In Ethiopia's Kutaber district, does community-based health insurance protect households from catastrophic health-care costs? A community- based comparative cross-sectional study

OBJECTIVE

Every health system needs to take action to shield households from the expense of medical costs. The Ethiopian government implemented community-based health insurance (CBHI) to protect households from catastrophic health care expenditure (CHE) and enhance the utilization of health care services. The impact of CBHI on CHE with total household expenditure and non-food expenditure measures hadn't been studied, so the study aimed to evaluate the impact of CBHI on CHE among households in Kutaber district, Ethiopia.

METHODS

A total of 472 households (225 insured and 247 uninsured) were selected by multistage sampling techniques. Households total out-of-pocket (OOP) health payments ≥10% threshold of total household expenditure or ≥40% threshold of household non-food expenditure categorized as CHE. The co-variants for participation in the CBHI scheme were estimated by using a probit regression model. A propensity score matching analysis was used to determine the impact of CBHI on CHE. A Chi-square (χ2) test was computed to compare CHE between insured and uninsured households.

RESULTS

The magnitude of CHE was 39.1% with total household expenditure and 1.8% with non-food expenditure measures among insured households. Insured households were 46.3% protected from CHE when compared to uninsured households with total household expenditure measures and 24.2% to 25% with non-food expenditure measures.

CONCLUSION

The magnitude of CHE was lower among CBHI-enrolled households. CBHI is an effective means of financial protection benefits for households as a share of total household expenditure and non-food expenditure measures. Therefore, increasing the upper limits of benefit packages, minimizing exclusions, and CBHI scale-up to uninsured households is essential.

Willingness to pay for community based health insurance scheme and factors associated with it among households in rural community of South West Shoa Zone, Ethiopia

Background

Out-of-pocket payments are the major significant barrier in achieving universal health coverage, particularly in developing countries' rural communities. In 2011, the Ethiopian government launched a pilot community-based health insurance (CBHI) scheme with the goal of increasing access to modern health care services and providing financial security to households in the informal sector and rural areas. The main objective of this study is to estimate willingness to pay (WTP) for CBHI scheme and factors that influence it among rural households in the South West Shoa Zone.

Methods

A household-level cross-sectional study was conducted to examine the WTP for the CBHI scheme and factors associated with it in rural communities of South West Shoa Zone. The study used a sample of 400 rural households. Systematic random sampling was employed during household selection, and double-bounded contingent valuation method was used to estimate WTP for the CBHI scheme.

Results

About 65 percent of the households are willing to pay for CBHI scheme. Moreover, the study found that the households were willing to pay 255.55 Birr per year on average. The result of the study also revealed that amount of bid, household income, family size, household head's education, household health status, membership to community-based health insurance scheme, membership in any association, and awareness about the scheme are factors that are significantly associated with WTP for the scheme.

Conclusions

Households are willing to pay a higher price than the policy price. Therefore, setting a new premium that reflects households' willingness to pay is highly valuable to policymakers. Social capital and awareness about CBHI scheme play an important role in influencing WTP. Thus, the study suggests that local communities need to strengthen their social cohesion and solidarity. It is also necessary to create awareness about the CBHI’s benefits.

Factors Affecting Payment Compliance of the Indonesia National Health Insurance Participants

Background

The study aims to explore factors that affect the compliance of Indonesia National Health Insurance (INHI) in paying the premiums.

Methods

The study design was qualitative with grounded theory research approach and constructivism paradigm. The study was conducted in 2018 and carried out for 3 months. We recruited 22 respondents from four different cities/districts. Triangulation was carried out through 26 informants from various stakeholders. Data were analyzed through coding, categorizing and pattern matching to obtain substantive theory.

Results

The resulting substantive theory consists of 6 constructs and 14 categories. Compliance with paying insurance premium depends on the intention to pay for contribution. Meanwhile, the intention to pay is related to internal and external factors of INHI participants. To improve payment contribution of independent participants, INHI program has to pay attention for factors originating internally from the participants themselves (understanding of INHI program, financial ability and self-attitude) and also externally such as operational system and the quality of health care.

Conclusion

Compliance of paying insurance premium is related to internal and external factors of participants. Thus, interventions to improve compliance to pay premium should take these factors into account, and not merely on increasing the knowledge of participants.

