Enrollment and clients' satisfaction with a community-based health insurance scheme: a community-based survey in Northwest Ethiopia

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.

The level of household satisfaction with community-based health insurance and associated factors in Southern Ethiopia

Background

Community-based health insurance (CBHI) is a program intended to prevent financial hardship brought on by the cost of medical care. All of Ethiopia's regions are implementing it; however, it has not yet been researched how the program is being received by the local population. This study's objective is to determine how satisfied Southern Ethiopian households are with community-based health insurance programs and connected variables.

Methods

A community-based cross-sectional study was conducted from April to May 2021. Information was gathered from 528 households (HHs) selected at random in the Gurage Zone of Southern Ethiopia using a questionnaire. Bivariate and multivariate logistic regression, as well as descriptive statistics, were applied. p values less than 0.05 was used as a cutoff point for identifying the self-determining factors.

Results

The adjusted odds ratio (AOR) for HHs with the poorest wealth status was 2.40 (95% confidence interval:1.14-4.90); for HHs with a good knowledge of the CBHI, it was 1.81 (95% CI: 1.87-3.40); and for households with illness in the past 3  months, it was 5.22 (95% CI: 2.91-9.34). Recurrent visits to the facility (AOR:5.04, 95% CI:1.18-23.44), a Model household in rural health extension program (AOR:3.21, 95% CI:1.76-5.85), being enrolled in the scheme for three years or less (AOR:0.55, 95% CI: 0.30-0.95), and having faith in the leadership of the governing board (AOR:10.53, 95% CI:4.690-23.54) and the availability of the prescribed medication (AOR:14.64, 95% CI:5.37-39.84) were the significant influencing factors.

Conclusion

This study revealed several variables that affected HHs' satisfaction with CBHI. We strongly advise all responsible parties to focus on increasing HH knowledge of the CBHI scheme, supporting HHs to serve as role models for rural health extension packages, and completing the CBHI pledged package to improve HHs' satisfaction with the CBHI scheme, which may then play a role in the sustainability of CBHI.

Household satisfaction with a pilot community-based health insurance scheme and associated factors in Addis Ababa

Background

Many countries introduce CBHI as their healthcare financing system to ensure healthcare access. Understanding the level of satisfaction and factors associated with it is essential to ensure the sustainability of the program. Therefore, this study aimed to assess household satisfaction with a CBHI scheme and its associated factors in Addis Ababa.

Design and methods

Institutional-based cross-sectional study was conducted in the 10 health centers found in the 10 sub-cities of Addis Ababa. Both quantitative and qualitative methods were used. Logistic regression analysis was carried out to identify its associated factors and thematic analysis was used for qualitative data. Finally, variables with a p-value of <0.05 have been considered statistically significant.

Results

In this study, the overall satisfaction level of households with CBHI was 46.3%. Satisfaction was associated with valid CBHI management regulations (AOR = 1.96, 95% CI: 1.12, 3.46), participants who received the right drug (AOR = 1.77, 95% CI: 1.08, 2.93), households who got immediate care (AOR = 4.95, 95% CI: 2.72, 8.98), those who agreed with the adequacy of medical equipment (AOR = 1.65, 95% CI: 1.02, 2.69), and households who agreed with qualification of health personnel (AOR = 1.89, 95% CI: 1.12, 3.20) were more satisfied with the scheme than their counterparts. The challenges mentioned by the discussants were the shortage of drugs, poor attitude of health professionals, absence of kenema pharmacy, lack of laboratory services, lack of awareness about the CBHI scheme, and tight payment schedule.

Conclusions

the satisfaction level of households was low. To achieve a better result, the concerned bodies should work to improve the availability of medication, and medical equipment and improve the attitude of healthcare workers.

Determinants of trust in healthcare facilities among community-based health insurance members in the Manna district of Ethiopia

BACKGROUND

Low-income countries, including Ethiopia, face substantial challenges in financing healthcare services to achieve universal health coverage. Consequently, millions of people suffer and die from health-related conditions. These can be efficiently managed in areas where community-based health insurance (CBHI) is properly implemented and communities have strong trust in healthcare facilities. However, the determinants of community trust in healthcare facilities have been under-researched in Ethiopia.

OBJECTIVE

To assess the determinants of trust in healthcare facilities among community-based health insurance members in the Manna District of Ethiopia.

