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Eze P, Ilechukwu S, Lawani LO. Impact of community-based health insurance in low- and middle-income countries: A systematic review and meta-analysis. PLoS One 2023; 18:e0287600. [PMID: 37368882 DOI: 10.1371/journal.pone.0287600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 06/08/2023] [Indexed: 06/29/2023] Open
Abstract
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.
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Affiliation(s)
- Paul Eze
- Department of Health Policy and Administration, Penn State University, University Park, PA, United States of America
| | - Stanley Ilechukwu
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Health Projects, South Saharan Social Development Organization (SSDO), Independence Layout, Enugu, Nigeria
| | - Lucky Osaheni Lawani
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
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Bashi J, Sia D, Tchouaket E, Balegamire SJ, Karemere H. Mutuelles de santé à Bukavu en République Démocratique du Congo: facteurs favorables à l’utilisation des services de santé par des adhérents. Pan Afr Med J 2020; 35:100. [PMID: 32636998 PMCID: PMC7320771 DOI: 10.11604/pamj.2020.35.100.20441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 12/10/2019] [Indexed: 11/11/2022] Open
Abstract
Introduction La présente étude s'intéresse aux déterminants de l'utilisation des services de santé par des adhérents aux trois mutuelles de santé dans la ville de Bukavu en République Démocratique du Congo. Méthodes L'étude, de type descriptif transversal, est une enquête de perception menée auprès des utilisateurs des services de santé affiliés aux mutuelles de santé dans les zones de santé de Bukavu. L'encodage et l'analyse statistique ont été réalisés avec le logiciel Epi Info version 2010. Résultats Les principaux déterminants de l'utilisation des services de santé par des adhérents aux mutuelles de santé sont: le lieu de résidence de l'adhérent, le niveau d'instruction du responsable du ménage, l'expérience antérieure des soins dans la structure sanitaire partenaire de la mutuelle de santé, la réputation de la structure partenaire des mutuelles de santé et la capacité des ménages à payer le ticket modérateur. Conclusion La présente étude révèle, qu'au-delà de la barrière financière, le développement d'une mutuelle de santé devrait permettre de promouvoir une meilleure régulation du ticket modérateur et une bonne qualité des soins pour satisfaire les besoins en soins de ses adhérents. Les facteurs qui ressortent de l'étude en tant que principaux déterminants de l'utilisation des services de santé des adhérents à une mutuelle de santé ne sont pas souvent pris en compte lors de l'implantation des mutuelles de santé dans des contextes similaires à ceux de Bukavu.
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Affiliation(s)
- Justine Bashi
- Bureau Diocésain des Œuvres Médicales de Bukavu, Bukavu, République Démocratique du Congo
| | - Drissa Sia
- Département des Sciences Infirmières, Université du Québec en Outaouais, Saint-Jerôme, Canada
| | - Eric Tchouaket
- Département des Sciences Infirmières, Université du Québec en Outaouais, Saint-Jerôme, Canada
| | | | - Hermès Karemere
- Faculté de Médecine, Ecole Régionale de Santé Publique, Université Catholique de Bukavu, Bukavu, République Démocratique du Congo
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Likka MH, Handalo DM, Weldsilase YA, Sinkie SO. The effect of community-based health insurance schemes on utilization of healthcare services in low- and middle-income countries: a systematic review protocol of quantitative evidence. JBI DATABASE OF SYSTEMATIC REVIEWS AND IMPLEMENTATION REPORTS 2018; 16:653-661. [PMID: 29521866 DOI: 10.11124/jbisrir-2017-003381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
REVIEW QUESTION/OBJECTIVE The objective of this systematic review is to identify, appraise and synthesize evidence to establish the effectiveness of community-based health insurance (CBHI) schemes in enhancing the utilization of healthcare services among their members in low- and middle-income countries (LMICs).Specifically, the review objective is to determine if individuals or households enrolled in CBHI schemes in LMICs utilize healthcare services (outpatient visits, hospital admissions, emergency visits, maternal and child healthcare services, or any other services involving the schemes) more frequently than those not included in CBHI schemes.