Health equity funds as the pathway to universal coverage in Cambodia: care seeking and financial risk protection

Cambodia has developed the health equity fund (HEF) system to improve access to health services for the poor, and this strengthens the health system towards the universal health coverage goal. Given rising healthcare costs, Cambodia has introduced several innovations and accomplished considerable progress in improving access to health services and catastrophic health expenditures for the targeted population groups. Though this is improving in recent years, HEF households remain at the higher risk of catastrophic spending as measured by the higher share of HEF households with catastrophic health expenses being at 6.9% compared to the non-HEF households of 5.5% in 2017. Poverty targeting poses another challenge for the health system. Nevertheless, HEF appeared to be more significantly associated with decreased out-of-pocket expenditure per illness among those who sought care from public providers. Increasing population and cost coverages of the HEF and effectively attracting beneficiaries to the public sector will further enhance the financial protection and pave the pathway towards universal coverage. Our recommendations focus on leveraging the HEF experience for expanding coverage and increasing equitable access, as well as strengthening the quality of healthcare services.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusion

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

The Role of Digital Strategies in Financing Health Care for Universal Health Coverage in Low- and Middle-Income Countries

Countries finance health care using a combination of 3 main functions: raising resources for health, pooling resources, and purchasing health services. In this paper, we examine how digital health technologies can be used to enhance these health financing functions in low- and middle-income countries and can thus contribute to progress toward universal health coverage. We illustrate our points by presenting some recent innovations in digital technologies for financing health care, identifying their contributions and their limits. Some examples include a mobile-health wallet application used in Kenya that encourages households to put money aside for future health expenses; an online software platform developed by a startup in Tanzania in partnership with a private insurance provider to give individuals and families the opportunity to choose among different health coverage options; and digital maps by a number of startups that bring together data on health facility locations and capacity, including equipment, staff, and types of services offered. We also sketch an agenda for future research and action for digital strategies for health financing. The development and adoption of effective solutions that align well with the universal health coverage agenda will require strong partnerships between stakeholders and enough proactive stewardship by authorities.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The effect of community-based health insurance schemes on utilization of healthcare services in low- and middle-income countries: a systematic review protocol of quantitative evidence

REVIEW QUESTION/OBJECTIVE

The objective of this systematic review is to identify, appraise and synthesize evidence to establish the effectiveness of community-based health insurance (CBHI) schemes in enhancing the utilization of healthcare services among their members in low- and middle-income countries (LMICs).Specifically, the review objective is to determine if individuals or households enrolled in CBHI schemes in LMICs utilize healthcare services (outpatient visits, hospital admissions, emergency visits, maternal and child healthcare services, or any other services involving the schemes) more frequently than those not included in CBHI schemes.

Community-based health insurance and communities' scheme requirement compliance in Thehuldere district, northeast Ethiopia: cross-sectional community-based study

BACKGROUND

Community-based health insurance (CBHI) is becoming a prominent and promising concept in tackling financial health care issues confronting the poor rural communities in developing countries. Ethiopia endorsed and constituted CBHI schemes in 13 pilot "woredas" in 2010/11. This study aimed to assess the compliance of the community to CBHI scheme requirements in Thehuledere district, northeast Ethiopia.

METHODS

A community-based cross-sectional study was conducted among 530 respondents between April and June 2015 in Thehuledere District, South Wollo Zone, northeast Ethiopia. A systematic random sampling technique was deployed to select the study participants. A self-administered, structured, pre-tested questionnaire was used to collect the data. Bivariate and multivariate logistic regression analyses were used to identify factors associated with CBHI compliance.

RESULTS

A total of 511 study participants were included in the study. Approximately 77.9% of the study population complied with CBHI requirements: members' age (AOR = 0.74, 95% CI: 0.62-0.8), premium fee affordability (AOR: 2.66, 95% CI: [1.13-4.42]), members' occupation (AOR = 0.14, 95% CI: 0.04-0.45), members' attitude toward CBHI management (AOR = 2.11 [1.14-3.90]), and CBHI members' knowledge (AOR = 0.24, 95% CI: [0.13-0.42]) were found to be major predictors of community compliance to CBHI requirements.

CONCLUSION

CBHI requirement compliance at the early stage was relatively high. We observed that members' age, premium fee affordability, occupation, attitude, and knowledge were significant predictors. CBHI management's involvement in awareness creation and training on requirements of the CBHI scheme would contribute to better outcomes and success.

Implementation of Community Health Fund in Tanzania: why do some districts perform better than others?

