Community-Based Health Insurance Increased Health Care Utilization and Reduced Mortality in Children Under-5, Around Bwindi Community Hospital, Uganda Between 2015 and 2017

Experiences of membership in munno mubulwadde (your friend indeed) - a novel community-based health insurance scheme in Luwero district in rural central Uganda

BACKGROUND

Community-Based Health Insurance (CBHI) schemes are recognized as an important health financing pathway to achieving universal health coverage (UHC). Although previous studies have documented CBHIs in low-income countries, the majority of these have been provider-based. Non-provider based schemes have received comparatively less empirical attention. We sought to describe a novel non-provider based CBHI munno mubulwadde (your friend indeed) comprising informal sector members in rural central Uganda to understand the structure of the scheme, the experiences of scheme members in terms of the perceived benefits and barriers to retention in the scheme.

METHODS

We report qualitative findings from a larger mixed-methods study. We conducted in-depth interviews with insured members (n = 18) and scheme administrators (n = 12). Four focus groups were conducted with insured members (38 participants). Data were inductively analyzed by thematic approach.

RESULTS

Munno mubulwadde is a union of ten CBHI schemes coordinated by one administrative structure. Members were predominantly low-income rural informal sector households who pay annual premiums ranging from $17 and $50 annually and received medical care at 13 scheme-contracted private health facilities in Luwero District in Central Uganda. Insured members reported that scheme membership protected them from catastrophic health expenditure during episodes of sickness among household members, and especially so among households with children under-five who were reported to fall sick frequently, the scheme enabled members to receive perceived better quality health care at private providers in the study district relative to the nearest public facilities. The identified barriers to retention in the scheme include inconvenient dates for premium payment that are misaligned with harvest periods for cash crops (e.g. maize corn) on which members depended for their agrarian livelihoods, long distances to insurance-contracted private providers, falling prices of cash crops which diminished real incomes and affordability of insurance premiums in successive years after initial enrolment.

CONCLUSION

Munno mubulwadde was perceived by as a valuable financial cushion during episodes of illness by rural informal sector households. Policy interventions for promoting price stability of cash crops in central Uganda could enhance retention of members in this non-provider CBHI which is worthy of further research as an additional funding pathway for realizing UHC in Uganda and other low-income settings.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Assessing the Determinants of Compliance with Contribution Payments to the National Health Insurance Scheme among Informal Workers in Indonesia

This study aimed to investigate the determinants of compliance with contribution payments to the National Health Insurance (NHI) scheme among informal workers in Bogor Regency, West Java Province, Indonesia. Surveys of 418 informal workers in Bogor Regency from April to May 2023 were conducted. Multivariate logistic regression analyses were performed to assess the factors associated with informal workers' compliance with NHI contribution payments. The results revealed that being female, having lower secondary education or below, perceiving good health of family members, having negative attitudes toward and poor knowledge of the NHI, experiencing financial difficulties, preferring to visit health facilities other than public ones, and utilizing fewer outpatient services were significantly associated with the noncompliance of informal workers with NHI contribution payments. It was concluded that economic factors alone cannot contribute to informal workers' payment compliance and that motivational factors (knowledge, attitudes toward the insurance system, and self-related health status) also encourage them to comply with contribution payments. Improving people's knowledge, especially on the risk-sharing concept of the NHI, should be done through extensive health insurance education using methods that are appropriate for the population's characteristics.

Effectiveness and impact of community-based health insurance on health service utilization in northwest Ethiopia: a quasi-experimental evaluation

Background

Addressing the health challenges of lower socioeconomic groups in Ethiopia is still a huge problem. In that regard, the government piloted the community-based health insurance (CBHI) in 2011 in a few districts and subsequently scaled up. However, the effectiveness of the program on the utilization of health services and its impact was not well explored. Thus, we aimed to evaluate the effectiveness of CBHI toward health services' utilization and its impact in northwest Ethiopia.

Methods

A quasi-experimental matched comparison group evaluation design with sequential explanatory mixed methods was employed. To evaluate the CBHI program, the effectiveness and impact dimensions from the Organization for Economic Cooperation and Development framework were used. A multistage sampling technique was used to select a total of 332 households enrolled in the CBHI program; 341 comparison households who did not enroll in the program were also randomly selected. A structured interviewer-administrated questionnaire was used to evaluate the effectiveness and impact of CBHI on health service utilization. The Propensity score matching model was employed for the estimation of the effect of the CBHI program on health service utilization. Challenges for program achievement toward health service utilization were explained through qualitative data and these were then analyzed thematically.