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Affiliation(s)
- Melaku Haile Likka
- Ethiopian Evidenced Based Healthcare and Development Centre: a Joanna Briggs Institute Centre of Excellence
- Graduate School of Integrated Arts and Sciences, Kochi Medical School, Kochi University, Kochi, Japan
| | - Dejene Melese Handalo
- Ethiopian Evidenced Based Healthcare and Development Centre: a Joanna Briggs Institute Centre of Excellence
- Department of Health Economics, Management and Policy, Institute of Health Sciences, Jimma University, Jimma, Ethiopia
| | | | - Shimeles Ololo Sinkie
- Department of Health Economics, Management and Policy, Institute of Health Sciences, Jimma University, Jimma, Ethiopia
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Ahmed S, Sarker AR, Sultana M, Chakrovorty S, Hasan MZ, Mirelman AJ, Khan JAM. Adverse Selection in Community Based Health Insurance among Informal Workers in Bangladesh: An EQ-5D Assessment. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:E242. [PMID: 29385072 PMCID: PMC5858311 DOI: 10.3390/ijerph15020242] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 01/04/2018] [Accepted: 01/29/2018] [Indexed: 11/29/2022]
Abstract
Community-based Health Insurance (CBHI) schemes are recommended for providing financial risk protection to low-income informal workers in Bangladesh. We assessed the problem of adverse selection in a pilot CBHI scheme in this context. In total, 1292 (646 insured and 646 uninsured) respondents were surveyed using the Bengali version of the EuroQuol-5 dimensions (EQ-5D) questionnaire for assessing their health status. The EQ-5D scores were estimated using available regional tariffs. Multiple logistic regression was applied for predicting the association between health status and CBHI scheme enrolment. A higher number of insured reported problems in mobility (7.3%; p = 0.002); self-care (7.1%; p = 0.000) and pain and discomfort (7.7%; p = 0.005) than uninsured. The average EQ-5D score was significantly lower among the insured (0.704) compared to the uninsured (0.749). The regression analysis showed that those who had a problem in mobility (m 1.25-2.17); self-care (OR = 2.29; 95% CI: 1.62-3.25) and pain and discomfort (OR = 1.43; 95% CI: 1.13-1.81) were more likely to join the scheme. Individuals with higher EQ-5D scores (OR = 0.46; 95% CI: 0.31-0.69) were less likely to enroll in the scheme. Given that adverse selection was evident in the pilot CBHI scheme, there should be consideration of this problem when planning scale-up of these kind of schemes.
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Affiliation(s)
- Sayem Ahmed
- Health Economics and Financing Research Group, Health Systems and Population Studies Division, Bangladesh (icddr,b), Dhaka 1212, Bangladesh.
- Health Economics and Policy Research Group, Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, SE-171 77 Stockholm, Sweden.
| | - Abdur Razzaque Sarker
- Health Economics and Financing Research Group, Health Systems and Population Studies Division, Bangladesh (icddr,b), Dhaka 1212, Bangladesh.
- Department of Management Science, University of Strathclyde, Glasgow G1 1XQ, UK.
| | - Marufa Sultana
- Health Economics and Financing Research Group, Health Systems and Population Studies Division, Bangladesh (icddr,b), Dhaka 1212, Bangladesh.
- Faculty of Health, Deakin University, Melbourne, VIC 3125, Australia.
| | - Sanchita Chakrovorty
- Health Economics and Financing Research Group, Health Systems and Population Studies Division, Bangladesh (icddr,b), Dhaka 1212, Bangladesh.
- Department of Agriculture Economics, Purdue University, IN 47907, USA.
| | - Md Zahid Hasan
- Health Economics and Financing Research Group, Health Systems and Population Studies Division, Bangladesh (icddr,b), Dhaka 1212, Bangladesh.
| | | | - Jahangir A M Khan
- Health Economics and Financing Research Group, Health Systems and Population Studies Division, Bangladesh (icddr,b), Dhaka 1212, Bangladesh.
- Health Economics and Policy Research Group, Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, SE-171 77 Stockholm, Sweden.
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK.