METHODS

A community-based cross-sectional study was conducted from March 01 to 30, 2020 among 634 household heads. A multistage sampling technique was used to recruit the study participants. A structured interviewer-administered questionnaire was used to collect the data. Descriptive statistics were computed as necessary. Multivariable linear regression analyses were performed, and variables with a p-value < 0.05 were considered to have a significant association with households' trust in healthcare facilities.

RESULTS

In total, 617 households were included in the study, with a response rate of 97.0%. Household age (ß=0.01, 95% CI:0.001, 0.0013), satisfaction with past health services (ß=0.13, 95% CI:0.05, 0.22), perceived quality of services (ß= -0.47, 95% CI: -0.64, -0.29), perceived provider's attitude towards CBHI members (ß = -0.68, 95% CI: -0.88, -0.49), and waiting time (ß= -0.002, 95% CI:- 0.003, -0.001) were determinants of trust in healthcare facilities.

CONCLUSION

This study showed that respondents' satisfaction with past experiences, older household age, long waiting time, perceived poor quality of services, and perceived unfavorable attitudes of providers towards CBHI members were found to be determinants of trust in healthcare facilities. Thus, there is a need to improve the quality of health services, care providers' attitudes, and clients' satisfaction by reducing waiting time in order to increase clients' trust in healthcare facilities.

Does community-based health insurance reduce disparities in modern health service utilization among households in Ethiopia? A community-based comparative cross-sectional study

Background

Community-based health insurance (CBHI) is an emerging and promising concept to access affordable and effective healthcare by substantially pooling risks to improve health service utilization (HSU) and equity. While there have been improvements in healthcare coverage in Ethiopia, disparities in healthcare remain a challenge in the healthcare system. Hence, the study aimed to assess the effects of CBHI on the reduction of disparities in modern health service (MHS) utilization among households.

Methods

A community-based comparative cross-sectional study was conducted between 1 February and 30 April 2022 among households in the Gida Ayana district, Ethiopia. The sample size of 356 was determined using the double population proportion formula, and participants were selected using multistage sampling. Data were entered into EpiData 4.6 and exported to SPSS 25 for analysis.

Results

Among 356 households, 321 (90.2%) reported that at least one member of their family fell ill in the previous 6 months; 153 (47.7%) and 168 (52.3%) households were among the insured and uninsured, respectively. Only 207 [64.5, 95% confidence interval (CI) = 59.0-69.7%] of them utilized health services. The level of MHS was 122 (79.7, 95% CI = 75.5-85.8%) and 85 (50.6, 95% CI = 42.8-58.4%) among insured and uninsured, respectively. Insured households were four times more likely to utilize MHS compared to uninsured households [adjusted odds ratio (AOR) = 4.27, 95% CI = 2.36-7.71]. Despite the households being insured, significant disparities in MHS utilization were observed across the place of residence (AOR = 14.98, 95% CI = 5.12-43.82) and education level (AOR = 0.20, 95% CI = 0.05-0.83).

Conclusion

Overall, the CBHI scheme significantly improved the level of MHS and reduced disparities in utilization across wealth status and family size differences. However, despite households being insured, significant disparities in the odds of MHS utilization were observed across the place of residence and education level. Hence, strengthening the CBHI scheme and focusing on the place of residence and the education level of households are recommended to improve MHS utilization and reduce its disparities.

Factors influencing drop-out of households from community based health insurance membership in rural districts of Gurage Zone, Southern Ethiopia: Community based case-control study

Background

Financial risk-sharing through community-based health insurance is a critical component of universal health coverage. However, its development is a great challenge, not only due to low enrollment but also due to the high dropout rate of members from the program, which threatens its sustainability. So far, the few existing studies in this area have focused on household enrollment into community-based health insurance, rather than on the number of members dropping out. This study aims to identify factors influencing households to drop out of community-based health insurance membership in rural districts of the Gurage Zone, Southern Ethiopia.

Methods

A community-based case-control study was carried out from May to July 2021. Supplemented by qualitative focus group discussions. Multi-stage sampling was employed. An interviewer-administered prearranged tool was used for collecting data. Epi-data version 3.1 and SPSS version 21 were used for data entry and analysis. The association between factor and outcome variable was determined using binary logistic regression analysis at p < 0.05 and 95% CI. Qualitative data were analyzed thematically and triangulated.

