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Sendekie AK, Gebremichael AH, Tadesse MW. Enrollment and clients' satisfaction with a community-based health insurance scheme: a community-based survey in Northwest Ethiopia. BMC Health Serv Res 2024; 24:70. [PMID: 38218770 PMCID: PMC10787395 DOI: 10.1186/s12913-024-10570-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 01/05/2024] [Indexed: 01/15/2024] Open
Abstract
BACKGROUND Although the Ethiopian government has implemented a community-based health insurance (CBHI) program, community enrollment and clients' satisfaction have not been well investigated in Gondar Zuria district, Northwest Ethiopia. This study assessed CBHI scheme enrollment, clients' satisfaction, and associated factors among households in the district. METHODS A community-based cross-sectional survey assessed CBHI scheme enrollment and clients' satisfaction among households in Gondar Zuria district, Northwest Ethiopia, from May to June 2022. A systematic random sampling method was used to select the study participants from eligible households. A home-to-home interview using a structured questionnaire was conducted. Data were analysed using the statistical packages for social sciences version 26. Logistic regression was used to identify variables associated with enrollment and clients' satisfaction. A p-value < 0.05 was considered statistically significant. RESULTS Out of 410 participants, around two-thirds (64.9%) of the participants were enrolled in the CBHI scheme. Residency status (AOR = 1.38, 95% CI: 1.02-5.32; p = 0.038), time taken to reach a health facility (AOR = 1.01, 95% CI: 1.00-1.02; p = 0.001), and household size (AOR = 0.77, 95% CI: 0.67-0.88; p < 0.001) were significantly associated with CBHI scheme enrollment. Two-thirds (66.5%) of enrolled households were dissatisfied with the overall services provided; in particular, higher proportions were dissatisfied with the availability of medication and laboratory tests (88.7%). Household size (AOR = 1.31, 95% CI: 1.01-2.24; p = 0.043) and waiting time to get healthcare services (AOR = 3.14, 95% CI: 1.01-9.97; p = 0.047) were predictors of clients' satisfaction with the CBHI scheme services. CONCLUSION Although a promisingly high proportion of households were enrolled in the CBHI scheme, most of them were dissatisfied with the service. Improving waiting times to get health services, improving the availability of medications and laboratory tests, and other factors should be encouraged.
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Affiliation(s)
- Ashenafi Kibret Sendekie
- Departement of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Ayenew Hailu Gebremichael
- Department of Sociology, School of Sociology and Social Work, College of Social Sciences and the Humanities, University of Gondar, Gondar, Ethiopia
| | - Melkamu Workie Tadesse
- School of Economics, College of Business and Economics, University of Gondar, Gondar, Ethiopia.
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Nguyen CM, Nguyen MP, Luc LDP. How public health insurance expansion affects healthcare utilizations in middle and low-income households: an observational study from national cross-section surveys in Vietnam. BMC Public Health 2023; 23:624. [PMID: 37004009 PMCID: PMC10067245 DOI: 10.1186/s12889-023-15500-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 03/21/2023] [Indexed: 04/03/2023] Open
Abstract
Public health insurance (PHI) has been implemented with different levels of participation in many countries, from voluntary to mandatory. In Vietnam, a law amendment made PHI compulsory nationwide in 2015 with a tolerance phase allowing people a flexible time to enroll. This study aims to examine mechanisms under which the amendment affected the enrollment, healthcare utilization, and out-of-pocket (OOP) expenditures by middle- and low-income households in this transitioning process.Using the biennial Vietnam Household Living Standard Surveys, the study applied the doubly robust difference-in-differences approach to compare outcomes in the post-amendment period from the 2016 survey with those in the pre-amendment period from the 2014 survey. The approach inheriting advantages from its predecessors, i.e., the difference-in-differences and the augmented inverse-probability weighting methods, can mitigate possible biases in policy evaluations due to the changes within the group and between groups over time in the cross-section observational study.The results showed health insurance expansion with extensive subsidies in premiums and medical coverage for persons other than the full-time employed, young children or elderly members in the family, significantly increased enrollments in the middle- and low-income groups by 9% and 8%, respectively. The number of visits for PHI-eligible services also increased, approximately 0.5 more visit per person in the middle-income and 1 more visit per person in the low-income. The amendment, however, so far did not show any significant effect on reducing OOP payments, neither for the low nor the middle-income groups. To further expand PHI coverage and financial protections, policymakers should focus on improving public health facilities, contracting PHI to more accredited private health providers, and motivating the high-income group's enrollments.
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Affiliation(s)
- Chi M Nguyen
- Indiana University School of Medicine, Indiana University - Purdue University Indianapolis, Indianapolis, USA.
| | - Mai P Nguyen
- Queensland University of Technology, Brisbane City, QLD, Australia
- Department of Medical Services Administration, Ministry of Health, Hanoi, Vietnam
| | - Lan D P Luc
- Macquarie Business School, Macquarie University, Sydney, Australia
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Tsala Dimbuene Z, Muanza Nzuzi R, Nzita Kikhela PD. Poverty, education and health insurance coverage among women of reproductive ages in the Democratic Republic of the Congo: a cross-sectional and multilevel analysis. BMJ Open 2022; 12:e064834. [PMID: 36523216 PMCID: PMC9748937 DOI: 10.1136/bmjopen-2022-064834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To investigate inequalities of health insurance coverage (outcome) at subnational level, and the effects of education and poverty on the outcome. DESIGN Secondary analysis of Demographic and Health Surveys. The outcome variable was health insurance ownership. SETTING The Democratic Republic of the Congo. SUBJECTS Women aged 15-49 years (n=18 827). RESULTS Findings indicated significant spatial variations of the health insurance ownership which ranged from 1.2% in Bandundu and Kasaï Oriental to 15.5% in Kinshasa the Capital City. Furthermore, findings showed that an additional year of women education increased by 10% the chance of health insurance ownership (adjusted OR, AOR 1.098; 95% CI 1.065 to 1.132). Finally, living in better-off households increased by 150% the chance of owing a health insurance (AOR 2.501; 95% CI 1.620 to 3.860) compared with women living in poor households. CONCLUSIONS Given the low levels of health insurance coverage, the Democratic Republic of the Congo will not reach the Sustainable Development Goal 3, aimed at improving maternal and child health unless a serious programmatic health shift is undertaken in the country to tackle inequalities among poor and uneducated women via universal health coverage.
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Affiliation(s)
- Zacharie Tsala Dimbuene
- Department of Population and Development Sciences, University of Kinshasa, Kinshasa, Congo (the Democratic Republic of the)
| | - Raphaël Muanza Nzuzi
- Department of Population and Development Sciences, University of Kinshasa, Kinshasa, Congo (the Democratic Republic of the)
| | - Paul-Denis Nzita Kikhela
- Department of Population and Development Sciences, University of Kinshasa, Kinshasa, Congo (the Democratic Republic of the)
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Sheikh N, Tagoe ET, Akram R, Ali N, Howick S, Morton A. Implementation barriers and remedial strategies for community-based health insurance in Bangladesh: insights from national stakeholders. BMC Health Serv Res 2022; 22:1200. [PMID: 36153512 PMCID: PMC9508716 DOI: 10.1186/s12913-022-08561-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 09/12/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Community-based health insurance (CBHI) is a part of the health system in Bangladesh, and overcoming the obstacles of CBHI is a significant policy concern that has received little attention. The purpose of this study is to analyze the implementation barriers of voluntary CBHI schemes in Bangladesh and the strategies to overcome these barriers from the perspective of national stakeholders.
Methods
This study is exploratory qualitative research, specifically case study design, using key informant interviews to investigate the barriers of CBHI that are faced during the implementation. Using a topic guide, we conducted thirteen semi-structured in-depth interviews with key stakeholders directly involved in the CBHI implementation process. The data were analyzed using the Framework analysis method.
Results
The implementation of CBHI schemes in Bangladesh is being constrained by several issues, including inadequate population coverage, adverse selection and moral hazard, lack of knowledge about health insurance principles, a lack of external assistance, and insufficient medical supplies. Door-to-door visits by local community-health workers, as well as regular promotional and educational campaigns involving community influencers, were suggested by stakeholders as ways to educate and encourage people to join the schemes. Stakeholders emphasized the necessity of external assistance and the design of a comprehensive benefits package to attract more people. They also recommended adopting a public–private partnership with a belief that collaboration among the government, microfinance institutions, and cooperative societies will enhance trust and population coverage in Bangladesh.
Conclusions
Our research concludes that systematically addressing implementation barriers by including key stakeholders would be a significant reform to the CBHI model, and could serve as a foundation for the planned national health protection scheme for Bangladesh leading to universal health coverage.
