The impact of community-based health insurance on universal health coverage in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Ideally health insurance aims to provide financial security, promote social inclusion, and ensure equitable access to quality healthcare services for all households. Community-based health insurance has been operating in Ethiopia since 2011. However, its nationwide impact on universal health coverage has not yet been evaluated despite several studies being conducted.

OBJECTIVE

We evaluated the impact of Ethiopia's community-based health insurance (2012-2021) on universal health coverage.

METHODS

On 27 August 2022, searches were conducted in Scopus, Hinari, PubMed, Google Scholar, and Semantic Scholar. Twenty-three studies were included. We used the Joana Briggs Institute checklists to assess the risk of bias. We included cross-sectional and mixed studies with low and medium risk. The data were processed in Microsoft Excel and analyzed using RevMan-5. The impact was measured first on insured households and then on insured versus uninsured households. We used a random model to measure the effect estimates (odds ratios) with a p value < 0.05 and a 95% CI.

RESULTS

The universal health coverage provided by the scheme was 45.6% (OR = 1.92, 95% CI: 1.44-2.58). Being a member of the scheme increased universal health coverage by 24.8%. The healthcare service utilization of the beneficiaries was 64.5% (OR = 1.95, 95% CI: 1.29-2.93). The scheme reduced catastrophic health expenditure by 79.4% (OR = 4.99, 95% CI: 1.27-19.67). It yielded a 92% (OR = 11.58, 95% CI: 8.12-16.51) perception of health service quality. The health-related quality of life provided by it was 63% (OR = 1.71, 95% CI: 1.50-1.94). Its population coverage was 40.1% (OR = 0.64, 95% CI: 0.41-1.02).

CONCLUSION

Although the scheme had positive impacts on health service issues by reducing catastrophic costs, the low universal health coverage on a limited population indicates that Ethiopia should move to a broader national scheme that covers the entire population.

Effects of Health Insurance on Quality of Care in Low-Income Countries: A Systematic Review

Objectives: To evaluate the effectiveness of health insurance on quality of care in low-income countries (LICs). Methods: We conducted a systematic review following PRISMA guidelines. We searched seven databases for studies published between 2010 and August 2022. We included studies that evaluated the effects of health insurance on quality of care in LICs using randomized experiments or quasi-experimental study designs. Study outcomes were classified using the Donabedian framework. Results: We included 15 studies out of the 6,129 identified. Available evidence seems to suggest that health insurance has limited effects on structural quality, and its effects on the process of care remain mixed. At the population level, health insurance is linked to improved anthropometric measures for children and biomarkers such as blood pressure and hemoglobin levels. Conclusion: Based on the currently available evidence, it appears that health insurance in LICs has limited effects on the quality of care. Further studies are required to delve into the mechanisms that underlie the impact of health insurance on the quality of care and identify the most effective strategies to ensure quality within insurance programs. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=219984, identifier PROSPERO CRD42020219984.

The Shared Experience of Insured and Uninsured Patients: A Comparative Study

Background

Despite efforts to ensure equitable quality of care for all patients, a significant gap persists between the quality of care experienced by insured and uninsured patients in Saudi Arabia. This study aims to identify and compare the differences between insured and uninsured patients in terms of their experience of quality of care in a tertiary hospital.

Methods

A descriptive cross-sectional study was utilized. Insured and uninsured individuals who had undergone identical medical procedures in early 2021 were identified from a public 500-bed tertiary hospital. About 350 patients participated in this study by completing an online, self-administered questionnaire, adopted by Abuosi and others in 2016, assessing six dimensions of quality of care.

Results

Significant differences were reported between the quality of care experienced by insured and uninsured subjects (M = 3.37, SD = 0.525, and M = 3.06, SD = 0.452, respectively, p=0.001). While insured group reported high quality of care, followed by fairness of care (r = 0.744 and r = 0.675, p ≤ 0.001, n = 175), uninsured subjects experienced less fairness with low quality of care.

