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Do Community-Based Health Insurance Schemes Improve Poor People's Access to Health Care? Evidence From Rural Senegal
Abstract
This article presents the results of the comparative research project, "Managed Care in Latin America: Its Role in Health System Reform." Conducted by teams in Argentina, Brazil, Chile, Ecuador, and the United States, the study focused on the exportation of managed care, especially from the United States, and its adoption in Latin American countries. Our research methods included qualitative and quantitative techniques. The adoption of managed care reflects the process of transnationalization in the health sector. Our findings demonstrate the entrance of the main multinational corporations of finance capital into the private sector of insurance and health services, and these corporations' intention to assume administrative responsibilities for state institutions and to secure access to medical social security funds. International lending agencies, especially the World Bank, support the corporatization and privatization of health care services, as a condition of further loans to Latin American countries. We conclude that this process of change, which involves the gradual adoption of managed care as an officially favored policy, reflects ideologically based discourses that accept the inexorable nature of managed care reforms.
... Seven empirical studies found greater affiliation of certain ethnic groups to CBHI schemes [18-20, 23, 25-27]. In a study in Senegal, the Peulh/Fulani ethnic group was less likely to participate in the program probably because of their nomadic lifestyle [25]. Religion, although not widely considered as a membership factor in the selected studies, could also influence household membership in a community-based health financing system. ...
... Lack of financial resources is often the first reason given by both members and non-members to explain low participation in CBHI [14, 16-18, 22, 23, 25, 26, 28-39]. Several studies have shown that the socioeconomic level of members is higher than that of non-members [17,18,21,25,30,31]. Although respondents most often consider the amount of the individual contribution to be fair or affordable (especially compared to the costs of not participating), many cannot afford to pay the contributions for all the members of the household. ...
... This scepticism about health workers' competence reinforces the lack of trust in health workers, which negatively influences membership. Thus, trust in health workers is based above all on their professional experience and ability to listen to and inform the patient [15,22,23,25,29,33,35,36]. ...
Background
In many low-income countries, households bear most of the health care costs. Community-based health insurance (CBHI) schemes have multiplied since the 1990s in West Africa. They have significantly improved their members’ access to health care. However, a large proportion of users are reluctant to subscribe to a local CBHI. Identifying the major factors affecting membership will be useful for improving CBHI coverage. The objective of this research is to obtain a general overview of existing evidence on the determinants of CBHI membership in West Africa.
Methods
A review of studies reporting on the factors determining membership in CBHI schemes in West Africa was conducted using guidelines developed by the Joanna Briggs Institute. Several databases were searched (PubMed, ScienceDirect, Global Health database, Embase, EconLit, Cairn.info, BDPS, Cochrane database and Google Scholar) for relevant articles available by August 15, 2022, with no methodological or linguistic restrictions in electronic databases and grey literature.
Results
The initial literature search resulted in 1611 studies, and 10 studies were identified by other sources. After eliminating duplicates, we reviewed the titles of the remaining 1275 studies and excluded 1080 irrelevant studies based on title and 124 studies based on abstracts. Of the 71 full texts assessed for eligibility, 32 additional papers were excluded (not relevant, outside West Africa, poorly described results) and finally 39 studies were included in the synthesis. Factors that negatively affect CBHI membership include advanced age, low education, low household income, poor quality of care, lack of trust in providers and remoteness, rules considered too strict or inappropriate, low trust in administrators and inadequate information campaign.
Conclusions
This study shows many lessons to be learned from a variety of countries and initiatives that could make CBHI an effective tool for increasing access to quality health care in order to achieve universal health coverage. Coverage through CBHI schemes could be improved through communication, improved education and targeted financial support.
... 6,12 While several stud-ies have documented voluntary health insurance experiences in Asia, 8,10,[13][14][15][16] only a limited number of evaluations have explored the factors influencing the decision to enrol or not to enrol in CHI in sub-Saharan countries. [17][18][19] The literature on CHI in sub-Saharan Africa has long been dominated by consul-tancy reports, which have focused on assessing the managerial and financial capacity of existing schemes rather than systematically exploring the factors mo-tivating or discouraging enrolment. [20][21][22][23] Understanding the reasons behind low enrolment rates is therefore a relevant research question. ...
... Following the example set by previous studies documenting CHI experiences in Africa and Asia, 8,[13][14][15][16]18,19 this study relied on the use of household survey data to explore determinants of enrol-ment in CHI. Household survey data have proved to be useful in quantifying the relationship between enrolment status and individual, household and community characteristics. ...
... The two previous studies which explored quantitatively the decision to enrol in CHI did so within the framework of broader analyses primarily aimed at as-sessing the impact of insurance status on household health service utilization and health spending. 18,19 The small sample size represents an important limitation of our study and in most instances is responsible for the width of the confidence intervals. The sample size and the choice to employ a case-control methodology were dictated by the limited number of households that had enrolled in CHI. ...
... These insurance schemes are typically managed by local NGOs, hospitals, civil society organizations, or organized cooperative societies with community participation in their management [6]. The primary objective of CBHI schemes is to mobilize local resources to provide quality healthcare services and increase healthcare accessibility in deprived areas [7]. Ghana, Rwanda, Japan, and China started with CBHI and then reformed their health financing system by integrating CBHI schemes into national health insurance; however, their journey to form national health insurance from the CBHI schemes was not straightforward [5,[8][9][10]. ...
... Although CBHI schemes offer financial protection against healthcare costs to a group of people, the literature indicates that such a financing strategy is not much effective in the advancement of achieving UHC goals [7]. ...
... The key grounds for this argument are adverse selection, moral hazard and heavy reliance on external subsidy challenge scheme implementation [4,7]. Major barriers of CBHI relate to conventional health insurance, including a small risk pooling, limited technical and organizational knowledge, low service coverage capacity, poor quality of care, and inadequate service providers [4]. ...
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.
... These authors find a positive effect of insurance after correction for endogeneity. Jütting [4] shows that membership of mutual health insurance increases the probability of using health services and members pay, on average, less than half the amount paid by non-members when they need care. In this paper, we follow Meer and Rosen [11] in usingthe employment status as an instrument to identify the effect of insurance oh health care utilization. ...
... Numerous theoretical and empirical works in health economics show a difference in the use of health services between insured and non-insured individuals [6]. These studies generally reveal a positive relationship between insurance and health care consumption [4]. Theoretically, health insurance affects agents' behavior through two main channels: First, by reducing the unit price of health services, health insurance is a subsidy for the purchase of medical care and thus affects the demand for care [2]. ...
... Furthermore, our results suggest that individuals tend to increase the number of visits to the dental professional by 4.68 when they have dental insurance but spend less nights (7.54 night) in hospital if they have hospitalization insurance. The positive impact of dental insurance is consistent with theoretical expectations and the empirical literature [4,[20][21][22]. Moreover, the positive impact of hospital insurance confirms the empirical work of Hullegie and Klein [18] and Manning, et al. [22] who find the same negative effect of hospitalization insurance. ...
... These schemes aim to protect individuals from financial catastrophe due to health-related costs and, thus, to enhance access to health services. These schemes mainly target the informal and rural sectors and involve the community in their design and management (Jütting, 2004). While community-based health insurance represents the evolution of CHF arrangements and fully applies the principle of risk pooling, in this paper, we refer to CHF as the general model of communitybased financing for health, and, specifically, we focus on the operational phase of zero-interest loans for healthcare at the inception of the insurance implementation. ...
... The effect on financial hardship also suggests longer-term benefits in mitigating vulnerability to other forms of shocks. The results are consistent with existing studies on CHF arrangements in different contexts (Aggarwal, 2010;Chankova et al., 2008;Dror et al., 2016;Galárraga et al., 2010;Jütting, 2004;Mebratie et al., 2019;Savitha and Kiran, 2015) and add to the body of the evaluation literature that mainly relies on longitudinal data. ...