Results

From 525 (175 cases and 350 controls) rural household heads 171 cases and 342 controls responded, yielding a response rate of 97.7%. Of those, 73.1 and 69.0% were males in cases and controls, respectively. The statistically significant influencing factors associated with dropout from community-based health insurance were: highest wealth status (adjusted odds ratio [AOR] = 2.36, 95% confidence interval [CI]:1.14-4.87), unfavorable attitude toward CBHI (AOR: 1.81, 95% CI: 1.87-3.37), no illness experienced in the last 3 months (AOR: 5.21, 95% CI: 2.90-9.33). no frequent health facility visits (AOR:5.03, 95% CI:1.17-23.43), no exposure to indigenous community insurance (AOR:0.10, 95% CI: 0.03-0.37), not graduated in the model household (AOR: 3.20, 95% CI:1.75-5.83), being a member in the program for more than 3 years (AOR:0.55, 95% CI: 0.29-0.94), not trusting governing bodies (AOR:10.52, 95% CI:4.70-23.53), the ordered drug was not available in the contractual facility (AOR:14.62, 95% CI:5.37-39.83), waiting time was >3 h (AOR:4.26, 95% CI:1.70-10.66), and poor perception of service quality (AOR:12.38, 95%CI:2.46-62.24).

Conclusion

The findings of this study illustrated various factors which positively and negatively influenced households to drop out from CBHI: wealth status, attitude toward CBHI, perceived poor provider attitude toward CBHI members, illness experience in the household, the experience of frequent health facility visits, model household graduation status, trust on CBHI committee (governing bodies), availability of a prescribed drug in the contractual health facility, waiting time and perceived quality of health service from the contractual facility, exposure to any of the indigenous insurance (IDIR and/or IQUB) and length of membership in program. We strongly recommend all responsible stakeholders give strong attention to promoting the community, and for providers to project a favorable attitude toward community-based health insurance, to achieve model household graduation, and improve quality of service by addressing the basic quality-related areas like waiting time, and drug availability).

Participation in community-based healthcare interventions and non-communicable diseases early detection of general population in Indonesia

Background

Community-based Healthcare Interventions (CBHIs) are regarded as a critical component of healthcare task-sharing in LMICs and have the potential to address LMICs’ health system weaknesses to improve NCDs prevention care. This study aims to investigate the relationship between participation in CBHIs and NCDs early detection at medical facilities among Indonesians.

Methods

Data come from the fifth Indonesian Family Life Survey (2014–2015), a total of 27,692 individuals (14,820 female and 12,872 male individuals age 15 and older). Multiple ordered logistics and logistics regression was used to assess the association between individual participation in CBHI and early detection of NCDs at medical facilities.

Findings

Participation in CBHIs are associated with higher odds of having regular blood pressure test (adjusted odds ratio [OR], 3.09; 95% confidence interval [CI], 2.67–3.58), cholesterol test (adjusted OR, 1.88; 95% CI, 1.60–2.22), blood glucose test (adjusted OR, 1.88; 95% CI, 1.58–2.23), electrocardiogram (adjusted OR, 1.37; 95% CI, 1.06–1.76) and basic dental examination (adjusted OR, 1.32; 95% CI, 1.09–1.60) at medical facilities. The odds of having pap smears (adjusted OR, 2.20; 95% CI, 1.62–2.98) and breast self-examination (adjusted OR, 1.73; 95% CI, 1.37–2.19) among females who participated in CBHIs are substantially larger than those who did not participate in CBHIs. No significant association is shown for the basic vision examination (adjusted OR, 1.14; 95% CI, 0.95–1.37), while the association of participation in CBHIs on prostate cancer checkup (adjusted OR, 0.18; 95% CI, 0.04–0.76) was negative and significant. The results were controlled with a wide range of predisposing, enabling and need factors for NCDs early detection.

Conclusion

and recommendation: CBHIs may benefit NCDs early detection for the general population in Indonesia. Policymakers and health practitioners need to design CBHIs programs that are attractive to the population, especially men and younger people.

•

CBHIs are a distinct mode of healthcare delivery and are regarded as a critical component of healthcare task-sharing in LMICs.