Conclusions

The insured individuals were found to be more attentive to the quality of care offered by the hospital than their counterparts. Efforts to close the gap in quality of care should include monitoring healthcare outcomes, adopting transparency standards, and facilitating procedures to minimize barriers among patients.

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

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

Can mutual health organisations influence the quality and the affordability of healthcare provision? The case of the Democratic Republic of Congo

Background

In their mission to achieve better access to quality healthcare services, mutual health organisations (MHOs) are not limited to providing health insurance. As democratically controlled member organisations, MHOs aim to make people’s voices heard. At national level, they seek involvement in the design of social protection policies; at local level, they seek to improve responsiveness of healthcare services to members’ needs and expectations.

Methods

In this qualitative study, we investigated whether MHOs in the Democratic Republic of Congo (DRC) succeed in defending members’ rights by improving healthcare quality while minimising expenses. The data originate from an earlier in-depth investigation conducted in the DRC in 2016 of the performance of 13 MHOs. We re-analysed this existing dataset and more specifically investigated actions that the MHOs undertook to improve quality and affordability of healthcare provision for their members, using a framework for analysis based on Hirschman’s exit-voice theory. This framework distinguishes four mechanisms for MHO members to use in influencing providers: (1) ‘exit’ or ‘voting with the feet’; (2) ‘co-producing a long voice route’ or imposing rules through strategic purchasing; (3) ‘guarding over the long voice route of accountability’ or pressuring authorities to regulate and enforce regulations; and (4) ‘strengthening the short voice route’ by transforming the power imbalance at the provider–patient interface.

Results

All studied MHOs used these four mechanisms to improve healthcare provision. Most healthcare providers, however, did not recognise their authority to do so. In the DRC, controlling quality and affordability of healthcare is firmly seen as a role for the health authorities, but the authorities only marginally take up this role. Under current circumstances, the power of MHOs in the DRC to enhance quality and affordability of healthcare is weak.

Conclusion

On their own, mutual health organisations in the DRC do not have sufficient power to influence the practices of healthcare providers. Greater responsiveness of the health services to MHO members requires cooperation of all actors involved in healthcare delivery to create an enabling environment where voices defending people’s rights are heard.

A critical analysis of purchasing arrangements in Kenya: the case of micro health insurance

BACKGROUND

Strategic purchasing can ensure that financial resources are used in a way that optimally enhances the attainment of health system goals. A number of low- and middle-income countries, including Kenya, have experimented with micro health insurance (MHIs) as a means to purchase health services for the informal sector. This study aimed to examine the purchasing practices of MHIs in Kenya.

METHODS

The study was guided by an analytical framework that compared purchasing practices of MHIs with the ideal actions for strategic purchasing along three pairs of principal-agent relationships (government-purchaser, purchaser-provider and citizen-purchaser). The study adopted a qualitative descriptive case study design with 2 MHIs as cases. Data were collected through document reviews (regulation, marketing materials, websites) and semi-structured interviews with key informants (n = 27).

RESULTS

The regulatory framework for MHIs did not adequately support strategic purchasing practice and was exacerbated by poor coordination between health and financial sectors. The MHIs strategically contracted health providers over whom they could exercise bargaining power, sometimes at the expense of quality. There were no clear channels for beneficiaries to provide timely feedback to the purchaser. MHIs premium payments were family-based, low-cost and offered limited benefits. Coverage was based on ability to pay, which may have excluded low-income households from membership.

CONCLUSIONS

Adequate policy, legal and regulatory frameworks that integrate MHIs into the broader health financing system and support strategic purchasing practices are required. The state departments responsible for finance and health should form coordinating structures that ensure that MHI's role in universal health coverage is owned across all relevant sectors, and that actors, such as regulators, perform in a coordinated manner. The frameworks should also seek to align purchasers' relationships with providers so that clear and consistent signals are received by providers from all purchasing mechanisms present within the health system.