... Qualitative evidence provides valuable clues to acknowledge the heterogeneity of the impact on different household categories. Consistent with other studies (Jütting, 2004;Umeh and Feeley, 2017), structured focus group findings suggest that more disadvantaged people in terms of access to healthcare are excluded from participating in the scheme (as confirmed by the quantitative comparison presented in Supplementary Appendix 3), thus raising equity concerns on the impact of the intervention. Among enrolled members, the poorest are likely to receive greater benefits from the scheme. ...
In low- and middle-income countries, catastrophic health expenditures and economic hardship constitute a common risk for households’ welfare. Community health financing (CHF) represents a viable option to improve financial protection, but robust impact evaluations are needed to advance the debate concerning universal health coverage in informal settings. This study aims at assessing the impact of a CHF pilot programme and, specifically, of the initial phase involving zero-interest loans on health expenditures and coping strategies in a rural district of Uganda. The analysis relies on a panel household survey performed before and after the intervention and complemented by qualitative data obtained from structured focus group discussions. Exploiting an instrumental variable approach, we measured the causal effect of the intervention, and the main findings were then integrated with qualitative evidence on the heterogeneity of the programme’s impact across different household categories. We found that the intervention of zero-interest healthcare loans is effective in improving financial protection and longer-term welfare. Community perceptions suggested that the population excluded from the scheme is disadvantaged when facing unpredictable health costs. Among the enrolled members, the poorest seem to receive a greater benefit from the intervention. Overall, our study provides support for the positive role of community-based mechanisms to progress towards universal coverage and offers policy-relevant insights to timely design comprehensive health financing reforms.
... Quand on parle de financement de la CSU, on fait référence aux réformes ou mécanismes qui permettent d'atteindre ces objectifs. C'est la manière dont les ressources financières sont mobilisées, mises en commun et utilisées pour acheter des soins et services de santé (Kutzin 2013 (Jütting 2001(Jütting , 2004Tine 2000). (2008) ...
... De ce fait, Biosca et Brown n'ont pas directement étudié l'effet des transferts sur l'enrôlement mais plutôt l'association entre le programme et la connaissance que les bénéficiaires ont de leurs droits à une couverture assurantielle, en partant du principe que la composante « sensibilisation » du programme favoriserait le partage d'informations (Biosca and Brown 2014).Au Sénégal, il n'y a pas, à notre connaissance, d'études mesurant l'impact de ses mutuelles sur l'utilisation des services de santé ou sur les paiements directs des ménages depuis les changements intervenus à partir de 2012. Les études allant dans ce sens datent du début des années 2000(Jütting 2001(Jütting , 2004Smith and Sulzbach 2008). Notre première contribution sera donc de combler un fossé entre le Sénégal et le reste du continent qui a largement évalué l'impact des mutuelles(Bodhisane and Pongpanich 2019;Ko et al. 2018;Mirach et al. 2019;Mladovsky 2014;Robyn, Hill, et al. 2012;Yilma et al. 2015bYilma et al. , 2015a. ...
Le Sénégal a lancé un plan stratégique national pour étendre les soins de santé universels et atteindre une couverture de 70 % d'ici 2022. Ce plan a trois objectifs : renforcer les initiatives de gratuité des soins de santé, réformer l'assurance maladie obligatoire et développer l'assurance maladie communautaire. Cette thèse s'articule autour de quatre chapitres portant sur la gratuité des soins (premier et deuxième chapitre) et l'assurance maladie communautaire (troisième chapitre) d'une part et l'économie politique des réformes du financement de la santé d'autre part (quatrième chapitre). Le premier chapitre examine les inégalités d'accès aux soins de santé gratuits pour les enfants de moins de cinq ans. Le deuxième chapitre est particulièrement axé sur les maladies non transmissibles et analyse les principes éthiques du rationnement de la dialyse. Le troisième chapitre analyse le rôle des transferts monétaires conditionnels dans l'enrôlement aux mutuelles de santé communautaires, et l'impact de ces derniers sur l'utilisation des services de santé et sur les paiements directs. Enfin, le quatrième chapitre est une analyse comparative des réformes du financement de la santé entreprises dans dix pays à revenu faible et intermédiaire, dont le Sénégal.
... We do not find support for other characteristics predicting demand for the MHI, including poverty level, education, and age. This paper also contributes to a growing literature describing the effects of MHI (Acharya et al., 2013;Chankova et al., 2008;Habib et al., 2010Habib et al., , 2016Jakab & Krishnan, 2004;Jutting 2004;Wagstaff & Lindelow, 2008). We build on the identification strategies used in this literature by exploiting the randomized timing of when MHI was introduced, reinforcing the internal validity of our causal interpretation. ...
... 3 Platteau et al. (2017) provide an extensive review of microinsurance demand more generally. 4 An older literature that is less well-identified also finds mixed results on adverse selection: a handful of papers find that MHI coverage is correlated with poor health (Asenso-Okyere et al., 1997;Bendig & Arun, 2011;Dror et al., 2007;Lammers & Warmerdam, 2010), while others fail to find support for the correlation (Dror et al., 2005;Jutting, 2004;Panda et al., 2014). These studies generally have used willingness to pay surveys or observed health after the decision to enroll in insurance has already been made. ...
Moral hazard and adverse selection are potential explanations for missing health insurance in low-income countries. In recent years, informal financial institutions have attempted to complete health insurance markets by offering micro health insurance (MHI). We evaluate an MHI offered through informal financial institutions (Self-Help Groups) in Maharashtra, India. Exploiting random assignment of when villages were offered the MHI, we do not find support for MHI increasing health care utilization. In contrast, we do find evidence for adverse selection: enrollees are significantly more likely than non-enrollees to report poor health prior to the introduction of MHI. This adverse selection persists even when the MHI is offered as a group insurance to Self-Help Groups, as opposed to individual insurance. Our results suggest that MHI offered through informal financial groups may not suffer from moral hazard, but does fall short of eliminating adverse selection.
... The impact of CBHI on per capita OPD visit as estimated in this study was lower compared to findings from the evaluation of the pilot study which reported 45-64% increase in frequency of visits [23]. The positive impact of CBHI on health service utilization in general corroborated sub-national studies in Ethiopia [25], and similar studies from elsewhere [44,47,55]. The relatively lower effect size we identified compared to findings from the evaluation of the pilot project in the early years [23] could be a result of differences between intensity of implementation of CBHI schemes between the pilot and scale-up phases. ...
Abstract 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
... Healthcare financing reform, including CBHI, has contributed towards breaking down financial barriers which hamper health service utilization and quality [6]. CBHI has increased healthcare utilization among members and will eventually contribute to the achievement of the goal of universal health coverage [6,20]. An increase in the healthcare demand has increased attention to quality of care on the healthcare supply side. ...
... The impact of CBHI on per capita OPD visit as estimated in this study was lower compared to ndings from the evaluation of the pilot study which reported 45-64% increase in frequency of visits (23). The positive impact of CBHI on health service utilization in general corroborated sub-national studies in Ethiopia (25), and similar studies from elsewhere (43,46,54). The relatively lower effect size we identi ed compared to ndings from the evaluation of the pilot project in the early years (23) could be a result of differences between intensity of implementation of CBHI schemes between the pilot and scale-up phases. ...
... This has shifted the paradigm of health care from poverty reduction towards social risk management. 2 Health is a widely and unanimously cherished motive to improve the well-being of society. It is important for the socio-economic development of the country. ...