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Hussien M, Azage M, Bayou NB. Financial viability of a community-based health insurance scheme in two districts of northeast Ethiopia: a mixed methods study. BMC Health Serv Res 2022; 22:1072. [PMID: 35996128 PMCID: PMC9396896 DOI: 10.1186/s12913-022-08439-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 08/10/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Community-based health insurance initiatives in low- and middle-income countries encountered a number of sustainability challenges due to their voluntary nature, small risk pools, and low revenue. In Ethiopia, the schemes' financial viability has not been well investigated so far. This study examined the scheme's financial viability and explored underlying challenges from the perspectives of various key stakeholders. METHODS This study employed a mixed methods case study in two purposively selected districts of northeast Ethiopia. By reviewing financial reports of health insurance schemes, quantitative data were collected over a seven years period from 2014 to 2020 to examine trends in financial status. Trends for each financial indicator were analyzed descriptively for the period under review. Interviews were conducted face-to-face with nine community members and 19 key informants. We used the maximum variation technique to select the study participants. Interviews were audio recorded, transcribed verbatim, and translated into English. Thematic analysis was applied with both inductive and deductive coding methods. RESULTS Both schemes experienced excess claims costs and negative net income in almost all the study period. Even after government subsidies, the scheme's net income remained negative for some reporting periods. The challenges contributing to the observed level of financial performance have been summarized under five main themes, which include adverse selection, moral hazard behaviors, stockout of medicines, delays in claims settlement for service providers, and low insurance premiums. CONCLUSIONS The health insurance scheme in both districts spent more than it received for claims settlement in almost all the period under the study, and experienced heavy losses in these periods, implying that it is not financially viable for the period in question. The scheme is also unable to fulfill its purpose of protecting members against out-of-pocket expenses at the point of health care. Interventions should target on the highlighted challenges to restore financial balance and enhance the scheme's viability.
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Affiliation(s)
- Mohammed Hussien
- Department of Health Systems Management and Health Economics, School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia.
| | - Muluken Azage
- Department of Environmental Health, School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Negalign Berhanu Bayou
- Department of Health Policy and Management, Faculty of Public Health, Institute of Health, Jimma University, Jimma, Ethiopia
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Habte A, Tamene A, Ejajo T, Dessu S, Endale F, Gizachew A, Sulamo D. Towards universal health coverage: The level and determinants of enrollment in the Community-Based Health Insurance (CBHI) scheme in Ethiopia: A systematic review and meta-analysis. PLoS One 2022; 17:e0272959. [PMID: 35980888 PMCID: PMC9387799 DOI: 10.1371/journal.pone.0272959] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 07/31/2022] [Indexed: 11/18/2022] Open
Abstract
Background Community-based health insurance (CBHI) is a risk-pooling approach that tries to disperse health expenditures across families with varying health profiles to provide greater access to healthcare services by allowing cross-subsidies from wealthy to poor populations. It is crucial to assess the level of CBHI enrolment and its determinants in Ethiopia, where government health spending is limited to less than 5% of GDP, far below the Alma Ata Declaration’s benchmark of 15%. Although various epidemiological studies on CBHI enrolment status and its determinants have been undertaken in Ethiopia, the results have been inconsistent, with significant variability. However, no nationwide study assessing the pooled estimates exists today. Furthermore, the estimated strength of association at the country level varied and was inconsistent across studies. Hence, this systematic review and meta-analysis aimed at estimating the pooled prevalence of CBHI enrolment and its determinants in Ethiopia. Methods A comprehensive search of studies was done by using PubMed, EMBASE, Science Direct, HINARI, Scopus, Web of Science, and the Cochrane Library. The database search was complemented by google scholar and some repositories for grey literature. The search was carried out from February 11 to March 12, 2022. The relevant data were extracted using a Microsoft Excel 2013 spreadsheet and analyzed using STATATM Version 16. Studies reporting the level and determinants of CBHI enrolment in Ethiopia were considered. A weighted DerSimonian Laired random effect model was applied to estimate the pooled national prevalence of CBHI enrolment. The Cochrane Q test statistics and I2 tests were used to assess the heterogeneity of the included studies. A funnel plot, Begg’s and Egger’s tests, were used to check for the presence of publication bias. Results Fifteen studies were eligible for this systematic review and meta-analysis with a total of 8418 study participants. The overall pooled prevalence of CBHI enrolment in Ethiopia was 45.5% (95% CI: 32.19, 58.50). Affordability of premium for the scheme[OR = 2.58, 95% CI 1.68, 3.47], knowledge of respondents on the CBHI scheme[OR = 4.35, 95% CI 2.69, 6.01], perceived quality of service[OR = 3.21, 95% CI 2.04, 4.38], trust in the scheme[OR = 2.32, 95% CI 1.57, 3.07], and the presence of a person with a chronic disease in the household [OR = 3.58, 95% CI 2.37, 4.78] were all found to influence CBHI enrolment. Conclusion Community health workers (CHWs) need to make a high effort to improve knowledge of CBHI in rural communities by providing health education. To deal with the issue of affordability, due emphasis should be placed on building local solidarity groups and strengthening local initiatives to aid poor members. Stakeholders in the health service delivery points need to focus on the dimensions of high service quality. The financial gap created by the adverse selection of households with chronically ill members should be rectified by implementing targeted subsidies with robust plans.
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Affiliation(s)
- Aklilu Habte
- School of Public Health, College of Medicine and Health Sciences, Wachemo University, Hosanna, Ethiopia
- * E-mail:
| | - Aiggan Tamene
- School of Public Health, College of Medicine and Health Sciences, Wachemo University, Hosanna, Ethiopia
| | - Tekle Ejajo
- School of Public Health, College of Medicine and Health Sciences, Wachemo University, Hosanna, Ethiopia
| | - Samuel Dessu
- Department of Public Health, College of Medicine and Health Sciences, Wolkite University, Wolkite, Ethiopia
| | - Fitsum Endale
- School of Public Health, College of Medicine and Health Sciences, Wachemo University, Hosanna, Ethiopia
| | - Addisalem Gizachew
- School of Public Health, College of Medicine and Health Sciences, Wachemo University, Hosanna, Ethiopia
| | - Dawit Sulamo
- School of Public Health, College of Medicine and Health Sciences, Wachemo University, Hosanna, Ethiopia
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Kalolo A, Gautier L, De Allegri M. Exploring the Role of Social Representation in Micro-Health Insurance Scheme Enrolment and Retainment in Sub-Saharan Africa: A Scoping Review. Health Policy Plan 2022; 37:915-927. [DOI: 10.1093/heapol/czac036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 03/30/2022] [Accepted: 04/22/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Low enrolment in micro-health insurance (MHI) schemes is a recurring issue affecting the viability of such schemes. Beyond the efforts addressing low subscription and retention in these schemes, little is known on how social representations are related to micro-health insurance schemes enrolment and retention. This scoping review aimed at exploring the role of social representations in shaping enrollment and retention in MHI in sub-Saharan Africa. We reviewed qualitative, quantitative and mixed methods studies conducted between 2004 and 2019 in sub-Saharan Africa. We limited our search to peer-reviewed and grey literature in English and French reporting on social representations of MHI. We defined social representations as conventions, cultural and religious beliefs, local rules and norms, local solidarity practices, political landscape and social cohesion. We applied the framework developed by Arksey and O’Malley and modified by Levac et al. to identify and extract data from relevant studies. We extracted information from a total of 78 studies written in English (60%) and in French (40%) of which 56% were conducted in West Africa. More than half of all studies explored either cultural and religious beliefs (56%) or social conventions (55%) whereas only 37% focused on social cohesion (37%). Only six papers (8%) touched upon all six categories of social representation considered in this study whereas 25% of the papers studied more than three categories. We found that all the studied social representations influence enrollment and retention in MHI schemes. Our findings highlight the paucity of evidence on social representations in relation to MHI schemes. This initial attempt to compile evidence on social representations invites more research on the role those social representations play on the viability of MHI schemes. Our findings call for program design and implementation strategies to consider and adjust to local social representations in order to enhance scheme attractiveness.