Health Insurance: Awareness, Utilization, and its Determinants among the Urban Poor in Delhi, India

This study reports the awareness, access, and utilization of health insurance by the urban poor in Delhi, India. The study included 2998 households from 85 urban clusters spread across Delhi. The data were collected through a pretested, interviewer-administered questionnaire. Logistic regression was performed for determinants of health insurance possession. Only 19% knew about health insurance; 18% had health insurance (8% Employees State Insurance Scheme - ESIS - 8% Central Government Health Scheme - CGHS - 1.4%; Rashtriya Swasthya Bima Yojana (RSBY) - 9.4% of the eligible households). In case of health needs, 95% of CGHS, 71% ESIS beneficiaries, and 9.5% of RSBY beneficiaries utilized the schemes for episodic and chronic illnesses. For hospitalization needs, 54% of RSBY, 86% of ESIS, 100% CGHS utilized respective services. Residential area, migration period, possession of ration card, household size, and occupation of the head of the household were significantly associated with possession of RSBY. RSBY played a limited role in meeting the healthcare needs of the people, thus may not be capable of contributing significantly in the efforts of achieving equity in healthcare for the poor. Relatively, ESIS and CGHS served the healthcare needs of the beneficiaries better. Expansion of ESIS to the informal workers may be considered.

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

Background

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

Aims

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

Methods

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

Results

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

Conclusion

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

An in-depth investigation of the causes of persistent low membership of community-based health insurance: a case study of the mutual health organisation of Dar Naïm, Mauritania

BACKGROUND

Persistent low membership is observed in many community-based health insurance (CBHI) schemes in Africa. Causes for low membership have been identified and solutions suggested, but this did not result in increased membership. In this case study of the mutual health organisation of Dar Naïm in Mauritania we explore the underlying drivers that may explain why membership continued to stagnate although several plans for change had been designed.

METHODS

We used a systems approach focussed on processes, underlying dynamics and complex interactions that produce the outcomes, to delve into 10 years of data collected between 2003 and 2012. We used qualitative research methods to analyse the data and interpret patterns.

RESULTS

Direct causes of stagnation and possible solutions had been identified in the early years of operations, but most of the possible solutions were not implemented. A combination of reasons explains why consecutive action plans were not put into practice, showing the complexity of implementation and the considerable management capacity required, as well as the challenges of integrating a novel organisational structure into exiting social structures.

CONCLUSIONS

For any CBHI project aiming at high membership, skilled professional management seems essential, with capacity to question and adapt routine procedures and interpret interactions within the wider society. Countries that include community-based health insurance in their strategic plan towards universal coverage will have to pay more attention to management capacity and the minutiae of implementation.

Quality Health Care and Willingness to Pay for Health Insurance Retention: A Randomized Experiment in Kolkata Slums

The low quality of health care in developing countries reduces the poor's incentives to use quality health services and their demand for health insurance. Using data from a field experiment in India, I show that randomly offering insurance policyholders a free preventive checkup with a qualified doctor has a twofold effect: receiving this additional benefit raises willingness to pay to renew health insurance by 53%, doubling the likelihood of hypothetical renewal; exposed individuals are 10 percentage points more likely to consult a qualified practitioner when ill after the checkup. Both effects are concentrated on poorer households. There is no effect on health knowledge and healthcare spending. This suggests that exposing insured households to quality preventive care can be a cost-effective way of raising the demand for quality health care and retaining policyholders in the insurance scheme. Copyright © 2016 John Wiley & Sons, Ltd.