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Duku SKO, Asenso-Boadi F, Nketiah-Amponsah E, Arhinful DK. Utilization of healthcare services and renewal of health insurance membership: evidence of adverse selection in Ghana. HEALTH ECONOMICS REVIEW 2016; 6:43. [PMID: 27624462 PMCID: PMC5021654 DOI: 10.1186/s13561-016-0122-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 09/08/2016] [Indexed: 06/06/2023]
Abstract
BACKGROUND Utilization of healthcare in Ghana's novel National Health Insurance Scheme (NHIS) has been increasing since inception with associated high claims bill which threatens the scheme's financial sustainability. This paper investigates the presence of adverse selection by assessing the effect of healthcare utilization and frequency of use on NHIS renewal. METHOD Routine enrolment and utilization data from 2008 to 2013 in two regions in Ghana was analyzed. Pearson Chi-square test was performed to test if the proportion of insured who utilize healthcare in a particular year and renew membership the following year is significantly different from those who utilize healthcare and drop-out. Logistic regressions were estimated to examine the relationship between healthcare utilization and frequency of use in previous year and NHIS renewal in current year. RESULTS We found evidence suggestive of the presence of adverse selection in the NHIS. Majority of insured who utilized healthcare renewed their membership whiles most of those who did not utilize healthcare dropped out. The likelihood of renewal was significantly higher for those who utilize healthcare than those who did not and also higher for those who make more health facility visits. CONCLUSION The NHIS claims bill is high because high risk individuals who self-select into the scheme makes more health facility visits and creates financial sustainability problems. Policy makers should adopt pragmatic ways of enforcing mandatory enrolment so that low risk individuals remain enrolled; and sustainable ways of increasing revenue whiles ensuring that the societal objectives of the scheme are not compromised.
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Affiliation(s)
- Stephen Kwasi Opoku Duku
- Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
- Faculty of Economics and Business Administration, Free University of Amsterdam, De Boelelaan 1105, 1081HV Amsterdam, The Netherlands
- Ghana Health Service, Accra, Ghana
| | | | | | - Daniel Kojo Arhinful
- Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
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Mladovsky P, Ndiaye P, Ndiaye A, Criel B. The impact of stakeholder values and power relations on community-based health insurance coverage: qualitative evidence from three Senegalese case studies. Health Policy Plan 2014; 30:768-81. [PMID: 24986883 DOI: 10.1093/heapol/czu054] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2014] [Indexed: 11/14/2022] Open
Abstract
Continued low rates of enrolment in community-based health insurance (CBHI) suggest that strategies proposed for scaling up are unsuccessfully implemented or inadequately address underlying limitations of CBHI. One reason may be a lack of incorporation of social and political context into CBHI policy. In this study, the hypothesis is proposed that values and power relations inherent in social networks of CBHI stakeholders can explain levels of CBHI coverage. To test this, three case studies constituting Senegalese CBHI schemes were studied. Transcripts of interviews with 64 CBHI stakeholders were analysed using inductive coding. The five most important themes pertaining to social values and power relations were: voluntarism, trust, solidarity, political engagement and social movements. Analysis of these themes raises a number of policy and implementation challenges for expanding CBHI coverage. First is the need to subsidize salaries for CBHI scheme staff. Second is the need to develop more sustainable internal and external governance structures through CBHI federations. Third is ensuring that CBHI resonates with local values concerning four dimensions of solidarity (health risk, vertical equity, scale and source). Government subsidies is one of the several potential strategies to achieve this. Fourth is the need for increased transparency in national policy. Fifth is the need for CBHI scheme leaders to increase their negotiating power vis-à-vis health service providers who control the resources needed for expanding CBHI coverage, through federations and a social movement dynamic. Systematically addressing all these challenges would represent a fundamental reform of the current CBHI model promoted in Senegal and in Africa more widely; this raises issues of feasibility in practice. From a theoretical perspective, the results suggest that studying values and power relations among stakeholders in multiple case studies is a useful complement to traditional health systems analysis.