Results

The evaluation showed 1.3 visits per capita per year of health service utilization among CBHI members. Households enrolled in CBHI increased health service utilization by 6.9 percentage points (ATT = 0.069; 95% CI: 0.034, 0.114). There was an improvement in health service utilization after the introduction of CBHI, however, there are challenges: (i) shortage of human resources, (ii) out-of-stock of drugs and medical supplies, and (iii) long waiting times for service and reimbursement claims. These issues limit the success of the program toward health service utilization.

Conclusion

The CBHI program contributed to health service utilization improvement among CBHI members. However, the utilization rate of health services among CBHI members is still less than the target stated for the program and also the WHO recommendation. Therefore, the findings of this evaluation can be used by program implementers, policy makers, and other stakeholders to overcome the identified challenges and to increase the success of the program.

Establishing community mental health clinics increased the number of patients receiving care in rural Western Uganda

Background

Mental, neurological, and substance-use disorders cause medium to long term disability in all countries. They are amenable to treatment but often treatment is only available in hospitals, as few staff feel competent to give treatment. The WHO developed the "Mental Health GAP" (mhGAP) course to train non-specialist clinical staff in basic diagnosis and treatment. At Bwindi Community Hospital, in south-west Uganda, mental health care was initially only provided at the hospital. It was extended outside the hospital in two implementation phases, initially by establishing 17 clinics in the community, run by qualified mental health staff from the hospital. In the second implementation phase staff in 12 health centers were trained using mhGAP and ran their own clinics under supervision.

Methods

Using routine data the defined data variables for the individuals attending the clinics was extracted.

Results

A total of 2,617 people attended a mental health care clinic in the study period between January 2016 and March 2020. Of these 1,051 people attended more than once. The number of patients attending clinics increased from 288 during the baseline to 693 in the first implementation phase then to 839 patients in the second implementation phase. After mhGAP training, about 30% of patients were seen locally by mhGAP trained healthcare personnel. The average number of mental health patients seen each month increased from 12 to 65 over the time of the study. The number of patients living >20 km from the hospital increased from 69 in the baseline to 693 in the second implementation phase. The proportion of patients seen at the hospital clinic dropped from 100% to 27%.

Conclusions

Providing mental health care in the community at a distance from the hospital substantially increased the number of people accessing mental health care. Training health center-based staff in mhGAP contributed to this. Not all patients could appropriately be managed by non-specialist clinical staff, who only had the five-day training in mhGAP. Supplies of basic medicines were not always adequate, which probably contributed to patients being lost to follow-up. About 50% of patients only attend the clinic once. Further work is required to understand the reasons.

Barriers and facilitators to the provision of maternal health services at community health centers during the COVID-19 pandemic: Experiences of midwives in Indonesia

OBJECTIVE

To explore the experiences of midwives in Indonesia on the provision of maternal health services during the COVID-19 pandemic.

DESIGN AND METHODS

A qualitative descriptive study using focus group discussions was undertaken. A conventional content analysis was used to analyze the data. Coding categories were generated from the transcripts.

SETTING AND PARTICIPANTS

Twenty-two midwives from five community health centers of three regions in the Province of Jambi, Indonesia were included.

FINDINGS

The interviewees shared similar barriers and facilitators in delivering the services, including the unavailability of adequate protective equipment, the limitation of the number of services, and dealing with the new public health measures related to the COVID-19. Overall, midwives demonstrated a continued commitment to provide maternal health services during the pandemic.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Significant changes in service delivery have been made to comply with pandemic related restrictions. Despite the unprecedentedly difficult working environment, the midwives continue to provide adequate services to the community by implementing a strict health protocol. Findings from this study contribute to a better understanding of how the quality of the services changed, as well as how new challenges can be addressed and positive changes can be reinforced.

Effect of community-based health insurance on catastrophic health expenditure among chronic disease patients in Asella referral hospital, Southeast Ethiopia: a comparative cross-sectional study

BACKGROUND

Chronic disease-related catastrophic health spending is frequent in Ethiopia affecting several households, particularly the poorest ones. A community-based health insurance (CBHI) scheme has been in place in Ethiopia since 2011. The scheme aims to provide financial protection against health expenditure but there is little evidence of how well it protects chronic patients financially.

OBJECTIVE

The objective of the study was to evaluate the effect of community-based health insurance in reducing the incidence of catastrophic health expenditure among patients attending chronic disease follow-up departments in Asella referral hospital, Southeast Ethiopia.