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Affiliation(s)
- Albino Kalolo
- Department of Public Health, St. Francis University College of Health and Allied Sciences, P.O. Box 175, Ifakara, Tanzania
| | - Lara Gautier
- Département de Gestion, d’Évaluation et de Politique de Santé, École de Santé Publique de l’Université de Montréal, Montreal, Canada
- Centre de recherche en santé publique, Université de Montréal et CIUSSS du Centre-Sud-de-l’Île-de-Montréal, Montreal, Canada
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, University Hospital and Medical Faculty, University of Heidelberg, Germany
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Hussien M, Azage M, Bayou NB. Continued adherence to community-based health insurance scheme in two districts of northeast Ethiopia: application of accelerated failure time shared frailty models. Int J Equity Health 2022; 21:16. [PMID: 35123498 PMCID: PMC8817608 DOI: 10.1186/s12939-022-01620-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 01/17/2022] [Indexed: 12/02/2022] Open
Abstract
Background The sustainability of a voluntary community-based health insurance scheme depends to a greater extent on its ability to retain members. In low- and middle-income countries, high rate of member dropout has been a great concern for such schemes. Although several studies have investigated the factors influencing dropout decisions, none of these looked into how long and why members adhere to the scheme. The purpose of this study was to determine the factors affecting time to drop out while accounting for the influence of cluster-level variables. Methods A community-based cross-sectional study was conducted among 1232 rural households who have ever been enrolled in two community-based health insurance schemes. Data were collected using an interviewer-administered questionnaire via a mobile data collection platform. The Kaplan–Meier estimates were used to compare the time to drop out among subgroups. To identify predictors of time to drop out, a multivariable analysis was done using the accelerated failure time shared frailty models. The degree of association was assessed using the acceleration factor (δ) and statistical significance was determined at 95% confidence interval. Results Results of the multivariable analysis revealed that marital status of the respondents (δ = 1.610; 95% CI: 1.216, 2.130), household size (δ = 1.168; 95% CI: 1.013, 1.346), presence of chronic illness (δ = 1.424; 95% CI: 1.165, 1.740), hospitalization history (δ = 1.306; 95% CI: 1.118, 1.527), higher perceived quality of care (δ = 1.322; 95% CI: 1.100, 1.587), perceived risk protection (δ = 1.218; 95% CI: 1.027, 1.444), and higher trust in the scheme (δ = 1.731; 95% CI: 1.428, 2.098) were significant predictors of time to drop out. Contrary to the literature, wealth status did not show a significant correlation with the time to drop out. Conclusions The fact that larger households and those with chronic illness remained longer in the scheme is suggestive of adverse selection. It is needed to reconsider the premium level in line with household size to attract small size households. Resolving problems related to the quality of health care can be a cross-cutting area of intervention to retain members by building trust in the scheme and enhancing the risk protection ability of the schemes.
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Hailie MT, Hassen SL, Temesgen MM. Client satisfaction on community based health insurance scheme and associated factors at Boru Meda Hospital, Northeast, Ethiopia: institutional based cross-sectional study. BMC Health Serv Res 2021; 21:1287. [PMID: 34847939 PMCID: PMC8630846 DOI: 10.1186/s12913-021-07223-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 10/25/2021] [Indexed: 11/11/2022] Open
Abstract
Background Community-based health insurance systems are usually voluntary and characterized by community members pooling funds and protecting themselves against the high costs of seeking medical care and treatment for illness. Client satisfaction with health service provision during the implementation of health insurance schemes has often been neglected. This study aimed to determine client satisfaction with the community-based health insurance scheme and associated factors. Methods An institutional-based cross-sectional study design was applied from February 22–March 11 /2019. A total of 420 study participants were included in the study using a systematic random sampling technique. Data were collected using a pretested semi-structured interviewer-administered questionnaire with a patient exit interview. Bivariate and multivariate logistic regression analyses were used to identify factors associated with Community-based Health Insurance of client satisfaction. Statistical significance was decided at a p-value less than 0.05. Result A total of 420 community-based health insurance clients of health service users participated in the study with a 100% response rate. The overall client satisfaction was 80% at 95% Cl (76.1, 83.9), respondents who have perceived that partially or none availability of prescribing drugs were 0.09 times less likely satisfied as compared to full availability of prescribing drugs (AOR =0.09; 95% Cl: (0.04, 0.19)). Besides, study participants waiting time to consult service providers within 30 min were more satisfied than those who were delayed 60 min and above (AOR =3.16; 95% Cl: (1.19, 8.41)). Conclusion Community-based health insurance client satisfaction provided in the present study was 80% indicating low proportion. Full availability of prescribing drugs, clients renewed their community-based health insurance membership, and preference of clients to use the hospital for future health care need were positively associated with client satisfaction while the perception of waiting time before physician consultation negatively affected client’s satisfaction. Therefore, the hospital management members and service providers need to give attention to reduce waiting time preceding consultation, improve drug availability, and sustain the hospital preference by the client.
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Affiliation(s)
- Mulugeta Tasew Hailie
- Amhara Public Health Institute, Planning, Monitoring, and Evaluation Directorate, Dessie, Ethiopia.
| | - Seid Legesse Hassen
- Amhara Public Health Institute, Research and Technology Transfer Directorate, Dessie, Ethiopia
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Hussien M, Azage M. Barriers and Facilitators of Community-Based Health Insurance Policy Renewal in Low- and Middle-Income Countries: A Systematic Review. CLINICOECONOMICS AND OUTCOMES RESEARCH 2021; 13:359-375. [PMID: 34007193 PMCID: PMC8123963 DOI: 10.2147/ceor.s306855] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 03/27/2021] [Indexed: 12/02/2022] Open
Abstract
PURPOSE A growing number of low- and middle-income countries are implementing small-scale community-based health insurance schemes to tackle the burdens posed by direct out-of-pocket payments. Apart from a few successful experiences, such schemes suffer from the problem of persistent low membership which could be attributed to either initial low enrollment or low renewal rate. However, there is a lack of comprehensive information on the factors that influence subscribers' policy renewal decisions. Hence, we systematically synthesize information to answer the review question "what are the barriers and facilitators of community-based health insurance policy renewal in low and middle-income countries?". METHODS We searched PubMed, Scopus, and Hinari electronic databases in line with the PRISMA guidelines. Our search was limited to studies published from January 2005 to February 2020 in the English language. Additional studies and grey literature were searched using Google Scholar. We included quantitative, qualitative, and mixed-method studies in the review. We assessed the methodological quality of the studies using standardized appraisal tools. The findings were synthesized inductively using a thematic analysis approach. RESULTS Our searches retrieved 2386 records among which 27 were included in the review. The thematic synthesis identified six major themes that influence the decision to renew scheme policy: socio-demographic factors; scheme-related awareness and understanding; participation in scheme and other voluntary groupings, need and benefit factors; health-care quality; and scheme operation and policy. CONCLUSION Lower socioeconomic status, poor quality of health care, lack of benefit from the scheme, lack of trust in scheme management, and dissatisfaction with scheme services are important barriers for community-based health insurance policy renewal. Better education, understanding the principles of the scheme, active participation in the scheme, and long-term illness experience of member households facilitate renewal decisions. These are important areas of intervention for governments and other relevant stakeholders to retain members and maintain the sustainability of the schemes. REGISTRATION The review protocol was registered in PROSPERO international prospective register of systematic reviews (ID = CRD42020168971).
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Affiliation(s)
- Mohammed Hussien
- Department of Health Systems Management and Health Economics, School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Muluken Azage
- Department of Environmental Health, School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
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Demissie GD, Atnafu A. Barriers and Facilitators of Community-Based Health Insurance Membership in Rural Amhara Region, Northwest Ethiopia: A Qualitative Study. CLINICOECONOMICS AND OUTCOMES RESEARCH 2021; 13:343-348. [PMID: 33976557 PMCID: PMC8106446 DOI: 10.2147/ceor.s293847] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 04/09/2021] [Indexed: 11/23/2022] Open
Abstract
Background More than 150 million people encounter huge cost of health expenses every year, and most of these treatment seekers face poverty owing to out-of-pocket payments. Community-based health insurance (CBHI) won popularity as a makeshift health financing mechanism for out-of-pocket payments in poor communities. The aim of this study was therefore to explore the facilitators and impediments of enrollment to community-based health insurance in rural parts of the Amhara region, Ethiopia. Methods Focus Group Discussion (FGD) was the main data collection instrument supplemented by key informant interview (KII). The FGD participants were selected using a purposive sampling technique. The participants were therefore selected based on their membership status of CBHI (members or non-members). Six FGDs and four KIIs were conducted in November 2019 in three districts. Before analyzing the data, all FGDs and KIIs were transcribed and transferred into ATLAS.ti version 7.1 software. An inductive thematic analysis approach was done, that is, on the basis of major themes emerged from the data. Results Low level of awareness, perception of high amount of premium, poor perception of quality of services and lack of trust are the barriers to join community-based health insurance. Conclusion There has been low level of awareness and misconception about community-based health insurance. The major reason to decline to join CBHI was low capacity to pay the premium.
