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Demsash AW. Spatial distribution and geographical heterogeneity factors associated with households' enrollment level in community-based health insurance. Front Public Health 2024; 12:1305458. [PMID: 38827604 PMCID: PMC11140031 DOI: 10.3389/fpubh.2024.1305458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 04/25/2024] [Indexed: 06/04/2024] Open
Abstract
Background Healthcare service utilization is unequal among different subpopulations in low-income countries. For healthcare access and utilization of healthcare services with partial or full support, households are recommended to be enrolled in a community-based health insurance system (CBHIS). However, many households in low-income countries incur catastrophic health expenditure. This study aimed to assess the spatial distribution and factors associated with households' enrollment level in CBHIS in Ethiopia. Methods A cross-sectional study design with two-stage sampling techniques was used. The 2019 Ethiopian Mini Demographic and Health Survey (EMDHS) data were used. STATA 15 software and Microsoft Office Excel were used for data management. ArcMap 10.7 and SaTScan 9.5 software were used for geographically weighted regression analysis and mapping the results. A multilevel fixed-effect regression was used to assess the association of variables. A variable with a p < 0.05 was considered significant with a 95% confidence interval. Results Nearly three out of 10 (28.6%) households were enrolled in a CBHIS. The spatial distribution of households' enrollment in the health insurance system was not random, and households in the Amhara and Tigray regions had good enrollment in community-based health insurance. A total of 126 significant clusters were detected, and households in the primary clusters were more likely to be enrolled in CBHIS. Primary education (AOR: 1.21, 95% CI: 1.05, 1.31), age of the head of the household >35 years (AOR: 2.47, 95% CI: 2.04, 3.02), poor wealth status (AOR: 0.31, 95% CI: 0.21, 1.31), media exposure (AOR: 1.35, 95% CI: 1.02, 2.27), and residing in Afar (AOR: 0.01, 95% CI: 0.003, 0.03), Gambela (AOR: 0.03, 95% CI: 0.01, 0.08), Harari (AOR: 0.06, 95% CI: 0.02, 0.18), and Dire Dawa (AOR: 0.02, 95% CI: 0.01, 0.06) regions were significant factors for households' enrollment in CBHIS. The secondary education status of household heads, poor wealth status, and media exposure had stationary significant positive and negative effects on the enrollment of households in CBHIS across the geographical areas of the country. Conclusion The majority of households did not enroll in the CBHIS. Effective CBHIS frameworks and packages are required to improve the households' enrollment level. Financial support and subsidizing the premiums are also critical to enhancing households' enrollment in CBHIS.
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Affiliation(s)
- Addisalem Workie Demsash
- Department of Health Informatics, Debre Berhan University, Asrat Woldeyes Health Science Campus, Debre Birhan, Ethiopia
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Hsiao WC, Yip W. Financing and provision of healthcare for two billion people in low-income nations: Is the cooperative healthcare model a solution? Soc Sci Med 2024; 345:115730. [PMID: 36803450 DOI: 10.1016/j.socscimed.2023.115730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 03/20/2022] [Accepted: 01/26/2023] [Indexed: 02/11/2023]
Abstract
The international consensus in support of universal health coverage (UHC), though commendable, thus far lacks a clear mechanism to finance and deliver accessible and effective basic healthcare to the two billion rural residents and informal workers of low- and lower-middle-income countries (LLMICs). Importantly, the two preferred financing modes for UHC, general tax revenue and social health insurance, are often infeasible for LLMICs. We identify from historical examples a community-based model that we argue shows promise as a solution to this problem. This model, which we call Cooperative Healthcare (CH), is characterized by community-based risk-pooling and governance and prioritizes primary care. CH leverages communities' existing social capital, such that even those for whom the private benefit of enrolling in a CH scheme is outweighed by the cost may choose to enroll (given sufficient social capital). For CH to be scalable, it needs to demonstrate that it can organize delivery of accessible and reasonable-quality primary healthcare that people value, with management accountable to the communities themselves through structures that people trust, combined with government legitimacy. Once LLMICs with CH programs have industrialized sufficiently to make universal social health insurance feasible, CH schemes can be rolled into such universal programs. We defend cooperative healthcare's suitability for this bridging role and urge LLMIC governments to launch experiments testing it out, with careful adaptation to local conditions.
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Affiliation(s)
- William C Hsiao
- Emeritus, Global Health and Population, 104 Mount Auburn St., 303, Cambridge, MA, 02138, USA.
| | - Winnie Yip
- Health Policy and Economics, Harvard University T H Chan School of Public Health, Boston, MA, USA
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Acharya D, Thapa KB, Sharma B, Rana MS. Causes of dropout from health insurance program: An experience from Lumbini Province, Nepal. DIALOGUES IN HEALTH 2023; 3:100150. [DOI: https:/doi.org/10.1016/j.dialog.2023.100150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/20/2023]
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Acharya D, Thapa KB, Sharma B, Rana MS. Causes of dropout from health insurance program: An experience from Lumbini Province, Nepal. DIALOGUES IN HEALTH 2023; 3:100150. [PMID: 38515800 PMCID: PMC10953976 DOI: 10.1016/j.dialog.2023.100150] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 07/31/2023] [Accepted: 07/31/2023] [Indexed: 03/23/2024]
Abstract
The Health Insurance Program (HIP) in Nepal is experiencing low enrolment and high dropout rates, but the causes of these issues have remained unknown. This study aimed to explore the causes of dropouts of the HIP implemented by the Health Insurance Board, Nepal. We employed an exploratory qualitative research design. We purposefully selected the informants for the data collection who had previously enrolled and currently not renewed their insurance scheme. We gathered qualitative information from 16 in-depth interviews, four key informant interviews, and four focus group discussion in Palpa and Bardia Districts of Lumbini Province, Nepal. The qualitative data were analyzed using thematic analysis. We identified two major themes and nine drop-out-related sub-themes. These were: unnecessary health insurance; negligence to renew; unable to pay the contribution amount; poor cooperation between institutions as well as insurees and insurers; limited coverage and ceiling amount; rigid processes to receive health services; health professionals' behaviors; poor quality healthcare services; inadequate information. Dropout-related factors were associated with personal or individual factors and institutional or policy-related (process-related) factors. The major causes/reasons for dropout include lengthy procedures, poor quality and unsatisfactory services, a lack of knowledge on health insurance norms and procedures, and health professionals' behavior towards insurees during treatment. Information, education, and communication programs related to health insurance are still necessary to make the insurees familiar with the insurance systems and its processes. These factors could be taken into account by policymakers while planning interventions to minimize the low enrollment and high dropout.
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Affiliation(s)
- Devaraj Acharya
- Bhairahawa Multiple Campus [TU], Siddharthanagar, Rupandehi, Lumbini Province, Nepal
| | | | - Bhagawoti Sharma
- Mahendra Multiple Campus [TU], Nepalgunj, Banke, Lumbini Province, Nepal
| | - Mohan Singh Rana
- Mahendra Multiple Campus [TU], Ghorahi, Dang, Lumbini Province, Nepal
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Acharya D, Thapa KB, Sharma B, Rana MS. Causes of dropout from health insurance program: An experience from Lumbini Province, Nepal. DIALOGUES IN HEALTH 2023; 3:100150. [DOI: ht10.1016/j.dialog.2023.100150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/20/2023]
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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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Amani PJ, Sebastian MS, Hurtig AK, Kiwara AD, Goicolea I. Healthcare workers´ experiences and perceptions of the provision of health insurance benefits to the elderly in rural Tanzania: an explorative qualitative study. BMC Public Health 2023; 23:459. [PMID: 36890474 PMCID: PMC9996914 DOI: 10.1186/s12889-023-15297-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 02/20/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND Healthcare workers play an important part in the delivery of health insurance benefits, and their role in ensuring service quality and availability, access, and good management practice for insured clients is crucial. Tanzania started a government-based health insurance scheme in the 1990s. However, no studies have specifically looked at the experience of healthcare professionals in the delivery of health insurance services in the country. This study aimed to explore healthcare workers' experiences and perceptions of the provision of health insurance benefits for the elderly in rural Tanzania. METHODS An exploratory qualitative study was conducted in the rural districts of Igunga and Nzega, western-central Tanzania. Eight interviews were carried out with healthcare workers who had at least three years of working experience and were involved in the provision of healthcare services to the elderly or had a certain responsibility with the administration of health insurance. The interviews were guided by a set of questions related to their experiences and perceptions of health insurance and its usefulness, benefit packages, payment mechanisms, utilisation, and availability of services. Qualitative content analysis was used to analyse the data. RESULTS Three categories were developed that describe healthcare workers´ experiences and perceptions of delivering the benefits of health insurance for the elderly living in rural Tanzania. Healthcare workers perceived health insurance as an important mechanism to increase healthcare access for elderly people. However, alongside the provision of insurance benefits, several challenges coexisted, such as a shortage of human resources and medical supplies as well as operational issues related to delays in funding reimbursement. CONCLUSION While health insurance was considered an important mechanism to facilitate access to care among rural elderly, several challenges that impede its purpose were mentioned by the participants. Based on these, an increase in the healthcare workforce and availability of medical supplies at the health-centre level together with expansion of services coverage of the Community Health Fund and improvement of reimbursement procedures are recommended to achieve a well-functioning health insurance scheme.