METHOD

A health facility-based comparative cross-sectional study was conducted in Asella referral hospital from March 2022 to May 2022. Systematic random sampling was used to select 325 chronic patients. Data were collected using an open data kit (ODK) collect app and then imported to STATA version 16 for analysis. Propensity score matching was used to evaluate the effect of community-based health insurance on catastrophic health expenditure.

RESULT

The study enrolled a total of 325 chronic patients (157 insurance members and 168 nonmembers). More than 30% of the study participants incurred health spending that could be catastrophic based on the 15% nonfood threshold. Catastrophic health expenditure was found in 31% of insured and 47% of uninsured participants. Overshoot and mean positive overshoot were 10% and 33% for insured members, respectively and the corresponding figures were 18% and 39% for nonmembers. Community-based health insurance contributes to a 19% ((ATT = -0.19, t = -2.97)) reduction in the incidence of catastrophic health expenditure among chronic patients. This result is found to be consistent for alternative measurements of the outcome variable and the use of alternative matching algorithms.

CONCLUSION

Chronic patients, particularly those in uninsured households, had a high incidence and intensity of catastrophic health expenditure. Hence, it is relevant to expand community-based health insurance to provide financial protection for people suffering from chronic conditions.

The impact of community-based health insurance on health service utilization and financial risk protection in Ethiopia

BACKGROUND

Evidence on the effectiveness of community-based health insurance (CBHI) in low-income countries is inconclusive. This study assessed the impact of CBHI on health service utilization and financial risk protection in Ethiopia.

METHODS

We conducted a comparative cross-sectional study nested within a larger national household survey in 2020. Data was collected from three groups of households-CBHI member households (n = 1586), non-member households from CBHI implementing woredas (n = 1863), and non-member households from non-CBHI implementing woredas (n = 789). Indicators of health service utilization, out-of-pocket health spending, catastrophic health expenditure, and impoverishment due to health spending among CBHI members were compared with non-members from CBHI implementing woredas and households from non-CBHI implementing woredas. Propensity score matching (PSM) was used to account for possible selection bias.

RESULTS

The annual number of OPD visits per capita among CBHI member households was 2.09, compared to 1.53 among non-member households from CBHI woredas and 1.75 among households from non-CBHI woredas. PSM estimates indicated that CBHI members had 0.36 (95% CI: 0.25, 0.44) and 0.17 (95% CI: -0.04, 0.19) more outpatient department (OPD) visits per capita per year than their matched non-member households from CBHI-implementing and non-CBHI implementing woredas, respectively. CBHI membership resulted in a 28-43% reduction in annual OOP payments as compared to non-member households. CBHI member households were significantly less likely to incur catastrophic health expenditures (measured as annual OOP payments of more than 10% of the household's total expenditure) compared to non-members (p < 0.01).

CONCLUSION

CBHI membership increases health service utilization and financial protection. CBHI proves to be an important strategy for promoting universal health coverage. Implementing CBHI in all woredas and increasing membership among households in woredas that are already implementing CBHI will further expand its benefits.

Predicting perinatal mortality based on maternal health status and health insurance service using homogeneous ensemble machine learning methods

BACKGROUND

Perinatal mortality in Ethiopia is the highest in Africa, with 68 per 1000 pregnancies intrapartum deaths. It is mainly associated with home delivery, which contributes to more than 75% of perinatal deaths. Financial constraints significantly impact timely access to maternal health care. Financial incentives, such as health insurance, may address the demand- and supply-side factors. This study, hence, aims to predict perinatal mortality based on maternal health status and health insurance service using homogeneous ensemble machine learning methods.

METHODS

The data was collected from the Ethiopian demographic health survey from 2011 to 2019 G.C. The data were pre-processed to get quality data that are suitable for the homogenous ensemble machine-learning algorithms to develop a model that predicts perinatal mortality. We have applied filter (chi-square and mutual information) and wrapper (sequential forward and sequential backward) feature selection methods. After selecting all the relevant features, we developed a predictive model using cat boost, random forest, and gradient boosting algorithms and evaluated the model using both objective (accuracy, precision, recall, F1_score, ROC) and subjective (domain expert) based evaluation techniques.

RESULTS

Perinatal mortality prediction models were developed using random forest, gradient boosting, and cat boost algorithms with the overall accuracy of 89.95%, 90.24%, and 82%, respectively. Risk factors of perinatal mortality were identified using feature importance analysis and relevant rules were extracted using the best performing model.

CONCLUSIONS

A prediction model that was developed using gradient boosting algorithms was selected for further use in the risk factor analysis, generating relevant rules, development of artifacts, and model deployment because it has registered better performance with 90.24% accuracy. The most determinant risk factors of perinatal mortality were identified using feature importance and some of them are community-based health insurance, mother's educational level, region and place of residence, age, wealth status, birth interval, preterm, smoking cigarette, anemia level, hemoglobin level, and marital status.

