heterogeneity, we conducted subgroup analysis and used a random model to calculate odds ratios with a p value less than 0.05 and a 95% CI.

RESULTS

In total, 14 articles were included in the qualitative synthesis, of which 12 were selected for the quantitative analysis. The pooled estimate revealed that the dropout rate of beneficiaries from the scheme was 34.0% (95% CI: 23-44%), provided that the renewal rate was 66.0%, and was found to be influenced by socio-demographic, health status, length of enrolment, knowledge, attitude, the scheme, and health service-related variables. The southern and Oromia regions reported the lowest and highest dropout rates, with 27.0% (95% CI: 24-29%) and 48.0% (95% CI: 18-78%), respectively. The dropout rates increased from 12.3% in 2012-2015 to 34.4% in 2020-2021.

CONCLUSION

More than one-third of the scheme's beneficiaries were found to have dropped out, and this has been found to increase over time, dictating that a community-based strategy and intervention, from the supply, insurer, and demand sides, seem indispensable in minimizing this huge dropout rate.

Effectiveness and impact of community-based health insurance on health service utilization in northwest Ethiopia: a quasi-experimental evaluation

Background

Addressing the health challenges of lower socioeconomic groups in Ethiopia is still a huge problem. In that regard, the government piloted the community-based health insurance (CBHI) in 2011 in a few districts and subsequently scaled up. However, the effectiveness of the program on the utilization of health services and its impact was not well explored. Thus, we aimed to evaluate the effectiveness of CBHI toward health services' utilization and its impact in northwest Ethiopia.

Methods

A quasi-experimental matched comparison group evaluation design with sequential explanatory mixed methods was employed. To evaluate the CBHI program, the effectiveness and impact dimensions from the Organization for Economic Cooperation and Development framework were used. A multistage sampling technique was used to select a total of 332 households enrolled in the CBHI program; 341 comparison households who did not enroll in the program were also randomly selected. A structured interviewer-administrated questionnaire was used to evaluate the effectiveness and impact of CBHI on health service utilization. The Propensity score matching model was employed for the estimation of the effect of the CBHI program on health service utilization. Challenges for program achievement toward health service utilization were explained through qualitative data and these were then analyzed thematically.

Results

The evaluation showed 1.3 visits per capita per year of health service utilization among CBHI members. Households enrolled in CBHI increased health service utilization by 6.9 percentage points (ATT = 0.069; 95% CI: 0.034, 0.114). There was an improvement in health service utilization after the introduction of CBHI, however, there are challenges: (i) shortage of human resources, (ii) out-of-stock of drugs and medical supplies, and (iii) long waiting times for service and reimbursement claims. These issues limit the success of the program toward health service utilization.

Conclusion

The CBHI program contributed to health service utilization improvement among CBHI members. However, the utilization rate of health services among CBHI members is still less than the target stated for the program and also the WHO recommendation. Therefore, the findings of this evaluation can be used by program implementers, policy makers, and other stakeholders to overcome the identified challenges and to increase the success of the program.

Impact of community-based health insurance in low- and middle-income countries: A systematic review and meta-analysis

BACKGROUND

To systematically evaluate the empirical evidence on the impact of community-based health insurance (CBHI) on healthcare utilization and financial risk protection in low- and middle-income countries (LMIC).

METHODS

We searched PubMed, CINAHL, Cochrane CENTRAL, CNKI, PsycINFO, Scopus, WHO Global Index Medicus, and Web of Science including grey literature, Google Scholar®, and citation tracking for randomized controlled trials (RCTs), non-RCTs, and quasi-experimental studies that evaluated the impact of CBHI schemes on healthcare utilization and financial risk protection in LMICs. We assessed the risk of bias using Cochrane's Risk of Bias 2.0 and Risk of Bias in Non-randomized Studies of Interventions tools for RCTs and quasi/non-RCTs, respectively. We also performed a narrative synthesis of all included studies and meta-analyses of comparable studies using random-effects models. We pre-registered our study protocol on PROSPERO: CRD42022362796.

RESULTS

We identified 61 articles: 49 peer-reviewed publications, 10 working papers, 1 preprint, and 1 graduate dissertation covering a total of 221,568 households (1,012,542 persons) across 20 LMICs. Overall, CBHI schemes in LMICs substantially improved healthcare utilization, especially outpatient services, and improved financial risk protection in 24 out of 43 studies. Pooled estimates showed that insured households had higher odds of healthcare utilization (AOR = 1.60, 95% CI: 1.04-2.47), use of outpatient health services (AOR = 1.58, 95% CI: 1.22-2.05), and health facility delivery (AOR = 2.21, 95% CI: 1.61-3.02), but insignificant increase in inpatient hospitalization (AOR = 1.53, 95% CI: 0.74-3.14). The insured households had lower out-of-pocket health expenditure (AOR = 0.94, 95% CI: 0.92-0.97), lower incidence of catastrophic health expenditure at 10% total household expenditure (AOR = 0.69, 95% CI: 0.54-0.88), and 40% non-food expenditure (AOR = 0.72, 95% CI: 0.54-0.96). The main limitations of our study are the limited data available for meta-analyses and high heterogeneity persisted in subgroup and sensitivity analyses.

CONCLUSIONS

Our study shows that CBHI generally improves healthcare utilization but inconsistently delivers financial protection from health expenditure shocks. With pragmatic context-specific policies and operational modifications, CBHI could be a promising mechanism for achieving universal health coverage (UHC) in LMICs.

Contemporary Universal Health Coverage in India - The Case of Federal State of Odisha (Orissa)

Purpose

The present study assessed the awareness of the public about Biju Swasthya Kalyan Yojana (BSKY), which is a flagship public-funded health insurance scheme of the Government of Odisha. The study also identified its determinants and examined utilisation of the scheme among households in Khordha district of Odisha.

Materials and Methods

Primary data were collected from randomly chosen 150 households using a pretested structured questionnaire from Balipatana block of Khordha district, Odisha. Descriptive statistics and binomial logistic regression were used to substantiate the objectives.

Results

The study found that even though 56.70% of the sample households had heard about BSKY, procedure-specific awareness was low. State government organised BSKY health insurance camp was found to be a major source of knowledge among the sample. The regression model had an R² of 0.414. The Chi² value showed that the model with predictor variables was a good fit. Caste, gender, economic category, health insurance, and awareness about insurance were significant determinants of BSKY awareness. A majority (79.30%) of the sample had the scheme card with them. However, only 12.60% of the cardholders used the card and only 10.67% received benefits. Mean out-of-pocket expenditure (OOPE) faced by the beneficiaries is Rs. 15743.59. Among the beneficiaries, 53.80% financed the OOPE from their savings, 38.50% by borrowing, and 7.70% financed the OOPE by both means.

Conclusion

The study found that even though majority of people had heard about BSKY, they were not aware of its nature, features, and operational procedures. The trend of low benefit received and higher OOPE among the scheme beneficiaries hampers the economic health of the poor. Finally, the study highlighted the need to increase the magnitude of scheme coverage and administrative efficiency.

Household satisfaction with a pilot community-based health insurance scheme and associated factors in Addis Ababa

Background

Many countries introduce CBHI as their healthcare financing system to ensure healthcare access. Understanding the level of satisfaction and factors associated with it is essential to ensure the sustainability of the program. Therefore, this study aimed to assess household satisfaction with a CBHI scheme and its associated factors in Addis Ababa.