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CBHIs have the potential to address LMICs' health system weaknesses to improve NCDs prevention care.

•

Participation in CBHIs are associated with regular blood pressure, cholesterol, blood glucose, electrocardiogram, and dental tests.

Pooled coverage of community based health insurance scheme enrolment in Ethiopia, systematic review and meta-analysis, 2016-2020

BACKGROUND

Community Based Health Insurance (CBHI) is a type of health insurance program that provides financial protection against the cost of illness and improving access to health care services for communities engaged in the informal sector. In Ethiopia, the coverage of CBHI enrolment varies across regions and decision of household enrolment is affected by different factors. There are pocket studies on CBHI scheme with different coverage in Ethiopia and there is no pooled study on CBHI enrolment coverage in Ethiopia for better understanding the scheme and decision making. The aim of this systematic review and meta-analysis was to identify the pooled coverage of CBHI enrolment in Ethiopia to understand its policy implications.

METHODS

The systematic review and meta-analysis was done by adhering the PRISMA guideline with exhaustive search in PubMed/Medline, HINARI, SCOPUS and Google scholar complemented by manual search. Two authors independently selected studies, extracted data, and assessed quality of studies. The I2 test statistic was used to test heterogeneity among studies. The overall coverage of CBHI scheme was estimated by using random-effects model.

RESULT

Among 269 identified, 17 studies were included in this meta-analysis and the overall coverage of CBHI scheme was 45% (95% CI 35%, 55%) in Ethiopia. The sub-group analysis shows higher enrolment rate 55.97 (95%CI: 41.68, 69.77) in earlier (2016-2017) studies than recent 37.33 (95%CI: 24.82, 50.77) studies (2018-2020).

CONCLUSION

The pooled coverage of CBHI enrolment is low in Ethiopia compared the national target of 80% set for 2020. It is also concentrated in only major regions of the country. The finding of the study helps national decision making for CBHI scheme service improvement. Due attention to be given to improving geographic expansion of CBHI and to the declining coverages with in the CBHI implementing regions by addressing the main bottlenecks restraining coverages.

TRIAL REGISTRATION

The protocol of this systematic review and meta-analysis was published in PROSPERO with registration number: CRD42021252762 .

The Impact of Community-Based Health Insurance on Household's Welfare in Chilga District, Amhara Regional State, Ethiopia

Household welfare is depleted by catastrophic health expenditure by forcing families to reduce the consumption of necessary goods and services, underutilization of health services, and of finally falling into the poverty trap. To mitigate such problem, the Government of Ethiopia launched CBHI schemes. Therefore, this study investigates the household welfare impact of Community based health insurance (CBHI) in the Chilga district. A multi-stage sampling technique was used to select 531 households (of which 356 were treated and 175 control groups). Probit and propensity score matching (PSM) were used to analyze the data. Probit model revealed the following: Level of education, access to credit, chronic disease, insurance premium, awareness, distance to health service, and health service waiting time are significant determinates for being insured in CBHI. The PSM method revealed that the insured households associated with visits increased by 2.6 times, reduced per-capita health expenditure by 17–14% points, increased the per-capita consumption of non-food items by 12–14% points, increased the per-capita consumption of food items by 12–13% points in a given matching algorithm compared to the counterparts. Therefore, CBHI has enhanced service utilization by reducing per-capita health expenditure and increasing consumption per-capita, in general, it improved household welfare. To this end, the results of this study suggested that the government (ministry of health) and concerned bodies (such as NGOs) should extend the coverage and accessibility of CBHI schemes, create aware to the society about CBHI, and subsidize premium costs of the poor.

Strengths and Weaknesses of Strategic Health Purchasing for Universal Health Coverage in Rwanda