The effects of Ghana's capitation policy on hospital Under-5 mortality in the Ashanti Region

Objective

The study estimated the capitation policy's effect on the under-5 mortality (U5MR) rate in hospitals in Ashanti Region.

Design

We used an interrupted time series design to estimate the impact from secondary data obtained from the DHIMS-2 database. Monthly under-5 deaths and the number of live births per month were extracted and entered into Stata 15.0 for analyses. The U5MR was calculated by dividing the number of live deaths by the number of live births for each of the 60 months of the study.

Setting

Health facilities of the Ashanti Region with Data in the DHIMS 2.

Intervention

the level and trend of U5MR for 31 months during the Capitation Policy implementation (January 2015 to July 2017) were compared with the level and trend 29 months after the withdrawal of the capitation policy (August 2017 to December 2019).

Outcome measures

changes in trend or level of U5MR after the withdrawal of capitation.

Main Results

During the capitation policy, monthly U5MR averaged 10.71 +/-2.71 per 1000 live births. It declined to 0.03 deaths per 1000 live births (p=0.65). After the policy withdrawal, the immediate (increase of 0.01 per 1000live births) and the trend (decline of 0.13 deaths per 1000 live births per month) were still not statistically significant.

Conclusion

We conclude that the capitation policy did not appear to have influenced under-5 mortality in the Ashanti Region. The design of future healthcare payment models should target quality improvement to reduce under-5 mortalities.

Funding

None declared.

Factors Associated With Community Based Health Insurance Healthcare Service Utilization of Households in South Gondar Zone, Amhara, Ethiopia. A Community-Based Cross-Sectional Study

In Ethiopia, community-based health insurance was implemented to promote equitable access to sustainable quality health care and increase financial protection. The purpose of this study was to identify factors associated with community-based Health Insurance, Health Care Service Utilization of Households in the South Gondar Zone. A community-based cross-sectional study was employed. Data were collected among 619 randomly selected households in the south Gondar zone. Chi-square and binary logistic regression analyses with a P-Value of less than .05 were used to determine the association. Out of the total households, 511(82.6%) were using the CBHI scheme for health care service utilization. Residence, marital status, education level, occupation status, family size, presence of under-five children in the household, presence of elders in the households, nearest health institution, presence of chronic illness in the household's, time taken to reach health institution, an attitude of a household were the determinant factors of community-based health insurance scheme health care service utilization of households. It is recommended that the local, regional and national governments, policymakers on optimal actions, NGOs, and other supporting organizations shall improve or scale-up the scheme by providing awareness to the community based on these significant factors and the attitude of households.

Health insurance coverage and antenatal care services utilization in West Africa

BACKGROUND

In recent decades, there has been a significant focus towards the improvement of maternal mortality indicators in low-and middle-income countries. Though progress has been made around the world, West Africa has maintained an elevated burden of diseases. One proposed solution to increasing access to primary care services is health insurance coverage. As limited evidence exists, we sought to understand the relationship between health insurance coverage and at least four antenatal care (ANC) visits in West Africa.

METHODS

Demographic and Health Survey data from 10 West African countries were weighted, cleaned, and analysed. The total sample was 79,794 women aged 15 to 49 years old were considered for the analysis. Health insurance coverage was the explanatory variable, and the outcome variable was number of ANC visits. The data were analysed using binary logistic regression. The results were presented using crude and adjusted odds ratio (aOR) at 95% confidence interval.

RESULTS

Approximately 86.73% of women who were covered by health insurance had four or more ANC visits, compared to 55.15% for women without insurance. In total, 56.91% of the total sample attended a minimum of four ANC visits. Women with health insurance coverage were more likely to make the minimum recommended number of ANC visits than their non-insured-peers (aOR [95% CI] =1.55 [1.37-1.73]).

CONCLUSION

Health insurance is a significant determinant in accessing primary care services for pregnant women. Yet, very few in the region are covered by an insurance scheme. In the wake of the COVID-19 pandemic, policy makers should prioritize rapid solutions to provide primary care while setting the infrastructure for long-term and sustainable options such as publicly run health insurance schemes.