Design and methods

Institutional-based cross-sectional study was conducted in the 10 health centers found in the 10 sub-cities of Addis Ababa. Both quantitative and qualitative methods were used. Logistic regression analysis was carried out to identify its associated factors and thematic analysis was used for qualitative data. Finally, variables with a p-value of <0.05 have been considered statistically significant.

Results

In this study, the overall satisfaction level of households with CBHI was 46.3%. Satisfaction was associated with valid CBHI management regulations (AOR = 1.96, 95% CI: 1.12, 3.46), participants who received the right drug (AOR = 1.77, 95% CI: 1.08, 2.93), households who got immediate care (AOR = 4.95, 95% CI: 2.72, 8.98), those who agreed with the adequacy of medical equipment (AOR = 1.65, 95% CI: 1.02, 2.69), and households who agreed with qualification of health personnel (AOR = 1.89, 95% CI: 1.12, 3.20) were more satisfied with the scheme than their counterparts. The challenges mentioned by the discussants were the shortage of drugs, poor attitude of health professionals, absence of kenema pharmacy, lack of laboratory services, lack of awareness about the CBHI scheme, and tight payment schedule.

Conclusions

the satisfaction level of households was low. To achieve a better result, the concerned bodies should work to improve the availability of medication, and medical equipment and improve the attitude of healthcare workers.

The impact of community-based health insurance on health service utilization and financial risk protection in Ethiopia

BACKGROUND

Evidence on the effectiveness of community-based health insurance (CBHI) in low-income countries is inconclusive. This study assessed the impact of CBHI on health service utilization and financial risk protection in Ethiopia.

METHODS

We conducted a comparative cross-sectional study nested within a larger national household survey in 2020. Data was collected from three groups of households-CBHI member households (n = 1586), non-member households from CBHI implementing woredas (n = 1863), and non-member households from non-CBHI implementing woredas (n = 789). Indicators of health service utilization, out-of-pocket health spending, catastrophic health expenditure, and impoverishment due to health spending among CBHI members were compared with non-members from CBHI implementing woredas and households from non-CBHI implementing woredas. Propensity score matching (PSM) was used to account for possible selection bias.

RESULTS

The annual number of OPD visits per capita among CBHI member households was 2.09, compared to 1.53 among non-member households from CBHI woredas and 1.75 among households from non-CBHI woredas. PSM estimates indicated that CBHI members had 0.36 (95% CI: 0.25, 0.44) and 0.17 (95% CI: -0.04, 0.19) more outpatient department (OPD) visits per capita per year than their matched non-member households from CBHI-implementing and non-CBHI implementing woredas, respectively. CBHI membership resulted in a 28-43% reduction in annual OOP payments as compared to non-member households. CBHI member households were significantly less likely to incur catastrophic health expenditures (measured as annual OOP payments of more than 10% of the household's total expenditure) compared to non-members (p < 0.01).

CONCLUSION

CBHI membership increases health service utilization and financial protection. CBHI proves to be an important strategy for promoting universal health coverage. Implementing CBHI in all woredas and increasing membership among households in woredas that are already implementing CBHI will further expand its benefits.

Evaluation of the National Health Insurance Program of Nepal: are political promises translated into actions?

BACKGROUND

Despite political promise to reduce out-of-pocket (OOP) expenditure on healthcare through the National Health Insurance Program (NHIP) of Nepal, its implementation is challenging with low enrolment and high drop-out rates. Program performance can often be linked with political economy considerations and interests of stakeholders. This study aimed to develop an in-depth understanding of organizational and systemic challenges in implementing NHIP.

METHODS

We conducted a structured narrative review of available literature on the NHIP in Nepal. We analysed data using a political economy analysis for health financing reform framework. The findings were explained under six broad categories: interest groups, bureaucracy, budgets, leadership, beneficiary and external actors. In addition, we triangulated and further presented the literature review findings using expert opinions (views expressed in public forums).

RESULTS

Nepal has formulated acts, rules, regulations, and policies to implement NHIP. Under this program, the Health Insurance Board (HIB) is the purchaser of health services, and health facilities under the Ministry of Health and Population (MoHP) are the providers. The NHIP has been rolled out in all 77 districts. Several challenges have hindered the performance of NHIP at the policy and implementation levels. Challenges under interest groups included inadequate or delayed reimbursement and drop-out of hospitals in implementing the programme. Bureaucracy-related challenges were hegemony of provider over the purchaser, and inadequate staff (delay in the approval of organogram of HIB). There was inadequate monitoring of premium collection, and claim reimbursement was higher than collected premium. Challenges under leadership included high political commitments but weak translation into action, consideration of health insurance as poor return on investment, and intention of leaders to privatize the NHIP. Beneficiaries experienced compromised quality of care or lack of services when needed, high drop-out rates and low interest in renewal of premiums. External actors provided technical assistance in policy design but limited support in implementation.

CONCLUSIONS

Despite enabling a policy environment, the NHIP faced many challenges in implementation. There is an urgent need for institutional arrangements (e.g. digitalization of claims and reimbursement, endorsement of organogram of HIB and recruitment of staff), increased coverage of financial protection and service (increased benefit package and introduction of cost-sharing/co-payment model), legislative reforms (e.g. legal provision for cost-sharing mechanism, integration of fragmented schemes, tripartite agreement to reimburse claims and accreditation of health facilities to ensure quality healthcare), and leveraging technical support from the external actors. High levels of commitment and accountability among political leaders and bureaucrats are required to strengthen financial sustainability and implementation.

Short and longer-term impacts of health insurance on catastrophic health expenditures in Kwara State, Nigeria

BACKGROUND

Out- of-pocket health expenditures (OOPs) constitute a significant proportion of total health expenditures in many low- and middle-income countries (LMICs), leading to an increased likelihood of exposure to financial catastrophe in the event of illness. Health insurance has the potential to reduce catastrophic health expenditures (CHE), but rigorous evidence of its sustained impact is limited, especially in LMICs. This study examined the short- and longer-term effects of a health insurance program in Kwara State, Nigeria on CHE.

METHODS

The analysis is based on a panel dataset consisting of 3 waves of household surveys in program and comparison areas. The balanced data consists of 1,039 households and 3,450 individuals. We employed a difference-in-differences (DiD) regression approach to estimate intention-to-treat effects, and then computed average treatment effects on the treated by combining DiD with propensity score weighting and an instrumental variables analysis. CHE was measured as OOPs exceeding 10% of household consumption and 40% of capacity-to-pay (CTP).

RESULTS

Using 10% of consumption as a CHE measure, we found that living in the program area was associated with a 4.3 percentage point (pp) decrease in CHE occurrence (p < 0.05), while the effect on insured households was 5.7 pp (p < 0.05). The longer-term impact four years after program introduction was not significant. Heterogeneity analyses show a reduction in CHE of 7.2 pp (p < 0.01) in the short-term for the poorest tercile. No significant effects were found for the middle and richest terciles, nor in the longer-term. Households with a chronically ill member experienced a reduction in CHE of 9.4 pp (p < 0.01) in the short-term, but not in the longer-term. Most estimates based on the 40% of CTP measure were not statistically significant.

CONCLUSION

These findings highlight the critical role of health insurance in reducing the likelihood of catastrophic health expenditures, especially for vulnerable populations such as the poor and the chronically ill, and by extension in achieving universal health coverage. They also show that the beneficial impacts of health insurance may attenuate over time, as households potentially adjust their health-seeking behavior to the new scheme.

