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Durizzo K, Harttgen K, Tediosi F, Sahu M, Kuwawenaruwa A, Salari P, Günther I. Toward mandatory health insurance in low-income countries? An analysis of claims data in Tanzania. HEALTH ECONOMICS 2022; 31:2187-2207. [PMID: 35933731 PMCID: PMC9543525 DOI: 10.1002/hec.4568] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 06/17/2022] [Accepted: 06/19/2022] [Indexed: 06/15/2023]
Abstract
Many low-income countries are in the process of scaling up health insurance with the goal of achieving universal coverage. However, little is known about the usage and financial sustainability of mandatory health insurance. This study analyzes 26 million claims submitted to the Tanzanian National Health Insurance Fund (NHIF), which covers two million public servants for whom public insurance is mandatory, to understand insurance usage patterns, cost drivers, and financial sustainability. We find that in 2016, half of policyholders used a health service within a single year, with an average annual cost of 33 US$ per policyholder. About 10% of the population was responsible for 80% of the health costs, and women, middle-age and middle-income groups had the highest costs. Out of 7390 health centers, only five health centers are responsible for 30% of total costs. Estimating the expected health expenditures for the entire population based on the NHIF cost structure, we find that for a sustainable national scale-up, policy makers will have to decide between reducing the health benefit package or increasing revenues. We also show that the cost structure of a mandatory insurance scheme in a low-income country differs substantially from high-income settings. Replication studies for other countries are warranted.
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Affiliation(s)
| | | | - Fabrizio Tediosi
- Swiss Tropical and Public Health InstituteAllschwilSwitzerland
- University of BaselBaselSwitzerland
| | - Maitreyi Sahu
- Swiss Tropical and Public Health InstituteAllschwilSwitzerland
- University of BaselBaselSwitzerland
- University of WashingtonSeattleWashingtonUSA
| | - August Kuwawenaruwa
- Swiss Tropical and Public Health InstituteAllschwilSwitzerland
- Ifakara Health InstituteDar es SalaamTanzania
| | - Paola Salari
- Swiss Tropical and Public Health InstituteAllschwilSwitzerland
- University of BaselBaselSwitzerland
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Rouyard T, Mano Y, Daff BM, Diouf S, Fall Dia K, Duval L, Thuilliez J, Nakamura R. Operational and Structural Factors Influencing Enrolment in Community-Based Health Insurance Schemes: An Observational Study Using 12 Waves of Nationwide Panel Data from Senegal. Health Policy Plan 2022; 37:858-871. [PMID: 35413098 PMCID: PMC9347027 DOI: 10.1093/heapol/czac033] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 04/04/2022] [Accepted: 04/12/2022] [Indexed: 11/13/2022] Open
Abstract
Community-based health insurance (CBHI) has been implemented in many low and middle-income countries to increase financial risk protection in populations without access to formal health insurance. While the design of such social programs is fundamental to ensuring equitable access to care, little is known about the operational and structural factors influencing enrolment in CBHI schemes. In this study, we took advantage of newly established data monitoring requirements in Senegal to explore the association between the operational capacity and structure of CBHI schemes-also termed 'mutual health organisations' (MHO) in francophone countries-and their enrolment levels. The dataset comprised 12 waves of quarterly data over 2017-2019 and covered all 676 MHOs registered in the country. Primary analyses were conducted using dynamic panel data regression analysis. We found that higher operational capacity significantly predicted higher performance: enrolment was positively associated with the presence of a salaried manager at the MHO level (12% more total enrollees, 23% more poor members) and with stronger cooperation between MHOs and local health posts (for each additional contract signed, total enrollees and poor members increased by 7% and 5%, respectively). However, higher operational capacity was only modestly associated with higher sustainability proxied by the proportion of enrollees up to date with premium payment. We also found that structural factors were influential, with MHOs located within a health facility enrolling fewer poor members (-16%). Sensitivity analyses showed that these associations were robust. Our findings suggest that policies aimed at professionalising and reinforcing the operational capacity of MHOs could accelerate the expansion of CBHI coverage, including in the most impoverished populations. However, they also suggest that increasing operational capacity alone may be insufficient to make CBHI schemes sustainable over time.