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Affiliation(s)
- Paul Joseph Amani
- Department of Health Systems Management, School of Public Administration and Management, Mzumbe University, Morogoro, Tanzania. .,Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden.
| | | | - Anna-Karin Hurtig
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
| | - Angwara Denis Kiwara
- Department of Development Studies, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Isabel Goicolea
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
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Mussa EC, Palermo T, Angeles G, Kibur M, Otchere F, Valli E, Waidler J, Quiñones S, Serdan AGG, Vinci V, Ouedraogo LM, Kebede GB, Tadele G, Adamu S, Abebe T, Tadesse Y, Nega F, Kebede M, Muluye F, Matsentu A, Aklilu D. Impact of community-based health insurance on health services utilisation among vulnerable households in Amhara region, Ethiopia. BMC Health Serv Res 2023; 23:55. [PMID: 36658561 PMCID: PMC9850585 DOI: 10.1186/s12913-023-09024-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 09/29/2022] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Ethiopia piloted community-based health insurance in 2011, and as of 2019, the programme was operating in 770 districts nationwide, covering approximately 7 million households. Enrolment in participating districts reached 50%, holding promise to achieve the goal of Universal Health Coverage in the country. Despite the government's efforts to expand community-based health insurance to all districts, evidence is lacking on how enrolment in the programme nudges health seeking behaviour among the most vulnerable rural households. This study aims to examine the effect of community-based health insurance enrolment among the most vulnerable and extremely poor households participating in Ethiopia's Productive Safety Net Programme on the utilisation of healthcare services in the Amhara region. METHODS Data for this study came from Amhara pilot integrated safety net programme baseline survey in Ethiopia and were collected between December 2018 and February 2019 from 5,398 households. We used propensity score matching method to estimate the impacts of enrolment in community-based health insurance on outpatient, maternal, and child preventive and curative healthcare services utilisation. RESULTS Results show that membership in community-based health insurance increases the probabilities of visiting health facilities for curative care in the past month by 8.2 percentage points (95% CI 5.3 to 11.1), seeking care from a health professional by 8.4 percentage points (95% CI 5.5 to 11.3), and visiting a health facility to seek any medical assistance for illness and check-ups in the past 12 months by 13.9 percentage points (95% CI 10.5 to 17.4). Insurance also increases the annual household per capita health facility visits by 0.84 (95% CI 0.64 to 1.04). However, we find no significant effects of community-based health insurance membership on utilisation of maternal and child healthcare services. CONCLUSIONS Findings that community-based health insurance increased outpatient services utilisation implies that it could also contribute towards universal health coverage and health equity in rural and informal sectors. The absence of significant effects on maternal and child healthcare services may be due to the free availability of such services for everyone at the public health facilities, regardless of insurance membership. Outpatient services use among insured households is still not universal, and understanding of the barriers to use, including supply-side constraints, will help improve universal health coverage.
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Affiliation(s)
- Essa Chanie Mussa
- UNICEF Office of Research—Innocenti, Via Degli Alfani 58, Florence, 50121 Italy ,grid.59547.3a0000 0000 8539 4635Department of Agricultural Economics, University of Gondar, Gondar, Ethiopia
| | - Tia Palermo
- grid.273335.30000 0004 1936 9887Department of Epidemiology and Environmental Health, University at Buffalo (State University of New York), Buffalo, NY 14214-8001 USA
| | - Gustavo Angeles
- grid.10698.360000000122483208Department of Maternal and Child Health, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27516 USA
| | - Martha Kibur
- UNICEF Country Office of Ethiopia, Box 1169, Addis Ababa, Ethiopia
| | - Frank Otchere
- UNICEF Office of Research—Innocenti, Via Degli Alfani 58, Florence, 50121 Italy
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Ly MS, Faye A, Ba MF. Impact of community-based health insurance on healthcare utilisation and out-of-pocket expenditures for the poor in Senegal. BMJ Open 2022; 12:e063035. [PMID: 36600430 PMCID: PMC9772627 DOI: 10.1136/bmjopen-2022-063035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES This study aims to assess the impact of the subsidised community health insurance scheme in Senegal particularly on the poor. DESIGN AND SETTING The study used data from a household survey conducted in 2019 in three regions, representing 29.3% of the total population. Inverse probability of treatment weighting approach was applied for the analysis. PARTICIPANTS 1766 households with 15 584 individuals selected through a stratified random sampling with two draws. MAIN OUTCOME MEASURES The impact of community-based health insurance (CBHI) was evaluated on poor people's access to care and on their financial protection. For the measurement of access to care, we were interested in the use of health services and non-withdrawal from care in case of illness. To assess financial protection, we looked at out-of-pocket expenditure by type of provider and by type of service, the weight of out-of-pocket expenditure on household income, non-exposure to impoverishing health expenditure and non-exposure to catastrophic health expenditure. RESULTS The results indicate that the CBHI increases primary healthcare utilisation for non-poor (OR 1.36 (CI90 1.02-1.8) for the general scheme and 1.37 (CI90 1.06-1.77) for the special scheme for indigent recipients of social cash transfers), protect them against catastrophic (OR 1.63 (CI90 1.12-2.39)) or impoverishing (OR 2.4 (CI90 1.27-4.5)) health expenditures. However, CBHI has no impact on the poor's healthcare utilisation (OR 0.61 (CI90 0.4-0.94)) and do not protect them from the burden related to healthcare expenditures (OR: 0.27 (CI90 0.13-0.54)). CONCLUSION Our study found that CBHI has an impact on the non-poor but does not sufficiently protect the poor. This leads us to conclude that a health insurance programme designed for the general population may not be appropriate for the poor. A qualitative study should be conducted to better understand the non-financial barriers to accessing care that may disproportionately affect the poorest.
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Affiliation(s)
| | - Adama Faye
- Cheikh Anta Diop University of Dakar, Dakar, Senegal
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Anjorin SS, Ayorinde AA, Abba MS, Mensah D, Okolie EA, Uthman OA, Oyebode OO. Equity of national publicly funded health insurance schemes under the universal health coverage agenda: a systematic review of studies conducted in Africa. J Public Health (Oxf) 2022; 44:900-909. [PMID: 34390345 DOI: 10.1093/pubmed/fdab316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The implementation of publicly funded health insurance schemes (PFHIS) is the major strategy to drive progress and achievement of universal health coverage (UHC) by 2030. We appraised evidence on the equity of insurance schemes across Africa. METHODS We conducted a systematic review of published studies that assessed equity in health insurance schemes implemented under the UHC agenda in Africa. Seven databases, Web of Science, Medline, CINAHL, Scopus, Cochrane Library, EMBASE and World Bank eLibrary, were searched; we operationalized the PROGRESS-Plus (place of residence; race/ethnicity/culture/language; occupation; gender/sex religion; education; socioeconomic status; social capital) equity framework to assess equity areas. RESULTS Forty-five studies met the inclusion criteria and were included in the study, in which 90% assessed equity by socioeconomic status. Evidence showed that rural residents, those self-employed or working in the informal sector, men, those with lower educational attainment, and the poor were less likely to be covered by health insurance schemes. Broadly, the insurance schemes, especially, community-based health insurance (CBI) schemes improved utilization by disadvantaged groups, however, the same groups were less likely to benefit from health services. CONCLUSIONS Evidence on equity of PFHIS is mixed, however, CBI schemes seem to offer more equitable coverage and utilization of essential health services in Africa.
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Affiliation(s)
- Seun S Anjorin
- Warwick Centre for Global Health, Division of Health Sciences, Warwick Medical School, University of Warwick, Gibbet Hills Campus, Coventry CV4 7HL, UK
| | - Abimbola A Ayorinde
- NIHR Applied Research Collaboration West Midlands, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Mustapha S Abba
- Warwick Centre for Global Health, Division of Health Sciences, Warwick Medical School, University of Warwick, Gibbet Hills Campus, Coventry CV4 7HL, UK
| | - Daniel Mensah
- Warwick Centre for Global Health, Division of Health Sciences, Warwick Medical School, University of Warwick, Gibbet Hills Campus, Coventry CV4 7HL, UK
| | - Elvis A Okolie
- Department of Public Health, School of Health and Life Sciences, Teesside University, Tee Valley, Middlesbrough, North Yorkshire, TS1 3BX, UK
| | - Olalekan A Uthman
- Warwick Centre for Global Health, Division of Health Sciences, Warwick Medical School, University of Warwick, Gibbet Hills Campus, Coventry CV4 7HL, UK
| | - Oyinlola O Oyebode
- Warwick Centre for Global Health, Division of Health Sciences, Warwick Medical School, University of Warwick, Gibbet Hills Campus, Coventry CV4 7HL, UK
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Osei Afriyie D, Krasniq B, Hooley B, Tediosi F, Fink G. Equity in health insurance schemes enrollment in low and middle-income countries: A systematic review and meta-analysis. Int J Equity Health 2022; 21:21. [PMID: 35151323 PMCID: PMC8841076 DOI: 10.1186/s12939-021-01608-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 12/10/2021] [Indexed: 01/11/2023] Open
Abstract
Background Ensuring access to essential quality health services and reducing financial hardship for all individuals regardless of their ability to pay are the main goals of universal health coverage. Various health insurance schemes have been recently implemented in low- and middle-income countries (LMICs) to achieve both of these objectives. We systematically reviewed all available literature to assess the extent to which current health insurance schemes truly reach the poor and underserved populations in LMICs. Methods In the systematic review, we searched on PubMed, Web of Science, EconLit and Google Scholar to identify eligible studies which captured health insurance enrollment information in LMICs from 2010 up to September 2019. Two authors independently selected studies, extracted data, and appraised included studies. The primary outcome of interest was health insurance enrollment of the most vulnerable populations relative to enrollment of the best-off subgroups. We classified households both with respect to their highest educational attainment and their relative wealth and used random-effects meta-analysis to estimate average enrollment gaps. Results 48 studies from 17 countries met the inclusion criteria. The average enrollment rate into health insurance schemes for vulnerable populations was 36% with an inter-quartile range of 26%. On average, across countries, households from the wealthiest subgroup had 61% higher odds (95% CI: 1.49 to 1.73) of insurance enrollment than households in the poorest group in the same country. Similarly, the most educated groups had 64% (95% CI: 1.32 to 1.95) higher odds of enrollment than the least educated groups. Conclusion The results of this study show that despite major efforts by governments, health insurance schemes in low-and middle-income countries are generally not reaching the targeted underserved populations and predominantly supporting better-off population groups. Current health insurance designs should be carefully scrutinized, and the extent to which health insurance can be used to support the most vulnerable populations carefully re-assessed by countries, which are aiming to use health insurance schemes as means to reach their UHC goals. Furthermore, studies exploring best practices to include vulnerable groups in health insurance schemes are needed. Registration Not available Supplementary Information The online version contains supplementary material available at 10.1186/s12939-021-01608-x.