Causal relationship between health insurance and overall health status of children: Insights from Pakistan

Evaluating the impact of health insurance always remains a methodologically challenging endeavor due to the absence of sample randomization. This paper evaluates the impact of health insurance on the health status of children in Pakistan using the data of the Multiple Indicator Cluster Survey (MICS) for Punjab, Pakistan, from 2017 to 2018. The study adopted the propensity score matching (PSM) method to address the sample selection bias. The sample is matched on potential covariates such as mother characteristics (education level), household head characteristics (gender, age, and education), and other household conditions (such as home dwelling, internet access, wealth index, migration member, number of children residing in the home, as child illness, etc.). The findings revealed that children with insurance have considerably better health than non-insured, at a 1% significance level. The results confirm that health insurance is not a luxury but a need that improves children's overall health. In this regard, governments should enhance and expand programs related to health insurance, especially for children. Health insurance programs will not only help poor people but also improve the overall infrastructure of health services in the country.

Evaluating health policies with subnational disparities: a text-mining analysis of the Urban Employee Basic Medical Insurance Scheme in China

Subnational disparities in most health systems often defy 'one-size-fits-all' approach in policy implementation. When local authorities implement a national policy in a decentralized context, they behave as a strategic policy actor in specifying the central mandates, selecting appropriate tools and setting key implementation parameters. Local policy discretion leads to diverse policy mixes across regions, thus complicating evidence-based evaluations of policy impacts. When measuring complex policy reforms, mainstream policy evaluation methodologies have tended to adopt simplified policy proxies that often disguise distinct policy choices across localities, leaving the heterogeneous effects of the same generic policy largely unknown. Using the emerging 'text-as-data' methodology and drawing from subnational policy documents, this study developed a novel approach to policy measurement through analysing policy big data. We applied this approach to examine the impacts of China's Urban Employee Basic Medical Insurance (UEBMI) on individuals' out-of-pocket (OOP) spending. We found substantial disparities in policy choices across prefectures when categorizing the UEBMI policy framework into benefit-expansion and cost-containment reforms. Overall, the UEBMI policies lowered enrollees' OOP spending in prefectures that embraced both benefit-expansion and cost-containment reforms. In contrast, the policies produced ill effects on OOP spending of UEBMI enrollees and uninsured workers in prefectures that carried out only benefit-expansion or cost-containment reforms. The micro-level impacts of UEBMI enrolment on OOP spending were conditional on whether prefectural benefit-expansion and cost-containment reforms were undertaken in concert. Only in prefectures that promulgated both types of reforms did UEBMI enrolment reduce OOP spending. These findings contribute to a comprehensive text-mining measurement approach to locally diverse policy efforts and an integration of macro-level policy analysis and micro-level individual analysis. Contextualizing policy measurements would improve the methodological rigour of health policy evaluations. This paper concludes with implications for health policymakers in China and beyond.

Financial viability of a community-based health insurance scheme in two districts of northeast Ethiopia: a mixed methods study

BACKGROUND

Community-based health insurance initiatives in low- and middle-income countries encountered a number of sustainability challenges due to their voluntary nature, small risk pools, and low revenue. In Ethiopia, the schemes' financial viability has not been well investigated so far. This study examined the scheme's financial viability and explored underlying challenges from the perspectives of various key stakeholders.

METHODS

This study employed a mixed methods case study in two purposively selected districts of northeast Ethiopia. By reviewing financial reports of health insurance schemes, quantitative data were collected over a seven years period from 2014 to 2020 to examine trends in financial status. Trends for each financial indicator were analyzed descriptively for the period under review. Interviews were conducted face-to-face with nine community members and 19 key informants. We used the maximum variation technique to select the study participants. Interviews were audio recorded, transcribed verbatim, and translated into English. Thematic analysis was applied with both inductive and deductive coding methods.

RESULTS

Both schemes experienced excess claims costs and negative net income in almost all the study period. Even after government subsidies, the scheme's net income remained negative for some reporting periods. The challenges contributing to the observed level of financial performance have been summarized under five main themes, which include adverse selection, moral hazard behaviors, stockout of medicines, delays in claims settlement for service providers, and low insurance premiums.

CONCLUSIONS

The health insurance scheme in both districts spent more than it received for claims settlement in almost all the period under the study, and experienced heavy losses in these periods, implying that it is not financially viable for the period in question. The scheme is also unable to fulfill its purpose of protecting members against out-of-pocket expenses at the point of health care. Interventions should target on the highlighted challenges to restore financial balance and enhance the scheme's viability.

The politics of universal health coverage

The UN has declared universal health coverage an urgent global goal. Efforts to achieve this goal have been supported by rigorous research on the scientific, technical, and administrative aspects of health systems design. Yet a substantial portion of the world's population does not have access to essential health services. There is growing recognition that achieving universal health coverage is a political challenge. However, fundamental concepts from the political science discipline are often overlooked in the health literature. This Series paper draws on political science research to highlight the ways in which politics can facilitate, or stymie, policy reform. Specifically, we present a framework of analysis that explores how interests, ideas, and institutions shape universal health coverage. We then examine key considerations relating to the implementation of relevant policies. This Series paper shows that a political understanding of universal health coverage is needed to achieve health for all.

Catastrophic Health Expenditure on Private Sector Pharmaceuticals: A Cross-Sectional Analysis from the State of Odisha, India

India has high rates of catastrophic health expenditure (CHE): 16% of Indian households incur CHE. To understand why CHE is so high, we conducted an in-depth analysis in the state of Odisha—a state with high rates of public sector facility use, reported eligibility for public insurance of 80%, and the provision of drugs for free in government-run facilities—yet with the second-highest rates of CHE across India (24%). We collected household data in 2019 representative of the state of Odisha and captured extensive information about healthcare seeking, including the facility type, its sector (private or public), how much was spent out-of-pocket, and where drugs were obtained. We employ Shapley decomposition to attribute variation in CHE and other financial hardship metrics to characteristics of healthcare, controlling for health and social determinants. We find that 36.3% (95% uncertainty interval: 32.7–40.1) of explained variation in CHE is attributed to whether a private sector pharmacy was used and the number of drugs obtained. Of all outpatient visits, 13% are with a private sector chemist, a similar rate as public primary providers (15%). Insurance was used in just 6% of hospitalizations and its use explained just 0.2% (0.1–0.4) of CHE overall. Eighty-six percent of users of outpatient care obtained drugs from the private sector. We estimate that eliminating spending on private drugs would reduce CHE by 56% in Odisha. The private sector for pharmaceuticals fulfills an essential health system function in Odisha—supplying drugs to the vast majority of patients. To improve financial risk protection in Odisha, the role currently fulfilled by private sector pharmacies must be considered alongside existing shortcomings in the public sector provision of drugs and the lack of outpatient care and drug coverage in public insurance programs.