In early 1990s, Tanzania, like other African countries, introduced user fees in public health systems. Although user fees were considered important in promoting health, they appear to reduce people's access to health services. To counteract the detrimental effects of the user fees, various types of health insurances were introduced, including the Community Health Fund (CHF). Drawing from the review of minutes, health facility visits and key informant interviews, this study explored why implementation of the CHF in Tanzania has been more successful in some districts than in others. The findings indicate that in Lindi district, the enrolment rate for the CHF was very low. This was attributed to high premium rates, frequent drug stock-out, lack of trust by the community members to the health providers, low incentives and local politics. In contrast, in Iramba district, the performance was better. Availability of drugs in the health facilities, effective supervision, commitment of the top district-level officials and incentives to the health facility committees were the main factors that facilitated good performance of the fund in Iramba district. The focus of the implementation needs to be placed on the active engagement of the local-level leaders and politicians who are responsible for the implementation of the policy. Equally important is the availability of quality health services in the health facilities.

[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.

Household Size and the Decision to Purchase Health Insurance in Cambodia: Results of a Discrete-Choice Experiment with Scale Adjustment

BACKGROUND

Community-based health insurance (CBHI) schemes have been introduced in low- and middle-income countries to increase health service utilization and provide financial protection from high healthcare expenditures.

OBJECTIVE

We assess the impact of household size on decisions to enroll in CBHI and demonstrate how to correct for group disparity in scale (i.e. variance differences).

METHODS

A discrete choice experiment was conducted across five CBHI attributes. Preferences were elicited through forced-choice paired comparison choice tasks designed based on D-efficiency. Differences in preferences were examined between small (1-4 family members) and large (5-12 members) households using conditional logistic regression. Swait and Louviere test was used to identify and correct for differences in scale.

RESULTS

One-hundred and sixty households were surveyed in Northwest Cambodia. Increased insurance premium was associated with disutility [odds ratio (OR) 0.61, p < 0.01], while significant increase in utility was noted for higher hospital fee coverage (OR 10.58, p < 0.01), greater coverage of travel and meal costs (OR 4.08, p < 0.01), and more frequent communication with the insurer (OR 1.33, p < 0.01). While the magnitude of preference for hospital fee coverage appeared larger for the large household group (OR 14.15) compared to the small household group (OR 8.58), differences in scale were observed (p < 0.05). After adjusting for scale (k, ratio of scale between large to small household groups = 1.227, 95 % confidence interval 1.002-1.515), preference differences by household size became negligible.

CONCLUSION

Differences in stated preferences may be due to scale, or variance differences between groups, rather than true variations in preference. Coverage of hospital fees, travel and meal costs are given significant weight in CBHI enrollment decisions regardless of household size. Understanding how community members make decisions about health insurance can inform low- and middle-income countries' paths towards universal health coverage.

Health Insecurity and Social Protection: Pathways, Gaps, and Their Implications on Health Outcomes and Poverty

Health insecurity has emerged as a major concern among health policy-makers particularly in low- and middle-income countries (LMICs). It includes the inability to secure adequate healthcare today and the risk of being unable to do so in the future as well as impoverishing healthcare expenditure. The increasing health insecurity among 150 million of the world's poor has moved social protection in health (SPH) to the top of the agenda among health policy-makers globally. This paper aims to provide a debate on the potential of social protection contribution to addressing health insecurity, poverty, and vulnerability brought by healthcare expenditure in low-income countries, to explore the gaps in current and proposed social protection measures in healthcare and provide suggestions on how social protection intervention aimed at addressing health insecurity, poverty, and vulnerability may be effectively implemented.

The Impact of Community Based Health Insurance in Enhancing Better Accessibility and Lowering the Chance of Having Financial Catastrophe Due to Health Service Utilization: A Case Study of Savannakhet Province, Laos

The Lao population mostly relies on out-of-pocket expenditures for health care services. This study aims to determine the role of community-based health insurance in making health care services accessible and in preventing financial catastrophe resulting from personal payment for inpatient services. A cross-sectional study design was applied. Data collection involved 126 insured and 126 uninsured households in identical study sites. Two logistic regression models were used to predict and compare the probability of hospitalization and financial catastrophe that occurred in both insured and uninsured households within the previous year. The findings show that insurance status does not significantly improve accessibility and financial protection against catastrophic expenditure. The reason is relatively simple, as catastrophic health expenditure refers to a total out-of-pocket payment equal to or more than 40% of household income minus subsistence. When household income declines as a result of inability to work due to illness, the 40% threshold is quickly reached. Despite this, results suggest that insured households are not significantly better off under community-based health insurance. However, compared to uninsured households, insured households do have better accessibility and a lower probability of reaching the financial catastrophe threshold.