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Affiliation(s)
- Getu Debalkie Demissie
- Department of Health Education and Behavioral Sciences, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Asmamaw Atnafu
- Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Khan JAM, Ahmed S, Sultana M, Sarker AR, Chakrovorty S, Rahman MH, Islam Z, Rehnberg C, Niessen LW. The effect of a community-based health insurance on the out-of-pocket payments for utilizing medically trained providers in Bangladesh. Int Health 2020; 12:287-298. [PMID: 31782795 PMCID: PMC7322207 DOI: 10.1093/inthealth/ihz083] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 08/07/2019] [Accepted: 08/09/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND We aimed to estimate the effect of the community-based health insurance (CBHI) scheme on the magnitude of out-of-pocket (OOP) payments for the healthcare of the informal workers and their dependents. The CBHI scheme was piloted through a cooperative of informal workers, which covered seven unions in Chandpur Sadar Upazila, Bangladesh. METHODS A quasi-experimental study was conducted using a case-comparison design. In total 1292 (646 insured and 646 uninsured) households were surveyed. Propensity score matching was done to minimize the observed baseline differences in the characteristics between the insured and uninsured groups. A two-part regression model was applied using both the probability of OOP spending and magnitude of such spending for healthcare in assessing the association with enrolment status in the CBHI scheme while controlling for other covariates. RESULTS The OOP payment was 6.4% (p < 0.001) lower for medically trained provider (MTP) utilization among the insured compared with the uninsured. However, no significant difference was found in the OOP payments for healthcare utilization from all kind of providers, including the non-trained ones. CONCLUSIONS The CBHI scheme could reduce OOP payments while providing better quality healthcare through the increased use of MTPs, which consequently could push the country towards universal health coverage.
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Affiliation(s)
- Jahangir A M Khan
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, United Kingdom
- Universal Health Coverage Programme, Health Systems and Population Studies Division, icddr, b, 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh
- Health Economics and Policy Research Group, Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Tomtebodavägen 18a, 171 65 Solna, Sweden
| | - Sayem Ahmed
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, United Kingdom
- Universal Health Coverage Programme, Health Systems and Population Studies Division, icddr, b, 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh
- Health Economics and Policy Research Group, Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Tomtebodavägen 18a, 171 65 Solna, Sweden
| | - Marufa Sultana
- Universal Health Coverage Programme, Health Systems and Population Studies Division, icddr, b, 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh
- Deakin Health Economics, School of Health and Social Development, Deakin University, 221 Burwood Highway Burwood VIC 3125 Melbourne, Australia
| | - Abdur Razzaque Sarker
- Health Economics and Financing Research, Population Studies Division, Bangladesh Institute of Development Studies (BIDS), E-17, Shahid Shahabuddin Shorok, Agargaon, Dhaka 1207, Bangladesh
| | - Sanchita Chakrovorty
- Universal Health Coverage Programme, Health Systems and Population Studies Division, icddr, b, 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh
- Department of Agricultural Economics, Purdue University, Room # 631, Krannert Building, 403 West State Street, West Lafayette, Indiana 47906, USA
| | - Mohammad Hafizur Rahman
- Health Economics Unit, Ministry of Health and Family Welfare, 14/2 Topkhana Road (3rd–4th Floor), Dhaka 1000, Bangladesh
| | - Ziaul Islam
- Universal Health Coverage Programme, Health Systems and Population Studies Division, icddr, b, 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh
| | - Clas Rehnberg
- Health Economics and Policy Research Group, Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Tomtebodavägen 18a, 171 65 Solna, Sweden
| | - Louis W Niessen
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, United Kingdom
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Ghimire P, Sapkota VP, Poudyal AK. Factors Associated with Enrolment of Households in Nepal's National Health Insurance Program. Int J Health Policy Manag 2019; 8:636-645. [PMID: 31779289 PMCID: PMC6885856 DOI: 10.15171/ijhpm.2019.54] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 06/23/2019] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Nepal has made remarkable efforts towards social health protection over the past several years. In 2016, the Government of Nepal introduced a National Health Insurance Program (NHIP) with an aim to ensure equitable and universal access to healthcare by all Nepalese citizens. Following the first year of operation, the scheme has covered 5 percent of its target population. There are wider concerns regarding the capacity of NHIP to achieve adequate population coverage and remain viable. In this context, this study aimed to identify the factors associated with enrolment of households in the NHIP. METHODS A cross-sectional household survey using face to face interview was carried out in 2 Palikas (municipalities) of Ilam district. 570 households were studied by recruiting equal number of NHIP enrolled and non-enrolled households. We used Pearson's chi-square test and binary logistic regression to identify the factors associated with household's enrolment in NHIP. All statistical analyses were performed using IBM SPSS version 23 software. RESULTS Enrolment of households in NHIP was found to be associated with ethnicity, socio-economic status, past experience of acute illness in family and presence of chronic illness. The households that belonged to higher socio-economic status were about 4 times more likely to enrol in the scheme. It was also observed that households from privileged ethnic groups such as Brahmin, Chhetri, Gurung, and Newar were 1.7 times more likely to enrol in NHIP compared to those from underprivileged ethnic groups such as janajatis (indigenous people) and dalits (the oppressed). The households with illness experience in 3 months preceding the survey were about 1.5 times more likely to enrol in NHIP compared to households that did not have such experience. Similarly, households in which at least one of the members was chronically ill were 1.8 times more likely to enrol compared to households with no chronic illness. CONCLUSION Belonging to the privileged ethnic group, having a higher socio-economic status, experiencing an acute illness and presence of chronically ill member in the family are the factors associated with enrolment of households in NHIP. This study revealed gaps in enrolment between rich-poor households and privileged-underprivileged ethnic groups. Extension of health insurance coverage to poor and marginalized households is therefore needed to increase equity and accelerate the pace towards achieving universal health coverage.
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Affiliation(s)
- Prabesh Ghimire
- Central Department of Pubic Health, Institute of Medicine, Tribhuwan University, Kathmandu, Nepal
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van Hees SGM, O'Fallon T, Hofker M, Dekker M, Polack S, Banks LM, Spaan EJAM. Leaving no one behind? Social inclusion of health insurance in low- and middle-income countries: a systematic review. Int J Equity Health 2019; 18:134. [PMID: 31462303 PMCID: PMC6714392 DOI: 10.1186/s12939-019-1040-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 08/19/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND One way to achieve universal health coverage (UHC) in low- and middle-income countries (LMIC) is the implementation of health insurance schemes. A robust and up to date overview of empirical evidence assessing and substantiating health equity impact of health insurance schemes among specific vulnerable populations in LMICs beyond the more common parameters, such as income level, is lacking. We fill this gap by conducting a systematic review of how social inclusion affects access to equitable health financing arrangements in LMIC. METHODS We searched 11 databases to identify peer-reviewed studies published in English between January 1995 and January 2018 that addressed the enrolment and impact of health insurance in LMIC for the following vulnerable groups: female-headed households, children with special needs, older adults, youth, ethnic minorities, migrants, and those with a disability or chronic illness. We assessed health insurance enrolment patterns of these population groups and its impact on health care utilization, financial protection, health outcomes and quality of care. RESULTS The comprehensive database search resulted in 44 studies, in which chronically ill were mostly reported (67%), followed by older adults (33%). Scarce and inconsistent evidence is available for individuals with disabilities, female-headed households, ethnic minorities and displaced populations, and no studies were yielded reporting on youth or children with special needs. Enrolment rates seemed higher among chronically ill and mixed or insufficient results are observed for the other groups. Most studies reporting on health care utilization found an increase in health care utilization for insured individuals with a disability or chronic illness and older adults. In general, health insurance schemes seemed to prevent catastrophic health expenditures to a certain extent. However, reimbursements rates were very low and vulnerable individuals had increased out of pocket payments. CONCLUSION Despite a sizeable literature published on health insurance, there is a dearth of good quality evidence, especially on equity and the inclusion of specific vulnerable groups in LMIC. Evidence should be strengthened within health care reform to achieve UHC, by redefining and assessing vulnerability as a multidimensional process and the investigation of mechanisms that are more context specific.
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Affiliation(s)
- Suzanne G M van Hees
- Radboud Institute for Health Sciences (RIHS), Department for Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands.
- Department of Work and Health, HAN University of Applied Sciences, Kapittelweg 33, P.O. Box 6960, 6503GL, Nijmegen, Netherlands.