In the context of scarce resources and increasing health care costs, strategic purchasing is viewed as a key mechanism to spur countries' progress toward universal health coverage (UHC), by using limited resources more effectively. We applied the Strategic Health Purchasing Progress Tracking Framework to examine the health purchasing arrangements in three health financing schemes in Rwanda-the Community Based Health Insurance (CBHI) scheme, the Rwanda Social Security Board (RSSB) medical scheme, and performance-based financing (PBF). Data were collected from secondary and primary sources between September 2020 and March 2021.The objective of the study was to identify areas of progress in strategic purchasing that can be built on, and to identify areas of overlap, duplication, or conflict that limit progress in strategic purchasing to advance UHC goals. This study found that Rwanda has made progress in many areas of strategic purchasing and has a strong foundation for building further. However, some overlaps and duplication of functions weaken the power of purchasers to improve resource allocation, incentives for providers, and accountability. In addition, some of the policies within the purchasing functions could be made more strategic. In particular, open-ended fee-for-service payment in the CBHI scheme not only threatens the scheme's financial sustainability but also imposes a high administrative burden. Better alignment and integration of contracting, incentives, and information system design to provide timely and relevant information for purchasing decisions would contribute to more strategic health purchasing and ensure that Rwanda's health sector achievements are sustained and expanded.

Willingness to Enroll for Community-Based Health Insurance and Associated Factors in Simada District, North-West, Ethiopia, 2020:A Community-Based Cross-Sectional Study

Background

Community-based health insurance is a not-for-profit type of health insurance that has been used by poor people to protect themselves against the high costs of seeking medical care and treatment for illness. This study aimed to assess communities’ willingness to enroll for community-based health insurance (CBHI) and its associated factors in Simada district, Northwest, Ethiopia.

Methods

A community-based mixed cross-sectional study design was conducted. Multistage simple random and purposive sampling techniques were used for quantitative and qualitative studies, respectively. Data were coded and entered into Epi info version 7.2.0.1 and exported to SPSS 20.0 for data analysis. Inferential statistics were done to determine an association between the outcome and independent variables. Statistically significant variables in binary logistic regression analysis with p-value <0.2 were entered for multivariable binary logistic regression analysis and P-value ≤0.05 was considered as statistically significant. Hosmer and Lemeshow’s goodness of fitness test was fitted and qualitative data were analyzed by using thematic analysis.

Results

Among 510 study participants, 454 (89%) [CI: (86.5%-91.6%)] were willing to enroll for community-based health insurance. Members of social capital [AOR: 7.6 (3.78–15.5)], distance from health facilities [AOR: 10.8 (4.9–23.5)], the experience of chronic illness in the family [AOR: 4.6 (1.88–11.4)], medium family wealth status [AOR: 3.1 (1.3–7.5)], and the number of family members [AOR: 2.25 (1.11–4.6)] were significantly associated with willingness to enroll for community-based health insurance.

Conclusion

Willingness to enroll in community-based health insurance in the study area is high. Members of social capital, the experience of chronic illness in the family, distance from a health facility, the number of family members, and medium family wealth status were factors found to be associated with willingness to enroll for the scheme. Therefore, emphasizing redesigning and planning strategies for better expanding the scheme accordingly.

Investigation of Moral Hazard Deportments in Community-Based Health Insurance in Guto Gida District, Western Ethiopia: A Qualitative Study

INTRODUCTION

Ethiopia introduced CBHI in 2011 as part of the health sector finance improvement. This study was accompanied to identify moral hazard behaviors in community-based health insurance in Guto Gida District of Oromia regional state.

METHODS

The qualitative study used data generated from focus group discussions and in-depth interviews. Three health service centers were purposively selected for the study. Thematic analysis was accomplished using the NVivo-12 software package as it operates better in qualitative data analysis.

RESULTS

The study found that member's frequent visit to health service centers, tendency to collect more drugs, sense of feeling cheated by the insurance, tendency to use their cards redundantly, giving their cards to nonmembers, and seeking for most often expensive drugs were the demand side moral hazard behaviors explored by the study. From the supply side, inflating the price of drugs, increasing the price of services, alleging for services not provided, overstating the number of customers obtained insurance package and insulting users are found as moral hazard problems.

CONCLUSION

The study concluded that moral hazard behavior is discouraging from both the demand and supply sides. The presence of moral hazard discourages members of CBHI and creates reluctances in the scheme officials and workers. The policy implication is that tremendous attention should be given to reducing the level of moral hazard behaviors from the sides of both users and providers.

