Adverse selection and supply-side factors in the enrollment in community-based health insurance in Northwest Ethiopia: A mixed methodology

Does mobile renewal make health insurance more responsive to clients? A case study of the National Health Insurance Scheme in Ghana

BACKGROUND

In 2018, Ghana's National Health Insurance Authority (NHIA) introduced a mobile strategy to enhance re-enrolment and improve client knowledge of their entitlements. This study investigated how Ghana's mobile strategy has influenced the NHIA's responsiveness to clients in terms of patient rights and entitlements, equity and satisfaction with health services.

METHODS

We surveyed people (n=1700) in 6 districts who had renewed their insurance in the previous 12 months, using any strategy (mobile or manual). Multiple regression analysis examined correlation between individual characteristics and renewal modality. Policy documents on the mobile programme's design and focus group discussions (n=12) on people's experiences renewing their insurance were analysed thematically.

RESULTS

While the mobile platform was designed for mobile National Health Insurance Scheme (NHIS) renewal and to provide information about insurance entitlements, few people surveyed (20%) knew about these informational features. Among those who renewed their NHIS coverage, 58% did so on the mobile renewal platform. Mobile renewal was high among those with tertiary education and those in the higher wealth quintiles. Mobile renewal was considered convenient, but required literacy in English, a phone and a mobile money wallet. For those who lacked some or all of these prerequisites but wanted to use mobile renewal, mobile vendors emerged as valued facilitators.

CONCLUSION

The mobile platform has increased the responsiveness of Ghana's NHIS through offering clients a more convenient mechanism to renew their insurance policies. It does not, however, eliminate the one month waiting period for activating the card, does not provide prompts to reassure clients of their renewal and does not empower most clients with information on entitlements. To improve the adoption and use of the mobile renewal strategy, the NHIA should publicise the platform's information-sharing functions and explore formally engaging mobile vendors.

The effects of individual and community-level factors on community-based health insurance enrollment of households in Ethiopia

Introduction

Community-based health insurance (CBHI) is a type of volunteer health insurance that has been adopted all over the world in which people of the community pool funds to protect themselves from the high costs of seeking medical care and treatment for the disease. In Ethiopia, healthcare services are underutilized due to a lack of resources in the healthcare system. The study aims to identify the individual and community level factors associated with community-based health insurance enrollment of households in Ethiopia.

Methods

Data from the Ethiopian mini demographic and health survey 2019 were used to identify factors associated with community-based health insurance enrollment of households in Ethiopia. Multilevel logistic regression analysis was used on a nationally representative sample of 8,663 households nested within 305 communities, considering the data’s layered structure. We used a p-value<0.05 with a 95% confidence interval for the results.

Result

The prevalence of community-based health insurance enrollment in Ethiopia was 20.2%. The enrollment rate of households in the scheme was high in both Amhara (57.9), and Tigray (57.9%) regions and low (3.0%) in the Afar region. At the individual level; the age of household heads, number of children 5 and under, number of household members, has land for agriculture, has a mobile telephone, receiving cash of food from the safety Net Program, Owning livestock, and herds of farm animals, wealth index, and at the community level; the region had a significant association with community-based health insurance enrollment.

Conclusion

Both individual and community-level characteristics were significant predictors of community-based health insurance enrollment in households. Furthermore, the ministry of health, health bureaus, and other concerning bodies prioritize clusters with low health insurance coverage to strengthen health system financing and intervene in factors that negatively affect the CBHI enrollment of households.

A mixed methods study of community-based health insurance enrollment trends and underlying challenges in two districts of northeast Ethiopia: A proxy for its sustainability

Background

The term "community-based health insurance" refers to a broad range of nonprofit, prepaid health financing models designed to meet the health financing needs of disadvantaged populations, particularly those in the rural and informal sectors. Due to their voluntary nature, such initiatives suffer from persistently low coverage in low- and middle-income countries. In Ethiopia, the schemes’ membership growth has not been well investigated so far. This study sought to examine the scheme’s enrollment trend over a five-year period, and to explore the various challenges that underpin membership growth from the perspectives of various key stakeholders.

Methods

The study employed a mixed methods case study in two purposively selected districts of northeast Ethiopia: Tehulederie and Kallu. By reviewing the databases of health insurance schemes, quantitative data were collected retrospectively from 2017 to 2021 to examine enrollment trends. Trends for each performance indicator were analyzed descriptively for the period under study. Face-to-face interviews were conducted with nine community members and 19 key informants. Study participants were purposely selected using the maximum variation technique. Interviews were audio recorded, transcribed verbatim, and translated into English. Thematic analysis was employed with both deductive and inductive coding approaches.