| | - Timothy O'Fallon
- International Centre for Evidence in Disability, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Marleen Dekker
- African Studies Center, Leiden University, Leiden, The Netherlands
| | - Sarah Polack
- International Centre for Evidence in Disability, London School of Hygiene and Tropical Medicine, London, UK
| | - Lena Morgon Banks
- International Centre for Evidence in Disability, London School of Hygiene and Tropical Medicine, London, UK
| | - Ernst J A M Spaan
- Radboud Institute for Health Sciences (RIHS), Department for Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands
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Mahmood SS, Hanifi SMA, Mia MN, Chowdhury AH, Rahman M, Iqbal M, Bhuiya A. Who enrols in voluntary micro health insurance schemes in low-resource settings? Experience from a rural area in Bangladesh. Glob Health Action 2019; 11:1525039. [PMID: 30289056 PMCID: PMC6179054 DOI: 10.1080/16549716.2018.1525039] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Micro health insurance (MHI) has proved to be a potential health-financing tool for many developing countries. Bangladesh also included MHI in its current health-financing strategy which aims to achieve universal health coverage. However, low uptake, low renewal and high dropouts have historically challenged financial sustainability of these schemes. OBJECTIVE This study aims to identify factors influencing people from low-resource settings, particularly those from Bangladesh, to enrol in MHI schemes. METHODS The study analyses the 'Amader Shasthya' MHI scheme operating in Chakaria, a sub-district under Cox's Bazar district, Bangladesh. A household survey was carried out during May-June 2016 among 2,000 households from the scheme coverage area. The Outreville's insurance-demand framework was used to identify enrolment influencing factors. Multivariate logistic regression analysis was carried out to identify significant influencing factors of enrolment. RESULTS Enrolment influencing factors were identified in four dimensions: economic, socio-cultural, demographic and structural. Households with the main income earner having 10+ years of schooling (odds 1.9 [CI 1.2-2.9] compared to illiterate), having financial literacy (odds 1.5 [CI 1.2-1.8] compared to financially illiterate) and being a public/private service holder (odds 1.6 [CI 1.1-2.4] compared to menial labour) were more likely to enrol. Membership in development programmes of NGOs also influenced enrolment decision significantly (odds 1.3 [CI 1.0-1.5]). The presence of chronic illness in household encouraged enrolment (odds 1.5 [CI 1.2-1.8]). Households living closer to health centres were more likely to enrol (odds 2.1 [CI 1.6-2.7]) compared to those living further away. CONCLUSION The findings are expected to have significant implications in terms of designing similar health insurance schemes, particularly in terms of designing demand-driven and context adapted schemes that have greater potential to attract a larger client pool, ensure effective risk pooling and eventually expedite the achievement of universal health coverage in low-resource settings.
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Affiliation(s)
- Shehrin Shaila Mahmood
- a Universal Health Coverage, Health Systems and Population Studies Division , icddr,b , Dhaka , Bangladesh
| | - Syed Manjoor Ahmed Hanifi
- a Universal Health Coverage, Health Systems and Population Studies Division , icddr,b , Dhaka , Bangladesh
| | - Mohammad Nahid Mia
- a Universal Health Coverage, Health Systems and Population Studies Division , icddr,b , Dhaka , Bangladesh
| | - Asiful Haidar Chowdhury
- a Universal Health Coverage, Health Systems and Population Studies Division , icddr,b , Dhaka , Bangladesh
| | - Mahabubur Rahman
- a Universal Health Coverage, Health Systems and Population Studies Division , icddr,b , Dhaka , Bangladesh
| | - Mohammad Iqbal
- a Universal Health Coverage, Health Systems and Population Studies Division , icddr,b , Dhaka , Bangladesh
| | - Abbas Bhuiya
- b Centre for Global Health, Population and Policy , University of Portsmouth , Portsmouth , UK
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Sydavong T, Goto D, Kawata K, Kaneko S, Ichihashi M. Potential demand for voluntary community-based health insurance improvement in rural Lao People's Democratic Republic: A randomized conjoint experiment. PLoS One 2019; 14:e0210355. [PMID: 30620771 PMCID: PMC6324784 DOI: 10.1371/journal.pone.0210355] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Accepted: 12/20/2018] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION In Lao People's Democratic Republic (PDR), community-based health insurance (CBHI) is the only voluntary insurance scheme; it typically targets self-employed people, most of whom reside in rural areas and are dependent on agricultural activities for subsistence. However, until very recently, the enrollment rate has fallen short and failed to reach a large percentage of the target group. To promote the CBHI scheme and increase demand, some supporting components should be considered for inclusion together with the health infrastructure component. OBJECTIVES This paper provides empirical evidence that the benefit package components of hypothetical CBHI schemes have causal effects on enrollment probabilities. Furthermore, we examine the distribution of willingness to pay (WTP) in response to policy changes based on a sample of 5,800 observations. METHODS A randomized conjoint experiment is conducted in rural villages in Savannakhet Province, Lao PDR, to elicit stated preference data. Each respondent ranks three options-two hypothetical alternatives and the CBHI status quo scheme. The levels of seven attributes-insurance coverage for medical consultations, hospitalizations, traffic accidents, pharmaceuticals and transportation; premiums; and prepaid discounts-are randomly and simultaneously assigned to the two alternatives. RESULTS The findings suggest that the average WTP is at least as large as 10.9% of the per capita income of those who live in rural areas, which is higher than the WTP for health insurance averaged across low- and middle-income countries (LMICs) in the literature. The component of round-trip transportation insurance coverage has a significant effect on WTP distribution, particularly increasing the share of the highest bin. CONCLUSION Therefore, the low CBHI scheme enrollment rate in Lao PDR does not necessarily imply low demand among the targeted population, as the finding from the WTP analysis illustrates potential demand for the CBHI scheme. Specifically, if transportation is addressed, enrollment is likely to significantly increase.
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Affiliation(s)
- Thiptaiya Sydavong
- Graduate School for International Development and Cooperation, Hiroshima University, Higashi-hiroshima, Hiroshima, Japan
- Department of Planning and Investment, Savannakhet Provincial Government, Savannakhet, Lao People’s Democratic Republic
| | - Daisaku Goto
- Graduate School for International Development and Cooperation, Hiroshima University, Higashi-hiroshima, Hiroshima, Japan
| | - Keisuke Kawata
- Institute of Social Science, University of Tokyo, Tokyo, Japan
| | - Shinji Kaneko
- Graduate School for International Development and Cooperation, Hiroshima University, Higashi-hiroshima, Hiroshima, Japan
| | - Masaru Ichihashi
- Graduate School for International Development and Cooperation, Hiroshima University, Higashi-hiroshima, Hiroshima, Japan
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Atnafu DD, Tilahun H, Alemu YM. Community-based health insurance and healthcare service utilisation, North-West, Ethiopia: a comparative, cross-sectional study. BMJ Open 2018; 8:e019613. [PMID: 30093509 PMCID: PMC6089309 DOI: 10.1136/bmjopen-2017-019613] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 06/11/2018] [Accepted: 07/03/2018] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVES The objective of this study was to compare differences in healthcare utilisation between community-based health insurance member households and non-member households and to identify factors for community-based health insurance enrolment in South Achefer District. DESIGN Comparative, cross-sectional study. SETTINGS Community-based. PARTICIPANTS A total of 652 selected households (326 insured and 326 uninsured households) participated in the study. METHODS A two-sample t-test (for proportions) and χ2 (for categorical data) were computed. MAIN OUTCOME MEASURE Utilisation of healthcare. RESULTS There was a significant difference in the rate of healthcare utilisation between insured (50.5%) and uninsured (29.3%) households (χ2=27.864, p<0.001). Significant variations of enrolment status in community-based health insurance were observed in the following variables: educational status, family size, occupation, marital status, travel time to the nearest health institution, perceived quality of care, first choice of place for treatment during illness and expected healthcare cost of a recent treatment. CONCLUSIONS Utilisation of health services among insured households with community-based health insurance was higher. Educational status, family size, occupation, marital status, travel time to the nearest health institution, perceived quality of care, first choice of place for treatment during illness and expected healthcare cost of a recent treatment should be emphasised to enhance community health insurance enrolment.
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Affiliation(s)
- Desta Debalkie Atnafu
- School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Hiwot Tilahun
- Curative and Rehabilitative Core Process, Amhara Regional Health Bureau, Bahir Dar, Ethiopia
| | - Yihun Mulugeta Alemu
- School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
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Ko H, Kim H, Yoon CG, Kim CY. Social capital as a key determinant of willingness to join community-based health insurance: a household survey in Nepal. Public Health 2018; 160:52-61. [PMID: 29734013 DOI: 10.1016/j.puhe.2018.03.033] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 11/12/2017] [Accepted: 03/24/2018] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Although community-based health insurance (CBHI) schemes have been considered as an intermediate stage to achieve universal health coverage (UHC) in low-resource settings, there is a knowledge gap on ways to make it better. STUDY DESIGN More than 4000 Nepalese households were randomly selected and surveyed. METHODS Logistic and multivariate multinomial regressions were estimated. RESULTS Overall, 88% of included household heads were willing to join CBHI, 61% were willing to pay annual premium less than 600 Nepalese rupees (US$5.6) per household, and more than a half (53%) responded that the government should subsidize a significant portion of the premium. Results showed that a higher level of social capital was significantly related with an increase in odds of accepting higher premiums, while individuals' health status and age did not have such associations. Individuals with bonding social capital were more likely to be inclined to join CBHI. Persons who said they can lend money for a living expense (bonding capital) did not want the government to subsidize the scheme, while this negative association would be reversed if persons had both bonding and bridging social capitals. CONCLUSION We found significantly positive relationships between social capital and willingness to join and willingness to pay for CBHI in Nepal. Policymakers, aiming to achieve UHC, should be advised that bonding and bridging social capital have differing relationships with willingness to cooperate the external funding sources.
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Affiliation(s)
- Hansoo Ko
- Division of Health Policy and Administration, University of Illinois at Chicago School of Public Health, USA
| | - Hwajun Kim
- Health Care Management and Policy, Seoul National University Graduate School of Public Health, Republic of Korea
| | - Chang-Gyo Yoon
- Health Care Management and Policy, Seoul National University Graduate School of Public Health, Republic of Korea
| | - Chang-Yup Kim
- Health Care Management and Policy, Seoul National University Graduate School of Public Health, Republic of Korea.