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Affiliation(s)
- Thomas Rouyard
- Research Center for Health Policy and Economics, Hitotsubashi University, Tokyo, Japan
| | - Yukichi Mano
- Graduate School of Economics, Hitotsubashi University, Tokyo, Japan
| | - Bocar Mamadou Daff
- National Agency for Universal Health Financial Protection, Dakar, Senegal
| | - Serigne Diouf
- National Agency for Universal Health Financial Protection, Dakar, Senegal
| | | | - Laetitia Duval
- Centre d'Économie de la Sorbonne, UMR 8174, Centre National de la Recherche Scientifique-Université Paris 1 Panthéon-Sorbonne, Paris, France
| | - Josselin Thuilliez
- Centre d'Économie de la Sorbonne, UMR 8174, Centre National de la Recherche Scientifique-Université Paris 1 Panthéon-Sorbonne, Paris, France
| | - Ryota Nakamura
- Research Center for Health Policy and Economics, Hitotsubashi University, Tokyo, Japan
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James N, Acharya Y. Increasing Health Insurance Enrollment in Low- and Middle-Income Countries: What Works, What Does Not, and Research Gaps: A Scoping Review. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2022; 59:469580221090396. [PMID: 35574923 PMCID: PMC9121503 DOI: 10.1177/00469580221090396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/01/2022] [Accepted: 03/09/2022] [Indexed: 11/16/2022]
Abstract
Health insurance programs have the potential to shield individuals in low- and middle-income countries from catastrophic health expenses and reduce their vulnerability to poverty. However, the uptake of insurance programs remains low in these countries. We reviewed existing evidence from experimental studies on approaches that researchers have tested in order to raise the uptake. In the 12 studies we synthesized, educational programs and subsidies were the dominant interventions. Consistent with findings from previous studies on other health products, subsidies were effective in raising the uptake of insurance programs in many contexts. Conversely, education interventions-in their current forms-were largely ineffective, although they bolstered the effect of subsidies. Other strategies, such as the use of microfinance institutions and social networks for outreach and enrollment, showed mixed results. Additional research is needed on effective approaches to raise the uptake of insurance programs, including tools from behavioral economics that have shown promise in other areas of health behavior.
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Affiliation(s)
- Nigel James
- The Pennsylvania State University,
University Park, PA, USA
| | - Yubraj Acharya
- The Pennsylvania State University,
University Park, PA, USA
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Jabar MA. Factors influencing health-seeking behavior among overseas Filipino workers. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2021. [DOI: 10.1080/20479700.2019.1603665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Melvin A. Jabar
- Behavioral Sciences Department, De La Salle University, Manila, Philippines
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Kusuma YS, Pal M, Babu BV. Health Insurance: Awareness, Utilization, and its Determinants among the Urban Poor in Delhi, India. J Epidemiol Glob Health 2018; 8:69-76. [PMID: 30859791 PMCID: PMC7325807 DOI: 10.2991/j.jegh.2018.09.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 09/06/2018] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Yadlapalli S. Kusuma
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Manisha Pal
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Bontha V. Babu
- Socio-Behavioural and Health Systems Research Division, Indian Council of Medical Research, New Delhi, India
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Bocoum F, Grimm M, Hartwig R, Zongo N. Can information increase the understanding and uptake of insurance? Lessons from a randomized experiment in rural Burkina Faso. Soc Sci Med 2018; 220:102-111. [PMID: 30415141 DOI: 10.1016/j.socscimed.2018.10.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 10/25/2018] [Accepted: 10/31/2018] [Indexed: 11/27/2022]
Abstract
Community Based Health Insurance Schemes are often confronted to very low uptake. We analyze the impact of a randomized information package on the understanding and adoption of Community Based Health Insurance in Burkina Faso. The sample consists of about 2000 households in the rural community of Ziniaré which we interviewed several times between 2013 and 2016. In contrast to previous studies in the literature, we assess the effects of an intensive information intervention combining tools and repeated interaction instead of only a single event of information provisioning. The information package combines three tools to present different types of information - a brochure presenting factual information, a video presenting a hypothetical health episode and a personalized phone call reminder. The brochure and video are delivered through home visits by specially trained agents. Despite the repeated interaction and the comprehensiveness of the information package, we find only modest improvements in the understanding of insurance principles following our intervention. Investigating treatment heterogeneity, we observe an increase in understanding in poorer households and in households with literate heads. Given the small improvements in insurance knowledge we do not see a significant effect on insurance uptake either. We conclude that information is not enough to increase insurance uptake and discuss the role of other factors that might matter including the political context in which our experiment was implemented.