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Affiliation(s)
- Philipa Mladovsky
- LSE Health, London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK, Institute of Tropical Medicine, Nationalestraat 155, B-2000, Antwerp, Belgium and Le Centre de Recherches sur les Politiques sociales (CREPOS), S/C West African Research Center, Rue E X Léon Gontran Damas, Fann Résidance, BP: 25 233, Fann, Dakar, Senegal
| | - Pascal Ndiaye
- LSE Health, London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK, Institute of Tropical Medicine, Nationalestraat 155, B-2000, Antwerp, Belgium and Le Centre de Recherches sur les Politiques sociales (CREPOS), S/C West African Research Center, Rue E X Léon Gontran Damas, Fann Résidance, BP: 25 233, Fann, Dakar, Senegal
| | - Alfred Ndiaye
- LSE Health, London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK, Institute of Tropical Medicine, Nationalestraat 155, B-2000, Antwerp, Belgium and Le Centre de Recherches sur les Politiques sociales (CREPOS), S/C West African Research Center, Rue E X Léon Gontran Damas, Fann Résidance, BP: 25 233, Fann, Dakar, Senegal
| | - Bart Criel
- LSE Health, London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK, Institute of Tropical Medicine, Nationalestraat 155, B-2000, Antwerp, Belgium and Le Centre de Recherches sur les Politiques sociales (CREPOS), S/C West African Research Center, Rue E X Léon Gontran Damas, Fann Résidance, BP: 25 233, Fann, Dakar, Senegal
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Parmar D, Souares A, de Allegri M, Savadogo G, Sauerborn R. Adverse selection in a community-based health insurance scheme in rural Africa: implications for introducing targeted subsidies. BMC Health Serv Res 2012; 12:181. [PMID: 22741549 PMCID: PMC3457900 DOI: 10.1186/1472-6963-12-181] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Accepted: 06/15/2012] [Indexed: 11/24/2022] Open
Abstract
Background Although most community-based health insurance (CBHI) schemes are voluntary, problem of adverse selection is hardly studied. Evidence on the impact of targeted subsidies on adverse selection is completely missing. This paper investigates adverse selection in a CBHI scheme in Burkina Faso. First, we studied the change in adverse selection over a period of 4 years. Second, we studied the effect of targeted subsidies on adverse selection. Methods The study area, covering 41 villages and 1 town, was divided into 33 clusters and CBHI was randomly offered to these clusters during 2004–06. In 2007, premium subsidies were offered to the poor households. The data was collected by a household panel survey 2004–2007 from randomly selected households in these 33 clusters (n = 6795). We applied fixed effect models. Results We found weak evidence of adverse selection before the implementation of subsidies. Adverse selection significantly increased the next year and targeted subsidies largely explained this increase. Conclusions Adverse selection is an important concern for any voluntary health insurance scheme. Targeted subsidies are often used as a tool to pursue the vision of universal coverage. At the same time targeted subsidies are also associated with increased adverse selection as found in this study. Therefore, it’s essential that targeted subsidies for poor (or other high-risk groups) must be accompanied with a sound plan to bridge the financial gap due to adverse selection so that these schemes can continue to serve these populations.
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Affiliation(s)
- Divya Parmar
- Institute of Public Health, INF 324, University of Heidelberg, Heidelberg 69120, Germany.
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Zhang L, Wang H. Dynamic process of adverse selection: Evidence from a subsidized community-based health insurance in rural China. Soc Sci Med 2008; 67:1173-82. [DOI: 10.1016/j.socscimed.2008.06.024] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2007] [Indexed: 10/21/2022]
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Kondo M, McPake B. Making choices between prepayment and user charges in Zambia. What are the results for equity? HEALTH ECONOMICS 2007; 16:1371-87. [PMID: 17330922 DOI: 10.1002/hec.1219] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
In many low-income countries, user charges were introduced in the 1990s. As problems emerged of equity of access, interest grew in developing prepayment mechanisms to protect users from risk of out-of-pocket payments. In Zambia, a prepayment scheme did not generate sufficient revenue, due to abuses of its terms. An alternative scheme using discount cards (a set of coupons to cover episodes of care at discount) was devised. We aimed to understand the equity implications of prepayment and discount cards relative to user charges. We proposed models predicting roles of income, perceived health status, perceived quality of care and time preference in choice of payment mechanism and use of health services. We tested these models using three data sets that could be accessed or collected. It is concluded that relative to user charges, prepayment may facilitate access without incurring income-related equity losses. Evidence concerning discount cards was weaker. We concluded that they facilitate access to a lesser extent. Discount cards offer a credible intermediate solution between user charges and prepayment that avoid some problems associated with prepayment. However, since prepayment seems to be associated with the most positive outcomes, finding other solutions to their problems would be preferred.