Results

Over the course of the study period, enrollment in the scheme at both districts exhibited non-linear trends with both positive and negative growth rates being identified. Overall, the scheme in Tehulederie has a relatively higher population coverage and better membership retention, which could be due to the strong foundation laid by a rigorous public awareness campaign and technical support during the pilot phase. The challenges contributing to the observed level of performance have been summarized under four main themes that include quality of health care, claims reimbursement for insurance holders, governance practices, and community awareness and acceptability.

Conclusions

The scheme experienced negative growth ratios in both districts, indicating that it is not functionally viable. It will fail to meet its mission unless relevant stakeholders at all levels of government demonstrate political will and commitment to its implementation, as well as advocate for the community. Interventions should target on the highlighted challenges in order to boost membership growth and ensure the scheme’s viability.

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.

Health insurance coverage in Ethiopia: financial protection in the Era of sustainable cevelopment goals (SDGs)

BACKGROUND

Health insurance is among the healthcare financing reforms proposed to increase the available healthcare resources and to decrease the risk of household financial crisis. Recently, Ethiopia has been implementing community-based health insurance which mainly targets the very large rural agricultural sector and small and informal sector in urban settings. Therefore, this study was aimed to assess the coverage of health insurance and its determinants in Ethiopia.

METHODS

Data were extracted from the 2019 mini Ethiopian Demographic and Health Survey (EDHS) to assess determinants of health insurance coverage in Ethiopia. The analysis included a weighted sample of 8663 respondents. Multivariable logistic regression analysis was conducted and the results were presented as adjusted odds ratio (AOR) at 95% confidence interval (CI), statistical significance was declared at a p-value < 0.05 in all analyses.

RESULTS

The health insurance coverage in Ethiopia was 28.1% (95%CI: 27.2%, 29%). Administration regions (Tigray: AOR = 16.9, 95%CI: 5.53, 51.59, Amhara: AOR = 25.8, 95%CI: 8.52, 78.02, Oromia, AOR = 4.27, 95%CI: 1.41, 12.92, Southern Nations, Nationalities and Peoples region, AOR = 4.06, 95%CI: 1.34, 12.32, Addis Ababa, AOR = 4.65, 95%CI: 1.46, 14.78), place of residence (rural, AOR = 1.38, 95%CI: 1.17, 1.63), sex of household head (male; AOR = 1.23, 95%CI: 1.07, 1.41), wealth index (middle, AOR = 1.75, 95%CI: 1.46, 2.09, richer, AOR = 1.86, 95%CI: 1.55, 2.24), family size (≥ 5 members, AOR = 1.17, 95%CI: 1.03, 1.33), having under-five children (AOR = 1.22, 95%CI: 1.076, 1.38), and age of household head (31-40 years, AOR = 1.71, 95%CI: 1.45, 2.01, 41-64 years, AOR = 2.49, 95%CI: 2.12, 2.92, 65 + years, AOR = 2.43, 95%CI: 2.01, 2.93) were factors associated with health insurance coverage.

CONCLUSIONS

Less than one-third of Ethiopians were covered by health insurance. Socio-economic factors and demographic factors were found to associate with health insurance coverage in Ethiopia. Therefore, enhancing health insurance coverage through contextualized implementation strategies would be emphasized.

Pooled coverage of community based health insurance scheme enrolment in Ethiopia, systematic review and meta-analysis, 2016-2020

BACKGROUND

Community Based Health Insurance (CBHI) is a type of health insurance program that provides financial protection against the cost of illness and improving access to health care services for communities engaged in the informal sector. In Ethiopia, the coverage of CBHI enrolment varies across regions and decision of household enrolment is affected by different factors. There are pocket studies on CBHI scheme with different coverage in Ethiopia and there is no pooled study on CBHI enrolment coverage in Ethiopia for better understanding the scheme and decision making. The aim of this systematic review and meta-analysis was to identify the pooled coverage of CBHI enrolment in Ethiopia to understand its policy implications.

METHODS

The systematic review and meta-analysis was done by adhering the PRISMA guideline with exhaustive search in PubMed/Medline, HINARI, SCOPUS and Google scholar complemented by manual search. Two authors independently selected studies, extracted data, and assessed quality of studies. The I2 test statistic was used to test heterogeneity among studies. The overall coverage of CBHI scheme was estimated by using random-effects model.