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Affiliation(s)
- Fadima Bocoum
- Institute de Recherche en Sciences de Santé (IRSS), Ouagadougou, Burkina Faso
| | | | - Renate Hartwig
- University of Namur, Belgium; University of Passau, Germany
| | - Nathalie Zongo
- Association Songui Manégré- Aide au développement Endogène (ASMADE), Ouagadougou, Burkina Faso
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Atafu A, Kwon S. Adverse selection and supply-side factors in the enrollment in community-based health insurance in Northwest Ethiopia: A mixed methodology. Int J Health Plann Manage 2018; 33:902-914. [PMID: 29781157 DOI: 10.1002/hpm.2546] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 04/19/2018] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Since 2010, the Ethiopian government introduced different measures to implement community-based health insurance (CBHI) schemes to improve access to health service and reduce the catastrophic effect of health care costs. OBJECTIVES The aim of this study was to examine the determinants of enrollment in CBHI in Northwest Ethiopia. METHODS In this study, we utilized a mix of quantitative (multivariate logistic regression applied to population survey linked with health facility survey) and qualitative (focus group discussion and in-depth interview) methods to better understand the factors that affect CBHI enrollment. RESULTS The study revealed important factors, such as household, informal association, and health facility, as barriers to CBHI enrollment. Age and educational status, self-rated health status, perceived quality of health services, knowledge, and information (awareness) about CBHI were among the characteristics of individual household head, affecting enrollment. Household size and participation in an informal association, such as local credit associations, were also positively associated with CBHI enrollment. Additionally, health facility factors like unavailability of laboratory tests were the main factor that hinders CBHI enrollment. CONCLUSIONS This study showed a possibility of adverse selection in CBHI enrollment. Additionally, perceived quality of health services, knowledge, and information (awareness) are positively associated with CBHI enrollment. Therefore, policy interventions to mitigate adverse selection as well as provision of social marketing activities are crucial to increase enrollment in CBHI. Furthermore, policy interventions that enhance the capacity of health facilities and schemes to provide the promised services are necessary.
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Affiliation(s)
- Asmamaw Atafu
- Graduate School of Public Health, Seoul National University, Seoul, South Korea.,Department of Health Service Management and Economics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Soonman Kwon
- Graduate School of Public Health, Seoul National University, Seoul, South Korea
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Peterson L, Comfort A, Hatt L, van Bastelaer T. Extending health insurance coverage to the informal sector: Lessons from a private micro health insurance scheme in Lagos, Nigeria. Int J Health Plann Manage 2018; 33:662-676. [PMID: 29658152 DOI: 10.1002/hpm.2519] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 02/24/2018] [Accepted: 02/27/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND As a growing number of low- and middle-income countries commit to achieving universal health coverage, one key challenge is how to extend coverage to informal sector workers. Micro health insurance (MHI) provides a potential model to finance health services for this population. This study presents lessons from a pilot study of a mandatory MHI plan offered by a private insurance company and distributed through a microfinance bank to urban, informal sector workers in Lagos, Nigeria. METHODS Study methods included a survey of microfinance clients, key informant interviews, and a review of administrative records. RESULTS Demographic, health care seeking, and willingness-to-pay data suggested that microfinance clients, particularly women, could benefit from a comprehensive MHI plan that improved access to health care and reduced out-of-pocket spending on health services. However, administrative data revealed declining enrollment, and key informant interviews further suggested low use of the health insurance plan. Key implementation challenges, including changes to mandatory enrollment requirements, insufficient client education and marketing, misaligned incentives, and weak back-office systems, undermined enrollment and use of the plan. CONCLUSIONS Mandatory MHI plans, intended to mitigate adverse selection and facilitate private insurers' entry into new markets, present challenges for covering informal sector workers, including when distributed through agents such as a microfinance bank. Properly aligning the incentives of the insurer and the agent are critical to effectively distribute and service insurance. Further, an urban environment presents unique challenges for distributing MHI, addressing client perceptions of health insurance, and meeting their health care needs.