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Affiliation(s)
- Masahide Kondo
- Department of Health Care Policy and Management, University of Tsukuba, Ibaraki, Japan.
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Habtom GK, Ruys P. Traditional risk-sharing arrangements and informal social insurance in Eritrea. Health Policy 2007; 80:218-35. [PMID: 16632070 DOI: 10.1016/j.healthpol.2006.02.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2005] [Accepted: 02/20/2006] [Indexed: 11/25/2022]
Abstract
In Eritrea neither the state nor the market is effective in providing health insurance to low-income people (in rural and informal job sector). Schemes intended for the informal sector are confronted with low and irregular incomes of target populations and consequently negligible potential for profit making. Because of this there, are no formal health insurance systems in Eritrea that cover people in the traditional (or informal) sector of the economy. In the absence of formal safety nets traditional Eritrean societies use their local social capital to alleviate unexpected social costs. In Eritrea traditional risk-sharing arrangements are made within extended families and mutual aid community associations. This study reveals that in a situation where the state no longer provides free public health services any more and access to private insurance is denied, the extension of the voluntary mutual aid community associations to Mahber-based health insurance schemes at the local level is a viable way for providing modern health services.
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Wang H, Zhang L, Yip W, Hsiao W. Adverse selection in a voluntary Rural Mutual Health Care health insurance scheme in China. Soc Sci Med 2006; 63:1236-45. [PMID: 16635541 DOI: 10.1016/j.socscimed.2006.03.008] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2005] [Indexed: 11/20/2022]
Abstract
This study examines adverse selection in a subsidized voluntary health insurance scheme, the Rural Mutual Health Care (RMHC) scheme, in a poor rural area of China. The study was made possible by a unique longitudinal data set: the total sample includes 3492 rural residents from 1020 households. Logistic regression was employed for the data analysis. The results show that although this subsidized scheme achieved a considerable high enrollment rate of 71% of rural residents, adverse selection still exists. In general, individuals with worse health status are more likely to enroll in RMHC than individuals with better health status. Although the household is set as the enrollment unit for the RMHC for the purpose of reducing adverse selection, nearly 1/3 of enrolled households are actually only partially enrolled. Furthermore, we found that adverse selection mainly occurs in partially enrolled households. The non-enrolled individuals in partially enrolled households have the best health status, while the enrolled individuals in partially enrolled households have the worst health status. Pre-RMHC, medical expenditure for enrolled individuals in partially enrolled households was 206.6 yuan per capita per year, which is 1.7 times as much as the pre-RMHC medical expenditure for non-enrolled individuals in partially enrolled households. The study also reveals that the pre-enrolled medical expenditure per capita per year of enrolled individuals was 9.6% higher than the pre-enrolled medical expenditure of all residents, including both enrolled and non-enrolled individuals. In conclusion, although the subsidized RMHC scheme reached a very high enrollment rate and the household is set as the enrollment unit for the purpose of reducing adverse selection, adverse selection still exists, especially within partially enrolled households. Voluntary RMHC will not be financially sustainable if the adverse selection is not fully taken into account.
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Affiliation(s)
- Hong Wang
- Yale University School of Medicine New Haven, CT 06520, USA.