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Chirwa GC, Suhrcke M, Moreno-Serra R. Socioeconomic inequality in premiums for a community-based health insurance scheme in Rwanda. Health Policy Plan 2021; 36:14-25. [PMID: 33263730 DOI: 10.1093/heapol/czaa135] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2020] [Indexed: 11/12/2022] Open
Abstract
Community-based health insurance (CBHI) has gained popularity in many low- and middle-income countries, partly as a policy response to calls for low-cost, pro-poor health financing solutions. In Africa, Rwanda has successfully implemented two types of CBHI systems since 2005, one of which with a flat rate premium (2005-10) and the other with a stratified premium (2011-present). Existing CBHI evaluations have, however, tended to ignore the potential distributional aspects of the household contributions made towards CBHI. In this paper, we investigate the pattern of socioeconomic inequality in CBHI household premium contributions in Rwanda within the implementation periods. We also assess gender differences in CBHI contributions. Using the 2010/11 and 2013/14 rounds of national survey data, we quantify the magnitude of inequality in CBHI payments, decompose the concentration index of inequality, calculate Kakwani indices and implement unconditional quantile regression decomposition to assess gender differences in CBHI expenditure. We find that the CBHI with stratified premiums is less regressive than CBHI with a flat rate premium system. Decomposition analysis indicates that income and CBHI stratification explain a large share of the inequality in CBHI payments. With respect to gender, female-headed households make lower contributions towards CBHI expenditure, compared with male-headed households. In terms of policy implications, the results suggest that there may be a need for increasing the premium bracket for the wealthier households, as well as for the provision of more subsidies to vulnerable households.
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Affiliation(s)
| | - Marc Suhrcke
- Centre for Health Economics, University of York, Heslington, York YO10 5DD, UK.,Luxembourg Institute of Socio-Economic Research (LISER), Maison des Sciences Humaines, 11, Porte des Sciences, L-4366 Esch-sur-Alzette/Belval
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Artignan J, Bellanger M. Does community-based health insurance improve access to care in sub-Saharan Africa? A rapid review. Health Policy Plan 2021; 36:572-584. [PMID: 33624113 DOI: 10.1093/heapol/czaa174] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/19/2020] [Indexed: 11/13/2022] Open
Abstract
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.
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Novignon J, Atakorah YB, Chijere Chirwa G. Exemption for the poor or the rich? An assessment of socioeconomic inequalities in Ghana's national health insurance exemption policies. Health Policy Plan 2021; 36:1058-1066. [PMID: 34050736 DOI: 10.1093/heapol/czab059] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 04/18/2021] [Accepted: 05/19/2021] [Indexed: 11/14/2022] Open
Abstract
Out-of-pocket payments for health are considered a major limitation to universal health coverage (UHC). Policymakers across the globe are committed to achieving UHC through the removal of financial barriers to health care. In Ghana, a national health insurance scheme was established for this purpose. A unique feature of the scheme is its premium exemption policies for vulnerable groups. In this article, we access the nature of socioeconomic inequality in these exemption policies. We used data from the Ghana Living Standards Survey rounds six and seven. Socioeconomic inequality was assessed using concentration curves and indices. Real household annual total consumption expenditure adjusted by adult equivalence scale was used as a wealth indicator. Four categories of exemption were used as outcome variables. These were exemptions for indigents, individuals <18 years, the aged and free maternal service. The analysis was also disaggregated by rural and urban locations of individuals. We found that while overall national health insurance scheme (NHIS) coverage was concentrated among the wealthy, all categories of premium exemption were concentrated among the poor. There was also evidence of a general decline in the magnitude of inequality over the survey years. With the specific exemptions, inequalities in exemption for indigents and maternal services were most relevant in rural locations, while inequalities in exemption for individuals <18 years and the aged were significant in urban areas. The findings suggest that the exemption policies under the NHIS are generally progressive and achieve the objective of inclusion for the underprivileged. However, it also provides lessons for better targeting and effective implementation. There may be a need for separate efforts to better target individuals in rural and urban locations to improve enrolment.
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Affiliation(s)
- Jacob Novignon
- Private Mail Bag, Department of Economics, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Yaw Boateng Atakorah
- Private Mail Bag, Department of Economics, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
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Degroote S, Ridde V, De Allegri M. Health Insurance in Sub-Saharan Africa: A Scoping Review of the Methods Used to Evaluate its Impact. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2020; 18:825-840. [PMID: 31359270 PMCID: PMC7716930 DOI: 10.1007/s40258-019-00499-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
We conducted a scoping review with the objective of synthesizing available literature and mapping what designs and methods have been used to evaluate health insurance reforms in sub-Saharan Africa. We systematically searched for scientific and grey literature in English and French published between 1980 and 2017 using a combination of three key concepts: "Insurance" and "Impact evaluation" and "sub-Saharan Africa". The search led to the inclusion of 66 articles with half of the studies pertaining to the evaluation of National Health Insurance schemes, especially the Ghanaian one, and one quarter pertaining to Community-Based Health Insurance and Mutual Health Organization schemes. Sixty-one out of the 66 studies (92%) included were quantitative studies, while only five (8%) were defined as mixed methods. Most studies included applied an observational design (n = 37; 56%), followed by a quasi-experimental (n = 27; 41%) design; only two studies (3%) applied an experimental design. The findings of our scoping review are in line with the observation emerging from prior reviews focused on content in pointing at the fact that evidence on the impact of health insurance is still relatively weak as it is derived primarily from studies relying on observational designs. Our review did identify an increase in the use of quasi-experimental designs in more recent studies, suggesting that we could observe a broadening and deepening of the evidence base on health insurance in Africa over the next few years.
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Affiliation(s)
- Stéphanie Degroote
- French Institute For Research on Sustainable Development (IRD), IRD Paris Descartes University (CEPED), 45 rue des Saints Pères, 75006, Paris, France
| | - Valery Ridde
- French Institute For Research on Sustainable Development (IRD), IRD Paris Descartes University (CEPED), 45 rue des Saints Pères, 75006, Paris, France
- Paris Sorbonne Cities University, Erl Inserm Sagesud, Paris, France
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, University Hospital and Medical Faculty, Heidelberg University, Heidelberg, Germany.
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Atnafu A, Gebremedhin T. Community-Based Health Insurance Enrollment and Child Health Service Utilization in Northwest Ethiopia: A Cross-Sectional Case Comparison Study. CLINICOECONOMICS AND OUTCOMES RESEARCH 2020; 12:435-444. [PMID: 32848434 PMCID: PMC7428314 DOI: 10.2147/ceor.s262225] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/29/2020] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
- Asmamaw Atnafu
- Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Tsegaye Gebremedhin
- Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Understanding unmet health-care need among older Ghanaians: a gendered analysis. AGEING & SOCIETY 2020. [DOI: 10.1017/s0144686x19001892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractHealth insurance schemes are important for bridging gaps in health-care needs between the rich and poor, especially in contexts where poverty is higher among seniors (persons aged 65 years and above). In this study we examined (a) gender-based predictors of unmet health-care need among seniors and (b) whether access was influenced by wealth status (measured by income quintiles). Gender-specific negative log–log regression models were fitted to data from the Study on Global Ageing and Health to examine associations between unmet health-care need and health insurance status controlling for theoretically relevant covariates. Insurance status was an important determinant of men and women's unmet health-care need but the relationship was moderated by income quintile for women and not men. While occupation was important for men, religion, marital status and income quintile were significantly associated with women's unmet health-care need. Based on the observed gender differences, we recommend the implementation of programmes aimed at improving the economic situation of older people, particularly women.
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Abstract
In the global South, low-income populations are faced with frequent health shocks. Formal mechanisms to protect them against these shocks are absent or limited. Thus, what are the mechanisms used by low-income rural populations to finance healthcare? This paper draws on a qualitative study to examine the healthcare financing mechanisms of low-income rural populations in Cameroon. The findings suggest that low-income populations use 13 mechanisms to finance healthcare. Depending on several factors, people may use more than one of these mechanisms. In addition, social factors shape people’s patterns of usage of these mechanisms. Patterns of usage of these mechanisms are embedded in the principle of reciprocity. The notion of reciprocity does seem to discourage people from enrolling in the limited voluntary health insurance programmes which exist in various communities. Newly insured people were more likely to drop out if they did not receive a payout.