Factors that affect the uptake of community-based health insurance in low-income and middle-income countries: a systematic protocol

INTRODUCTION

Many people residing in low-income and middle-income countries (LMICs) are regularly exposed to catastrophic healthcare expenditure. It is therefore pertinent that LMICs should finance their health systems in ways that ensure that their citizens can use needed healthcare services and are protected from potential impoverishment arising from having to pay for services. Ways of financing health systems include government funding, health insurance schemes and out-of-pocket payment. A health insurance scheme refers to pooling of prepaid funds in a way that allows for risks to be shared. The health insurance scheme particularly suitable for the rural poor and the informal sector in LMICs is community-based health insurance (CBHI), that is, insurance schemes operated by organisations other than governments or private for-profit companies. We plan to search for and summarise currently available evidence on factors associated with the uptake of CBHI, as we are not aware of previous systematic reviews that have looked at this important topic.

METHODS

This is a protocol for a systematic review of the literature. We will include both quantitative and qualitative studies in this review. Eligible quantitative studies include intervention and observational studies. Qualitative studies to be included are focus group discussions, direct observations, interviews, case studies and ethnography. We will search EMBASE, PubMed, Scopus, ERIC, PsycInfo, Africa-Wide Information, Academic Search Premier, Business Source Premier, WHOLIS, CINAHL and the Cochrane Library for eligible studies available by 31 October 2013, regardless of publication status or language of publication. We will also check reference lists of included studies and proceedings of relevant conferences and contact researchers for eligible studies. Two authors will independently screen the search output, select studies and extract data, resolving discrepancies by consensus and discussion. Qualitative data will be extracted using standardised data extraction tools adapted from the Critical Appraisal Skills Program (CASP) qualitative appraisal checklist and put together in a thematic analysis where applicable. We will statistically pool data from quantitative studies in a meta-analysis; but if included quantitative studies differ significantly in study settings, design and/or outcome measures, we will present the findings in a narrative synthesis. This protocol has been registered with PROSPERO (ID=CRD42013006364).

DISSEMINATION

Recommendations will be made to health policy makers, managers and researchers in LMICs to help inform them on ways to strengthen and increase the uptake of CBHI.

Promoting universal financial protection: a case study of new management of community health insurance in Tanzania

BACKGROUND

The National Health Insurance Fund (NHIF), a compulsory formal sector scheme took over the management of the Community Health Fund (CHF), a voluntary informal sector scheme, in 2009. This study assesses the origins of the reform, its effect on management and reporting structures, financial flow adequacy, reform communication and acceptability to key stakeholders, and initial progress towards universal coverage.

METHODS

The study relied on national data sources and an in-depth collective case study of a rural and an urban district to assess awareness and acceptability of the reform, and fund availability and use relative to need in a sample of facilities.

RESULTS

The reform was driven by a national desire to expand coverage and increase access to services. Despite initial delays, the CHF has been embedded within the NHIF organisational structure, bringing more intensive and qualified supervision closer to the district. National CHF membership has more than doubled. However, awareness of the reform was limited below the district level due to the reform's top-down nature. The reform was generally acceptable to key stakeholders, who expected that benefits between schemes would be harmonised.The reform was unable to institute changes to the CHF design or district management structures because it has so far been unable to change CHF legislation which also limits facility capacity to use CHF revenue. Further, revenue generated is currently insufficient to offset treatment and administration costs, and the reform did not improve the revenue to cost ratio. Administrative costs are also likely to have increased as a result of the reform.

CONCLUSION

Informal sector schemes can benefit from merger with formal sector schemes through improved data systems, supervision, and management support. However, effects will be maximised if legal frameworks can be harmonised early on and a reduction in administrative costs is not guaranteed.

Assessing effectiveness of a community based health insurance in rural Burkina Faso

Background

Financial barriers are a recognized major bottleneck of access and use of health services. The aim of this study was to assess effectiveness of a community based health insurance (CBHI) scheme on utilization of health services as well as on mortality and morbidity.

Methods

Data were collected from April to December 2007 from the Nouna’s Demographic Surveillance System on overall mortality, utilization of health services, household characteristics, distance to health facilities, membership in the Nouna CBHI. We analyzed differentials in overall mortality and selected maternal health process measures between members and non-members of the insurance scheme.

Results

After adjusting for covariates there was no significant difference in overall mortality between households who could not have been members (because their area was yet to be covered by the stepped-wedged scheme), non-members but whose households could have been members (areas covered but not enrolled), and members of the insurance scheme. The risk of overall mortality increased significantly with distance to health facility (35% more outside Nouna town) and with education level (37% lower when at least primary school education achieved in households).