RESULT

Among 269 identified, 17 studies were included in this meta-analysis and the overall coverage of CBHI scheme was 45% (95% CI 35%, 55%) in Ethiopia. The sub-group analysis shows higher enrolment rate 55.97 (95%CI: 41.68, 69.77) in earlier (2016-2017) studies than recent 37.33 (95%CI: 24.82, 50.77) studies (2018-2020).

CONCLUSION

The pooled coverage of CBHI enrolment is low in Ethiopia compared the national target of 80% set for 2020. It is also concentrated in only major regions of the country. The finding of the study helps national decision making for CBHI scheme service improvement. Due attention to be given to improving geographic expansion of CBHI and to the declining coverages with in the CBHI implementing regions by addressing the main bottlenecks restraining coverages.

TRIAL REGISTRATION

The protocol of this systematic review and meta-analysis was published in PROSPERO with registration number: CRD42021252762 .

Contributions and challenges of healthcare financing towards universal health coverage in Ethiopia: a narrative evidence synthesis

Background

High burden of healthcare expenditure precludes the poor from access to quality healthcare services. In Ethiopia, a significant proportion of the population has faced financial catastrophe associated with the costs of healthcare services. The Ethiopian Government aims to achieve universal health coverage (UHC) by 2030; however, the Ethiopian health system is struggling with low healthcare funding and high out-of-pocket (OOP) expenditure despite the implementation of several reforms in health care financing (HCF). This review aims to map the contributions, successes and challenges of HCF initiatives in Ethiopia.

Methods

We searched literature in three databases: PubMed, Scopus, and Web of science. Search terms were identified in broader three themes: health care financing, UHC and Ethiopia. We synthesised the findings using the health care financing framework: revenue generation, risk pooling and strategic purchasing.

Results

A total of 52 articles were included in the final review. Generating an additional income for health facilities, promoting cost-sharing, risk-sharing/ social solidarity for the non-predicted illness, providing special assistance mechanisms for those who cannot afford to pay, and purchasing healthcare services were the successes of Ethiopia’s health financing. Ethiopia's HCF initiatives have significant contributions to healthcare infrastructures, medical supplies, diagnostic capacity, drugs, financial-risk protection, and healthcare services. However, poor access to equitable quality healthcare services was associated with low healthcare funding and high OOP payments.

Conclusion

Ethiopia's health financing initiatives have various successes and contributions to revenue generation, risk pooling, and purchasing healthcare services towards UHC. Standardisation of benefit packages, ensuring beneficiaries equal access to care and introducing an accreditation system to maintain quality of care help to manage service disparities. A unified health insurance system that providing the same benefit packages for all, is the most efficient way to attain equitable access to health care.

Factors Associated with the Implementation of an Improved Community Health Fund in the Ubungo Municipality Area, Dar es Salaam Region, Tanzania

Community-based health insurance schemes help households to afford healthcare services. This paper describes healthcare facilities and community factors that are associated with the Improved Community Health Fund (iCHF) scheme in the Ubungo district of Tanzania. A cross-sectional descriptive study was conducted using online questionnaires that were completed by healthcare providers and community members in public-owned healthcare facilities in the Ubungo Municipal Council district of Dar es Salaam, Tanzania, between October and November 2021. The data were analyzed using descriptive statistics and the chi-squared test of association. We found a statistically significant relationship between income level and satisfaction with the iCHF scheme. For community-related factors, income level was statistically significant in the level of involvement in iCHF implementation among local leaders. Further, income level was statistically significant in relation to community behavior/culture toward the iCHF. Occupation was statistically significant in iCHF implementation, iCHF premiums, and iCHF membership size. A statistically significant relationship was also found between income, iCHF membership size, and iCHF premiums. Moreover, people would be willing to pay the required premiums if the quality of the healthcare services under the iCHF scheme improves. Therefore, the government should allocate resources to reduce the challenges that are facing iCHF implementation, such as the preference for a user fee scheme over the iCHF, the issues that are faced by enrollment officers, and inadequate iCHF premiums and membership size.

Barriers and Facilitators of Community-Based Health Insurance Membership in Rural Amhara Region, Northwest Ethiopia: A Qualitative Study

Background

More than 150 million people encounter huge cost of health expenses every year, and most of these treatment seekers face poverty owing to out-of-pocket payments. Community-based health insurance (CBHI) won popularity as a makeshift health financing mechanism for out-of-pocket payments in poor communities. The aim of this study was therefore to explore the facilitators and impediments of enrollment to community-based health insurance in rural parts of the Amhara region, Ethiopia.