Operational and Structural Factors Influencing Enrolment in Community-Based Health Insurance Schemes: An Observational Study Using 12 Waves of Nationwide Panel Data from Senegal

Community-based health insurance (CBHI) has been implemented in many low and middle-income countries to increase financial risk protection in populations without access to formal health insurance. While the design of such social programs is fundamental to ensuring equitable access to care, little is known about the operational and structural factors influencing enrolment in CBHI schemes. In this study, we took advantage of newly established data monitoring requirements in Senegal to explore the association between the operational capacity and structure of CBHI schemes-also termed 'mutual health organisations' (MHO) in francophone countries-and their enrolment levels. The dataset comprised 12 waves of quarterly data over 2017-2019 and covered all 676 MHOs registered in the country. Primary analyses were conducted using dynamic panel data regression analysis. We found that higher operational capacity significantly predicted higher performance: enrolment was positively associated with the presence of a salaried manager at the MHO level (12% more total enrollees, 23% more poor members) and with stronger cooperation between MHOs and local health posts (for each additional contract signed, total enrollees and poor members increased by 7% and 5%, respectively). However, higher operational capacity was only modestly associated with higher sustainability proxied by the proportion of enrollees up to date with premium payment. We also found that structural factors were influential, with MHOs located within a health facility enrolling fewer poor members (-16%). Sensitivity analyses showed that these associations were robust. Our findings suggest that policies aimed at professionalising and reinforcing the operational capacity of MHOs could accelerate the expansion of CBHI coverage, including in the most impoverished populations. However, they also suggest that increasing operational capacity alone may be insufficient to make CBHI schemes sustainable over time.

The role of crop insurance in reducing pesticide use: Evidence from rice farmers in China

Pesticides play a significant role in increasing agricultural yields. However, the overuse of chemical pesticides on crops is a major challenge faced by China, which damages human health, threatens food security, and increases production costs. This paper provides empirical evidence on the relationship between crop insurance and pesticide use. Based on micro-survey data collected from 3410 households, we estimate a control function (CF) approach and find that farmers who purchase crop insurance use 33.30% lower pesticides than those who do not. A series of robustness tests confirm these findings. The results of the moderating effect analysis suggest that rice cultivation training, experience, schooling years, and agricultural laborers can negatively moderate the effect of crop insurance on pesticide use. Furthermore, we also find that the treatment effect of crop insurance is stronger for farmers who are most inclined to purchase crop insurance.

Continued adherence to community-based health insurance scheme in two districts of northeast Ethiopia: application of accelerated failure time shared frailty models

Background

The sustainability of a voluntary community-based health insurance scheme depends to a greater extent on its ability to retain members. In low- and middle-income countries, high rate of member dropout has been a great concern for such schemes. Although several studies have investigated the factors influencing dropout decisions, none of these looked into how long and why members adhere to the scheme. The purpose of this study was to determine the factors affecting time to drop out while accounting for the influence of cluster-level variables.

Methods

A community-based cross-sectional study was conducted among 1232 rural households who have ever been enrolled in two community-based health insurance schemes. Data were collected using an interviewer-administered questionnaire via a mobile data collection platform. The Kaplan–Meier estimates were used to compare the time to drop out among subgroups. To identify predictors of time to drop out, a multivariable analysis was done using the accelerated failure time shared frailty models. The degree of association was assessed using the acceleration factor (δ) and statistical significance was determined at 95% confidence interval.

Results

Results of the multivariable analysis revealed that marital status of the respondents (δ = 1.610; 95% CI: 1.216, 2.130), household size (δ = 1.168; 95% CI: 1.013, 1.346), presence of chronic illness (δ = 1.424; 95% CI: 1.165, 1.740), hospitalization history (δ = 1.306; 95% CI: 1.118, 1.527), higher perceived quality of care (δ = 1.322; 95% CI: 1.100, 1.587), perceived risk protection (δ = 1.218; 95% CI: 1.027, 1.444), and higher trust in the scheme (δ = 1.731; 95% CI: 1.428, 2.098) were significant predictors of time to drop out. Contrary to the literature, wealth status did not show a significant correlation with the time to drop out.

Conclusions

The fact that larger households and those with chronic illness remained longer in the scheme is suggestive of adverse selection. It is needed to reconsider the premium level in line with household size to attract small size households. Resolving problems related to the quality of health care can be a cross-cutting area of ​​intervention to retain members by building trust in the scheme and enhancing the risk protection ability of the schemes.

Effectiveness of health voucher scheme and micro-health insurance scheme to support the poor and extreme poor in selected urban areas of Bangladesh: An assessment using a mixed-method approach

Background

National healthcare financing strategy recommends tax-based equity funds and insurance schemes for the poor and extreme poor living in urban slums and pavements as the majority of these population utilise informal providers resulting in adverse health effects and financial hardship. We assessed the effect of a health voucher scheme (HVS) and micro-health insurance (MHI) scheme on healthcare utilisation and out-of-pocket (OOP) payments and the cost of implementing such schemes.

Methods

HVS and MHI schemes were implemented by Concern Worldwide through selected NGO health centres, referral hospitals, and private healthcare facilities in three City Corporations of Bangladesh from December 2016 to March 2020. A household survey with 1,294 enrolees, key-informant interviews, focus group discussions, consultative meetings, and document reviews were conducted for extracting data on healthcare utilisation, OOP payments, views of enrolees, and suggestions of implementers, and costs of services at the point of care.

Results

Healthcare utilisation including maternal, neonatal and child health (MNCH) services, particularly from medically trained providers, was higher and OOP payments were lower among the scheme enrolees compared to corresponding population groups in general. The beneficiaries were happy with their access to healthcare, especially for MNCH services, and their perceived quality of care was fair enough. They, however, suggested expanding the benefits package, supported by an additional workforce. The cost per beneficiary household for providing services per year was €32 in HVS and €15 in MHI scheme.

Conclusion

HVS and MHI schemes enabled higher healthcare utilisation at lower OOP payments among the enrolees, who were happy with their access to healthcare, particularly for MNCH services. However, they suggested a larger benefits package in future. The provider’s costs of the schemes were reasonable; however, there are potentials of cost containment by purchasing the health services for their beneficiaries in a competitive basis from the market. Scaling up such schemes addressing the drawback would contribute to achieving universal health coverage.

Out-of-pocket Health Spending and Its Impact on Household Well-being in Maharashtra

Health is one of the major determinants of the overall well-being of a society. The World Health Organization has emphasised the right to health for all, and the universal health coverage is a paradigm of this emphasis with an agenda of nobody to be left behind in the provision of health services without any financial burden by 2030.This article tries to analyse the extent of catastrophic expenditure being incurred by the people despite being sheltered under a financial protection (Health Insurance) in the state of Maharashtra. The impact caused by out-of-pocket (OOP) health expenditure on the economic status of the people in the state is assessed using the National Sample Survey Office’s 71st round conducted by the Ministry of Health and Family Welfare, Government of India. It was found that over 4.18% of the population endured the burden caused by OOP expenditure by falling below the poverty line post health payments. A higher proportion of rural population is observed to have experienced a fall in the economic status from above poverty line (APL) to below poverty line (BPL) due to high OOP expenditure than that of the urban population in Maharashtra.

Does community-based health insurance improve access to care in sub-Saharan Africa? A rapid review

In sub-Saharan African countries, out-of-pocket payments can be a major barrier to accessing appropriate healthcare services. Community-based health insurance (CBHI) has emerged as a context-appropriate risk-pooling mechanism to provide some financial protection to populations without access to formal health insurance. The aim of this rapid review was to examine the peer-reviewed literature on the impact of CBHI on the use of healthcare services as well as its capacity to improve equity in the use of healthcare between different socio-economic groups. A systematic search of three electronic databases (Pubmed, Cochrane Library and Littérature en Santé) was performed. Data were extracted on scheme and study characteristics, as well as the impact of the schemes on relevant outcomes. Sixteen publications met the inclusion criteria, studying schemes from seven different countries. They provide strong evidence that community-based health insurance can contribute to improving access to outpatient care and weak evidence that they improve access to inpatient care. There was low evidence on their capacity to improve equity in access to healthcare among insured members. In the absence of sufficient public spending for healthcare, such schemes may be able to provide some valuable benefits for communities with limited access to primary-level care in sub-Saharan Africa. The overall high risk of bias of the studies and the wide existing variety of insurance arrangements suggest caution in generalizing these results. These findings need to be validated and further developed by rigorous studies.