This review article focuses on community barriers among tribes living in different parts of rural regions in India and placed to find out the possible resolution/passion. The access to health care services has a very low coverage in rural region of the country especially in tribal communities. A systematic search was covered since last two decades from 2000 to 2020 of articles were extracted from Google Scholar, PubMed, Science Direct, JSTOR, WHO portal, Research Gate, Census 2011, etc. The health indicators of tribes were originated alarming status quo as widely held malnourished and sufferer from different disease and illness. Findings towards accessing quality health care services revealed that difficult geographical situation, communication in own language, financial constraint, low level of education, illiteracy, approaching traditional medicine and ancient culture as community barriers were remained constant. Low level of education, strong cultural believes and traditional culture norms are the strongest community barriers reflected their self-decision-making for not accessing the modern health care facility. An approach as creating effective awareness in harmonic way could be useful for bridging the gaps by involving existing medical resources and staffs, which can play a critical role in reducing the barriers. Thus, review findings suggest the need for implementing awareness programs can divert towards quality health care and thereby can “connect the unconnected” to stay healthy.
... 10 In Rwanda, insured people in the poorest expenditure quintile had a higher rate of catastrophic health expenditure than the rest of the population. 11 The same mixed findings on the impact of CBHI have been reported in Senegal by Jutting, 32 Chankova, Sulzbach and Diop, 10 and Smith and Sulzbach. 27 These impact evaluations showed that CBHI had a positive effect on access to hospitalisation, 10 32 on the use of assisted delivery by health professionals, 27 and on the reduction of delivery and hospitalisation expenses. ...
Objectives
This study aims to assess the impact of the subsidised community health insurance scheme in Senegal particularly on the poor.
Design and setting
The study used data from a household survey conducted in 2019 in three regions, representing 29.3% of the total population. Inverse probability of treatment weighting approach was applied for the analysis.
Participants
1766 households with 15 584 individuals selected through a stratified random sampling with two draws.
Main outcome measures
The impact of community-based health insurance (CBHI) was evaluated on poor people’s access to care and on their financial protection. For the measurement of access to care, we were interested in the use of health services and non-withdrawal from care in case of illness. To assess financial protection, we looked at out-of-pocket expenditure by type of provider and by type of service, the weight of out-of-pocket expenditure on household income, non-exposure to impoverishing health expenditure and non-exposure to catastrophic health expenditure.
Results
The results indicate that the CBHI increases primary healthcare utilisation for non-poor (OR 1.36 (CI90 1.02–1.8) for the general scheme and 1.37 (CI90 1.06–1.77) for the special scheme for indigent recipients of social cash transfers), protect them against catastrophic (OR 1.63 (CI90 1.12–2.39)) or impoverishing (OR 2.4 (CI90 1.27–4.5)) health expenditures. However, CBHI has no impact on the poor’s healthcare utilisation (OR 0.61 (CI90 0.4–0.94)) and do not protect them from the burden related to healthcare expenditures (OR: 0.27 (CI90 0.13–0.54)).
Conclusion
Our study found that CBHI has an impact on the non-poor but does not sufficiently protect the poor. This leads us to conclude that a health insurance programme designed for the general population may not be appropriate for the poor. A qualitative study should be conducted to better understand the non-financial barriers to accessing care that may disproportionately affect the poorest.
... Te country is in the process of implementing the Health Sector Transformation Plan II (HSTP-II), in which patients' legitimate expectations and fnancial fairness are incorporated as key priority agendas [27,28]. To encourage fairness in fnancial contributions, the Ethiopian government implemented the community-based health insurance (CBHI) program in 2011 as an emerging and promising concept, which addresses healthcare challenges faced in particular by the poor individuals [29]. In the CBHI program, members regularly pay small premiums into a collective fund which is then used to pay for health services that they require [30]. ...
Background. An effective designation of health facilities improves the facility’s ability to respond to patients’ legitimate expectations. Limited evidence exists regarding the association between health system responsiveness and financial fairness in Sub-Saharan Africa, particularly in Ethiopia. The purpose of the study was, therefore to evaluate the health system responsiveness among insured and uninsured outpatients in primary healthcare facilities and determine the association between health insurance and health system responsiveness among outpatients. Methods. A facility-based cross-sectional study was conducted between March 30 and April 30,2021. The study sampled 423 participants using a systematic random sampling technique, and the data was collected with structured and pretested questionnaires administered by interviewers. Responsiveness was measured using the short version of the World Health Organization’s multicountry responsiveness survey, which has seven dimensions including autonomy, communication, confidentiality, attention, dignity, choice, and amenities. Using quantile regression, a specific association between health insurance and the health system responsiveness index was examined, adjusting for sociodemographic, quality, and satisfaction-related factors. Results. Of a total of 417 outpatients, 70.74% had health insurance. There was no statistical difference in health system responsiveness among insured and uninsured outpatients. Possession of health insurance was not associated with responsiveness (−0.67; 95%CI: −1.59, 0.25). There was a statistically significant negative relationship between age and responsiveness (−1.33; 95% CI: −2.47, −0.19) among 30–39 year olds and (−1.66; 95% CI: −3.02, −0.32) among 40–49 year olds. However, there was a positive statistical association between responsiveness with urban residence (+1.33; 95%CI: 0.37, 2.29), perceived quality of healthcare (+2.96; 95%CI: 1.95, 4.05), and patient satisfaction (3; 95%CI: 1.94, 4.07). Conclusions. There was no difference in the responsiveness of the health system between insured and uninsured outpatients. All domains need further improvement, particularly those more closely related to patients’ concerns, such as waiting time to get service and choices of healthcare providers. Furthermore, health facility administrators and the government should enhance responsive healthcare services in parallel with quality improvement and patient satisfaction, based on feedback from service users for better performance.
... The top 20 documents represented 69.8% of the dataset's 1429 citations, accounting for 998 citations. As Table 3 illustrates, (Jütting 2004;Carrasquillo and Pati 2004;Mills 2009) are the most cited article with citation scores of 184, 101, & 89, respectively. The remaining documents from the top 20 list were cited 14 to 82 times (see Table 3). ...
Emerging environmental sustainability issues require governments to develop effective policies to respond to them appropriately. The insurance industry can contribute to the risk management of climate change and environmental issues by offering green insurance products. In this study, a bibliometric analysis was conducted to research the articles investigating the policy implications of different types of green, environmental, and sustainability insurance as risk management, risk mitigation, and damage or impact assessment techniques applied in diverse practices. Bibliometric analysis approaches, such as bibliographic coupling and co-occurrence analyses, were utilized. The analysis revealed seven key research themes. Recommendations for future research include investigating the impacts and development of assessment instruments of environmental, sustainable, and green insurance and their various products.
... Community-based health insurance schemes for example, have seen large number of people enrolling into the schemes for financial protection against high costs of illnesses. Members of a certain CBHI scheme tend to visit health facility more frequent than non-members (Jutting's, 2003). This is contributed by the fact financial barriers when one needs health care services are reduced by pre-payment and risksharing within the members of the scheme. ...