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Ahmed S, Sarker AR, Sultana M, Chakrovorty S, Hasan MZ, Mirelman AJ, Khan JAM. Adverse Selection in Community Based Health Insurance among Informal Workers in Bangladesh: An EQ-5D Assessment. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:E242. [PMID: 29385072 PMCID: PMC5858311 DOI: 10.3390/ijerph15020242] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 01/04/2018] [Accepted: 01/29/2018] [Indexed: 11/29/2022]
Abstract
Community-based Health Insurance (CBHI) schemes are recommended for providing financial risk protection to low-income informal workers in Bangladesh. We assessed the problem of adverse selection in a pilot CBHI scheme in this context. In total, 1292 (646 insured and 646 uninsured) respondents were surveyed using the Bengali version of the EuroQuol-5 dimensions (EQ-5D) questionnaire for assessing their health status. The EQ-5D scores were estimated using available regional tariffs. Multiple logistic regression was applied for predicting the association between health status and CBHI scheme enrolment. A higher number of insured reported problems in mobility (7.3%; p = 0.002); self-care (7.1%; p = 0.000) and pain and discomfort (7.7%; p = 0.005) than uninsured. The average EQ-5D score was significantly lower among the insured (0.704) compared to the uninsured (0.749). The regression analysis showed that those who had a problem in mobility (m 1.25-2.17); self-care (OR = 2.29; 95% CI: 1.62-3.25) and pain and discomfort (OR = 1.43; 95% CI: 1.13-1.81) were more likely to join the scheme. Individuals with higher EQ-5D scores (OR = 0.46; 95% CI: 0.31-0.69) were less likely to enroll in the scheme. Given that adverse selection was evident in the pilot CBHI scheme, there should be consideration of this problem when planning scale-up of these kind of schemes.
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Affiliation(s)
- Sayem Ahmed
- Health Economics and Financing Research Group, Health Systems and Population Studies Division, Bangladesh (icddr,b), Dhaka 1212, Bangladesh.
- Health Economics and Policy Research Group, Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, SE-171 77 Stockholm, Sweden.
| | - Abdur Razzaque Sarker
- Health Economics and Financing Research Group, Health Systems and Population Studies Division, Bangladesh (icddr,b), Dhaka 1212, Bangladesh.
- Department of Management Science, University of Strathclyde, Glasgow G1 1XQ, UK.
| | - Marufa Sultana
- Health Economics and Financing Research Group, Health Systems and Population Studies Division, Bangladesh (icddr,b), Dhaka 1212, Bangladesh.
- Faculty of Health, Deakin University, Melbourne, VIC 3125, Australia.
| | - Sanchita Chakrovorty
- Health Economics and Financing Research Group, Health Systems and Population Studies Division, Bangladesh (icddr,b), Dhaka 1212, Bangladesh.
- Department of Agriculture Economics, Purdue University, IN 47907, USA.
| | - Md Zahid Hasan
- Health Economics and Financing Research Group, Health Systems and Population Studies Division, Bangladesh (icddr,b), Dhaka 1212, Bangladesh.
| | | | - Jahangir A M Khan
- Health Economics and Financing Research Group, Health Systems and Population Studies Division, Bangladesh (icddr,b), Dhaka 1212, Bangladesh.
- Health Economics and Policy Research Group, Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, SE-171 77 Stockholm, Sweden.
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK.
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Fadlallah R, El-Jardali F, Hemadi N, Morsi RZ, Abou Samra CA, Ahmad A, Arif K, Hishi L, Honein-AbouHaidar G, Akl EA. Barriers and facilitators to implementation, uptake and sustainability of community-based health insurance schemes in low- and middle-income countries: a systematic review. Int J Equity Health 2018; 17:13. [PMID: 29378585 PMCID: PMC5789675 DOI: 10.1186/s12939-018-0721-4] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 01/08/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Community-based health insurance (CBHI) has evolved as an alternative health financing mechanism to out of pocket payments in low- and middle-income countries (LMICs), particularly in areas where government or employer-based health insurance is minimal. This systematic review aimed to assess the barriers and facilitators to implementation, uptake and sustainability of CHBI schemes in LMICs. METHODS We searched six electronic databases and grey literature. We included both quantitative and qualitative studies written in English language and published after year 1992. Two reviewers worked in duplicate and independently to complete study selection, data abstraction, and assessment of methodological features. We synthesized the findings based on thematic analysis and categorized according to the ecological model into individual, interpersonal, community and systems levels. RESULTS Of 15,510 citations, 51 met the eligibility criteria. Individual factors included awareness and understanding of the concept of CBHI, trust in scheme and scheme managers, perceived service quality, and demographic characteristics, which influenced enrollment and sustainability. Interpersonal factors such as household dynamics, other family members enrolled in the scheme, and social solidarity influenced enrollment and renewal of membership. Community-level factors such as culture and community involvement in scheme development influenced enrollment and sustainability of scheme. Systems-level factors encompassed governance, financial and delivery arrangement. Government involvement, accountability of scheme management, and strong policymaker-implementer relation facilitated implementation and sustainability of scheme. Packages that covered outpatient and inpatient care and those tailored to community needs contributed to increased enrollment. Amount and timing of premium collection was reported to negatively influence enrollment while factors reported as threats to sustainability included facility bankruptcy, operating on small budgets, rising healthcare costs, small risk pool, irregular contributions, and overutilization of services. At the delivery level, accessibility of facilities, facility environment, and health personnel influenced enrollment, service utilization and dropout rates. CONCLUSION There are a multitude of interrelated factors at the individual, interpersonal, community and systems levels that drive the implementation, uptake and sustainability of CBHI schemes. We discuss the implications of the findings at the policy and research level. TRIAL REGISTRATION The review protocol is registered in PROSPERO International prospective register of systematic reviews (ID = CRD42015019812 ).
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Affiliation(s)
- Racha Fadlallah
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
- Center for Systematic Review in Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon
| | - Fadi El-Jardali
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
- Center for Systematic Review in Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON Canada
| | - Nour Hemadi
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
- Center for Systematic Review in Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon
| | - Rami Z. Morsi
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Clara Abou Abou Samra
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Ali Ahmad
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Khurram Arif
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Lama Hishi
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | | | - Elie A. Akl
- Center for Systematic Review in Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON Canada
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
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Umeh CA, Feeley FG. Inequitable Access to Health Care by the Poor in Community-Based Health Insurance Programs: A Review of Studies From Low- and Middle-Income Countries. GLOBAL HEALTH: SCIENCE AND PRACTICE 2017; 5:299-314. [PMID: 28655804 PMCID: PMC5487091 DOI: 10.9745/ghsp-d-16-00286] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 05/09/2017] [Indexed: 11/18/2022]
Abstract
The poor lack equitable access to health care in community-based health insurance schemes. Flexible installment payment plans, subsidized premiums, and elimination of co-pays can increase enrollment and use of health services by the poor. Background: Out-of-pocket payments for health care services lead to decreased use of health services and catastrophic health expenditures. To reduce out-of-pocket payments and improve access to health care services, some countries have introduced community-based health insurance (CBHI) schemes, especially for those in rural communities or who work in the informal sector. However, there has been little focus on equity in access to health care services in CBHI schemes. Methods: We searched PubMed, Web of Science, African Journals OnLine, and Africa-Wide Information for studies published in English between 2000 and August 2014 that examined the effect of socioeconomic status on willingness to join and pay for CBHI, actual enrollment, use of health care services, and drop-out from CBHI. Our search yielded 755 articles. After excluding duplicates and articles that did not meet our inclusion criteria (conducted in low- and middle-income countries and involved analysis based on socioeconomic status), 49 articles remained that were included in this review. Data were extracted by one author, and the second author reviewed the extracted data. Disagreements were mutually resolved between the 2 authors. The findings of the studies were analyzed to identify their similarities and differences and to identify any methodological differences that could account for contradictory findings. Results: Generally, the rich were more willing to pay for CBHI than the poor and actual enrollment in CBHI was directly associated with socioeconomic status. Enrollment in CBHI was price-elastic—as premiums decreased, enrollment increased. There were mixed results on the effect of socioeconomic status on use of health care services among those enrolled in CBHI. We found a high drop-out rate from CBHI schemes that was not related to socioeconomic status, although the most common reason for dropping out of CBHI was lack of money to pay the premium. Conclusion: The effectiveness of CBHI schemes in achieving universal health coverage in low- and middle-income countries is questionable. A flexible payment plan where the poor can pay in installments, subsidized premiums for the poor, and removal of co-pays are measures that can increase enrollment and use of CBHI by the poor.