Public health insurance and birth outcomes: evidence from Punjab, Pakistan

Public health insurance targeted towards low-income households has gained traction in many developing countries. However, there is limited evidence as to the effectiveness of these programs in countries where institutional constraints may limit participation by the eligible population. This paper evaluates a recent health insurance initiative introduced in Pakistan and discusses whether eligibility for the programme improves maternal health seeking behaviour. The Prime Minister National Health Program provides free insurance coverage to low-income families. The programme is in the early phases of implementation and has, since 2016, only been rolled out in a few eligible districts within the country. This allows for a comparison of eligible households in districts where the programme has been introduced to those that are eligible to receive insurance at a future date. Using repeated cross-sectional data from multiple rounds of representative household survey, a difference-in-difference model has been estimated. Results show that at least for a specific beneficiary group (i.e. pregnant women), there has been a positive increase in utilization of hospital services. Furthermore, we provide evidence using mother fixed effects that the programme increased the likelihood of a child's birth being documented. Since possession of a birth certificate can secure civic rights for a child, this is an unintended but positive outcome of the programme.

WITHDRAWN: The effect of commercial health insurance and health policy incentives on health risk assessment of residents

Ahead of Print article withdrawn by publisher.

The failure of community-based health insurance schemes in Tanzania: opening the black box of the implementation process

BACKGROUND

Globally, there is increased advocacy for community-based health insurance (CBHI) schemes. Like other low and middle-income countries (LMICs), Tanzania officially established the Community Health Fund (CHF) in 2001 for rural areas; and Tiba Kwa Kadi (TIKA) for urban population since 2009. This study investigated the implementation of TIKA scheme in urban districts of Tanzania.

METHODS

A descriptive qualitative case study was conducted in four urban districts in Tanzania in 2019. Data were collected using semi-structured interviews, focus group discussions and review of documents. A thematic approach was used to analyse the data.

RESULTS

While TIKA scheme was important in increasing access to health services for the poor and other disadvantaged groups, it faced many challenges which hindered its performance. The challenges included frequent stock-out of drugs and medical supplies, which frustrated TIKA members and hence contributed to non-renewal of membership. In addition, the scheme was affected by poor collections and management of the revenue collected from TIKA members, limited benefit packages and low awareness of the community.

CONCLUSIONS

Similar to rural-based Community Health Fund, the TIKA scheme faced structural and operational challenges which subsequently resulted into low uptake of the schemes. In order to achieve universal health coverage, the government should consider integrating or merging Community-Based Health Insurance schemes into a single national pool with decentralised arms to win national support while also maintaining local accountability.

Making Health Insurance Pro-poor: Lessons from 20 Developing Countries

The last 20 years have seen a substantial growth in research on the extent to which health sector reforms are pro-poor or pro-rich. What has been missing is knowledge synthesis work to derive operational lessons from the empirical research. This article fills the gap for the most popular form of health financing reform, health insurance. Based on publications covering 20 developing countries, we find that health insurance is no panacea for improving equity in the health sector. More importantly, we find certain design elements of health insurance can increase the likelihood of tackling inequality in the health sector in developing countries.

Financial protection and coping strategies in rural Uganda: an impact evaluation of community-based zero-interest healthcare loans

In low- and middle-income countries, catastrophic health expenditures and economic hardship constitute a common risk for households' welfare. Community health financing (CHF) represents a viable option to improve financial protection, but robust impact evaluations are needed to advance the debate concerning universal health coverage in informal settings. This study aims at assessing the impact of a CHF pilot programme and, specifically, of the initial phase involving zero-interest loans on health expenditures and coping strategies in a rural district of Uganda. The analysis relies on a panel household survey performed before and after the intervention and complemented by qualitative data obtained from structured focus group discussions. Exploiting an instrumental variable approach, we measured the causal effect of the intervention, and the main findings were then integrated with qualitative evidence on the heterogeneity of the programme's impact across different household categories. We found that the intervention of zero-interest healthcare loans is effective in improving financial protection and longer-term welfare. Community perceptions suggested that the population excluded from the scheme is disadvantaged when facing unpredictable health costs. Among the enrolled members, the poorest seem to receive a greater benefit from the intervention. Overall, our study provides support for the positive role of community-based mechanisms to progress towards universal coverage and offers policy-relevant insights to timely design comprehensive health financing reforms.

"Demand Side" Health Insurance in India: The Price of Obfuscation

In India, most healthcare expenses are patients' out-of-pocket payments to private sector providers. Catastrophic health expenditures drive millions of families deeper into poverty. To save poorer households, hundreds of government-funded health insurance schemes have been introduced since the 2000s. These "demand side" schemes suggest that treatments in the private sector will be fully reimbursed. Fieldwork in one of India's largest hospitals shows that GFHIs overpromise. GFHIs are designed to turn patients into co-creators of healthcare value, but instead they deepen individuals' lack of market transparency. Poor patients pay the price for the state's lack of trust in them.

Effect of health insurance program for the poor on out-of-pocket inpatient care cost in India: evidence from a nationally representative cross-sectional survey

BACKGROUND

In India, Out-of-pocket expenses accounts for about 62.6% of total health expenditure - one of the highest in the world. Lack of health insurance coverage and inadequate coverage are important reasons for high out-of-pocket health expenditures. There are many Public Health Insurance Programs offered by the Government that cover the cost of hospitalization for the people below poverty line (BPL), but their coverage is still not complete. The objective of this research is to examine the effect of Public Health Insurance Programs for the Poor on hospitalizations and inpatient Out-of-Pocket costs.

METHODS

Data from the recent national survey by the National Sample Survey Organization, Social Consumption in Health 2014 are used. Propensity score matching was used to identify comparable non-enrolled individuals for individuals enrolled in health insurance programs. Binary logistic regression model, Tobit model, and a Two-part model were used to study the effects of enrolment under Public Health Insurance Programs for the Poor on the incidence of hospitalizations, length of hospitalization, and Out-of- Pocket payments for inpatient care.

RESULTS

There were 64,270 BPL people in the sample. Individuals enrolled in health insurance for the poor have 1.21 higher odds of incidence of hospitalization compared to matched poor individuals without the health insurance coverage. Enrollment under the poor people health insurance program did not have any effect on length of hospitalization and inpatient Out-of-Pocket health expenditures. Logistic regression model showed that chronic illness, household size, and age of the individual had significant effects on hospitalization incidence. Tobit model results showed that individuals who had chronic illnesses and belonging to other backward social group had significant effects on hospital length of stay. Tobit model showed that days of hospital stay, education and age of patient, using a private hospital for treatment, admission in a paying ward, and having some specific comorbidities had significant positive effect on out-of-pocket costs.

CONCLUSIONS

Enrolment in the public health insurance programs for the poor increased the utilization of inpatient health care. Health insurance coverage should be expanded to cover outpatient services to discourage overutilization of inpatient services. To reduce out-of-pocket costs, insurance needs to cover all family members rather than restricting coverage to a specific maximum defined.