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Xian W, Xu X, Li J, Sun J, Fu H, Wu S, Liu H. Health care inequality under different medical insurance schemes in a socioeconomically underdeveloped region of China: a propensity score matching analysis. BMC Public Health 2019; 19:1373. [PMID: 31653250 PMCID: PMC6815066 DOI: 10.1186/s12889-019-7761-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 10/10/2019] [Indexed: 12/04/2022] Open
Abstract
Background Since economic inequality is often accompanied by health inequalities, health care inequalities are increasingly becoming a hot issue on a global scale. As a developing country, China is still facing the same problems as other countries in the world. Especially in underdeveloped regions, owing to the relatively backward economy, health care inequality may be more serious. The objective of this study was to explore health care inequality in a socioeconomically underdeveloped city, thus providing a certain theoretical basis for further development and reform of the medical insurance schemes. Methods We mainly extracted relevant insurance information of 628,952 insured enrollees, as well as consumption of outpatient visit and hospitalization. The propensity score matching had been used to estimate different urban medical insurance schemes effect on healthcare utilization, the choice of hospital types and healthcare cost. Results Insured enrollees spent most hospitalization expenses in tertiary-level hospitals, which had lowest hospitalization compensation ratios. Healthcare utilization and cost vary significantly by different insurance schemes. Urban employees had significantly higher outpatient visit rates in all hospital types than urban residents. Urban employees preferred to receive hospitalization treatment in tertiary-level hospitals, while those who receive hospitalization treatment in first-level hospitals are more likely to be enrolled in Urban Residents Basic Medical Insurance. Hospitalization expenses and hospitalization compensation ratios of urban employees were also significantly higher than urban residents in all hospital types. Conclusions Health care inequality is mainly reflected in the imbalance between hospitalization expenses and hospitalization compensation ratios, as well as inequalities under different medical insurance schemes in healthcare utilization, the choice of hospital types and healthcare cost in socioeconomically underdeveloped regions of China. We should conduct a targeted medical insurance reform for the socioeconomically underdeveloped regions, rather than applying templates of ordinary regions. Further efforts are needed in the future to provide equal health care for every patient.
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Affiliation(s)
- Wei Xian
- School of Public Health, China Medical University, Shenyang, People's Republic of China.,Department of Information Center, The Fourth Affiliated Hospital of China Medical University, Shenyang, People's Republic of China
| | - Xueying Xu
- School of Public Health, China Medical University, Shenyang, People's Republic of China
| | - Junling Li
- School of Public Health, China Medical University, Shenyang, People's Republic of China
| | - Jinbin Sun
- School of Public Health, China Medical University, Shenyang, People's Republic of China
| | - Hezi Fu
- Simon Fraser University, Burnaby, Canada
| | - Shaoning Wu
- School of Public Health, China Medical University, Shenyang, People's Republic of China
| | - Hongbo Liu
- School of Public Health, China Medical University, Shenyang, People's Republic of China.
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De Allegri M, Lohmann J, Souares A, Hillebrecht M, Hamadou S, Hien H, Haidara O, Robyn PJ. Responding to policy makers' evaluation needs: combining experimental and quasi-experimental approaches to estimate the impact of performance based financing in Burkina Faso. BMC Health Serv Res 2019; 19:733. [PMID: 31640694 PMCID: PMC6805435 DOI: 10.1186/s12913-019-4558-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 09/24/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The last two decades have seen a growing recognition of the need to expand the impact evaluation toolbox from an exclusive focus on randomized controlled trials to including quasi-experimental approaches. This appears to be particularly relevant when evaluation complex health interventions embedded in real-life settings often characterized by multiple research interests, limited researcher control, concurrently implemented policies and interventions, and other internal validity-threatening circumstances. To date, however, most studies described in the literature have employed either an exclusive experimental or an exclusive quasi-experimental approach. METHODS This paper presents the case of a study design exploiting the respective advantages of both approaches by combining experimental and quasi-experimental elements to evaluate the impact of a Performance-Based Financing (PBF) intervention in Burkina Faso. Specifically, the study employed a quasi-experimental design (pretest-posttest with comparison) with a nested experimental component (randomized controlled trial). A difference-in-differences approach was used as the main analytical strategy. DISCUSSION We aim to illustrate a way to reconcile scientific and pragmatic concerns to generate policy-relevant evidence on the intervention's impact, which is methodologically rigorous in its identification strategy but also considerate of the context within which the intervention took place. In particular, we highlight how we formulated our research questions, ultimately leading our design choices, on the basis of the knowledge needs expressed by the policy and implementing stakeholders. We discuss methodological weaknesses of the design arising from contextual constraints and the accommodation of various interests, and how we worked ex-post to address them to the best extent possible to ensure maximal accuracy and credibility of our findings. We hope that our case may be inspirational for other researchers wishing to undertake research in settings where field circumstances do not appear to be ideal for an impact evaluation. TRIAL REGISTRATION Registered with RIDIE (RIDIE-STUDY-ID- 54412a964bce8 ) on 10/17/2014.
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Affiliation(s)
- Manuela De Allegri
- Institute of Global Health, Medical Faculty, Heidelberg University, Germany; Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Julia Lohmann
- Institute of Global Health, Medical Faculty, Heidelberg University, Germany; Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Aurélia Souares
- Institute of Global Health, Medical Faculty, Heidelberg University, Germany; Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Michael Hillebrecht
- Institute of Global Health, Medical Faculty, Heidelberg University, Germany; Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
| | - Saidou Hamadou
- The World Bank; Nouvelle Route Bastos B. P 1128, Yaoundé, Cameroon
| | - Hervé Hien
- Centre MURAZ, 2054 Avenue Mamadou KONATE, 01 B.P. 390, Bobo-Dioulasso, 01 Burkina Faso
| | - Ousmane Haidara
- The World Bank; Health, Nutrition, Population Global Practice, 1818 H Street, NW, Washington, DC 20433 USA
| | - Paul Jacob Robyn
- The World Bank; Health, Nutrition, Population Global Practice, 1818 H Street, NW, Washington, DC 20433 USA
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van Hees SGM, O'Fallon T, Hofker M, Dekker M, Polack S, Banks LM, Spaan EJAM. Leaving no one behind? Social inclusion of health insurance in low- and middle-income countries: a systematic review. Int J Equity Health 2019; 18:134. [PMID: 31462303 PMCID: PMC6714392 DOI: 10.1186/s12939-019-1040-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 08/19/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND One way to achieve universal health coverage (UHC) in low- and middle-income countries (LMIC) is the implementation of health insurance schemes. A robust and up to date overview of empirical evidence assessing and substantiating health equity impact of health insurance schemes among specific vulnerable populations in LMICs beyond the more common parameters, such as income level, is lacking. We fill this gap by conducting a systematic review of how social inclusion affects access to equitable health financing arrangements in LMIC. METHODS We searched 11 databases to identify peer-reviewed studies published in English between January 1995 and January 2018 that addressed the enrolment and impact of health insurance in LMIC for the following vulnerable groups: female-headed households, children with special needs, older adults, youth, ethnic minorities, migrants, and those with a disability or chronic illness. We assessed health insurance enrolment patterns of these population groups and its impact on health care utilization, financial protection, health outcomes and quality of care. RESULTS The comprehensive database search resulted in 44 studies, in which chronically ill were mostly reported (67%), followed by older adults (33%). Scarce and inconsistent evidence is available for individuals with disabilities, female-headed households, ethnic minorities and displaced populations, and no studies were yielded reporting on youth or children with special needs. Enrolment rates seemed higher among chronically ill and mixed or insufficient results are observed for the other groups. Most studies reporting on health care utilization found an increase in health care utilization for insured individuals with a disability or chronic illness and older adults. In general, health insurance schemes seemed to prevent catastrophic health expenditures to a certain extent. However, reimbursements rates were very low and vulnerable individuals had increased out of pocket payments. CONCLUSION Despite a sizeable literature published on health insurance, there is a dearth of good quality evidence, especially on equity and the inclusion of specific vulnerable groups in LMIC. Evidence should be strengthened within health care reform to achieve UHC, by redefining and assessing vulnerability as a multidimensional process and the investigation of mechanisms that are more context specific.
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Affiliation(s)
- Suzanne G M van Hees
- Radboud Institute for Health Sciences (RIHS), Department for Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands.