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Mariam DH. Indigenous social insurance as an alternative financing mechanism for health care in Ethiopia (the case of eders). Soc Sci Med 2003; 56:1719-26. [PMID: 12639588 DOI: 10.1016/s0277-9536(02)00166-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
With increasing demand for services further propagated by population growth and by people's response to newly emerging pathologies, nations in sub-Saharan Africa are faced with insurmountable problems in sustaining their health systems. Realizing the inadequacy of solely relying on the public sector, these countries are seeking alternative mechanisms for health financing. Among the alternatives suggested are risk-sharing mechanisms that include community-based schemes that tap the potential of indigenous social arrangements. In Ethiopia, eders are major forms of indigenous arrangements utilized mainly for assisting victims in bereavement and executing funeral-related activities. These associations are also called upon in various self-help activities and sometimes provide health insurance, even though mostly in an informal manner. Therefore, they have the potential to serve as social financing mechanisms. Since these are already functioning groups, the administrative cost for the extra health-related activity will not be as high as in the case of forming a new insurance entity. In addition, the fact that eders are based on mutual understanding among members minimizes the possibility of adverse selection. Based on the above background, an exploratory study was conducted in 40 villages distributed in various parts of Ethiopia to assess the possible roles eders might play in providing insurance for health financing. Both qualitative and quantitative (household and health facility exit interview surveys) methods of data collection were utilized. The study concludes that eder-based schemes are, indeed, options for experimentation as mechanisms for financing health care in rural Ethiopia. It was also found that 21.5% of respondents in the household and 16% of those in the exit surveys were already utilizing eders to finance part of their health expenditure. In addition, 86% of the respondents in the household and 90% of those in the exit survey were willing to participate in eder-based health insurance schemes.
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Affiliation(s)
- Damen Haile Mariam
- Department of Community Health, Faculty of Medicine, Addis Ababa University, P.O. Box 11950, Addis Ababa, Ethiopia.
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Criel B, Van der Stuyft P, Van Lerberghe W. The Bwamanda hospital insurance scheme: effective for whom? A study of its impact on hospital utilization patterns. Soc Sci Med 1999; 48:897-911. [PMID: 10192557 DOI: 10.1016/s0277-9536(98)00391-8] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The Bwamanda hospital insurance scheme in Zaire was launched in the mid-eighties and is one of the few well-established and documented initiatives in the field of district-based insurance schemes in sub-Saharan Africa. It was established that hospital utilization in Bwamanda is significantly higher among the insured population. A higher hospital utilization is however not a goal in itself: it is a positive phenomenon if it takes place for problems where the hospital's know-how and technology are needed to solve the patient's problem. This paper investigates the effect of the insurance scheme on hospital utilization patterns. More specifically, the distribution of this higher utilization over the different hospital departments, as well as its spatial distribution in the entire district area are analyzed. The impact of the insurance scheme on the effectiveness, equity and efficiency of hospital utilization are discussed. The relevance and possible implications of these findings on the design of the Bwamanda insurance scheme are discussed. Finally, it is argued that the methods used in the present study contribute to a coherent framework for the evaluation of similar initiatives.
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Affiliation(s)
- B Criel
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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González Block MA. Comparative research and analysis methods for shared learning from health system reforms. Health Policy 1997; 42:187-209. [PMID: 10176300 DOI: 10.1016/s0168-8510(97)00072-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The pace and breadth of health reforms point to the need for a comparative methodology to support shared learning from country experiences. A common understanding of health reforms is a first prerequisite for comparative research. Dimensions characterising content, sequence, process, purpose and scope of policy change are identified on the basis of a literature review. Reforms can have a gradual build up, starting with piecemeal policy changes that can be eventually integrated to enhance their benefits. Comprehensive reforms can be defined as policy formulation and implementation that comprises the systemic, programmatic, organisational and instrumental policy levels through explicit strategies sustained in well-documented experiences and theories and implemented with the support of a specialised agency with consensus-building capacity. A minimum-data set is proposed on the basis of an extensive literature review to support the comparability of health reform case studies and descriptions. Its components are: the current health system, its background and context, the reform rationale, the specific proposals, political actors and processes, achievements and limitations, and lastly the reform's wider impact. Case studies can be compared historically, through particularistic comparisons, using ideal types and by means of exemplars. The advantages and limitation of each method are analysed as well as how they can be combined to frame the research questions and minimise resources. Finally, the International Clearinghouse for Health System Reform Initiatives is described as an instrument to disseminate comparative research and analysis in support of shared learning.
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