Does community-based health insurance improve access to care in sub-Saharan Africa? A rapid review

In sub-Saharan African countries, out-of-pocket payments can be a major barrier to accessing appropriate healthcare services. Community-based health insurance (CBHI) has emerged as a context-appropriate risk-pooling mechanism to provide some financial protection to populations without access to formal health insurance. The aim of this rapid review was to examine the peer-reviewed literature on the impact of CBHI on the use of healthcare services as well as its capacity to improve equity in the use of healthcare between different socio-economic groups. A systematic search of three electronic databases (Pubmed, Cochrane Library and Littérature en Santé) was performed. Data were extracted on scheme and study characteristics, as well as the impact of the schemes on relevant outcomes. Sixteen publications met the inclusion criteria, studying schemes from seven different countries. They provide strong evidence that community-based health insurance can contribute to improving access to outpatient care and weak evidence that they improve access to inpatient care. There was low evidence on their capacity to improve equity in access to healthcare among insured members. In the absence of sufficient public spending for healthcare, such schemes may be able to provide some valuable benefits for communities with limited access to primary-level care in sub-Saharan Africa. The overall high risk of bias of the studies and the wide existing variety of insurance arrangements suggest caution in generalizing these results. These findings need to be validated and further developed by rigorous studies.

Household preferences and willingness to pay for health insurance in Kampala City: a discrete choice experiment

INTRODUCTION

Uganda is in discussions to introduce a national health insurance scheme. However, there is a paucity of information on household preferences and willingness to pay for health insurance attributes that may guide the design of an acceptable health insurance scheme. Our study sought to assess household preferences and willingness to pay for health insurance in Kampala city using a discrete choice experiment.

METHODS

This study was conducted from 16th February 2020 to 10th April 2020 on 240 households in the Kawempe division of Kampala city stratified into slum and non-slum communities in order to get a representative sample of the area. We purposively selected the communities that represented slum and non-slum communities and thereafter applied systematic sampling in the selection of the households that participated in the study from each of the communities. Four household and policy-relevant attributes were used in the experimental design of the study. Each respondent attended to 9 binary choice sets of health insurance plans that included one fixed choice set. Data were analyzed using mixed logit models.

RESULTS

Households in both the non-slum and slum communities had a high preference for health insurance plans that included both private and public health care providers as compared to plans that included public health care providers only (non-slum coefficient β = 0.81, P < 0.05; slum β = 0.87, p < 0.05) and; health insurance plans that covered extended family members as compared to plans that had limitations on the number of family members allowed (non-slum β = 0.44, P < 0.05; slum β = 0.36, p < 0.05). Households in non-slum communities, in particular, had a high preference for health insurance plans that covered chronic illnesses and major surgeries to other plans (0.97 β, P < 0.05). Our findings suggest that location of the household influences willingness to pay with households from non-slum communities willing to pay more for the preferred attributes.

CONCLUSION

Potential health insurance schemes should consider including both private and public health care providers and allow more household members to be enrolled in both slum and non-slum communities. However, the inclusion of more HH members should be weighed against the possible depletion of resources and other attributes. Potential health insurance schemes should also prioritize coverage for chronic illnesses and major surgeries in non-slum communities, in particular, to make the scheme attractive and acceptable for these communities.

Challenges with accessing health care for young children presumed to have malaria in the rural district of Butaleja, Uganda: a qualitative study

Objective:

A qualitative study was conducted to gain insight into challenges reported by Butaleja households during a previous household survey. Specifically, this paper discusses heads of households’ and caregivers’ perceptions of challenges they face when seeking care for their very young children with fever presumed to be malaria.

Methods:

Eleven focus groups (FGs) were carried out with household members (five with heads of households and six with household caregivers) residing in five sub-counties located across the district. Purposive sampling was used to ensure the sample represented the religious diversity and geographical distance from the peri-urban center of the district. Each FG consisted of five to six participants. The FGs were conducted at a community centre by two pairs of researchers residing in the district and who were fluent in both English and the local dialect of Lunyole. The discussions were recorded, translated, and transcribed. Transcripts were reviewed and coded with the assistance of QDA Miner (version 4.0) qualitative data management software, and analyzed using thematic content analysis.

Results:

The FG discussions identified four major areas of challenges when managing acute febrile illness in their child under the age of five with presumed malaria (1) difficulties with getting to public health facilities due to long geographical distances and lack of affordable transportation; (2) poor service once at a public health facility, including denial of care, delay in treatment, and negative experiences with the staff; (3) difficulties with managing the child’s illness at home, including challenges with keeping home-stock medicines and administering medicines as prescribed; and (4) constrained to use private outlets despite their shortcomings.

Conclusions:

Future interventions may need to look beyond the public health system to improve case management of childhood malaria at the community level in rural districts such as Butaleja. Given the difficulties with accessing quality private health outlets, there is a need to partner with the private sector to explore feasible models of community-based health insurance programs and expand the role of informal private providers.