How an Electronic Medical Record System Facilitates and Demonstrates Effective Psychosocial Screening in Pediatric Primary Care

Using questionnaires, administrative claims, and chart review data, the current study explored the impact of using an electronic medical record system to administer, score, and store the Pediatric Symptom Checklist (PSC-17) during annual pediatric well-child visits. Within a sample of 1773 Medicaid-insured outpatients, the electronic system demonstrated that 90.5% of cases completed a PSC-17 screen electronically, billing codes indicating a screen was administered agreed with the existence of a questionnaire in the chart in 98.8% of cases, the classification of risk based on PSC-17 scores agreed with the classification of risk based on the Current Procedural Terminology code modifiers in 72.9% of cases, and 90.0% of clinicians' progress notes mentioned PSC-17 score in treatment planning. Using an electronic approach to psychosocial screening in pediatrics facilitated the use of screening information gathered during the clinical visit and allowed for enhanced tracking of outcomes and quality monitoring.

Willingness to join community based health insurance and its determinants in East Gojjam zone, Northwest Ethiopia

Objective

The main purpose of this research was to determine the magnitude of willingness to join to community based health insurance (CBHI) and to identify factors associated with it.

Results

A total of 604 study participants responded for the interviews, making the response rate 98.2%. All in all, 492 (81.5%) of the study participant households were willing to join the CBHI scheme. Households which had experience of borrowing for medical expenses within the last 12 months prior to the study were 2.7 times more likely to join CBHI scheme than those who didn’t have borrowed (AOR = 2.65; 95% CI 1.03, 6.83). Female headed households were 2.7 times more likely to take up the scheme compare to male headed households (AOR = 2.74; 95% CI 1.18, 6.37). High proportion of households was willing to join the CBHI scheme in the study area. Educational status of household head, experience of borrowing for medical expenses, sex of household head, household animal asset as measured by tropical livestock unit were factors found to be associated with willingness to take up CBHI scheme.

The diversity of glycosylation of cellobiohydrolase I from Trichoderma reesei determined with mass spectrometry

Cellulases are glycosylated enzymes that have wide applications in fields like biofuels. It has been widely accepted that glycosylation of cellulases impact their performance. Trichoderma reesei is the most important cellulase-producer and cellobiohydrolase I (CBHI) is the most important cellulase from T. reesei. Therefore, the glycosylation of T. reesei CBHI has been a focus of research. However, investigations have been focused on N-glycosylation of three of the four potential glycosylation sites, as well as O-glycosylation on the linker region, while a full picture of glycosylation of T. reesei CBHI is still needed. In this work, with extensive mass spectrometric investigations on CBHI from two T. reesei strains grown under three conditions, several new discoveries were made: 1) N45 and N64 are N-glycosylated with high mannose type glycans; 2) the catalytic domain of CBHI is extensively O-glycosylated with hexoses and N-acetylhexosamines; 3) experimental evidence on the mannosylation of carbohydrate binding domain (other than the linker adjacent region) was found. With structural analysis, we found several glycosylation sites (such as T383, S8, and S46) are located at the openings of the substrate-binding tunnel, and potentially involve in the binding of cellulose. These investigations provide a full and comprehensive picture on the glycosylation of CBHI from T. reesei, which benefits the engineering of CBHI by raising potential sites for modification.

Factors affecting the willingness to join community-based health insurance (CBHI) scheme: A case study survey from Savannakhet Province, Lao P.D.R

PURPOSE

Community-based health insurance (CBHI) targets independent worker (self-employed) is currently struggling with inadequate size of risk pooling, low enrollment, and high dropout rate as well as financial sustainability. The objective of this study is to find out the factors that significantly affect the CBHI enrollment incentive. The study applied cross-sectional study design to perform situation analysis, in which the Andersen behavioral model was used as a guideline to identify preliminary characteristics that involved with enrolling incentive.

FINDINGS

The model found that existence of both outpatient department (OPD) and inpatient department (IPD) health service utilization had significant impact on the CBHI enrollment, this statement is strongly related to adverse selection issues. Households resides in Kaysone Phomvihane district had higher probability of joining the scheme in comparison with relatively less-developed Champhone district. Households with no CBHI knowledge were also more likely to enroll the scheme. Occupation was also found to be a significant factors; of which farmers and laborers had lower possibility enrollment.

CONCLUSIONS

Economic condition of the district has a significant impact on enrolment. However, the increase in personal income does not directly enhance the desire for enrolment. Most of the high-income households prefer to use a local, private clinic, and foreign hospitals in Thailand or Vietnam. Households with unemployed heads had the highest possibility of enrolling. The reason is the unemployed respondents include the elderly who stay at home without performing major tasks in exchange for their living. That group of people has the highest probability of either OPD or IPD.