[Study of the Consumers' preference on the universal health coverage development strategy through health mutual in Ziguinchor Region, Southwest of Senegal]

In Senegal, the informal and rural sector that accounts for over 80% of the population is covered only up to 7% by a health insurance system. That is why, for the implementation of development strategy of the universal health coverage (UHC) through mutual health insurance providers, the Government of Senegal has focused on this sector. The objective of this study was to assess the consumer's preference on the UHC development strategies through mutual health insurance providers. This was a qualitative and exploratory study based on a literature review, and indepth interview with the heads of households. It was also based on focus groups of people with and without health mutual membership, and the Expert Committee meetings. The results showed that the most critical attributes in the decision-making of consumers to join the health mutual in Ziguinchor were the membership units; the content of the benefit package, the payment modalities of the premium, the premium amount, the availability of transportation, the co-payment level, convention arrangement with health facilities, and health mutual governance. For a successful implementation of the UHC development strategy through health mutual organizations, policymakers should explore the possibility of introducing the modality of payment in kind, the revision of the co-payment amount, and the promotion of equity through the introduction of a differentiated premium contribution by income. They should also establish a crossborder strategy with The Gambia and Guinea-Bissau to improve health care access to people living in the borders. The promotion of innovative funding and risk equalization between health insurance schemes is also recommended. In areas where the microfinance institutions are well organized and structured their substitution to health mutuals should be an option the decision-makers have to explore.

Voluntary Health Insurance expenditure in low- and middle-income countries: Exploring trends during 1995-2012 and policy implications for progress towards universal health coverage

BACKGROUND

Most low- and middle-income countries (LMIC) rely significantly on private health expenditure in the form of out-of-pocket payments (OOP) and voluntary health insurance (VHI). This paper assesses VHI expenditure trends in LMIC and explores possible explanations. This illuminates challenges deriving from changes in VHI expenditure as countries aim to progress equitably towards universal health coverage (UHC).

METHODS

Health expenditure data was retrieved from the WHO Global Health Expenditure Database to calculate VHI, OOP and general government health (GGHE) expenditure as a share of total health expenditure (THE) for the period of 1995-2012. A literature analysis offered potential reasons for trends in countries and regions.

RESULTS

In 2012, VHI as a percentage of THE (abbreviated as VHI%) was below 1 % in 49 out of 138 LMIC. Twenty-seven countries had no or more than five years of data missing. VHI% ranged from 1 to 5 % in 39 LMIC and was above 5 % in 23 LMIC. There is an upwards average trend in VHI% across all regions. However, increases in VHI% cannot be consistently linked with OOP falling or being redirected into private prepayment. There are various countries which exhibit rising VHI alongside a rise in OOP and fall in GGHE, which is a less desirable path in order to equitably progress towards UHC.

DISCUSSION AND CONCLUSION

Reasons for the VHI expenditure trends across LMIC include: external influences; government policies on the role of VHI and its regulation; and willingness and ability of the population to enrol in VHI schemes. Many countries have paid insufficient attention to the potentially risky role of VHI for equitable progress towards UHC. Expanding VHI markets bear the risk of increasing fragmentation and inequities. To avoid this, health financing strategies need to be clear regarding the role given to VHI on the path towards UHC.

Health insurance in India: what do we know and why is ethnographic research needed

The percentage of India's national budget allocated to the health sector remains one of the lowest in the world, and healthcare expenditures are largely out-of-pocket (OOP). Currently, efforts are being made to expand health insurance coverage as one means of addressing health disparity and reducing catastrophic health costs. In this review, we document reasons for rising interest in health insurance and summarize the country's history of insurance projects to date. We note that most of these projects focus on in-patient hospital costs, not the larger burden of out-patient costs. We briefly highlight some of the more popular forms that government, private, and community-based insurance schemes have taken and the results of quantitative research conducted to assess their reach and cost-effectiveness. We argue that ethnographic case studies could add much to existing health service and policy research, and provide a better understanding of the life cycle and impact of insurance programs on both insurance holders and healthcare providers. Drawing on preliminary fieldwork in South India and recognizing the need for a broad-based implementation science perspective (studying up, down and sideways), we identify six key topics demanding more in-depth research, among others: (1) public awareness and understanding of insurance; (2) misunderstanding of insurance and how this influences health care utilization; (3) differences in behavior patterns in cash and cashless insurance systems; (4) impact of insurance on quality of care and doctor-patient relations; (5) (mis)trust in health insurance schemes; and (6) health insurance coverage of chronic illnesses, rehabilitation and OOP expenses.