- Department of Work and Health, HAN University of Applied Sciences, Kapittelweg 33, P.O. Box 6960, 6503GL, Nijmegen, Netherlands.
| | - Timothy O'Fallon
- International Centre for Evidence in Disability, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Marleen Dekker
- African Studies Center, Leiden University, Leiden, The Netherlands
| | - Sarah Polack
- International Centre for Evidence in Disability, London School of Hygiene and Tropical Medicine, London, UK
| | - Lena Morgon Banks
- International Centre for Evidence in Disability, London School of Hygiene and Tropical Medicine, London, UK
| | - Ernst J A M Spaan
- Radboud Institute for Health Sciences (RIHS), Department for Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands
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Nakovics MI, Brenner S, Robyn PJ, Tapsoba LDG, De Allegri M. Determinants of individual healthcare expenditure: A cross-sectional analysis in rural Burkina Faso. Int J Health Plann Manage 2019; 34:e1478-e1494. [PMID: 31225677 DOI: 10.1002/hpm.2812] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 04/28/2019] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION Overwhelming evidence suggests that out-of-pocket expenditures (OOPEs) hamper access to care and impose a heavy economic burden across sub-Saharan Africa (SSA). Still, current user fee reduction and removal policies often target specific groups and services, leaving large sections of the population exposed to OOPE. METHODS To estimate the magnitude and the determinants of OOPE for curative services in Burkina Faso, we used data from a household survey conducted in 24 districts between October 2013 and March 2014 (n = 7844). Given a context of medical pluralism, we purposely focused on total OOPE irrespective of type of care sought. We used a two-part regression model to estimate determinants of OOPE. RESULTS Nearly 60% of those who reported an illness episode incurred a positive expenditure, with an average amount of 9362.52 FRS CFA per episode (1 USD = 577.94 FRS CFA). The first model revealed that the probability of incurring a positive OOPE was positively associated with perceived illness severity (P < .001), hospitalization (P < .001), and negatively associated with age (P = .026), distance (P = .060), and poorest wealth quintile (P = .054). The second model revealed that the magnitude of OOPE was positively associated with age (P = .087), education (P = .025), being household head (P = .015), having a chronic comorbidity (P = .025), perceived illness severity (P = .029), and hospitalization (P < .001) and negatively associated with symptoms unlikely to lead to adverse outcomes if not attended to in time (P = .056). CONCLUSION Our findings indicate that OOPEs remain a problem in Burkina Faso and that broader spectrum policy reforms are urgently needed to ensure adequate financial protection.
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Affiliation(s)
- Meike Irene Nakovics
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Stephan Brenner
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Paul Jacob Robyn
- Health, Nutrition and Population Global Practice, World Bank, Washington, District of Columbia, USA
| | | | - Manuela De Allegri
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, University of Heidelberg, Heidelberg, Germany
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Liu K, Subramanian SV, Lu C. Assessing national and subnational inequalities in medical care utilization and financial risk protection in Rwanda. Int J Equity Health 2019; 18:51. [PMID: 30917822 PMCID: PMC6437855 DOI: 10.1186/s12939-019-0953-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Accepted: 03/19/2019] [Indexed: 11/17/2022] Open
Abstract
Background Ensuring equitable access to medical care with financial risk protection has been at the center of achieving universal health coverage. In this paper, we assess the levels and trends of inequalities in medical care utilization and household catastrophic health spending (HCHS) at the national and sub-national levels in Rwanda. Methods Using the Rwanda Integrated Living Conditions Surveys of 2005, 2010, 2014, and 2016, we applied multivariable logit models to generate the levels and trends of adjusted inequalities in medical care utilization and HCHS across the four survey years by four socio-demographic dimensions: poverty, gender, education, and residence. We measured the national- and district-level inequalities in both absolute and relative terms. Results At the national level, after controlling for other factors, we found significant inequalities in medical care utilization by poverty and education and -in HCHS by poverty in all four years. From 2005 to 2016, inequalities in medical care utilization by the four dimensions did not change significantly, while the inequality in HCHS by poverty was reduced significantly. At the district level, inequalities in both medical care utilization and HCHS were larger than zero in all four years and decreased over time. Conclusions Poverty and poor education were significant contributors to inequalities in medical care utilization and HCHS in Rwanda. Policies or interventions targeting poor households or households headed by persons receiving no education are needed in order to effectively reduce inequalities in medical care utilization and HCHS. Electronic supplementary material The online version of this article (10.1186/s12939-019-0953-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Kai Liu
- Department of Social Security, School of Labor and Human Resources, Renmin University of China, Beijing, China
| | - S V Subramanian
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Chunling Lu
- Division of Global Health Equity, Brigham & Women's Hospital, Boston, MA, USA. .,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA. .,Department of Science and Technology-National Research Foundation (DST-NRF) Center of Excellence in Human Development, University of Witwatersrand, Johannesburg, South Africa.
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Dake FAA. Examining equity in health insurance coverage: an analysis of Ghana's National Health Insurance Scheme. Int J Equity Health 2018; 17:85. [PMID: 29914497 PMCID: PMC6006705 DOI: 10.1186/s12939-018-0793-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 06/04/2018] [Indexed: 11/10/2022] Open
Abstract
Background Following years of out-of-pocket payment for healthcare, some countries in Africa including Ghana, Kenya and Rwanda have instituted social health protection programs through health insurance to provide access to quality and affordable healthcare especially for the poor. This paper examines equity in coverage under Ghana’s National Health Insurance Scheme (NHIS). Methods Secondary data from the 2008 Ghana Demographic and Health Survey based on an analytical sample of 4821 females (15–49 years) and 4568 males (15–59 years) were analysed using descriptive, bivariate and multivariate methods. Concentration curves and indices were used to examine equity in coverage on the NHIS. Results As at 2008, more than 60% of Ghanaians aged 15–59 years were not covered under the NHIS with slightly more females (38.9%) than males (29.7%) covered. Coverage was highest among the highly educated, professionals, those from households in the richest wealth quintile and urban residents. Lack of coverage was most concentrated among the poor. Conclusions Universal coverage under the NHIS is far from being achieved with marked exclusion of the poor. There is the need for deliberate action to enrol the poor under the NHIS.
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Affiliation(s)
- Fidelia A A Dake
- Regional Institute for Population Studies, University of Ghana, P.O. Box LG 96, Legon, Accra, Ghana.
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25
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Liu K, Cook B, Lu C. Health inequality and community-based health insurance: a case study of rural Rwanda with repeated cross-sectional data. Int J Public Health 2018; 64:7-14. [DOI: 10.1007/s00038-018-1115-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 05/07/2018] [Accepted: 05/10/2018] [Indexed: 10/14/2022] Open
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Mwase T, Brenner S, Mazalale J, Lohmann J, Hamadou S, Somda SMA, Ridde V, De Allegri M. Inequities and their determinants in coverage of maternal health services in Burkina Faso. Int J Equity Health 2018; 17:58. [PMID: 29751836 PMCID: PMC5948792 DOI: 10.1186/s12939-018-0770-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 04/29/2018] [Indexed: 11/30/2022] Open
Abstract
Background Poor and marginalized segments of society often display the worst health status due to limited access to health enhancing interventions. It follows that in order to enhance the health status of entire populations, inequities in access to health care services need to be addressed as an inherent element of any effort targeting Universal Health Coverage. In line with this observation and the need to generate evidence on the equity status quo in sub-Saharan Africa, we assessed the magnitude of the inequities and their determinants in coverage of maternal health services in Burkina Faso. Methods We assessed coverage for three basic maternal care services (at least four antenatal care visits, facility-based delivery, and at least one postnatal care visit) using data from a cross-sectional household survey including a total of 6655 mostly rural, poor women who had completed a pregnancy in the 24 months prior to the survey date. We assessed equity along the dimensions of household wealth, distance to the health facility, and literacy using both simple comparative measures and concentration indices. We also ran hierarchical random effects regression to confirm the presence or absence of inequities due to household wealth, distance, and literacy, while controlling for potential confounders. Results Coverage of facility based delivery was high (89%), but suboptimal for at least four antenatal care visits (44%) and one postnatal care visit (53%). We detected inequities along the dimensions of household wealth, literacy and distance. Service coverage was higher among the least poor, those who were literate, and those living closer to a health facility. We detected a significant positive association between household wealth and all outcome variables, and a positive association between literacy and facility-based delivery. We detected a negative association between living farther away from the catchment facility and all outcome variables. Conclusion Existing inequities in maternal health services in Burkina Faso are likely going to jeopardize the achievement of Universal Health Coverage. It is important that policy makers continue to strengthen and monitor the implementation of strategies that promote proportionate universalism and forge multi-sectoral approach in dealing with social determinants of inequities in maternal health services coverage.
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Affiliation(s)
- Takondwa Mwase
- Institute of Public Health, Faculty of Medicine, Heidelberg University, INF 130.3, Heidelberg, Germany.