Expression of an endoglucanase-cellobiohydrolase fusion protein in Saccharomyces cerevisiae, Yarrowia lipolytica, and Lipomyces starkeyi

The low secretion levels of cellobiohydrolase I (CBHI) in yeasts are one of the key barriers preventing yeast from directly degrading and utilizing lignocellulose. To overcome this obstacle, we have explored the approach of genetically linking an easily secreted protein to CBHI, with CBHI being the last to be folded. The Trichoderma reesei eg2 (TrEGII) gene was selected as the leading gene due to its previously demonstrated outstanding secretion in yeast. To comprehensively characterize the effects of this fusion protein, we tested this hypothesis in three industrially relevant yeasts: Saccharomyces cerevisiae, Yarrowia lipolytica, and Lipomyces starkeyi. Our initial assays with the L. starkeyi secretome expressing differing TrEGII domains fused to a chimeric Talaromyces emersonii-T. reesei CBHI (TeTrCBHI) showed that the complete TrEGII enzyme, including the glycoside hydrolase (GH) 5 domain is required for increased expression level of the fusion protein when linked to CBHI. We found that this new construct (TrEGII-TeTrCBHI, Fusion 3) had an increased secretion level of at least threefold in L. starkeyi compared to the expression level of the chimeric TeTrCBHI. However, the same improvements were not observed when Fusion 3 construct was expressed in S. cerevisiae and Y. lipolytica. Digestion of pretreated corn stover with the secretomes of Y. lipolytica and L. starkeyi showed that conversion was much better using Y. lipolytica secretomes (50% versus 29%, respectively). In Y. lipolytica, TeTrCBHI performed better than the fusion construct. Furthermore, S. cerevisiae expression of Fusion 3 construct was poor and only minimal activity was observed when acting on the substrate, pNP-cellobiose. No activity was observed for the pNP-lactose substrate. Clearly, this approach is not universally applicable to all yeasts, but works in specific cases. With purified protein and soluble substrates, the exoglucanase activity of the GH7 domain embedded in the Fusion 3 construct in L. starkeyi was significantly higher than that of the GH7 domain in TeTrCBHI expressed alone. It is probable that a higher fraction of fusion construct CBHI is in an active form in Fusion 3 compared to just TeTrCBHI. We conclude that the strategy of leading TeTrCBHI expression with a linked TrEGII module significantly improved the expression of active CBHI in L. starkeyi.

"One for all and all for one": consensus-building within communities in rural India on their health microinsurance package

Introduction

This study deals with consensus by poor persons in the informal sector in rural India on the benefit-package of their community-based health insurance (CBHI). In this article we describe the process of involving rural poor in benefit-package design and assess the underlying reasons for choices they made and their ability to reach group consensus.

Methods

The benefit-package selection process entailed four steps: narrowing down the options by community representatives, plus three Choosing Healthplans All Together (CHAT) rounds conducted among female members of self-help groups. We use mixed-methods and four sources of data: baseline study, CHAT exercises, in-depth interviews, and evaluation questionnaires. We define consensus as a community resolution reached by discussion, considering all opinions, and to which everyone agrees. We use the coefficient of unalikeability to express consensus quantitatively (as variability of categorical variables) rather than just categorically (as a binomial Yes/No).

Findings

The coefficient of unalikeability decreased consistently over consecutive CHAT rounds, reaching zero (ie, 100% consensus) in two locations, and confirmed gradual adoption of consensus. Evaluation interviews revealed that the wish to be part of a consensus was dominant in all locations. The in-depth interviews indicated that people enjoyed the participatory deliberations, were satisfied with the selection, and that group decisions reflected a consensus rather than majority. Moreover, evidence suggests that pre-selectors and communities aimed to enhance the likelihood that many households would benefit from CBHI.

Conclusion

The voluntary and contributory CBHI relies on an engaging experience with others to validate perceived priorities of the target group. The strongest motive for choice was the wish to join a consensus (more than price or package-composition) and the intention that many members should benefit. The degree of consensus improved with iterative CHAT rounds. Harnessing group consensus requires catalytic intervention, as the process is not spontaneous.