Methods

Focus Group Discussion (FGD) was the main data collection instrument supplemented by key informant interview (KII). The FGD participants were selected using a purposive sampling technique. The participants were therefore selected based on their membership status of CBHI (members or non-members). Six FGDs and four KIIs were conducted in November 2019 in three districts. Before analyzing the data, all FGDs and KIIs were transcribed and transferred into ATLAS.ti version 7.1 software. An inductive thematic analysis approach was done, that is, on the basis of major themes emerged from the data.

Results

Low level of awareness, perception of high amount of premium, poor perception of quality of services and lack of trust are the barriers to join community-based health insurance.

Conclusion

There has been low level of awareness and misconception about community-based health insurance. The major reason to decline to join CBHI was low capacity to pay the premium.

Factors affecting enrollment status of households for community based health insurance in a resource-limited peripheral area in Southern Ethiopia. Mixed method

BACKGROUND

Despite the efforts made by the government of Ethiopia, the community-based health insurance (CBHI) enrollment rate failed to reach the potential beneficiaries. Therefore, this study aimed to assess the enrollment status of households for community-based health insurance and associated factors in peripheral areas of Southern Ethiopia.

METHODS

We conducted a community based cross-sectional study design with both quantitative and qualitative methods. Systematic random sampling was employed to select 820 households from 27, April to 12 June 2018. A pretested structured questionnaire, in-depth interview, and focus group discussion guiding tool were used to obtain information. A binary logistic regression model was used to assess the association between independent and outcome variables. A P-Value of less than 0.05 was taken as a cutoff to declare association in multivariable analysis. Qualitative data were analyzed manually using the thematic analysis method.

RESULTS

Out of 820 households, 273[33.30%; 95% CI: 29.9-36.20] were enrolled in the community based health insurance scheme. Having good knowledge [AOR = 13.97, 95%CI: 8.64, 22.60], having family size of greater than five [AOR = 1.88, 95% CI: 1.15, 3.06], presence of frequently ill individual [AOR = 3.90, 95% CI: 2.03, 7.51] and presence of chronic illness [AOR = 3.64, 95% CI: 1.67, 7.79] were positively associated with CBHI enrollment. In addition, poor quality of care, lack of managerial commitment, lack of trust and transparency, unavailability of basic logistics and supplies were also barriers for CBHI enrollment.

CONCLUSION AND RECOMMENDATION

The study found that lower community based health insurance enrollment status. A higher probability of CBHI enrollment among higher health care demanding population groups was observed. Poor perceived quality of health care, poor managerial support and lack of trust were found to be barriers for non-enrollment. Therefore, wide-range awareness creation strategies should be used to address adverse selection and poor knowledge. In addition, trust should be built among communities through transparent management. Furthermore, the quality of care being given in public health facilities should be improved to encourage the community to be enrolled in CBHI.

Perceived Quality of Healthcare and Availability of Supplies Determine Household-Level Willingness to Join a Community-Based Health Insurance Scheme in Amhara Region, Ethiopia

Purpose

The Ethiopian health system has been challenged by a shortage of funds and is heavily reliant on foreign donation. However, voluntary community-based health insurance (CBHI) has been implemented to reach and cover the very large agricultural sector since 2010. Thus, the level of acceptability of the scheme needs to be regularly assessed through households’ willingness to join before the nationwide rollout of the scheme. This study was intended to assess the level of willingness to join in community-based health insurance and associated factors in northwest Ethiopia.

Patients and Methods

Using a pretested structured questionnaire, a cross-sectional community-based study was conducted in 2017 in Amhara Region, northwest Ethiopia. Using a multi-stage sampling method, from 15 clusters in which CBHI was implemented, 1,179 households without CBHI membership were included as a sample for the study. Bivariable and multivariable logistic regression was fitted to assess the association between predictor variables and the outcome of interest.

Results

Out of the total (1,179) participants, 60.5% (713) were willing to join the scheme. Households’ occupation (AOR=2.26; 95% CI:=1.12–5.07), perceived good (AOR=2.21; 95% CI:=1.53−3.21), and medium (AOR=1.44; 95% CI=1.22–2.0) healthcare quality and richer wealth status (AOR=1.72; 95% CI=1.08–2.73) were associated with higher odds of willingness to join the scheme.