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Affiliation(s)
- Lauren Peterson
- International Health, Abt Associates, Bethesda, Maryland, USA
| | - Alison Comfort
- University of California - San Francisco, Department of Obstetrics, Gynecology & Reproductive Sciences, San Francisco, California, USA
| | - Laurel Hatt
- Results for Development, Washington, District of Columbia, USA
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Dror DM, Chakraborty A, Majumdar A, Panda P, Koren R. Impact of community-based health insurance in rural India on self-medication & financial protection of the insured. Indian J Med Res 2017; 143:809-820. [PMID: 27748307 PMCID: PMC5094122 DOI: 10.4103/0971-5916.192075] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND & OBJECTIVES The evidence-base of the impact of community-based health insurance (CBHI) on access to healthcare and financial protection in India is weak. We investigated the impact of CBHI in rural Uttar Pradesh and Bihar s0 tates of India on insured households' self-medication and financial position. METHODS Data originated from (i) household surveys, and (ii) the Management Information System of each CBHI. Study design was "staggered implementation" cluster randomized controlled trial with enrollment of one-third of the treatment group in each of the years 2011, 2012 and 2013. Around 40-50 per cent of the households that were offered to enroll joined. The benefits-packages covered outpatient care in all three locations and in-patient care in two locations. To overcome self-selection enrollment bias, we constructed comparable control and treatment groups using Kernel Propensity Score Matching (K-PSM). To quantify impact, both difference-in-difference (DiD), and conditional-DiD (combined K-PSM with DiD) were used to assess robustness of results. RESULTS Post-intervention (2013), self-medication was less practiced by insured HHs. Fewer insured households than uninsured households reported borrowing to finance care for non-hospitalization events. Being insured for two years also improved the HH's location along the income distribution, namely insured HHs were more likely to experience income quintile-upgrade in one location, and less likely to experience a quintile-downgrade in two locations. INTERPRETATION & CONCLUSIONS The realized benefits of insurance included better access to healthcare, reduced financial risks and improved economic mobility, suggesting that in our context health insurance creates welfare gains. These findings have implications for theoretical, ethical, policy and practice considerations.
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Affiliation(s)
- David M Dror
- Micro Insurance Academy, New Delhi, India and Institute of Health Policy & Management, Erasmus University, Rotterdam, The Netherlands
| | - Arpita Chakraborty
- Micro Insurance Academy, New Delhi, India and Institute of Health Policy & Management, Erasmus University, Rotterdam, The Netherlands; Public Health Foundation of India, Gurgaon, India,
| | - Atanu Majumdar
- Micro Insurance Academy, New Delhi, India and Institute of Health Policy & Management, Erasmus University, Rotterdam, The Netherlands
| | - Pradeep Panda
- Micro Insurance Academy, New Delhi, India and Institute of Health Policy & Management, Erasmus University, Rotterdam, The Netherlands
| | - Ruth Koren
- Tel Aviv University, Rabin Medical Center, Petah Tikva, Israel
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Panda P, Chakraborty A, Raza W, Bedi AS. Renewing membership in three community-based health insurance schemes in rural India. Health Policy Plan 2016; 31:1433-1444. [DOI: 10.1093/heapol/czw090] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2016] [Indexed: 11/13/2022] Open
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Ahmed S, Hoque ME, Sarker AR, Sultana M, Islam Z, Gazi R, Khan JAM. Willingness-to-Pay for Community-Based Health Insurance among Informal Workers in Urban Bangladesh. PLoS One 2016; 11:e0148211. [PMID: 26828935 PMCID: PMC4734618 DOI: 10.1371/journal.pone.0148211] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 01/14/2016] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Reliance on out-of-pocket payment for healthcare may lead poor households to undertake catastrophic health expenditure, and risk-pooling mechanisms have been recommended to mitigate such burdens for households in Bangladesh. About 88% of the population of Bangladesh depends on work in the informal sector. We aimed to estimate willingness-to-pay (WTP) for CBHI and identify its determinants among three categories of urban informal workers rickshaw-pullers, shopkeepers and restaurant workers. METHODS The bidding game version of contingent valuation method was used to estimate weekly WTP. In three urban locations 557 workers were interviewed using a structured questionnaire during 2010 and 2011. Multiple-regression analysis was used to predict WTP by demographic and household characteristics, occupation, education level and past illness. RESULTS WTP for a CBHI scheme was expressed by 86.7% of informal workers. Weekly average WTP was 22.8 BDT [Bangladeshi