Older Persons Cash Transfer (OPCT) was introduced in Kenya in 2006 to provide financial assistance to the elderly people in the country. National budget allocation for the programme as well as enrollment of new beneficiaries have consistently increased over the years but vulnerability among the elderly population still remain high. The study area is located in an arid and semi-arid region, in Kitui County, Kenya that is characterized by limited income generations activities and low food production due to unpredictable weather. The aim of this study was to assess the socio-economic impacts of Older Persons Cash Transfer (OPCT) on the beneficiaries living in Mulundi sub-Location, Kitui County, Kenya. This study adopted a cross-sectional mixed methods approach to investigate the impacts of OPCT using both quantitative and qualitative data. A census survey was applied to undertake household study for all the 113 registered OPCT beneficiaries in Mulundi sub-location. The study found that female beneficiaries were more (58%) than men (42%) where majority of female beneficiaries were widowed (53%) and 72% were in the age between 65 and 75 years old. Apart from the few elderly (21%) who had alternative sources of income, majority (79%) depended on OPCT as the main source of income for their upkeep. Most of beneficiaries used the cash to buy food (44%), and pay school fees for their dependants (30%) while others spent on health care (12%) and buying clothing (10%). Due to age limit 32% of the elderly rarely got involved in the community development activities compared to 25% who totally were never involved. Majority of the beneficiaries felt that the monthly stipend allocation to each beneficiary was not adequate to cater for most of their needs. In line with that opinion, majority of the beneficiaries (57%) were not satisfied with the programme. This study established several challenges hindering realization of socio-economic impacts of cash transfer in the study area which included; inadequate and irregular disbursement of grants, management challenges, lack of clear channel for the beneficiaries to express their grievances and complaints, increased cost of living, and lack of transparency in the programme. This study recommends that appropriate measures should be put to investigate on the challenges to enhance management so that socio-economic benefits of the programme can be achieved.
... Health insurance is among the healthcare financing reforms proposed to increase the available healthcare resources and decrease the risk of household financial crisis [6]. Health insurance has been endorsed in LMICs to improve access to healthcare services because it avoids direct payments of fees by patients and spread the financial risk among all the insured members [7,8]. ...
Background:
Health insurance is among the healthcare financing reforms proposed to increase the available healthcare resources and to decrease the risk of household financial crisis. Recently, Ethiopia has been implementing community-based health insurance which mainly targets the very large rural agricultural sector and small and informal sector in urban settings. Therefore, this study was aimed to assess the coverage of health insurance and its determinants in Ethiopia.
Methods:
Data were extracted from the 2019 mini Ethiopian Demographic and Health Survey (EDHS) to assess determinants of health insurance coverage in Ethiopia. The analysis included a weighted sample of 8663 respondents. Multivariable logistic regression analysis was conducted and the results were presented as adjusted odds ratio (AOR) at 95% confidence interval (CI), statistical significance was declared at a p-value < 0.05 in all analyses.
Results:
The health insurance coverage in Ethiopia was 28.1% (95%CI: 27.2%, 29%). Administration regions (Tigray: AOR = 16.9, 95%CI: 5.53, 51.59, Amhara: AOR = 25.8, 95%CI: 8.52, 78.02, Oromia, AOR = 4.27, 95%CI: 1.41, 12.92, Southern Nations, Nationalities and Peoples region, AOR = 4.06, 95%CI: 1.34, 12.32, Addis Ababa, AOR = 4.65, 95%CI: 1.46, 14.78), place of residence (rural, AOR = 1.38, 95%CI: 1.17, 1.63), sex of household head (male; AOR = 1.23, 95%CI: 1.07, 1.41), wealth index (middle, AOR = 1.75, 95%CI: 1.46, 2.09, richer, AOR = 1.86, 95%CI: 1.55, 2.24), family size (≥ 5 members, AOR = 1.17, 95%CI: 1.03, 1.33), having under-five children (AOR = 1.22, 95%CI: 1.076, 1.38), and age of household head (31-40 years, AOR = 1.71, 95%CI: 1.45, 2.01, 41-64 years, AOR = 2.49, 95%CI: 2.12, 2.92, 65 + years, AOR = 2.43, 95%CI: 2.01, 2.93) were factors associated with health insurance coverage.
Conclusions:
Less than one-third of Ethiopians were covered by health insurance. Socio-economic factors and demographic factors were found to associate with health insurance coverage in Ethiopia. Therefore, enhancing health insurance coverage through contextualized implementation strategies would be emphasized.
... Similar studies in Cameroon, Kenya and Senegal also highlight income as an important enabling factor that determines enrolment in health protection schemes [81,86,87]. Within the health economics literature in sub-Sahara Africa, poverty has been given excessive weight as the main determinant health insurance coverage [4,22,26,27,88,89]. Due to the lower enrolment of people from poorer socioeconomic backgrounds in the scheme, some of the papers described the scheme as a near pro-rich bias health protection scheme that requires considerable modifications to meet the needs of the "hardcore poor. ...
Background
We conducted an integrative review in an attempt to methodically and systematically understand the individual (personal factors) that influence National Health Insurance Scheme [NHIS] enrolment among older adults aged 50 years and above. The study was premised on evidence pointing to a state of little or no change in the enrolment rates [especially among older adults], which contrasts with the initial euphoria that greeted the launch of the scheme - which culminated in high enrolment rates.
Methods
The integrative literature review was conducted to synthesise the available evidence on individual determinants of NHIS among older adults. The methodological approach of the integrative literature review follows a five-stage interdependent and interconnected procedure of problem identification, literature search, data evaluation, data analysis and results presentation. Studies that met the inclusion criteria were peer-reviewed articles published in the English Language, from January 2010 to July 2020 and have Ghana as its setting or study area. The Andersen's Behavioural Model was used to categorize the predictor variables.
Results
Predisposing factors [gender, age, level of education and marital status], enabling factors [income] and need factors [health conditions or health attributes of older adults] were identified as individual predictors of NHIS enrolment among older adults. The findings support argument of Andersen's Behavioural Model [where predisposing, enabling and need factors are considered as individual determinants of health behaviour].
Conclusions
The findings call for policy reforms that take into account the aforementioned individual predictors of NHIS enrolment, especially among the aged.
... This has implications for efforts towards achieving UHC as well as SDGs Goal 3 in the study state. Our finding is consistent with previous studies in LMICs reported by SHIELD [29], Chomi et al. [17], Jutting [30], Asibey and Agyemang [31] Robyn et al. [12], and Mensah et al. [32] who found a significant association with health insurance and care-seeking behaviour. However, the finding is in contrast with another study which reported that health insurance has an effect on increased utilization of healthcare services, particularly in situations where an insured individual is still able to access quality care in the absence of insurance [33]. ...
Background:
Appropriate health-seeking behaviour (HSB) is crucial for improving health outcomes and achieving universal health coverage (UHC). Accessing healthcare through the state social health insurance scheme (SSHIS) could lead to improved HSB. The study explores the influence of access to healthcare through health insurance on the HSB of the enrollees of the SSHIS in southeast, Nigeria.
Methods:
A descriptive cross-sectional study undertaken in twelve health facilities in Anambra state using quantitative and qualitative research methods. Data were collected through a facility-based survey (n = 447) and sex-disaggregated focus group discussions (n = 12) of health insurance enrollees. Univariate and bivariate analyses were performed for quantitative data, while qualitative data were analyzed using a manual content approach.
Result:
The findings revealed a positive change in enrollee's HSB post-health insurance enrollment. Majority (83%) of the respondents reported that they immediately take action when ill post-health insurance enrollment as against 34% (pre-health insurance) resulting in a 49% increase, with a statistically significant difference (p < 0.02). There was a statistically significant association between positive HSB and marital status (p < 0.04); educational level (p < 0.00); occupation (p < 0.03) and ownership of health facility (p < 0.00). There was an increase in the percentage of enrollees who use the hospital as their first choice of provider during an illness episode post-health insurance enrollment. This increased from 37.4% to 90.2% (post-health insurance enrollment), representing a 52.8% increase, which is statistically significant (p < 0.03), in seeking care in hospitals. Similarly, the percentage (46%) of enrollees using patent medicine vendors (PMVs) as their first choice of provider when ill prior to enrollment in health insurance decreased to 8.1% post-health insurance enrollment, representing a 38% decline with a statistically significant (p < 0.00) drop in PMV patronage. Reasons for positive HSB include low cost of services and availability of quality care such as quality drugs, presence of doctors, and other skilled health workers by the health insurance facilities.