Conclusion

As The study revealed that level of willingness to join is lower compared to other studies. Therefore, social protection activities for the low-income population and enhancement of the capacity of health facilities are crucial.

Acceptance of the proposed social health insurance among government-owned company employees in Northwest Ethiopia: implications for starting social health insurance implementation

BACKGROUND

Ethiopia is currently planning to introduce Social Health Insurance (SHI) that will lead to universal health coverage and assist a country to achieve its health system's objectives and to prevent the catastrophic health expenditure. But there is no evidence until now about the level of acceptance of the proposed SHI among government-owned companies' employees. Therefore, this study was intended to assess the acceptance of SHI and associated factors among government-owned companies' employees in northwest Ethiopia.

METHODS

An institution-based cross-sectional study was conducted from February 1 to April 30, 2019. A randomly selected 541 government-owned companies' employees were participated in the study. A pretested self-administered structured questionnaire was used that consisted sociodemographic and economic, health status-related factors, attitude (measured by 12 items), organizational related factors and knowledge about SHI (measured by 11 items). Finally, binary logistic regression analysis was performed and in the multivariable logistic regression analysis, a significant level at a p-value of < 0.05 and Adjusted Odds Ratio (AOR) with 95% confidence interval (CI) were used to identify factors statistically associated with SHI acceptance.

RESULTS

Overall, 32% (95% CI: 27.7-36.2) of the government-owned companies' employees accepted the proposed Ethiopian SHI scheme. Self-perceived health status (AOR: 8.55, 95% CI: 2.69-27.13), heard about SHI (AOR: 1.69, 95% CI: 1.12-2.54), coverage of medical healthcare cost (AOR: 0.60, 95% CI: 0.39-0.92), work experience (AOR: 0.49, 95% CI: 0.26-0.89) and quality of healthcare service at the facilities (AOR: 0.17, 95% CI: 0.04-0.71) were significantly associated with acceptance of SHI among government-owned companies' employees.

CONCLUSIONS

One-third of the study participants accepted the proposed Ethiopian SHI scheme. Self-perceived health status, quality of healthcare service at health facilities, coverage of the medical cost by their organization, heard about SHI and work experience were the factors that affect acceptance of the proposed SHI among the government-owned company employees. Therefore, policymakers should devise a plan to promote the benefit packages of SHI for the formal sector employees to start the implementation.

Clients' Experience and Satisfaction of Utilizing Healthcare Services in a Community Based Health Insurance Program in Bangladesh

Background: Community-based health insurance is recognized as a promising tool for health system improvement for low-income people that improves the health status of enrolees and enhances productivity and labor supply. The experience and opinion of the clients who utilized health services through the insurance scheme are important for improving healthcare services, shaping health policies and providing feedback on the quality, availability, and responsiveness of healthcare services. However, studies focusing on clients' satisfaction provided by the health insurance scheme are still limited globally. Objective: To address this knowledge gap, this current study attempted to measure the degree of clients' satisfaction towards healthcare services and insurance scheme, based on their experience of health care which will serve the future reference point to implement potential quality improvement initiatives of community-based health insurance program. Methods: A cross-sectional household survey was conducted within the catchment area of a community-based health insurance pilot program named Labor Association for Social Protection (LASP) during April⁻June 2014 to compare the evaluation of healthcare services provided by LASP scheme. In the descriptive analyses, the characteristics of the study participants were presented regarding frequency and the percentages with 95% confidence interval. Spearman correlation analysis was conducted between the satisfaction score of each indicator and overall satisfaction score; multivariate linear regression analysis was used to identify the factors associated with overall health scheme satisfaction. Results: The overall satisfaction mean score was 4.17 ± 0.04 (95% CI: 4.08⁻4.26) out of 5.00. The most satisfied domains were related to the diagnostic services (4.46 ± 0.98), explanation about the prescribed medicine (4.23 ± 0.81), the surrounding environment of healthcare facility (4.21 ± 0.70) and the behavior of health personnel toward clients (4.18 ± 0.73). Conclusions: Our study observed that the overall satisfaction level towards health services is quite favorable, but satisfaction scores can still be improved. These findings could contribute towards developing and designing the healthcare services packages of community-based health scheme which is in line with the health care financing strategy of Bangladesh as well as the recommendation of the World Health Organization for developing social health insurance as part of path to Universal Health Coverage.