Conclusion

There was no statistically significant difference in overall mortality between members and non-members. The enrolment rates remain low, with selection bias. It is important that community based health insurances, exemptions fees policy and national health insurances be evaluated on prevention of deaths and severe morbidities instead of on drop-out rates, selection bias, adverse selection and catastrophic payments for health care only. Effective social protection will require national health insurance.

Social health assistance schemes: the case of Medical Financial Assistance for the rural poor in four counties of China

BACKGROUND

Economic transition which took place in China over the last three decades, has led to a rapid marketization of the health care sector. Today inequity in health and poverty resulting from major illness has become a serious problem in rural areas of China. Medical Financial Assistance (MFA) is a health assistance scheme that helps rural poor people cope with major illness and alleviate their financial burden from major illness, which will definitely play a significant role in the process of rebuilding Chinese new rural health system. It mainly provides assistance to cover medical expenditure for inpatient services or the treatment of major illnesses, with joint funding from the central and local government. The purpose of this paper is to review the design, funding, implementation and to explore the preliminary effects of four counties' MFA in Hubei and Sichuan province of China.

METHODS

We used an analytical framework built around the main objective of any social assistance scheme. The framework contains six 'targeting' procedural 'steps' which may explain why a specific group does not receive the assistance it ought to receive. More specifically, we explored to what extent the targeting, a key component of social assistance programs, is successful, based on the qualitative and quantitative data collected from four representative counties in central and western China.

RESULTS

In the study sites, the budget of MFA ranged from 0.8 million Yuan to 1.646 million Yuan in each county and the budget per eligible person ranged from 32.67 Yuan to 149.09 Yuan. The preliminary effects of MFA were quite modest because of the scarcity of funds dedicated to the scheme. The coverage rate of MFA ranged from 17.8% to 24.1% among the four counties. MFA in the four counties used several ways to ration a restricted budget and provided only limited assistance. Substantial problems remained in terms of eligibility and identification of the beneficiaries, utilization and management of funds.

CONCLUSIONS

MFA needs to be improved further although it evidences the concern of the government for the poor rural people with major illness. Some ideas on how to improve MFA are put forward for future policy making.

A functional model for monitoring equity and effectiveness in purchasing health insurance premiums for the poor: evidence from Cambodia and the Lao PDR

OBJECTIVES

To assess the impact on equity and effectiveness of introducing targeted subsidies for the poor into existing voluntary health insurance schemes in Low Income Countries with special reference to cross-subsidisation.

METHODS

A functional model was constructed using routine collected financial data to analyse changes in financial flows and resulting shifts in cross-subsidization between poor and non-poor. Data were collected from two sites, in Cambodia at Kampot operational health district and in the Lao People's Democratic Republic at Nambak district.

RESULTS

Six key variables were identified as determining the financial flows between the subsidy and the insurance schemes and with health providers: population coverage, premium rate, facility contact rate, capitation rate, cost of treatment and changes in administration costs. Negative cross-subsidization was revealed where capitation was used as the payment mechanism and where utilisation rates of the poor were significantly below the non-poor. The same level of access for the poor could have been achieved with a lower Health Equity Fund subsidy if used as a direct reimbursement of user charges by the Health Equity Fund to the provider rather than through the Community Based Health Insurance scheme.

CONCLUSIONS

Purchasing premiums for the poor under these conditions is more costly than direct reimbursement to the provider for the same level of service delivery. Negative cross-subsidization is a serious risk that must be managed appropriately and the benefits of a larger risk pool (cross-subsidization of the poor) are not evident. Benefits from combined coverage may accrue in the longer term with an expanded base of voluntary payers or when those with subsidized premiums are lifted out of poverty.

Universal coverage of health services: tailoring its implementation

In 2005, the Member States of WHO adopted a resolution encouraging countries to develop health financing systems capable of achieving and/or maintaining universal coverage of health services - where all people have access to needed health services without the risk of severe financial consequences. In doing this, a major challenge for many countries will be to move away from out-of-pocket payments, which are often used as an important source of fund collection. Prepayment methods will need to be developed or expanded but, in addition to questions of revenue collection, specific attention will also have to be paid to pooling funds to spread risks and to enable their efficient and equitable use. Developing prepayment mechanisms may take time, depending on countries' economic, social and political contexts. Specific rules for health financing policy will need to be developed and implementing organizations will need to be tailored to the level that countries can support and sustain. In this paper we propose a comprehensive framework focusing on health financing rules and organizations that can be used to support countries in developing their health financing systems in the search for universal coverage.