Taka; 95% confidence interval (CI) 20.9-24.8] or 0.32 USD and varied significantly across occupational groups (p = 0.000) and locations (p = 0.003). WTP was highest among rickshaw-pullers (28.2 BDT or 0.40 USD; 95% CI: 24.7-31.7), followed by restaurant workers (20.4 BDT 0.29 USD; 95% CI: 17.0-23.8) and shopkeepers (19.2 BDT or 0.27 USD; 95% CI: 16.1-22.4). Multiple regression analysis identified monthly income, occupation, geographical location and educational level as the key determinants of WTP. WTP increased 0.196% with each 1% increase in monthly income, and was 26.9% lower among workers with up to a primary level of education versus those with higher than primary, but less than one year of education. CONCLUSION Informal workers in urban areas thus are willing to pay for CBHI and socioeconomic differences explain the magnitude of WTP. The policy maker might think introducing community-based model including public-community partnership model for healthcare financing of informal workers. Decision making regarding the implementation of such schemes should consider worker location and occupation.
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Affiliation(s)
- Sayem Ahmed
- Health Economics & Financing Research Group, Centre for Equity and Health Systems, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
- Health Economics and Policy Research Group, Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden
| | | | - Abdur Razzaque Sarker
- Health Economics & Financing Research Group, Centre for Equity and Health Systems, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Marufa Sultana
- Health Economics & Financing Research Group, Centre for Equity and Health Systems, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Ziaul Islam
- Health Economics & Financing Research Group, Centre for Equity and Health Systems, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Rukhsana Gazi
- Health Economics & Financing Research Group, Centre for Equity and Health Systems, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Jahangir A. M. Khan
- Health Economics & Financing Research Group, Centre for Equity and Health Systems, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
- Health Economics and Policy Research Group, Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden
- James P Grant School of Public health, BRAC University and International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, United Kingdom
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Dror DM, Panda P, May C, Majumdar A, Koren R. "One for all and all for one": consensus-building within communities in rural India on their health microinsurance package. Risk Manag Healthc Policy 2014; 7:139-53. [PMID: 25120378 PMCID: PMC4128598 DOI: 10.2147/rmhp.s66011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction This study deals with consensus by poor persons in the informal sector in rural India on the benefit-package of their community-based health insurance (CBHI). In this article we describe the process of involving rural poor in benefit-package design and assess the underlying reasons for choices they made and their ability to reach group consensus. Methods The benefit-package selection process entailed four steps: narrowing down the options by community representatives, plus three Choosing Healthplans All Together (CHAT) rounds conducted among female members of self-help groups. We use mixed-methods and four sources of data: baseline study, CHAT exercises, in-depth interviews, and evaluation questionnaires. We define consensus as a community resolution reached by discussion, considering all opinions, and to which everyone agrees. We use the coefficient of unalikeability to express consensus quantitatively (as variability of categorical variables) rather than just categorically (as a binomial Yes/No). Findings The coefficient of unalikeability decreased consistently over consecutive CHAT rounds, reaching zero (ie, 100% consensus) in two locations, and confirmed gradual adoption of consensus. Evaluation interviews revealed that the wish to be part of a consensus was dominant in all locations. The in-depth interviews indicated that people enjoyed the participatory deliberations, were satisfied with the selection, and that group decisions reflected a consensus rather than majority. Moreover, evidence suggests that pre-selectors and communities aimed to enhance the likelihood that many households would benefit from CBHI. Conclusion The voluntary and contributory CBHI relies on an engaging experience with others to validate perceived priorities of the target group. The strongest motive for choice was the wish to join a consensus (more than price or package-composition) and the intention that many members should benefit. The degree of consensus improved with iterative CHAT rounds. Harnessing group consensus requires catalytic intervention, as the process is not spontaneous.
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Affiliation(s)
- David M Dror
- Micro Insurance Academy, New Delhi, India ; Erasmus University, Rotterdam, the Netherlands
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