Study of Awareness, Enrollment, and Utilization of Rashtriya Swasthya Bima Yojana (National Health Insurance Scheme) in Maharashtra, India

INTRODUCTION

Government of India launched a social health protection program called Rashtriya Swasthya Bima Yojana (RSBY) in the year 2008 to provide financial protection from catastrophic health expenses to below poverty line households (HHs). The objectives of the current paper are to assess the current status of RSBY in Maharashtra at each step of awareness, enrollment, and utilization. In addition, urban and rural areas were compared, and social, political, economic, and cultural (SPEC) factors responsible for the better or poor proportions, especially for the awareness of the scheme, were identified.

METHODS

The study followed mixed methods approach. For quantitative data, a systematic multistage sampling design was adopted in both rural and urban areas covering 6000 HHs across 22 districts. For qualitative data, five districts were selected to conduct Stakeholder Analysis, Focused Group Discussions, and In-Depth Interviews with key informants to supplement the findings. The data were analyzed using innovative SPEC-by-steps tool developed by Health Inc.

RESULTS

It is seen that that the RSBY had a very limited success in Maharashtra. Out of 6000 HHs, only 29.7% were aware about the scheme and 21.6% were enrolled during the period of 2010-2012. Only 11.3% HHs reported that they were currently enrolled for RSBY. Although 1886 (33.1%) HHs reported at least one case of hospitalization in the last 1 year, only 16 (0.3%) HHs could actually utilize the benefits during hospitalization. It is seen that at each step, there is an increase in the exclusion of eligible HHs from the scheme. The participants felt that such schemes did not reach their intended beneficiaries due to various SPEC factors.

DISCUSSION AND CONCLUSION

The results of this study were quite similar to other studies done in the recent past. RSBY might still be continued in Maharashtra with modified focus along with good and improved strategy. Various other similar schemes in India can definitely learn few important lessons such as the need to improve awareness, issuing prompt enrollment cards with proper details, achieving universal enrollment, ongoing and prompt renewal, and ensuring proper utilization by proactively educating the vulnerable sections.

The concept of mechanism from a realist approach: a scoping review to facilitate its operationalization in public health program evaluation

BACKGROUND

Public health interventions are complex by nature, and their evaluation requires unpacking their intervention logic and their interactions with open social systems. By focusing on the interrelationships between context, mechanism, and outcome, Pawson and Tilley's realist approach appears a promising innovation for public health-related evaluation works. However, and as expected of any methodological innovation, this approach is being constructed gradually by answering the multiple challenges to its operationalization that fall in its path. One of these challenges, users of this approach agree on, is the necessity of clarifying its key concept of mechanism.

METHOD

We first collected the definitions of mechanism from published works of Pawson and colleagues. Secondly, a scoping review was conducted to identify the ones quoted by users of the realist approach for evaluating public health interventions (1997-2012). We then appraised the clarity and precision of this concept against the three dimensions defined by Daigneault and Jacobs "term, sense and referent."

RESULTS

Of the 2344 documents identified in the scoping review, 49 documents were included. Term: Users of the realist approach use adjectives qualifying the term mechanism that were not specifically endorsed by Pawson and colleagues. Sense: None of the attributes stated by Pawson and colleagues has been listed in all of the documents analyzed, and some contributions clarified its attributes. Referent: The concept of mechanism within a realist approach can be ascribed to theory-based evaluation, complex social interventions, and critical realism.

CONCLUSION

This review led us to reconsider the concept of mechanism within the realist approach by confronting the theoretical stance of its proponents to the practical one of its users. This resulted in a clearer, more precise definition of the concept of mechanism which may in turn trigger further improvements in the way the realist approach is applied in evaluative practice in public health and potentially beyond. A mechanism is hidden but real, is an element of reasoning and reactions of agents in regard to the resources available in a given context to bring about changes through the implementation of an intervention, and evolves within an open space-time and social system of relationships.