Community-Based Health Insurance Enrollment and Child Health Service Utilization in Northwest Ethiopia: A Cross-Sectional Case Comparison Study

PURPOSE

Utilization of primary healthcare services in the rural communities of Ethiopia is very low. The Ethiopian government has introduced community-based health insurance (CBHI) to improve the health service utilization of the rural community. Thus, this study was conducted to examine the association between CBHI enrollment and child health service utilization in northwest Ethiopia.

PATIENTS AND METHODS

A cross-sectional case comparison study among CBHI enrolled and unenrolled households was conducted. A total of 226 sick children from 2008 surveyed households were included in the study. Bivariate-probit regression analysis was employed to account the endogenous nature of insurance enrollment and child health services utilization.

RESULTS

The results showed that the overall sick child healthcare visit in the CBHI enrolled group was about 0.44 (44%) point more compared to those unenrolled households. CBHI enrolled households in the poorest wealth group have a higher probability of visiting healthcare facilities for their sick children (coefficient: 0.13, SD: 0.07, 95% CI: -0.01, 0.27), whereas CBHI enrolled households with older age household head have a lower probability of visiting healthcare facilities for their sick children (coefficient: -0.16, SD: 0.08, 95% CI: -0.32, 0.01).

CONCLUSION

A promising positive effect on sick children's health services utilization among CBHI enrolled was noticed. Moreover, households in the poorest wealth status and older age head affect the use of sick children's healthcare services among those CBHI enrolled. Therefore, policy measures to expand benefit packages and supply-side interventions are essential to enhance the effects of CBHI on different health service utilization.

Do employer-sponsored health insurance schemes affect the utilisation of medically trained providers and out-of-pocket payments among ready-made garment workers? A case-control study in Bangladesh

OBJECTIVE

We estimated the effect of an employer-sponsored health insurance (ESHI) scheme on healthcare utilisation of medically trained providers and reduction of out-of-pocket (OOP) expenditure among ready-made garment (RMG) workers.

DESIGN

We used a case-control study design with cross-sectional preintervention and postintervention surveys.

SETTINGS

The study was conducted among workers of seven purposively selected RMG factories in Shafipur, Gazipur in Bangladesh.

PARTICIPANTS

In total, 1924 RMG workers (480 from the insured and 482 from the uninsured, in each period) were surveyed from insured and uninsured RMG factories, respectively, in the preintervention (October 2013) and postintervention (April 2015) period.

INTERVENTIONS

We tested the effect of a pilot ESHI scheme which was implemented for 1 year.

OUTCOME MEASURES

The outcome measures were utilisation of medically trained providers and reduction of OOP expenditure among RMG workers. We estimated difference-in-difference (DiD) and applied two-part regression model to measure the association between healthcare utilisation, OOP payments and ESHI scheme membership while controlling for the socioeconomic characteristics of workers.

RESULTS

The ESHI scheme increased healthcare utilisation of medically trained providers by 26.1% (DiD=26.1; p<0.01) among insured workers compared with uninsured workers. While accounting for covariates, the effect on utilisation significantly reduced to 18.4% (p<0.05). The DiD estimate showed that OOP expenditure among insured workers decreased by -3700 Bangladeshi taka and -1100 Bangladeshi taka compared with uninsured workers when using healthcare services from medically trained providers or all provider respectively, although not significant. The multiple two-part models also reported similar results.

CONCLUSION

The ESHI scheme significantly increased utilisation of medically trained providers among RMG workers. However, it has no significant effect on OOP expenditure. It can be recommended that an educational intervention be provided to RMG workers to improve their healthcare-seeking behaviours and increase their utilisation of ESHI-designated healthcare providers while keeping OOP payments low.

Effect of Community-Based Health Insurance on Utilization of Outpatient Health Care Services in Southern Ethiopia: A Comparative Cross-Sectional Study

Background

Community-based health insurance schemes are becoming increasingly recognized as a potential strategy to achieve universal health coverage in developing countries. Despite great efforts to improve accessibility to modern health-care services in the past two decades, in Ethiopia, utilization of health-care services have remained very low. Given the financial barriers of the poor households and lack of sustainable health-care financing mechanisms in the country has been recognized to be major factors, the country has implemented community-based health insurance in piloted regions of Ethiopia aiming to improve utilization of health-care services by removing financial barriers. However, there is a dearth of literature regarding the effect of the implemented insurance scheme on the utilization of health-care services.

Objective

To analyze the effects of a community-based health insurance scheme on the utilization of health-care services in Yirgalem town, southern Ethiopia.

Methods

The study used both a quantitative and qualitative mixed approach using a comparative cross-sectional study design for a quantitative part using a randomly selected sample of 405 (135 member and 270 non-member) household heads. To complement the findings from the household survey, focus group discussions were used. Multivariate logistic regression was employed to identify the effect of community-based health insurance on health-care utilization.

Results

The study reveals that community-based health insurance member households were about three times more likely to utilize outpatient care than their non-member counterparts [AOR: 2931; 95% CI (1.039, 7.929); p-value=0.042].

Conclusion

Community-based health insurance is an effective tool to increase utilization of health-care services and provide the scheme to member households.

The impact of medical insurance programmes on the health of the insured: Evidence from China

The impact of medical insurance on the health of the insured has long been an issue of major concern within academia. From the beginning of the 21^st century, the Chinese government has invested a large amount of money in national medical insurance programmes. China's current national medical insurance system consists of three types of programmes: basic medical insurance for urban employees (BMIUE), basic medical insurance for urban and rural residents (BMIURR), and public medical insurance (PMI). These three types of medical insurance have significant differences in terms of premiums, policy deductibles, and levels of coinsurance, thus providing us with the opportunity to study the different impacts these programmes have on their covered members. Based on the 2016 China Family Panel Studies (CFPS) conducted by the China Social Science Research Centre in Peking University, this paper applies the ordered probit model to study the various impacts of these three programmes on the insured under each plan. The study found that compared with citizens who are not enrolled in any insurance programme, citizens who are covered by one of the three programmes report better health; compared with those covered by the BMIUE and BMIURR plans, members covered under the PMI programme report significantly better health; and after controlling for the adverse selection of participants in either the BMIUE or BMIURR plan, citizens who are enrolled in the BMIUE programme have a higher utilization rate of medical resources and report better health than those enrolled in the BMIURR plan.

Whether the industrial workers of slums have access to job insurance?

Purpose

Securing a job in an industry is a boon for most of the slum dwellers. When the primary earner of a slum household suffers from occupational illness and injuries, without insurance coverage or partial coverage of insurance, this boon may become a curse in the long run. The occupational security and safety along with the fact that whether such workers are insured is an important aspect and has a close link with the expenditure on illness. Thus, the accessibility to employees’ insurance in the risky industrial occupation, particularly for slum dwellers, is crucial to protect them from falling into poverty. Studies on occupational health of the poor workers are either limited to informal sectors or remain industry specific and the analysis of their accessibility to job insurance is rarely done. The paper aims to discuss these issues.

Design/methodology/approach

The research questions are framed to analyze the types of insurance accessible to workers across various industries; the accessibility to insurance, however, varying across risk intensities of various industries; and the determinants of insurance accessibility of the industrial workers living in slums. The determinants of accessibility of job insurance are analyzed with a binary Logit model. A multi-stage random sampling technique is used to collect the primary data from 320 industrial workers living in the slums of the Indian state of West Bengal.

Findings

The industrial workers, irrespective of the types of industries, are exposed to a high-risk category without proper job insurance. The higher industrial income is not adequate to prevent financial hardships. Access to insurance is more likely for the respondents with job tenure of more than two years and less likely for the workers who are working for more than eight hours per day.