| | - Stephan Brenner
- Institute of Public Health, Faculty of Medicine, Heidelberg University, INF 130.3, Heidelberg, Germany
| | - Jacob Mazalale
- University of Malawi, Chancellor College, PO Box 280, Zomba, Malawi
| | - Julia Lohmann
- Institute of Public Health, Faculty of Medicine, Heidelberg University, INF 130.3, Heidelberg, Germany
| | - Saidou Hamadou
- University of Montreal Public Health Research Institute (IRSPUM), 7101 Avenue de Parc, Room 3060, Montreal, QC H3N 1X9, Canada
| | - Serge M A Somda
- Centre MURAZ 2054 Avenue Mamadou KONATE, 01 B.P. 390, Bobo-Dioulasso 01, Burkina Faso
| | - Valery Ridde
- University of Montreal Hospital Research Centre (CRHHUM), 850 Saint Denis, 3rd Floor, Montreal, QC, H2X 0A9, Canada
| | - Manuela De Allegri
- Institute of Public Health, Faculty of Medicine, Heidelberg University, INF 130.3, Heidelberg, Germany
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Liu K, Lu C. Decomposing health inequality with population-based surveys: a case study in Rwanda. Int J Equity Health 2018; 17:57. [PMID: 29747643 PMCID: PMC5946429 DOI: 10.1186/s12939-018-0769-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 04/29/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ensuring equal access to care and providing financial risk protection are at the center of the global health agenda. While Rwanda has made impressive progress in improving health outcomes, inequalities in medical care utilization and household catastrophic health spending (HCHS) between the impoverished and non-impoverished populations persist. Decomposing inequalities will help us understand the factors contributing to inequalities and design effective policy instruments in reducing inequalities. This study aims to decompose the inequalities in medical care utilization among those reporting illnesses and HCHS between the poverty and non-poverty groups in Rwanda. METHODS Using the 2005 and 2010 nationally representative Integrated Living Conditions Surveys, our analysis focuses on measuring contributions to inequalities from poverty status and other sources. We conducted multivariate logistic regression analysis to obtain poverty's contribution to inequalities by controlling for all observed covariates. We used multivariate nonlinear decomposition method with logistic regression models to partition the relative and absolute contributions from other sources to inequalities due to compositional or response effects. RESULTS Poverty status accounted for the majority of inequalities in medical care utilization (absolute contribution 0.093 in 2005 and 0.093 in 2010) and HCHS (absolute contribution 0.070 in 2005 and 0.032 in 2010). Health insurance status (absolute contribution 0.0076 in 2005 and 0.0246 in 2010) and travel time to health centers (absolute contribution 0.0025 in 2005 and 0.0014 in 2010) were significant contributors to inequality in medical care utilization. Health insurance status (absolute contribution 0.0021 in 2005 and 0.0011 in 2010), having under-five children (absolute contribution 0.0012 in 2005 and 0.0011 in 2010), and having disabled family members (absolute contribution 0.0002 in 2005 and 0.0001 in 2010) were significant contributors to inequality in HCHS. Between 2005 and 2010, the main sources of the inequalities remained unchanged. CONCLUSIONS Expanding insurance coverage and reducing travel time to health facilities for those living in poverty could be used as policy instruments to mitigate inequalities in medical care utilization and HCHS between the poverty and non-poverty groups.
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Affiliation(s)
- Kai Liu
- Department of Social Security, School of Labor and Human Resources, Renmin University of China, Haidian District, Beijing, China
| | - Chunling Lu
- Division of Global Health Equity, Brigham & Women's Hospital, Boston, MA, USA. .,Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA. .,Department of Science and Technology-National Research Foundation (DST-NRF) Center of Excellence in Human Development, University of Witwatersrand, Johannesburg, South Africa.
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Atake EH, Amendah DD. Porous safety net: catastrophic health expenditure and its determinants among insured households in Togo. BMC Health Serv Res 2018. [PMID: 29530045 PMCID: PMC5848572 DOI: 10.1186/s12913-018-2974-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND In Togo, about half of health care costs are paid at the point of service, which reduces access to health care and exposes households to catastrophic health expenditure (CHE). To address this situation, the Togolese government introduced a National Health Insurance Scheme (NHIS) in 2011. This insurance currently covers only employees and retirees of the State as well as their dependents, although plans for extension exist. This study is the first attempt to examine the extent to which Togo's NHIS protects its members financially against the consequences of ill-health. METHODS Data was obtained from a cross-sectional representative households' survey involving 1180 insured households that had reported illness in the household in the 4 weeks preceding the survey or hospitalization in the 12 months preceding the survey. The incidence and intensity of CHE were measured by the catastrophic health payment method. A logistic regression was used to analyse determinants of CHE. RESULTS The results indicate that the proportion of insured households with CHE varies widely between 3.94% and 75.60%, depending on the method and the threshold used. At the 40% threshold, health care cost represents 60.95% of insured households' total monthly non-food expenditure. This study showed that the socioeconomic status, the type of health facility used, hospitalization and household size were the highest predictors of CHE. Whatever the chosen threshold, care in referral and district hospitals significantly increases the likelihood of CHE. In addition, the proportion of households facing CHE is higher in the lowest income groups. The behaviour of health care providers, poor quality of care and long waiting time were the main factors leading to CHE. CONCLUSION A sizable proportion of insured households face CHE, suggesting gaps in the coverage. To limit the impoverishment of insured households with low income, policies for free or heavily subsidized hospital services should be considered. The results call for an equitable health insurance scheme, which is affordable for all insured households.
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Affiliation(s)
| | - Djesika D Amendah
- African Population and Health Research Center, APHRC Campus, Kirawa Road, P.O. Box 10787 - 00100, Nairobi, Kenya
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Oraro T, Ngube N, Atohmbom GY, Srivastava S, Wyss K. The influence of gender and household headship on voluntary health insurance: the case of North-West Cameroon. Health Policy Plan 2017; 33:163-170. [DOI: 10.1093/heapol/czx152] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2017] [Indexed: 11/12/2022] Open
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Umeh CA, Feeley FG. Inequitable Access to Health Care by the Poor in Community-Based Health Insurance Programs: A Review of Studies From Low- and Middle-Income Countries. GLOBAL HEALTH: SCIENCE AND PRACTICE 2017; 5:299-314. [PMID: 28655804 PMCID: PMC5487091 DOI: 10.9745/ghsp-d-16-00286] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 05/09/2017] [Indexed: 11/18/2022]
Abstract
The poor lack equitable access to health care in community-based health insurance schemes. Flexible installment payment plans, subsidized premiums, and elimination of co-pays can increase enrollment and use of health services by the poor. Background: Out-of-pocket payments for health care services lead to decreased use of health services and catastrophic health expenditures. To reduce out-of-pocket payments and improve access to health care services, some countries have introduced community-based health insurance (CBHI) schemes, especially for those in rural communities or who work in the informal sector. However, there has been little focus on equity in access to health care services in CBHI schemes. Methods: We searched PubMed, Web of Science, African Journals OnLine, and Africa-Wide Information for studies published in English between 2000 and August 2014 that examined the effect of socioeconomic status on willingness to join and pay for CBHI, actual enrollment, use of health care services, and drop-out from CBHI. Our search yielded 755 articles. After excluding duplicates and articles that did not meet our inclusion criteria (conducted in low- and middle-income countries and involved analysis based on socioeconomic status), 49 articles remained that were included in this review. Data were extracted by one author, and the second author reviewed the extracted data. Disagreements were mutually resolved between the 2 authors. The findings of the studies were analyzed to identify their similarities and differences and to identify any methodological differences that could account for contradictory findings. Results: Generally, the rich were more willing to pay for CBHI than the poor and actual enrollment in CBHI was directly associated with socioeconomic status. Enrollment in CBHI was price-elastic—as premiums decreased, enrollment increased. There were mixed results on the effect of socioeconomic status on use of health care services among those enrolled in CBHI. We found a high drop-out rate from CBHI schemes that was not related to socioeconomic status, although the most common reason for dropping out of CBHI was lack of money to pay the premium. Conclusion: The effectiveness of CBHI schemes in achieving universal health coverage in low- and middle-income countries is questionable. A flexible payment plan where the poor can pay in installments, subsidized premiums for the poor, and removal of co-pays are measures that can increase enrollment and use of CBHI by the poor.
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Affiliation(s)
- Chukwuemeka A Umeh
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA.
| | - Frank G Feeley
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
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Gouda HN, Hodge A, Bermejo R, Zeck W, Jimenez-Soto E. The Impact of Healthcare Insurance on the Utilisation of Facility-Based Delivery for Childbirth in the Philippines. PLoS One 2016; 11:e0167268. [PMID: 27911935 PMCID: PMC5135090 DOI: 10.1371/journal.pone.0167268] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 10/21/2016] [Indexed: 11/19/2022] Open
Abstract
Objectives In recent years, the government of the Philippines embarked upon an ambitious Universal Health Care program, underpinned by the rapid scale-up of subsidized insurance coverage for poor and vulnerable populations. With a view of reducing the stubbornly high maternal mortality rates in the country, the program has a strong focus on maternal health services and is supported by a national policy of universal facility-based delivery (FBD). In this study, we examine the impact that recent reforms expanding health insurance coverage have had on FBD. Results Data from the most recent Philippines 2013 Demographic Health Survey was employed. This study applies quasi-experimental methods using propensity scores along with alternative matching techniques and weighted regression to control for self-selection and investigate the impact of health insurance on the utilization of FBD. Findings Our findings reveal that the likelihood of FBD for women who are insured is between 5 to 10 percent higher than for those without insurance. The impact of health insurance is more pronounced amongst rural and poor women for whom insurance leads to a 9 to 11 per cent higher likelihood of FBD. Conclusions We conclude that increasing health insurance coverage is likely to be an effective approach to increase women’s access to FBD. Our findings suggest that when such coverage is subsidized, as it is the case in the Philippines, women from poor and rural populations are likely to benefit the most.