Understanding CBHI hospitalisation patterns: a comparison of insured and uninsured women in Gujarat, India

Background

Community-based health insurance has been associated with increased hospitalisation in low-income settings, but with limited analysis of the illnesses for which claims are submitted. A review of claims submitted to VimoSEWA, an inpatient insurance scheme in Gujarat, India, found that fever, diarrhoea and hysterectomy, the latter at a mean age of 37 years, were the leading reasons for claims by adult women. We compared the morbidity, outpatient treatment-seeking and hospitalisation patterns of VimoSEWA-insured women with uninsured women.

Methods

We utilised data from a cross-sectional survey of 1,934 insured and uninsured women in Gujarat, India. Multivariable logistic regression identified predictors of insurance coverage and the association of insurance with hospitalisation. Self-reported data on morbidity, outpatient care and hospitalisation were compared between insured and uninsured women.

Results

Age, marital status and occupation of adult women were associated with insurance status. Reported recent morbidity, type of illness and outpatient treatment were similar among insured and uninsured women. Multivariable analysis revealed strong evidence of a higher odds of hospitalisation amongst the insured (OR = 2.7; 95% ci. 1.6, 4.7). The leading reason for hospitalisation for uninsured and insured women was hysterectomy, at a similar mean age of 36, followed by common ailments such as fever and diarrhoea. Insured women appeared to have a higher probability of being hospitalised than uninsured women for all causes, rather than specifically for fever, diarrhoea or hysterectomy. Length of stay was similar while choice of hospital differed between insured and uninsured women.

Conclusions

Despite similar reported morbidity patterns and initial treatment-seeking behaviour, VimoSEWA members were more likely to be hospitalised. The data did not provide strong evidence that inpatient hospitalisation replaced outpatient treatment for common illnesses or that insurance was the primary inducement for hysterectomy in the population. Rather, it appears that VimoSEWA members behaved differently in deciding if, and where, to be hospitalised for any condition. Further research is required to explore this decision-making process and roles, if any, played by adverse selection and moral hazard. Lastly, these hospitalisation patterns raise concerns regarding population health needs and access to quality preventive and outpatient services.

The impact of stakeholder values and power relations on community-based health insurance coverage: qualitative evidence from three Senegalese case studies

Continued low rates of enrolment in community-based health insurance (CBHI) suggest that strategies proposed for scaling up are unsuccessfully implemented or inadequately address underlying limitations of CBHI. One reason may be a lack of incorporation of social and political context into CBHI policy. In this study, the hypothesis is proposed that values and power relations inherent in social networks of CBHI stakeholders can explain levels of CBHI coverage. To test this, three case studies constituting Senegalese CBHI schemes were studied. Transcripts of interviews with 64 CBHI stakeholders were analysed using inductive coding. The five most important themes pertaining to social values and power relations were: voluntarism, trust, solidarity, political engagement and social movements. Analysis of these themes raises a number of policy and implementation challenges for expanding CBHI coverage. First is the need to subsidize salaries for CBHI scheme staff. Second is the need to develop more sustainable internal and external governance structures through CBHI federations. Third is ensuring that CBHI resonates with local values concerning four dimensions of solidarity (health risk, vertical equity, scale and source). Government subsidies is one of the several potential strategies to achieve this. Fourth is the need for increased transparency in national policy. Fifth is the need for CBHI scheme leaders to increase their negotiating power vis-à-vis health service providers who control the resources needed for expanding CBHI coverage, through federations and a social movement dynamic. Systematically addressing all these challenges would represent a fundamental reform of the current CBHI model promoted in Senegal and in Africa more widely; this raises issues of feasibility in practice. From a theoretical perspective, the results suggest that studying values and power relations among stakeholders in multiple case studies is a useful complement to traditional health systems analysis.