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Affiliation(s)
- Chukwuemeka A Umeh
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA.
| | - Frank G Feeley
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
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Greef TDGD, Monareng LV, Roos JH. A quantitative study on factors influencing enrolment of dairy farmers in a community health insurance scheme. BMC Health Serv Res 2016; 16:686. [PMID: 27938402 PMCID: PMC5148826 DOI: 10.1186/s12913-016-1925-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 11/24/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Access to affordable and effective health care is a challenge in low- and middle- income countries. Out-of-pocket expenditure for health care is a major cause of impoverishment. One way to facilitate access and overcome catastrophic expenditure is through a health insurance mechanism, whereby risks are shared and financial inputs pooled by way of contributions. This study examined factors that influenced the enrolment status of dairy farmers in Western Kenya to a community health insurance (CHI) scheme. METHODS Quantitative, cross-sectional research was used to describe factors influencing the enrolment in the CHI scheme. Quota and convenience sampling was used, recruiting a sample of 135 farmers who supply milk to a dairy cooperation. Data were collected using a structured interview schedule and analysed using Stata SE, Data Analysis and Statistical Software, Version 12. RESULTS Factors influencing non-enrolment were identified as affordability (40%; n = 47), unfamiliarity with the management of the scheme (37%; n = 44) and a lack of understanding about the scheme (41%; n = 48). An exploratory factor analysis was used to reduce the variables to two factors: information provision and understanding community health insurance (CHI). Logistic regression identified factors associated with enrolment in the Tanykina Community Healthcare Plan (TCHP). Supplies of less than six litres of milk per day (OR: 0.22; 95% CI: 0.06-0.84) and information provision (OR: 8.77; 95% CI: 2.25-34.16) were significantly associated with enrolment in the TCHP. Nearly 30% (29.6%; n = 40) of the respondents remarked that TCHP is expensive and 17% (n = 23) asked for more education on CHI and TCHP in an open-ended question. CONCLUSION Recommendations related to marketing strategies, financial approach, information provision and further research were outlined to be made to the management of the TCHP as well as to those involved in public health.
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Affiliation(s)
- Tineke de Groot-de Greef
- Department of Health Studies, University of South Africa, P.O. Box 392, Unisa 0003, Pretoria, South Africa.,Christian University of Applied Sciences, Ede, Netherlands
| | - Lydia V Monareng
- Department of Health Studies, University of South Africa, P.O. Box 392, Unisa 0003, Pretoria, South Africa.
| | - Janetta H Roos
- Department of Health Studies, University of South Africa, P.O. Box 392, Unisa 0003, Pretoria, South Africa
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Duku SKO, Asenso-Boadi F, Nketiah-Amponsah E, Arhinful DK. Utilization of healthcare services and renewal of health insurance membership: evidence of adverse selection in Ghana. HEALTH ECONOMICS REVIEW 2016; 6:43. [PMID: 27624462 PMCID: PMC5021654 DOI: 10.1186/s13561-016-0122-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 09/08/2016] [Indexed: 06/06/2023]
Abstract
BACKGROUND Utilization of healthcare in Ghana's novel National Health Insurance Scheme (NHIS) has been increasing since inception with associated high claims bill which threatens the scheme's financial sustainability. This paper investigates the presence of adverse selection by assessing the effect of healthcare utilization and frequency of use on NHIS renewal. METHOD Routine enrolment and utilization data from 2008 to 2013 in two regions in Ghana was analyzed. Pearson Chi-square test was performed to test if the proportion of insured who utilize healthcare in a particular year and renew membership the following year is significantly different from those who utilize healthcare and drop-out. Logistic regressions were estimated to examine the relationship between healthcare utilization and frequency of use in previous year and NHIS renewal in current year. RESULTS We found evidence suggestive of the presence of adverse selection in the NHIS. Majority of insured who utilized healthcare renewed their membership whiles most of those who did not utilize healthcare dropped out. The likelihood of renewal was significantly higher for those who utilize healthcare than those who did not and also higher for those who make more health facility visits. CONCLUSION The NHIS claims bill is high because high risk individuals who self-select into the scheme makes more health facility visits and creates financial sustainability problems. Policy makers should adopt pragmatic ways of enforcing mandatory enrolment so that low risk individuals remain enrolled; and sustainable ways of increasing revenue whiles ensuring that the societal objectives of the scheme are not compromised.
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Affiliation(s)
- Stephen Kwasi Opoku Duku
- Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
- Faculty of Economics and Business Administration, Free University of Amsterdam, De Boelelaan 1105, 1081HV Amsterdam, The Netherlands
- Ghana Health Service, Accra, Ghana
| | | | | | - Daniel Kojo Arhinful
- Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
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Schoeps A, Lietz H, Sié A, Savadogo G, De Allegri M, Müller O, Sauerborn R, Becher H, Souares A. Health insurance and child mortality in rural Burkina Faso. Glob Health Action 2015; 8:27327. [PMID: 25925193 PMCID: PMC4414785 DOI: 10.3402/gha.v8.27327] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Revised: 03/28/2015] [Accepted: 03/29/2015] [Indexed: 11/17/2022] Open
Abstract
Background Micro health insurance schemes have been implemented across developing countries as a means of facilitating access to modern medical care, with the ultimate aim of improving health. This effect, however, has not been explored sufficiently. Objective We investigated the effect of enrolment into community-based health insurance on mortality in children under 5 years of age in a health and demographic surveillance system in Nouna, Burkina Faso. Design We analysed the effect of health insurance enrolment on child mortality with a Cox regression model. We adjusted for variables that we found to be related to the enrolment in health insurance in a preceding analysis. Results Based on the analysis of 33,500 children, the risk of mortality was 46% lower in children enrolled in health insurance as compared to the non-enrolled children (HR=0.54, 95% CI 0.43–0.68) after adjustment for possible confounders. We identified socioeconomic status, father's education, distance to the health facility, year of birth, and insurance status of the mother at time of birth as the major determinants of health insurance enrolment. Conclusions The strong effect of health insurance enrolment on child mortality may be explained by increased utilisation of health services by enrolled children; however, other non-observed factors cannot be excluded. Because malaria is a main cause of death in the study area, early consultation of health services in case of infection could prevent many deaths. Concerning the magnitude of the effect, implementation of health insurance could be a major driving factor of reduction in child mortality in the developing world.
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Affiliation(s)
- Anja Schoeps
- Institute of Public Health, University of Heidelberg, Heidelberg, Germany;
| | - Henrike Lietz
- Institute of Public Health, University of Heidelberg, Heidelberg, Germany
| | - Ali Sié
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso
| | | | - Manuela De Allegri
- Institute of Public Health, University of Heidelberg, Heidelberg, Germany
| | - Olaf Müller
- Institute of Public Health, University of Heidelberg, Heidelberg, Germany
| | - Rainer Sauerborn
- Institute of Public Health, University of Heidelberg, Heidelberg, Germany
| | - Heiko Becher
- Institute of Public Health, University of Heidelberg, Heidelberg, Germany.,Institute for Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Aurélia Souares
- Institute of Public Health, University of Heidelberg, Heidelberg, Germany
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Macha J, Kuwawenaruwa A, Makawia S, Mtei G, Borghi J. Determinants of community health fund membership in Tanzania: a mixed methods analysis. BMC Health Serv Res 2014; 14:538. [PMID: 25411021 PMCID: PMC4246628 DOI: 10.1186/s12913-014-0538-9] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Accepted: 10/20/2014] [Indexed: 11/29/2022] Open
Abstract
Background In many developing countries, initiatives are underway to strengthen voluntary community based health insurance as a means of expanding access to affordable care among the informal sector. However, increasing coverage with voluntary health insurance in low income settings can prove challenging. There are limited studies on determinants of enrolling in these schemes using mixed methods. This study aims to shed light on the characteristics of those joining a community health fund, a type of community based health insurance, in Tanzania and the reasons for their membership and subsequent drop out using mixed methods. Methods A cross sectional survey of households in four rural districts was conducted in 2008, covering a total of 1,225 (524 members of CHF and 701 non-insured) households and 7,959 individuals. In addition, 12 focus group discussions were carried out with CHF members, non-scheme members and members of health facility governing committees in two rural districts. Logistic regression was used to assess the determinants of CHF membership while thematic analysis was done to analyse qualitative data. Results The quantitative analysis revealed that the three middle income quintiles were more likely to enrol in the CHF than the poorest and the richest. CHF member households were more likely to be large, and headed by a male than uninsured households from the same areas. The qualitative data supported the finding that the poor rather than the poorest were more likely to join as were large families and of greater risk of illness, with disabilities or persons with chronic diseases. Households with elderly members or children under-five years were also more likely to enrol. Poor understanding of risk pooling deterred people from joining the scheme and was the main reason for not renewing membership. On the supply side, poor quality of public care services, the limited benefit package and a lack of provider choice were the main factors for low enrolment. Conclusions Determinants of CHF membership are diverse and improving the quality of health services and expanding the benefit package should be prioritised to expand voluntary health insurance coverage.