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Affiliation(s)
- Hebe N. Gouda
- The University of Queensland, School of Public Health, Public Health Building, Brisbane, Queensland, Australia
- Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Wacol, Queensland, Australia
- * E-mail:
| | - Andrew Hodge
- The University of Queensland, School of Public Health, Public Health Building, Brisbane, Queensland, Australia
| | - Raoul Bermejo
- UNICEF Philippines Country Office, Manila, Philippines
- Institute of Tropical Medicine, Antwerp, Belgium
| | - Willibald Zeck
- UNICEF Philippines Country Office, Manila, Philippines
- Medical University of Graz, Department of Obstetrics and Gynaecology, Graz, Austria
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Kuuire VZ, Tenkorang EY, Rishworth A, Luginaah I, Yawson AE. Is the Pro-Poor Premium Exemption Policy of Ghana’s NHIS Reducing Disparities Among the Elderly? POPULATION RESEARCH AND POLICY REVIEW 2016. [DOI: 10.1007/s11113-016-9420-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Amo-Adjei J, Anku PJ, Amo HF, Effah MO. Perception of quality of health delivery and health insurance subscription in Ghana. BMC Health Serv Res 2016; 16:317. [PMID: 27472916 PMCID: PMC4966716 DOI: 10.1186/s12913-016-1602-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 07/28/2016] [Indexed: 11/25/2022] Open
Abstract
Background National health insurance schemes (NHIS) in developing countries and perhaps in developed countries as well is a considered a pro-poor intervention by helping to bridge the financial burden of access to quality health care. Perceptions of quality of health service could have immense impacts on enrolment. This paper shows how perception of service quality under Ghana’s insurance programme contributes to health insurance subscription. Methods The study used the 2014 Ghana Demographic and Health Survey (GDHS) dataset. Both descriptive proportions and binary logistic regression techniques were applied to generate results that informed the discussion. Results Our results show that a high proportion of females (33 %) and males (35 %) felt that the quality of health provided to holders of the NHIS card was worse. As a result, approximately 30 % of females and 22%who perceived health care as worse by holding an insurance card did not own an insurance policy. While perceptions of differences in quality among females were significantly different (AOR = 0.453 [95 % CI = 0.375, 0.555], among males, the differences in perceptions of quality of health services under the NHIS were independent in the multivariable analysis. Beyond perceptions of quality, being resident in the Upper West region was an important predictor of health insurance ownership for both males and females. Conclusion For such a social and pro-poor intervention, investing in quality of services to subscribers, especially women who experience enormous health risks in the reproductive period can offer important gains to sustaining the scheme as well as offering affordable health services.
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Affiliation(s)
- Joshua Amo-Adjei
- African Population and Health Research Centre, Nairobi, Kenya. .,Department of Population and Health, University of Cape Coast, Cape Coast, Ghana.
| | - Prince Justin Anku
- Department of Population and Health, University of Cape Coast, Cape Coast, Ghana
| | - Hannah Fosuah Amo
- Department of Business Administration, Valley View University, Oyibi, Ghana
| | - Mavis Osei Effah
- Department of Accounting and Finance, University of Cape Coast, Cape Coast, Ghana
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Rees CP, Hawkesworth S, Moore SE, Dondeh BL, Unger SA. Factors Affecting Access to Healthcare: An Observational Study of Children under 5 Years of Age Presenting to a Rural Gambian Primary Healthcare Centre. PLoS One 2016; 11:e0157790. [PMID: 27336164 PMCID: PMC4919103 DOI: 10.1371/journal.pone.0157790] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 05/08/2016] [Indexed: 11/23/2022] Open
Abstract
Main Objective Prompt access to primary healthcare before onset of severe illness is vital to improve morbidity and mortality rates. The Gambia has high rates of child mortality and research is needed to investigate contributing factors further. This study aimed to identify factors affecting access to primary healthcare for children <5 years (y) in rural Gambia focusing on delayed presentation and severe illness at presentation as indicators in a setting where primary healthcare is delivered free of charge. Methods Data were extracted from an electronic medical records system at a rural primary healthcare clinic in The Gambia for children (0–5y) between 2009 and 2012. First clinic attendances with malaria, lower respiratory tract infections (LRTI) and diarrhoeal disease, the main contributors to mortality in this setting, were identified and categorized as delayed/non-delayed and severe/non-severe representing our two main outcome measures. Potential explanatory variables, identified through a comprehensive literature review were obtained from an ongoing demographic surveillance system for this population. Variables associated with either delayed/non-delayed and/or with severe/non-severe presentations identified by univariate analysis (p<0.1) were assessed in multivariate models using logistic regression (p<0.05). Results Out of 6554 clinic attendances, 571 relevant attendances were identified. Delayed presentation was common (45% of all presentations) and there was a significantly reduced risk associated with being from villages with free regular access to transport (OR 0.502, 95%CI[0.310, 0.814], p = 0.005). Children from villages with free regular transport were also less likely to present with severe illness (OR 0.557, 95%CI[0.325, 0.954], p = 0.033). Conclusions Transport availability rather than distance to health clinic is an important barrier to accessing healthcare for children in The Gambia, and public health interventions should aim to reduce this barrier.
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Affiliation(s)
- Claire P. Rees
- Centre for Primary Care & Public Health, Barts & The London School of Medicine & Dentistry, London, United Kingdom
| | - Sophie Hawkesworth
- MRC International Nutrition Group, London School of Hygiene & Tropical Medicine, London, United Kingdom
- MRC International Nutrition Group, at MRC Keneba, MRC Unit The Gambia, Banjul, The Gambia
| | - Sophie E. Moore
- MRC International Nutrition Group, London School of Hygiene & Tropical Medicine, London, United Kingdom
- MRC International Nutrition Group, at MRC Keneba, MRC Unit The Gambia, Banjul, The Gambia
- MRC Human Nutrition Research, Elsie Widdowson Laboratory, Cambridge, United Kingdom
| | - Bai L. Dondeh
- MRC International Nutrition Group, London School of Hygiene & Tropical Medicine, London, United Kingdom
- MRC International Nutrition Group, at MRC Keneba, MRC Unit The Gambia, Banjul, The Gambia
| | - Stefan A. Unger
- MRC International Nutrition Group, London School of Hygiene & Tropical Medicine, London, United Kingdom
- MRC International Nutrition Group, at MRC Keneba, MRC Unit The Gambia, Banjul, The Gambia
- University of Edinburgh, Department of Child Life and Health, Edinburgh, United Kingdom
- * E-mail:
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Abiiro GA, Torbica A, Kwalamasa K, De Allegri M. What factors drive heterogeneity of preferences for micro-health insurance in rural Malawi? Health Policy Plan 2016; 31:1172-83. [DOI: 10.1093/heapol/czw049] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2016] [Indexed: 11/12/2022] Open
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Lu C, Mejía-Guevara I, Hill K, Farmer P, Subramanian SV, Binagwaho A. Community-Based Health Financing and Child Stunting in Rural Rwanda. Am J Public Health 2015; 106:49-55. [PMID: 26562109 DOI: 10.2105/ajph.2015.302913] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We analyzed the likelihood of rural children (aged 6-24 months) being stunted according to whether they were enrolled in Mutuelles, a community-based health-financing program providing health insurance to rural populations and granting them access to health care, including nutrition services. METHODS We retrieved health facility data from the District Health System Strengthening Tool and calculated the percentage of rural health centers that provided nutrition-related services required by Mutuelles' minimum service package. We used data from the 2010 Rwanda Demographic and Health Survey and performed multilevel logistic analysis to control for clustering effects and sociodemographic characteristics. The final sample was 1061 children. RESULTS Among 384 rural health centers, more than 90% conducted nutrition-related campaigns and malnutrition screening for children. Regardless of poverty status, the risk of being stunted was significantly lower (odds ratio = 0.60; 95% credible interval = 0.41, 0.83) for Mutuelles enrollees. This finding was robust to various model specifications (adjusted for Mutuelles enrollment, poverty status, other variables) or estimation methods (fixed and random effects). CONCLUSIONS This study provides evidence of the effectiveness of Mutuelles in improving child nutrition status and supported the hypothesis about the role of Mutuelles in expanding medical and nutritional care coverage for children.