Conclusion:
Health insurance has been established as an effective strategy for improving appropriate HSB. Hence, increasing coverage of health insurance among the uninsured is crucial in improving access to quality and affordable health care towards achieving UHC, particularly in developing countries.
... This implies that while the Federal government coordinating the tertiary arm, the State government manages the secondary arm comprising general hospitals and health centers and Local government is concerned with the provision of basic health to grassroot people. In the past, studies had ascribed several problems militating against the growth of health insurance demand to include: inadequate awareness and education; non-engagement of employers; inadequate health facilities; concentration on elites, corporate and institutional clients; inadequate well trained health personnel or physicians; increasing population; and poor working conditions of medical personnel (Swartz 2009 & Jütting, 2005), and the health system in these countries have failed to provide adequate access to health services and financial protection for citizens, such that many people still rely on out-of-pocket payment to provide finances for their health care needs (Drechsler & Jütting, 2007;Jütting, 2004 However, insurance usage and patronage in Nigeria has constantly underperformed in terms of its contribution to the gross domestic product, penetration and demand. More so, health risks are not appropriately pooled; so the poor, the low income earners, the elderly, and less healthy are excluded from insurance in spite of the emergence of many illnesses that are not common with us and the lack of fund by many families to pay for these illnesses when they occur (Dror & Jacquier, 1999;Sanusi & Awe, 2009;Kannegiesser, 2009). ...
This study assesses socio-demographic variables on the demand for health insurance in Lagos State. For this purpose, the researchers have been able to examine selected socioeconomic and demographic variables and their effects on health insurance accessibility and desire of individual households. The explanatory research design was employed. A convenience sampling technique was adopted. Data was gathered from individual households within Alimosho and Ojo Local Government Areas of Lagos State through the use of an interviewed schedule. The sample consisted of 212 respondents made up of individual households within the sample areas. Data collected was analysed using multiple regression technique. The study was able to establish some level of contributory linkage between selected socio-demographic variables and demand for health insurance. The findings show that while education and income both appeared to have significant 15 effect, gender and age both have positive contributory effect. The study therefore recommends that health insurance providers should endeavour to education the larger society of the significance of health insurance products to human existence. Secondly, a robust strategic health insurance outlines should be designed to incorporate the vulnerable ones in the society to ensure equality and fairness in the provision of National Health Insurance Scheme. Lastly, Health Maintenance Organisations should endeavour to implement flexible payment plans for participants in order to improve participation of more individuals.
... [1][2][3] However, it is not easy to activate and expand the public health insurance system to cover the informal sector, owing to factors like poverty, poor tax systems, systematic and operational insufficiencies, lack of awareness, and avoidance of paying insurance contributions, that are associated with the informal sector. [4][5][6] ...
Though it has passed over 30 years, Korea’s community-based health insurance (CBHI) expansion can provide useful policy implications to developing countries with similar conditions, that is, lack of fiscal resources, health infrastructure, and medical resources to expand coverage to the informal sector. We summarized three groups of success factors through in-depth interviews and narrative analysis: system design, system operation, and public perception of the system. Korean CBHI could expand to the informal sector with the same system design as the formal sector such as mandatory enrolment, compulsory designation of medical service providers along with the low-benefit, low-contribution, and a low-payment system. However, expansion to the informal sector was somewhat different, as the CBHI exercised and operated the scheme with flexibility, semi-autonomy and leadership to fit for local context in terms of operation. Moreover, cultural factors that encouraged public awareness and increased participation significantly contributed in appealing to the informal sector. Overall, the systemic, operational, and cultural factors interacted with each other and created a synergy effect that local members in the informal sector found attractive.
... 15,16 This concept addresses health care challenges faced by poor people, especially the vulnerable and rural residents. 17 The introduction of the National Health Insurance Scheme (NHIS) in Ghana became imminent due to the failure of many health funding mechanisms, to ensure financial accessibility and UHC to the population. 18 The NHIS program introduced an exemption scheme to improve access to affordable health care services among the poor and vulnerable (people with no source of income or fixed place of residence, nor live or depend on a person who is employed and has a fixed place of residence). ...
Purpose:
Health-related expenditures pose a significant burden on vulnerable populations. This study assessed the availability and affordability of primary health care among disadvantaged populations in urban Kumasi Metropolis, Ghana.
Methods:
This study was a descriptive cross-sectional study conducted among multi-level participants of vulnerable populations ≥18 years of age (n=710) constituting the older adults/aged, pregnant women, head porters, sex workers, and other vulnerable groups (people with disabilities and the homeless). Data were collected using a semistructured questionnaire. Poisson regression with robust variance was used to assess the association between vulnerability and access to health care.
Results:
There were significant differences in the availability and adequacy of health care among the vulnerable groups studied. Distance to the source of care was >5 km for majority of the vulnerable groups and the average expenditure on a visit to the health facility was GH¢ 27.04 (∼US$ 5.55 as at January 2019). Challenges to health care among the vulnerable groups included monetary (37.9%), stigmatization (18.6%), and staff attitude (25.9%). Head porters and other vulnerable groups were less likely to view health care as affordable compared with older adults. The difference in the perception of health care affordability was, however, explained by sociodemographic characteristic and health care-related factors.
Conclusion:
Despite the introduction of a National Health Insurance Scheme in Ghana, this study highlights challenges in health care access among vulnerable populations independent of the type of vulnerability. This suggests the need for stakeholders to adopt other innovative care strategies that may have broader applicability for all populations.
... La littérature sur les effets de l'assurance maladie sur l'utilisation des services de santé n'est pas toujours unanime, des études montrant un impact positif, d'autres n'en trouvant aucun. Ainsi, Jütting (2003) trouve au Sénégal que les membres d'une mutuelle utilisent plus les hôpitaux que les non membres et qu'ils dépensent moins de 50% de ce que les non-membres dépensent. En Jordanie, Ekman (2007) constate que l'assurance augmente l'intensité d'utilisation des soins ambulatoires et réduit les dépenses de santé. ...
... The impact of CBHI on per capita OPD visit as estimated in this study was lower compared to ndings from the evaluation of the pilot study which reported 45-64% increase in frequency of visits (23). The positive impact of CBHI on health service utilization in general corroborated sub-national studies in Ethiopia (25), and similar studies from elsewhere (43,46,54). The relatively lower effect size we identi ed compared to ndings from the evaluation of the pilot project in the early years (23) could be a result of differences between intensity of implementation of CBHI schemes between the pilot and scale-up phases. ...
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.
... In addition to raising hope in policy circles aiming for UHC, CBHI schemes have been subject to much attention in the research literature. Studies investigating their effects on financial protection and health-related outcomes have shown that they could help mitigate out-of-pocket expenditures (Ekman, 2004;Jütting, 2004;Aggarwal, 2010), increase healthcare utilization Aggarwal, 2010) and, in some cases, improve health outcomes (Wang et al., 2009;Aggarwal, 2010). However, conflicting results have been reported as well, suggesting that these effects vary across populations and settings (Fink et al., 2013;Raza et al., 2016). ...