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Affiliation(s)
- Jane Macha
- Ifakara Health Institute, P.O BOX 78373, Plot 463, Kiko Ave., Mikocheni, Dar es Salaam, Tanzania.
| | - August Kuwawenaruwa
- Ifakara Health Institute, P.O BOX 78373, Plot 463, Kiko Ave., Mikocheni, Dar es Salaam, Tanzania.
| | - Suzan Makawia
- Ifakara Health Institute, P.O BOX 78373, Plot 463, Kiko Ave., Mikocheni, Dar es Salaam, Tanzania.
| | - Gemini Mtei
- Ifakara Health Institute, P.O BOX 78373, Plot 463, Kiko Ave., Mikocheni, Dar es Salaam, Tanzania.
| | - Josephine Borghi
- Ifakara Health Institute, P.O BOX 78373, Plot 463, Kiko Ave., Mikocheni, Dar es Salaam, Tanzania. .,London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.
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Enrolment of older people in social health protection programs in West Africa – Does social exclusion play a part? Soc Sci Med 2014; 119:36-44. [DOI: 10.1016/j.socscimed.2014.08.011] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Revised: 06/26/2014] [Accepted: 08/13/2014] [Indexed: 11/23/2022]
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Mladovsky P, Ndiaye P, Ndiaye A, Criel B. The impact of stakeholder values and power relations on community-based health insurance coverage: qualitative evidence from three Senegalese case studies. Health Policy Plan 2014; 30:768-81. [PMID: 24986883 DOI: 10.1093/heapol/czu054] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2014] [Indexed: 11/14/2022] Open
Abstract
Continued low rates of enrolment in community-based health insurance (CBHI) suggest that strategies proposed for scaling up are unsuccessfully implemented or inadequately address underlying limitations of CBHI. One reason may be a lack of incorporation of social and political context into CBHI policy. In this study, the hypothesis is proposed that values and power relations inherent in social networks of CBHI stakeholders can explain levels of CBHI coverage. To test this, three case studies constituting Senegalese CBHI schemes were studied. Transcripts of interviews with 64 CBHI stakeholders were analysed using inductive coding. The five most important themes pertaining to social values and power relations were: voluntarism, trust, solidarity, political engagement and social movements. Analysis of these themes raises a number of policy and implementation challenges for expanding CBHI coverage. First is the need to subsidize salaries for CBHI scheme staff. Second is the need to develop more sustainable internal and external governance structures through CBHI federations. Third is ensuring that CBHI resonates with local values concerning four dimensions of solidarity (health risk, vertical equity, scale and source). Government subsidies is one of the several potential strategies to achieve this. Fourth is the need for increased transparency in national policy. Fifth is the need for CBHI scheme leaders to increase their negotiating power vis-à-vis health service providers who control the resources needed for expanding CBHI coverage, through federations and a social movement dynamic. Systematically addressing all these challenges would represent a fundamental reform of the current CBHI model promoted in Senegal and in Africa more widely; this raises issues of feasibility in practice. From a theoretical perspective, the results suggest that studying values and power relations among stakeholders in multiple case studies is a useful complement to traditional health systems analysis.
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Affiliation(s)
- Philipa Mladovsky
- LSE Health, London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK, Institute of Tropical Medicine, Nationalestraat 155, B-2000, Antwerp, Belgium and Le Centre de Recherches sur les Politiques sociales (CREPOS), S/C West African Research Center, Rue E X Léon Gontran Damas, Fann Résidance, BP: 25 233, Fann, Dakar, Senegal
| | - Pascal Ndiaye
- LSE Health, London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK, Institute of Tropical Medicine, Nationalestraat 155, B-2000, Antwerp, Belgium and Le Centre de Recherches sur les Politiques sociales (CREPOS), S/C West African Research Center, Rue E X Léon Gontran Damas, Fann Résidance, BP: 25 233, Fann, Dakar, Senegal
| | - Alfred Ndiaye
- LSE Health, London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK, Institute of Tropical Medicine, Nationalestraat 155, B-2000, Antwerp, Belgium and Le Centre de Recherches sur les Politiques sociales (CREPOS), S/C West African Research Center, Rue E X Léon Gontran Damas, Fann Résidance, BP: 25 233, Fann, Dakar, Senegal
| | - Bart Criel
- LSE Health, London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK, Institute of Tropical Medicine, Nationalestraat 155, B-2000, Antwerp, Belgium and Le Centre de Recherches sur les Politiques sociales (CREPOS), S/C West African Research Center, Rue E X Léon Gontran Damas, Fann Résidance, BP: 25 233, Fann, Dakar, Senegal
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Odeyemi IAO. Community-based health insurance programmes and the National Health Insurance Scheme of Nigeria: challenges to uptake and integration. Int J Equity Health 2014; 13:20. [PMID: 24559409 PMCID: PMC3941795 DOI: 10.1186/1475-9276-13-20] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Accepted: 02/07/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Nigeria has included a regulated community-based health insurance (CBHI) model within its National Health Insurance Scheme (NHIS). Uptake to date has been disappointing, however. The aim of this study is to review the present status of CBHI in SSA in general to highlight the issues that affect its successful integration within the NHIS of Nigeria and more widely in developing countries. METHODS A literature survey using PubMed and EconLit was carried out to identify and review studies that report factors affecting implementation of CBHI in SSA with a focus on Nigeria. RESULTS CBHI schemes with a variety of designs have been introduced across SSA but with generally disappointing results so far. Two exceptions are Ghana and Rwanda, both of which have introduced schemes with effective government control and support coupled with intensive implementation programmes. Poor support for CBHI is repeatedly linked elsewhere with failure to engage and account for the 'real world' needs of beneficiaries, lack of clear legislative and regulatory frameworks, inadequate financial support, and unrealistic enrolment requirements. Nigeria's CBHI-type schemes for the informal sectors of its NHIS have been set up under an appropriate legislative framework, but work is needed to eliminate regressive financing, to involve scheme members in the setting up and management of programmes, to inform and educate more effectively, to eliminate lack of confidence in the schemes, and to address inequity in provision. Targeted subsidies should also be considered. CONCLUSIONS Disappointing uptake of CBHI-type NHIS elements in Nigeria can be addressed through closer integration of informal and formal programmes under the NHIS umbrella, with increasing involvement of beneficiaries in scheme design and management, improved communication and education, and targeted financial assistance.
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Affiliation(s)
- Isaac A O Odeyemi
- Health Economics & Outcomes Research, Astellas Pharma Europe Ltd, 2000 Hillswood Drive, Chertsey KT16 0RS, UK.
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Ridde V, Belaid L, Mallé Samb O, Faye A. Les modalités de collecte du financement de la santé au Burkina Faso de 1980 à 2012. SANTÉ PUBLIQUE 2014. [DOI: 10.3917/spub.145.0715] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Marwa B, Njau B, Kessy J, Mushi D. Feasibility of introducing compulsory community health fund in low resource countries: views from the communities in Liwale district of Tanzania. BMC Health Serv Res 2013; 13:298. [PMID: 23924271 PMCID: PMC3750583 DOI: 10.1186/1472-6963-13-298] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 08/02/2013] [Indexed: 11/28/2022] Open
Abstract
Background In 1995, Tanzania introduced the voluntary Community Health Fund (CHF) with the aim of ensuring universal health coverage by increasing financial investment in the health sector. The uptake of the CHF is low, with an enrolment of only 6% compared to the national target of 75%. Mandatory models of community health financing have been suggested to increase enrolment and financial capacity. This study explores communities’ views on the introduction of a mandatory model, the Compulsory Community Health Fund (CCHF) in the Liwale district of Tanzania. Methods A cross-sectional study which involved 387 participants in a structured face to face survey and 33 in qualitative interviews (26 in focus group discussions (FGD) and 7 in in-depth interviews (IDI). Structured survey data were analyzed using SPSS version 16 to produce descriptive statistics. Qualitative data were analyzed using content analysis. Results 387 people completed a survey (58% males), mean age 38 years. Most participants (347, 89.7%) were poor subsistence farmers and 229 (59.2%) had never subscribed to any form of health insurance scheme. The idea of a CCHF was accepted by 221 (57%) survey participants. Reasons for accepting the CCHF included: reduced out of pocket expenditure, improved quality of health care and the removal of stigma for those who receive waivers at health care delivery points. The major reason for not accepting the CCHF was the poor quality of health care services currently offered. Participants suggested that enrolment to the CCHF be done after harvesting when the population were more likely to have disposable income, and that the quality care of care and benefits package be improved. Conclusions The CHF is acceptable to the most of study participants and feasible in rural Tanzania as an alternative mechanism to finance health care for the rural poor. Community members are willing to join the scheme provided they are well informed, involved in the design and implementation, and assured quality health care. Strong political will and a supportive environment are key ingredients for the success of the CCHF.
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