Social implications

This study provides a significant insight to the policymakers concerning health dynamics of the slum dwellers, which can improve their livelihood.

Originality/value

The analysis of the industry-specific risk intensities with accessibility to insurance contributes to understanding the coverage of the insurance scheme for the workers in slums.

The impact of user charges on health outcomes in low-income and middle-income countries: a systematic review

BACKGROUND

User charges are widely used health financing mechanisms in many health systems in low-income and middle-income countries (LMICs) due to insufficient public health spending on health. This study systematically reviews the evidence on the relationship between user charges and health outcomes in LMICs, and explores underlying mechanisms of this relationship.

METHODS

Published studies were identified via electronic medical, public health, health services and economics databases from 1990 to September 2017. We included studies that evaluated the impact of user charges on health in LMICs using randomised control trial (RCT) or quasi-experimental (QE) study designs. Study quality was assessed using Cochrane Risk of Bias and Risk of Bias in Non-Randomized Studies-of Intervention for RCT and QE studies, respectively.

RESULTS

We identified 17 studies from 12 countries (five upper-middle income countries, five lower-middle income countries and two low-income countries) that met our selection criteria. The findings suggested a modest relationship between reduction in user charges and improvements in health outcomes, but this depended on health outcomes measured, the populations studied, study quality and policy settings. The relationship between reduced user charges and improved health outcomes was more evident in studies focusing on children and lower-income populations. Studies examining infectious disease-related outcomes, chronic disease management and nutritional outcomes were too few to draw meaningful conclusions. Improved access to healthcare as a result of reduction in out-of-pocket expenditure was identified as the possible causal pathway for improved health.

CONCLUSIONS

Reduced user charges were associated with improved health outcomes, particularly for lower-income groups and children in LMICs. Accelerating progress towards universal health coverage through prepayment mechanisms such as taxation and insurance can lead to improved health outcomes and reduced health inequalities in LMICs.

TRIAL REGISTRATION NUMBER

CRD 42017054737.

Predictors of Enrolment in the National Health Insurance Scheme Among Women of Reproductive Age in Nigeria

Background: Despite the implementation of the National Health Insurance Scheme (NHIS) since 2005 in Nigeria, the level of health insurance coverage remains low. The study aims to examine the predictors of enrolment in the NHIS among women of reproductive age in Nigeria.

Methods: Secondary data from the 2013 Nigeria Demographic and Health Survey (NDHS) were utilized to examine factors influencing enrolment in the NHIS among women of reproductive age (n=38 948) in Nigeria. Demographic and socio-economic characteristics of women were determined using univariate, bivariate and multivariate analyses. Data analysis was performed using STATA version 12 software.

Results: We found that 97.9% of women were not covered by health insurance. Multivariate analysis indicated that factors such as age, education, geo-political zone, socio-economic status (SES), and employment status were significant predictors of enrolment in the NHIS among women of reproductive age.

Conclusion: This study concludes that health insurance coverage among women of reproductive age in Nigeria is very low. Additionally, demographic and socio-economic factors were associated with enrolment in the NHIS among women. Therefore, policy-makers need to establish a tax-based health financing mechanism targeted at women who are young, uneducated, from poorest households, unemployed and working in the informal sector of the economy. Extending health insurance coverage to women from poor households and those who work in the informal sector through a tax-financed non-contributory health insurance scheme would accelerate progress towards universal health coverage (UHC).

The Impact of Health Insurance Policy on the Health of the Senior Floating Population-Evidence from China

The impact of health insurance on residents’ health is one of the focal points of academic research. Due to the fact that China’s medical insurance system is composed of a variety of programs and that the pooling districts are at the lower administrative level, enrollment in different medical insurance programs or at different places may have certain influences on the health of residents. This has mostly been neglected by previous studies. This paper uses data from the 2015 China Migrants Dynamic Survey (CMDS), focusing on the senior floating population and taking the difference in government subsidy proportions as an instrumental variable in order to identify the effects of health insurance programs and regional differences on the health of the senior floating population. Three effects were observed: First, participation in the health insurance system significantly improves floating seniors’ self-rated health. Second, the health status of floating seniors affects their choice of health insurance program: Less healthy persons tend to choose high-paying, wide-coverage basic medical insurance available for urban employees. Using an instrumental variable to control for the problem of endogeneity, it is discovered that compared with the basic medical insurance system for urban residents, the system for urban employees significantly enhances the health of the senior floating population. Third, “adverse selection” could be observed in the choice between enrolling in health insurance at the place of settlement or another place. Senior migrants with worse self-rated health tend to choose place of settlement in order to enjoy higher compensation and less complex reimbursement procedures. With an instrumental variable to control for the problem of endogeneity, it was found that compared with joining the medical insurance system at other places, joining at a place of settlement could improve the health of the floating senior population.

Factors for healthcare utilization and effect of mutual health insurance on healthcare utilization in rural communities of South Achefer Woreda, North West, Ethiopia

OBJECTIVE

To identify factors for healthcare utilization and to describe effect of Mutual Health Insurance on health service utilization in rural community in South Achefer, North West Ethiopia.

METHODS

Across-sectional study was conducted. A total of 652 households consented to participate in the study (326 insured and 326 uninsured households). Propensity score matching was used to explain possible differences in the baseline variables between enrolled and un-enrolled households. Logistic regression analysis was used to identify factors for healthcare utilization.

RESULTS

Healthcare utilization among insured households was 50.5% (95% CI: 44.8%, 56.2%). Whilst among uninsured households, healthcare utilization was 29.3% (95% CI: 24.11, 34.47). In general, the overall healthcare utilization was 39.89% (95% CI: 35.7, 43.8). The overall increase in patient-attendance given illness among insured households was 25.2% higher compared with uninsured (t = 4.94, 95% CI: 0.145, 0.359). Educated (primary and above) (AOR = 1.84; 95% CI: 1.14, 2.98), chronic patient (AOR = 1.86; 95% CI: 1.13, 3.06), first choice was health facilities at the point of illness (AOR = 6.33; 95% CI: 2.97-13.51), rich (AOR = 2.1; 95%CI: 1.29, 3.43), and insured (AOR = 2.16; 95% CI: 1.45, 3.23) were independently associated with increased healthcare utilization.

CONCLUSION

Enrolment to mutual health insurance increases healthcare utilization. Presence of illness in the households, household earnings, educational status, first choice of treatment at point of illness, and membership to Mutual Health Insurance scheme should be targeted during escalating of healthcare utilization.

The impact of community-based health insurance on the utilization of medically trained healthcare providers among informal workers in Bangladesh

We aimed to estimate the impact of a Community-Based Health Insurance (CBHI) scheme on utilization of healthcare from medically trained providers (MTP) by informal workers. A quasi-experimental study was conducted where insured households were included in the intervention group and uninsured households in comparison group. In total 1,292 (646 insured and 646 uninsured) households were surveyed from Chandpur district comprising urban and rural areas after 1 year period of CBHI introduction. Matching of the characteristics of insured and uninsured groups was performed using a propensity score matching approach to minimize the observed baseline differences among the groups. Multilevel logistic regression model, with adjustment for individual and household characteristics was used for estimating association between healthcare utilization from the MTP and insurance enrolment. The utilization of healthcare from MTP was significantly higher in the insured group (50.7%) compared to the uninsured group (39.4%). The regression analysis demonstrated that the CBHI beneficiaries were 2.111 (95% CI: 1.458–3.079) times more likely to utilize healthcare from MTP.CBHI scheme increases the utilization of MTP among informal workers. Ensuring such healthcare for these workers and their dependents is a challenge in many low and middle income countries. The implementation and scale-up of CBHI schemes have the potential to address this challenge of universal health coverage.