Community-based health insurance (CBHI) has been implemented in many low and middle-income countries to increase financial risk protection in populations without access to formal health insurance. While the design of such social programs is fundamental to ensuring equitable access to care, little is known about the operational and structural factors influencing enrolment in CBHI schemes. In this study, we took advantage of newly established data monitoring requirements in Senegal to explore the association between the operational capacity and structure of CBHI schemes—also termed ‘mutual health organisations’ (MHO) in francophone countries—and their enrolment levels. The dataset comprised 12 waves of quarterly data over 2017–2019 and covered all 676 MHOs registered in the country. Primary analyses were conducted using dynamic panel data regression analysis. We found that higher operational capacity significantly predicted higher performance: enrolment was positively associated with the presence of a salaried manager at the MHO level (12% more total enrollees, 23% more poor members) and with stronger cooperation between MHOs and local health posts (for each additional contract signed, total enrollees and poor members increased by 7% and 5%, respectively). However, higher operational capacity was only modestly associated with higher sustainability proxied by the proportion of enrollees up to date with premium payment. We also found that structural factors were influential, with MHOs located within a health facility enrolling fewer poor members (−16%). Sensitivity analyses showed that these associations were robust. Our findings suggest that policies aimed at professionalising and reinforcing the operational capacity of MHOs could accelerate the expansion of CBHI coverage, including in the most impoverished populations. However, they also suggest that increasing operational capacity alone may be insufficient to make CBHI schemes sustainable over time.
... While CBHI has became part and parcel of health financing scheme in developing countries and thereby dozens of scientific evidence on its impacts on health outcomes is available in different country's context, the complex nature of the issues and divergent contextual factors always leave a room for further research works (Dow & Schmeer, 2003;Nshakira-Rukundo et al., 2020). For instance, scientific studies on major determinant factors of insurance subscription (Mebratie et al., 2015bb;Dror et al., 2016;Panda et al., 2014), drop out (Atinga et al., 2015;Dong et al., 2009;Mladovsky, 2014), access and utilization to modern health care (Jütting, 2004) reduce out of pocket payment and thereby financial protection (Habib et al., 2016;Nguyen et al., 2011) and other related socio-economic issues (Asfaw & von Braun, 2004a;Landmann & Frölich, 2015;Parmar et al., 2012), has been considerably assessed in comparative terms. Moreover, two systematic reviews conducted by Ekman (2004) and Preker et al. (2002) on impacts on CBHI indicated that membership to the scheme improved use of facilities in modern health care in nearly 14 nations. ...
Though financial protection and improvement in health seeking behavior of rural societies is the intended role of health insurance schemes, empirical evidence indicated that the scheme faced multitude of implementation challenges. This paper examined insurance enrollees’ perceived preferential treatment for paying clients and other concomitant problems in Eastern Gojjam district of north western Ethiopia. Researchers conducted in-depth interviews with 53 enrollees, six FGDs (with a total of 48 discussants) and 7 key informants with professionals from public healthcare facilities and other health insurance administrators. The data encoding, transcription, and thematic analysis process was all conducted manually. Findings indicated that, despite the economic relief households gained, the thrust on the service delivery process seems to be far behind. Comparing them with paying patients combined with the presumed “free medical treatment” that they associated with the insurance, the perceived preferential treatment for paying patients by practitioners seems common. Due to this, most participants hold a belief that visiting private health facilities during critical illness appears preferable to get quality health service. The perceived preferential treatment is alleged to be happening during consultation with physicians, medicine prescription, referral service, patient flow management, and others. Shortage of drugs induced frequent stock out and thereby prolonged reimbursement process, high patient flow induced over load in public health facilities, unnecessary price increment by private pharmacies on insurance beneficiaries and confusion on annual renewal payment without using service are all concomitant problems. Necessary awareness creation interventions and also improvements of public health facilities are recommended.
... Until now, little attention has been paid to identifying the healthcare delivery system gaps as experienced by the consumers (Walt et al. 2008) primarily residing in the rural region. Several studies have been conducted on the preference, willingness to pay for different packages (David Mark et al. 2007), premium estimation, network of healthcare providers, and management structures (Jütting 2004;Dror et al. 2007;Jain et al. 2014). Still, very limited research is being carried out that looks deeper into the ground realities and experiences of the population residing in the rural area. ...
Low- and middle-income countries face challenges in healthcare financing, especially in the rural region. Till now, little research has been done to identify issues of the healthcare delivery system and to understand the preferences of the rural population to enrol in the health insurance scheme. This study investigates the ground-level issues intending to provide an empirical view of health insurance preferences for the population residing in the rural region. Data for the study were collected by conducting ten focus group discussions (FGD) and were analysed using grounded theory. 'Insight through participation' emerged as the core category that was generated from five categories: (1) quality-related issues; (2) governance issues; (3) design aspects; (4) financial support for healthcare services; (5) information, education and communication (IEC) activities; and other 17 subcategories. The finding highlights that quality-related issues represented the perceived poor quality of healthcare services and governance issues represented poor governance traits. The categories design aspects, financial support for healthcare services, and IEC activities define the need and the preferences of the people for health insurance. Understanding the issues of the healthcare delivery system and the consumers' preferences in the design of health insurance schemes may increase the enrolment rates.
... There are several possible ways to classify health insurance schemes either introduced by health facilities, members based organizations, local communities or cooperatives, according to, kind of benefits provided, degree of risk pooling, circumstances of their creation, fund ownership and management and the distinction whether the schemes focus on coverage for high-cost, low frequency events or on low cost, high frequency events. Similar characteristics of these schemes are; voluntary membership, non-profit character, prepayment of contribution in to a fund and entitlement to specified benefits, important role of the community in the design and running of the scheme and institutional relationship to one or several health care providers (Jutting, 2003). The changing lifestyles, high level of competition and environmental pollution have engender various health related problems. ...
In Nigeria, health Insurance has been identified as a risk transfer mechanism used primarily to hedge against an unforeseen contingency. Recently debates have revolved around extending health insurance coverage to a wider range of the population as this will ensure growth in the socioeconomic productivity in Nigeria. This study therefore examined the nexus between health insurance and socioeconomic productivity in Nigeria using descriptive research method. Findings from the study showed that there is a significant relationship between private health insurance and socioeconomic productivity. This implies that enrolees on healthcare insurance services are more productive as the out-of-pocket payment for healthcare services tend to be far lower than individuals without healthcare insurance services. The study also revealed that there is a significant relationship between hospital reimbursement benefit and economic development in Nigeria. Lastly the study revealed that accident insurance has a significant effect on economic development in Nigeria. Based on these findings the study recommends that the National Health Insurance Scheme (NHIS) should expand coverage to more persons in the rural and urban centres: while incentives should be provided to promote not-for-profit and community-based insurance schemes. It was also recommended that there is need for the introduction and enforcement of Hospital Reimbursement Benefit through public-private partnership. Finally, the study recommends that the government need to create strong awareness for the benefit of Accident insurance in order to protect the people against sudden eventualities.
... The findings from this study were similar to a number of studies that have examined the effects of health insurance/ micro health insurance schemes on healthcare utilisation and financial outcomes among members [36][37][38][39][40][41]. A number of studies have found higher utilisation of healthcare services among the insured individuals in different settings such as Bangladesh [27,42], Congo [43], Senegal [44], India [45], and Philippines [36,41]. However, a systematic review study found that only 14 out of 24 studies that examined the healthcare utilisation effects of health insurance observed positive outcomes [40]. ...
Background
National healthcare financing strategy recommends tax-based equity funds and insurance schemes for the poor and extreme poor living in urban slums and pavements as the majority of these population utilise informal providers resulting in adverse health effects and financial hardship. We assessed the effect of a health voucher scheme (HVS) and micro-health insurance (MHI) scheme on healthcare utilisation and out-of-pocket (OOP) payments and the cost of implementing such schemes.
Methods
HVS and MHI schemes were implemented by Concern Worldwide through selected NGO health centres, referral hospitals, and private healthcare facilities in three City Corporations of Bangladesh from December 2016 to March 2020. A household survey with 1,294 enrolees, key-informant interviews, focus group discussions, consultative meetings, and document reviews were conducted for extracting data on healthcare utilisation, OOP payments, views of enrolees, and suggestions of implementers, and costs of services at the point of care.