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Affiliation(s)
- Chunling Lu
- Chunling Lu and Paul Farmer are with the Division of Global Health Equity, Brigham and Women's Hospital, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA. Iván Mejía-Guevara is with the Harvard Center for Population and Development Studies, Harvard University, Cambridge, MA. Kenneth Hill is with the Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston. S. V. Subramanian is with the Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health. Agnes Binagwaho is with the Ministry of Health, Government of Rwanda, Kigali, Rwanda
| | - Iván Mejía-Guevara
- Chunling Lu and Paul Farmer are with the Division of Global Health Equity, Brigham and Women's Hospital, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA. Iván Mejía-Guevara is with the Harvard Center for Population and Development Studies, Harvard University, Cambridge, MA. Kenneth Hill is with the Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston. S. V. Subramanian is with the Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health. Agnes Binagwaho is with the Ministry of Health, Government of Rwanda, Kigali, Rwanda
| | - Kenneth Hill
- Chunling Lu and Paul Farmer are with the Division of Global Health Equity, Brigham and Women's Hospital, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA. Iván Mejía-Guevara is with the Harvard Center for Population and Development Studies, Harvard University, Cambridge, MA. Kenneth Hill is with the Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston. S. V. Subramanian is with the Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health. Agnes Binagwaho is with the Ministry of Health, Government of Rwanda, Kigali, Rwanda
| | - Paul Farmer
- Chunling Lu and Paul Farmer are with the Division of Global Health Equity, Brigham and Women's Hospital, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA. Iván Mejía-Guevara is with the Harvard Center for Population and Development Studies, Harvard University, Cambridge, MA. Kenneth Hill is with the Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston. S. V. Subramanian is with the Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health. Agnes Binagwaho is with the Ministry of Health, Government of Rwanda, Kigali, Rwanda
| | - S V Subramanian
- Chunling Lu and Paul Farmer are with the Division of Global Health Equity, Brigham and Women's Hospital, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA. Iván Mejía-Guevara is with the Harvard Center for Population and Development Studies, Harvard University, Cambridge, MA. Kenneth Hill is with the Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston. S. V. Subramanian is with the Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health. Agnes Binagwaho is with the Ministry of Health, Government of Rwanda, Kigali, Rwanda
| | - Agnes Binagwaho
- Chunling Lu and Paul Farmer are with the Division of Global Health Equity, Brigham and Women's Hospital, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA. Iván Mejía-Guevara is with the Harvard Center for Population and Development Studies, Harvard University, Cambridge, MA. Kenneth Hill is with the Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston. S. V. Subramanian is with the Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health. Agnes Binagwaho is with the Ministry of Health, Government of Rwanda, Kigali, Rwanda
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Louis VR, Schoeps A, Tiendrebéogo J, Beiersmann C, Yé M, Damiba MR, Lu GY, Mbayiha AH, De Allegri M, Jahn A, Sié A, Becher H, Müller O. An insecticide-treated bed-net campaign and childhood malaria in Burkina Faso. Bull World Health Organ 2015; 93:750-8. [PMID: 26549902 PMCID: PMC4622154 DOI: 10.2471/blt.14.147702] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 05/22/2015] [Accepted: 05/29/2015] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE To investigate if the first national insecticide-treated bed-net campaign in Burkina Faso, done in 2010, was followed by a decrease in childhood malaria in a district with high baseline transmission of the disease. METHODS We obtained data on the prevalence of Plasmodium falciparum parasitaemia in children aged 2 weeks to 36 months from malaria surveys in 2009 and 2011. We assessed morbidity in children younger than 5 years by comparing data from the Nouna health district's health management information system before and after the campaign in 2010. We analysed mortality data from 2008 to 2012 from Nouna's health and demographic surveillance system. FINDINGS The bed-net campaign was associated with an increase in the reported use of insecticide-treated nets. In 2009, 73% (630/869) of children reportedly slept under nets. In 2011, 92% (449/487) did. The campaign had no effect on the proportion of young children with P. falciparum parasitaemia after the rainy season; 52% (442/858) in 2009 and 53% (263/499) in 2011. Cases of malaria increased markedly after the campaign, as did the number of children presenting with other diseases. The campaign was not associated with any changes in child mortality. CONCLUSION The 2010 insecticide-treated net campaign in Burkina Faso was not associated with a decrease in care-seeking for malaria or all-cause mortality in children younger than 5 years. The most likely explanation is the high coverage of nets in the study area before the campaign which could have had an effect on mosquito vectors, limiting the campaign's impact.
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Affiliation(s)
- Valérie R Louis
- Institute of Public Health, Medical School, Heidelberg University, Im Neuenheimer Feld 324, 69120 Heidelberg, Germany
| | - Anja Schoeps
- Institute of Public Health, Medical School, Heidelberg University, Im Neuenheimer Feld 324, 69120 Heidelberg, Germany
| | | | - Claudia Beiersmann
- Institute of Public Health, Medical School, Heidelberg University, Im Neuenheimer Feld 324, 69120 Heidelberg, Germany
| | - Maurice Yé
- Centre de Recherche en Santé de Nouna (CRSN), BP02 Nouna, Burkina Faso
| | - Marie R Damiba
- Centre de Recherche en Santé de Nouna (CRSN), BP02 Nouna, Burkina Faso
| | - Guang Y Lu
- Institute of Public Health, Medical School, Heidelberg University, Im Neuenheimer Feld 324, 69120 Heidelberg, Germany
| | - André H Mbayiha
- Institute of Public Health, Medical School, Heidelberg University, Im Neuenheimer Feld 324, 69120 Heidelberg, Germany
| | - Manuela De Allegri
- Institute of Public Health, Medical School, Heidelberg University, Im Neuenheimer Feld 324, 69120 Heidelberg, Germany
| | - Albrecht Jahn
- Institute of Public Health, Medical School, Heidelberg University, Im Neuenheimer Feld 324, 69120 Heidelberg, Germany
| | - Ali Sié
- Centre de Recherche en Santé de Nouna (CRSN), BP02 Nouna, Burkina Faso
| | - Heiko Becher
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Olaf Müller
- Institute of Public Health, Medical School, Heidelberg University, Im Neuenheimer Feld 324, 69120 Heidelberg, Germany
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Ridde V, Turcotte-Tremblay AM, Souares A, Lohmann J, Zombré D, Koulidiati JL, Yaogo M, Hien H, Hunt M, Zongo S, De Allegri M. Protocol for the process evaluation of interventions combining performance-based financing with health equity in Burkina Faso. Implement Sci 2014; 9:149. [PMID: 25304365 PMCID: PMC4201720 DOI: 10.1186/s13012-014-0149-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 09/19/2014] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The low quality of healthcare and the presence of user fees in Burkina Faso contribute to low utilization of healthcare and elevated levels of mortality. To improve access to high-quality healthcare and equity, national authorities are testing different intervention arms that combine performance-based financing with community-based health insurance and pro-poor targeting. There is a need to evaluate the implementation of these unique approaches. We developed a research protocol to analyze the conditions that led to the emergence of these intervention arms, the fidelity between the activities initially planned and those conducted, the implementation and adaptation processes, the sustainability of the interventions, the possibilities for scaling them up, and their ethical implications. METHODS/DESIGN The study adopts a longitudinal multiple case study design with several embedded levels of analyses. To represent the diversity of contexts where the intervention arms are carried out, we will select three districts. Within districts, we will select both primary healthcare centers (n =18) representing different intervention arms and the district or regional hospital (n =3). We will select contrasted cases in relation to their initial performance (good, fair, poor). Over a period of 18 months, we will use quantitative and qualitative data collection and analytical tools to study these cases including in-depth interviews, participatory observation, research diaries, and questionnaires. We will give more weight to qualitative methods compared to quantitative methods. DISCUSSION Performance-based financing is expanding rapidly across low- and middle-income countries. The results of this study will enable researchers and decision makers to gain a better understanding of the factors that can influence the implementation and the sustainability of complex interventions aiming to increase healthcare quality as well as equity.
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Affiliation(s)
- Valéry Ridde
- University of Montreal Hospital Research Center (CRCHUM), 850 Saint-Denis, 3rd Floor, Montréal, QC, H2X 0A9, Canada.
- University of Montreal School of Public Health, 7101 Avenue du Parc, 3rd Floor, Montréal, QC H3N 1X9, Canada.
| | - Anne-Marie Turcotte-Tremblay
- University of Montreal Hospital Research Center (CRCHUM), 850 Saint-Denis, 3rd Floor, Montréal, QC, H2X 0A9, Canada.
- University of Montreal School of Public Health, 7101 Avenue du Parc, 3rd Floor, Montréal, QC H3N 1X9, Canada.
| | - Aurélia Souares
- Institute of Public Health, Medical Faculty, Heidelberg University, Im Neuenheimer Feld 324, 69120, Heidelberg, Germany.
| | - Julia Lohmann
- Institute of Public Health, Medical Faculty, Heidelberg University, Im Neuenheimer Feld 324, 69120, Heidelberg, Germany.
| | - David Zombré
- University of Montreal Hospital Research Center (CRCHUM), 850 Saint-Denis, 3rd Floor, Montréal, QC, H2X 0A9, Canada.
- University of Montreal School of Public Health, 7101 Avenue du Parc, 3rd Floor, Montréal, QC H3N 1X9, Canada.
| | - Jean Louis Koulidiati
- Institute of Public Health, Medical Faculty, Heidelberg University, Im Neuenheimer Feld 324, 69120, Heidelberg, Germany.
| | - Maurice Yaogo
- AFRICSanté & Université Catholique de l'Afrique de l'Ouest - Unité Universitaire de Bobo-Dioulasso, 01 BP 298, Bobo-Dioulasso, Burkina Faso.
| | - Hervé Hien
- Centre MURAZ, 01 BP, Bobo-Dioulasso, Burkina Faso.
- Institut de recherche en sciences de la santé (IRSS) du CNRST, 03 BP 7192 03, Ouagadougou, Burkina Faso.
| | - Matthew Hunt
- School of Physical and Occupational Therapy, McGill University, 3630 Promenade Sir William Osler, 2nd Floor, Montréal, QC H3G 1Y5, Canada.
| | - Sylvie Zongo
- Institut des Sciences des Sociétés (INSS-CNRST), 03 BP 7047, Ouagadougou, Burkina Faso.
| | - Manuela De Allegri
- Institute of Public Health, Medical Faculty, Heidelberg University, Im Neuenheimer Feld 324, 69120, Heidelberg, Germany.
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The impact of targeted subsidies for facility-based delivery on access to care and equity - evidence from a population-based study in rural Burkina Faso. J Public Health Policy 2012; 33:439-53. [PMID: 22932023 DOI: 10.1057/jphp.2012.27] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
We conducted the first population-based impact assessment of a financing policy introduced in Burkina Faso in 2007 on women's access to delivery services. The policy offers an 80 per cent subsidy for facility-based delivery. We collected information on delivery in five repeated cross-sectional surveys carried out from 2006 to 2010 on a representative sample of 1050 households in rural Nouna Health District. Over the 5 years, the proportion of facility-based deliveries increased from 49 to 84 per cent (P<0.001). The utilization gap across socio-economic quintiles, however, remained unchanged. The amount received for all services associated with births decreased by 67 per cent (P<0.001), but women continued to pay on average 1423 CFA (\[euro]1=655 CFA), about 500 CFA more than the set tariff of 900 CFA. Our findings indicate the operational effectiveness of the policy in increasing the use of facility-based delivery services for women. The potential to reduce maternal mortality substantially has not yet been assessed by health outcome measures of neonatal and maternal mortality.
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