The impact of health insurance on maternal health care utilization: evidence from Ghana, Indonesia and Rwanda

While research has assessed the impact of health insurance on health care utilization, few studies have focused on the effects of health insurance on use of maternal health care. Analyzing nationally representative data from the Demographic and Health Surveys (DHS), this study estimates the impact of health insurance status on the use of maternal health services in three countries with relatively high levels of health insurance coverage-Ghana, Indonesia and Rwanda. The analysis uses propensity score matching to adjust for selection bias in health insurance uptake and to assess the effect of health insurance on four measurements of maternal health care utilization: making at least one antenatal care visit; making four or more antenatal care visits; initiating antenatal care within the first trimester and giving birth in a health facility. Although health insurance schemes in these three countries are mostly designed to focus on the poor, coverage has been highly skewed toward the rich, especially in Ghana and Rwanda. Indonesia shows less variation in coverage by wealth status. The analysis found significant positive effects of health insurance coverage on at least two of the four measures of maternal health care utilization in each of the three countries. Indonesia stands out for the most systematic effect of health insurance across all four measures. The positive impact of health insurance appears more consistent on use of facility-based delivery than use of antenatal care. The analysis suggests that broadening health insurance to include income-sensitive premiums or exemptions for the poor and low or no copayments can increase use of maternal health care.

A Comparative Study on Outcome of Government and Co-Operative Community-Based Health Insurance in Nepal

Background

There are different models for community-based health insurance (CBHI), and in Nepal, among them, the government and the local communities (co-ops) are responsible for operating the CBHI models that are in practice.

Aims

The aim of this study is to compare the outcomes in relation to benefit packages, population coverage, inclusiveness, healthcare utilization, and promptness of treatment for the two types of CBHI models in Nepal.

Methods

This study was an observational and interactive descriptive study using the concurrent mixed approach of data collection, framing, and compilation. Quantitative data were collected from records, and qualitative data were collected from key informants in all 12 CBHI groups. Unstructured questionnaires, observation checklists, and memo notepads were used for data collection. Descriptive statistics and the Mann–Whitney U test were used when appropriate. Ethically, written informed consent was obtained from the respondents who participated in the study, and they were told that they could withdraw from the study anytime.

Results

The study revealed the following: new enrolment did not increase in either group; however, the healthcare utilization rate did (Government 107% and co-ops 137%), while the benefit packages remained almost same for both groups. Overall, inclusiveness was higher for the government group. For the CBHI co-ops, enrollment among the religious minority and the discount negotiated with the hospitals for treatment were significantly higher, and the promptness in reaching a hospital was significantly faster (p < 0.05) than that in the government-operated CBHI.

Conclusion

Findings indicate that CBHI through co-ops would be a better model because of its lower costs and ability to enhance self-responsiveness and the overall health system. Health insurance coverage is the most important component to achieve universal health coverage.

Financial risk protection from social health insurance

This paper estimates the impact of social health insurance on financial risk by utilizing data from a natural experiment created by the phased roll-out of a social health insurance program for the poor in India. We estimate the distributional impact of insurance on of out-of-pocket costs and incorporate these results with a stylized expected utility model to compute associated welfare effects. We adjust the standard model, accounting for conditions of developing countries by incorporating consumption floors, informal borrowing, and asset selling which allow us to separate the value of financial risk reduction from consumption smoothing and asset protection. Results show that insurance reduces out-of-pocket costs, particularly in higher quantiles of the distribution. We find reductions in the frequency and amount of money borrowed for health reasons. Finally, we find that the value of financial risk reduction outweighs total per household costs of the insurance program by two to five times.

Extending health insurance to the poor in India: An impact evaluation of Rashtriya Swasthya Bima Yojana on out of pocket spending for healthcare

India launched the 'Rashtriya Swasthya Bima Yojana' (RSBY) health insurance scheme for the poor in 2008. Utilising 3 waves (1999-2000, 2004-05 and 2011-12) of household level data from nationally representative surveys of the National Sample Survey Organisation (NSSO) (N = 346,615) and district level RSBY administrative data on enrolment, we estimated causal effects of RSBY on out-of-pocket expenditure. Using 'difference-in-differences' methods on households in matched districts we find that RSBY did not affect the likelihood of inpatient out-of-pocket spending, the level of inpatient out of pocket spending or catastrophic inpatient spending. We also do not find any statistically significant effect of RSBY on the level of outpatient out-of-pocket expenditure and the probability of incurring outpatient expenditure. In contrast, the likelihood of incurring any out of pocket spending (inpatient and outpatient) rose by 30% due to RSBY and was statistically significant. Although out of pocket spending levels did not change, RSBY raised household non-medical spending by 5%. Overall, the results suggest that RSBY has been ineffective in reducing the burden of out-of-pocket spending on poor households.

The need for better evidence to evaluate the health & economic benefits of India's Rashtriya Swasthya Bima Yojana

In this review the existing evidence on the impact of Rashtriya Swasthya Bima Yojana (RSBY) is discussed in the context of international literature available on health insurance. We describe potential pathways through which health insurance can affect health and economic outcomes, discuss evidence from other developing countries, and identify potential biases and inconsistencies in existing studies on RSBY impact. Given the relatively recent introduction of RSBY, lack of quality, verifiable data on utilization patterns, and the absence of reliable evaluation studies, there is a need to exercise caution while assessing the merits of the programme. Considering the enormous potential and cost of the programme, we emphasize the need for a rigorous impact evaluation of RSBY. It will not only help capture the real impact of the scheme, but may also be able to estimate the extent of systemic inefficiencies at the level of the consumer.

Subsidized health insurance coverage of people in the informal sector and vulnerable population groups: trends in institutional design in Asia

BACKGROUND

Many low- and middle-income countries with a social health insurance system face challenges on their road towards universal health coverage (UHC), especially for people in the informal sector and vulnerable population groups or the informally employed. One way to address this is to subsidize their contributions through general government revenue transfers to the health insurance fund. This paper provides an overview of such health financing arrangements in Asian low- and middle-income countries. The purpose is to assess the institutional design features of government subsidized health insurance type arrangements for vulnerable and informally employed population groups and to explore how these features contribute to UHC progress.

METHODS

This regional study is based on a literature search to collect country information on the specific institutional design features of such subsidization arrangements and data related to UHC progress indicators, i.e. population coverage, financial protection and access to care. The institutional design analysis focuses on eligibility rules, targeting and enrolment procedures; financing arrangements; the pooling architecture; and benefit entitlements.

RESULTS

Such financing arrangements currently exist in 8 countries with a total of 14 subsidization schemes. The most frequent groups covered are the poor, older persons and children. Membership in these arrangements is mostly mandatory as is full subsidization. An integrated pool for both the subsidized and the contributors exists in half of the countries, which is one of the most decisive features for equitable access and financial protection. Nonetheless, in most schemes, utilization rates of the subsidized are higher compared to the uninsured, but still lower compared to insured formal sector employees. Total population coverage rates, as well as a higher share of the subsidized in the total insured population are related with broader eligibility criteria.

CONCLUSIONS

Overall, government subsidized health insurance type arrangements can be effective mechanism to help countries progress towards UHC, yet there is potential to improve on institutional design features as well as implementation.