Results
Healthcare utilisation including maternal, neonatal and child health (MNCH) services, particularly from medically trained providers, was higher and OOP payments were lower among the scheme enrolees compared to corresponding population groups in general. The beneficiaries were happy with their access to healthcare, especially for MNCH services, and their perceived quality of care was fair enough. They, however, suggested expanding the benefits package, supported by an additional workforce. The cost per beneficiary household for providing services per year was €32 in HVS and €15 in MHI scheme.
Conclusion
HVS and MHI schemes enabled higher healthcare utilisation at lower OOP payments among the enrolees, who were happy with their access to healthcare, particularly for MNCH services. However, they suggested a larger benefits package in future. The provider’s costs of the schemes were reasonable; however, there are potentials of cost containment by purchasing the health services for their beneficiaries in a competitive basis from the market. Scaling up such schemes addressing the drawback would contribute to achieving universal health coverage.
... The data disclosed that individuals in the lowest and low-income group are more likely to be enrolled in the JBHI scheme in comparison to others. This is supported by previous studies, suggesting that inclusion of the poorest was dependent on the design and implementation features of the scheme [70][71][72][73][74][75][76][77][78]. JBHI collects weekly premiums throughout the year, which makes payment of premiums affordable even for the very poorest households. ...
International Journal for Equity in Health 20(1):235. DOI: 10.1186/s12939-021-01574-4
... The data disclosed that individuals in the lowest and low-income group are more likely to be enrolled in the JBHI scheme in comparison to others. This is supported by previous studies, suggesting that inclusion of the poorest was dependent on the design and implementation features of the scheme [70][71][72][73][74][75][76][77][78]. JBHI collects weekly premiums throughout the year, which makes payment of premiums affordable even for the very poorest households. ...
Background: There is an increasing global concern of financing poor people who live in low- and middle-income countries. The burden of non-communicable diseases of these people is, by in large, connected to a lack of access to effective and affordable medical care, weak financing, and delivery of health services. Policymakers have assumed, until recently, that poor people in developing countries would not pay health insurance premiums for the cost of future hospitalization. The emergence of community-based health financing (CBHF) has brought forth a renewed and empowered alternative. CBHF schemes are designed to be sustainable, varying in size, and well organized. Developing countries, such as Nigeria, have been testing and finetuning such schemes in the hope that they may 1 day reciprocate high-income countries.
Methods: A sample size of 372 respondents was used to assess the slums of Awka, the capital city of Anambra State, Nigeria, and empirically evaluate the socio-demographic characteristics of those who uptake CBHF using the provider Jamii Bora Trust (JBT). Cross-sectional research used a quantitative research approach with the instrumentality of structured questionnaires. Descriptive analysis was adopted to determine the socio-demographic characteristics of those who have CBHF uptake in Awka and evaluate the presence and benefits of CBHF in the city’s slums.
Results: The results show that more youth and middle-aged persons from 18 to 50 years are more insured (i.e., 73.8% combined) than those who are over 50 years of age. Gender distribution confirm more females (i.e., 61.9%) to be health-insured than their male counterpart (i.e., 38.1%). This perhaps reflected the reproductive roles by women and the fact that women have better health-seeking behavioral attitude. Moreover, the results correlate with previous studies that confirm women are more involved in local sustainable associations in low-income settings, of this nature, in sub-Saharan Africa. Corroborating this further, married people are more insured (i.e., 73.8%) than those who are not married (i.e., 26.2%) and insured members report higher use of hospitalization care than the non-insured.
Conclusion: CBHF uptake favored members in the lower income quintiles who are more likely to use healthcare services covered by the JBT scheme. This confirmed that prepayment schemes and the pooling of risk could reduce financial barriers to healthcare among the urban poor. Recommendations are suggested to improve enrollment levels in the CBHF programs.
... Studies from Ghana [11] and Rwanda [12] have shown that HI made access to care more equitable across the general population and reduced the burden of healthcare costs among the poor. Other studies from Ghana and Senegal [13,14] have shown that the insured population aged 60 years and older were able to access inpatient and outpatient care services more than the uninsured. However, there are also negative experiences with HI; a study from Ghana showed that HI failed to protect its members equally, benefiting the educated, rich and those residing closer to health facilities more than others [15]. ...
Background
Health insurance (HI) has increasingly been accepted as a mechanism to facilitate access to healthcare in low and middle-income countries. However, health insurance members, especially those in Sub-Saharan Africa, have reported a low responsiveness in health systems. This study aimed to explore the experiences and perceptions of healthcare services from the perspective of insured and uninsured elderly in rural Tanzania.
Method
An explanatory qualitative study was conducted in the rural districts of Igunga and Nzega, located in western-central Tanzania. Eight focus group discussions were carried out with 78 insured and uninsured elderly men and women who were purposely selected because they were 60 years of age or older and had utilised healthcare services in the past 12 months prior to the study. The interview questions were inspired by the domains of health systems’ responsiveness. Qualitative content analysis was used to analyse the data.
Results
Elderly participants appreciated that HI had facilitated the access to healthcare and protected them from certain costs. But they also complained that HI had failed to provide equitable access due to limited service benefits and restricted use of services within schemes. Although elderly perspectives varied widely across the domains of responsiveness, insured individuals generally expressed dissatisfaction with their healthcare.
Conclusions
The national health insurance policy should be revisited in order to improve its implementation and expand the scope of service coverage. Strategic decisions are required to improve the healthcare infrastructure, increase the number of healthcare workers, ensure the availability of medicines and testing facilities at healthcare centers, and reduce long administrative procedures related to HI. A continuous training plan for healthcare workers focused on patients´ communication skills and care rights is highly recommended.
... Financial shortage to access health-care services might be averted by moving from out-of-pocket payment (OOP). Community-Based Health Insurance (CBHI) is a platform accomplished and functioned by a community-based organization, exclusive of government or a private for-profit company, that offers risk-pooling to cover the expenses of health care services [4]. ...
Introduction
Modern health services utilization in developing countries has continued low. Financial shortage to access health-care services might be averted by stirring from out-of-pocket payment for health care at the time of use. The government of Ethiopia; depend greatly on foreign aid (50%) and out-of-pocket payments (34%) to fund health services for its population. This study was aimed to identify factors associated with households’ enrollment to CBHI scheme membership.
Methods
Case-control study design was conducted from May 18–July 27, 2019 among 332 participants (166 enrolled and 166 non-enrolled to CBHI scheme). Simple random sampling technique was used to select the study participants. Bi-variable and multivariable logistic regression model were fitted to identify factors associated with enrollment to community based health insurance. Adjusted odds ratio (AOR) with 95% CI was used to report association and significance was declared at P<0.05.
Result
A total of 332 (100% response rate) were involved in the study. Educational status (College and above, AOR = 3.90, 95%CI; 1.19, 12.75), good awareness about CBHI scheme (AOR = 21.595, 95% CI; 7.561, 61.681), affordability of premium payment (AOR = 3.403, 95% CI; 5.638–4.152), wealth index {(Poor, AOR = 2.59, 95%CI; 1.08, 6.20), (Middle, AOR = 4.13, 95%CI; 1.11, 15.32)} perceived health status (AOR = 5.536; 95% CI; 1.403–21.845), perceived quality of care (AOR: 21.014 95%CI; 4.178, 105.686) and treatment choice (AOR = 2.94, 95%CI; 1.47, 5.87) were factors significantly associated with enrollment to CBHI.
Conclusion
Enrolment to CBHI schemes is influenced by educational level, awareness level, affordability of premium, wealth index, perceived health status, perceived quality of care and treatment choice. Implementation strategies aimed at raising community awareness, setting affordable premium, and providing quality healthcare would help in increasing enrollment of all eligible community groups to the CBHI scheme.
... al., 2004). Thus, health security is increasingly being recognized as integral to any poverty reduction strategy (Jutting, 2003). While the objective of poverty reduction remains a central concern, there has been a shift of focus away from poverty reduction per se to social risk management (Holzmann & Jorgensen, 2000). ...
Frequent incidence of illness among households which incur huge amount of money for healthcare bills is a significant reason for poverty and indebtedness in developing countries. Since the poor cannot afford to pay insurance premium high enough to justify private investment, public intervention is necessitated. A number of public health care schemes have come up in India since recently, both at the state and central level. This paper makes an assessment of the performance of Mizoram State Health Care Scheme basically using the database of the implementing agency. Though the scheme has been implemented satisfactorily in certain areas, especially turnaround time for bill settlements, coverage and financial soundness, the study also indentified the areas where improvements can be made.
The global insurance system is growing rapidly in a large number of countries in the world, including Indonesia. OJK shows support for increasing the growth of the Islamic finance industry in Indonesia by establishing a Sharia micro-insurance product which was officially launched in 2014. Therefore, to maintain its existence it must be supported by good governance. So, this study aims to meet the development trend of Microinsurance research published by leading journals on microinsurance. The data analyzed consisted of 198 indexed research publications. The data is then processed and analyzed using the VoS viewer application to find out the bibliometric map of Islamic microinsurance research development.
The study aims to assess the public perception on the effectiveness of health insurance services provided by the Government of Nepal. This study adopts a descriptive and analytical research design. A sample of usable 135 respondents was collected using purposive sampling method from the respondents in Kathmandu District. The influencing factors of public perception taken were level of awareness, information sources, level of satisfaction and problems faced. The study also examined the public perception influenced on the health insurance service growth in Nepal. The study concluded that for the successful implementation of health insurance coverage, it was found necessary to understand the basic dynamics of consumer preferences, service providers, acceptability, and pricing of health insurance products.
The concept of micro health insurance (MHI) has gained increasing importance in the context of both the international research community and the international development sector. Although many MHI schemes have been existing for years, there is still a lack of data and basic knowledge about the historical background, emergence and status quo of micro health insurance in sub-Saharan Africa. This article contributes to filling this gap by presenting different institutional types of MHI in order to give a systematic overview of emergence and spread of MHI in its different types in various regions of sub-Saharan Africa. The current status of MHI in Africa is presented to complete the overview. In conclusion, the chosen approach reveals (a) a remarkable diversity of MHI and certain recent trends of MHI development in sub-Saharan Africa and (b) a regional concentration of institutional ideas hinting at regional but also continent-wide learning processes.
Engozi, a traditional health and social-services system has existed for centuries in southwestern Uganda. Members contributed funds for: healthcare, transport for patients to hospitals and burial ceremonies for members. Membership focused on clanship or neighbourhood. The establishment of “free public healthcare services” led to the decline of the engozi system. However, due to inadequate government resource allocation to health sector, the government health services cannot meet the needs of the rural communities. Equitable access to healthcare is still unachievable even after the abolition of user fees. Cost of services is still a key barrier, and the poor have limited access to quality healthcare services. CBHI was fronted as one strategy to address such inequities. In 1996, the Kisiizi community leveraged on the engozi groups’ traditions to establish the first Community-based Health Insurance (CBHI) Scheme in Uganda, promoting access to quality healthcare at a low cost. CBHI has been successful in reducing out-of-pocket payments, obtaining financial protection against catastrophic health expenditures and improving access to healthcare in low-income communities. The goal of this study was to explore the significance of community values and traditions in addressing healthcare inequities through a CBHI approach. This study adopted a case study methodology and qualitative methods., The study was guided by Woolcock’s social capital theory.
Conclusion: This paper affirms that communities characterized by solid intra-community ties are more likely to experience success with CBHI. It adds that compliance to society values and traditions; and active involvement of community leaders in the planning and execution of CBHI are essential determinants of success. Consequently, the CBHI scheme addresses contemporary healthcare inequities through; breaking financial barriers to accessing quality healthcare, promoting early healthcare-seeking behavior, and leads to increased equity in healthcare access and utilization.
Mikrokrankenversicherungen (MKV) für arme Bevölkerungsschichten haben vor allem das Ziel, die Folgen hoher Krankheitsausgaben abzumildern. In den letzten zwei Jahrzehnten hat sich ein weites Spektrum institutioneller Ausgestaltungen von MKV entwickelt, die sich hinsichtlich der Handlungslogik und der Anreizstruktur stark unterscheiden. Dieser Beitrag legt dabei den Schwerpunkt auf den Stellenwert von Partizipation und zeigt typinhärente Einschränkungen von Partizipationsmöglichkeiten für Mitglieder bzw. Kunden auf. Mitgliederpartizipation stellt in Mikrokrankenversicherungen einen entscheidenden Betriebsfaktor dar, da sich dadurch Informationsprobleme reduzieren und Transaktionskosten senken lassen. Eine hohe Intensität an Partizipation kann eine Vielzahl zumeist positiver Effekte auf die Geschäftsfunktionen einer Mikroversicherung erzeugen. Der vorliegende Beitrag untersucht, inwieweit genossenschaftlich organisierte MKV durch die besonderen Partizipationsmöglichkeiten Vorteile bei den betrieblichen Funktionen gegenüber anders organisierten MKV besitzen.
The Community‐Based Health Insurance (CBHI) scheme was introduced in Ethiopia to overcome the population's over‐reliance on direct out‐of‐pocket expenditures for health care and the associated low level of health service utilization. CBHI is an advance payment arrangement, established on the household level, and targeted mainly at informal sectors in rural areas. After a successful 3‐year pilot implementation, the Ethiopian government decided to expand the CBHI scheme implementation. It has received wide interest among community members, especially those living with chronic diseases and perceived impaired family health status. Low enrollment to the scheme was the barrier to its initial expansion due to limited awareness and misconceptions about the program, financial constraints to paying premiums, and dissatisfaction with the health services. The evaluation of CBHI scheme implementation and future implications in Ethiopia could be better seen from both the learning experience during the implementation process and achievements of the policy objectives. Community‐Based Health Insurance (CBHI) was introduced in Ethiopia to reduce out‐of‐pocket expenditures, ensure citizens' access to and utilization of essential health services Various facilitators and barriers to the CHBI scheme enrollment were identified The CBHI policy's success in Ethiopia could be better seen from the perspective of both the learning experiences during the implementation process and achievement of its objectives. Community‐Based Health Insurance (CBHI) was introduced in Ethiopia to reduce out‐of‐pocket expenditures, ensure citizens' access to and utilization of essential health services Various facilitators and barriers to the CHBI scheme enrollment were identified The CBHI policy's success in Ethiopia could be better seen from the perspective of both the learning experiences during the implementation process and achievement of its objectives. 埃塞俄比亚引入了以社区为基础的健康保险（CBHI）计划，以克服人口对用于医疗的直接自付费用的过度依赖以及相关的医疗服务使用程度低的问题。CBHI是一种预付款安排，其建立在家庭层面，主要针对农村地区的非正式部门。经过3年的成功试点后，埃塞俄比亚政府决定扩大CBHI计划的实施范围。它引起了社区成员的广泛兴趣，特别是那些患有慢性病和被认为家庭健康状况受损的人。由于对该计划的认识不足和误解、支付保费的财务限制以及对医疗服务的不满，该计划的低参与率曾是其最初扩张的障碍。对埃塞俄比亚CBHI政策成功和未来影响的判断可能不得不考虑具有广泛前景的学习经验和政策目标的成就。 El plan de seguro de salud basado en la comunidad (CBHI) se introdujo en Etiopía para superar la dependencia excesiva de la población de los gastos de bolsillo directos para la atención de la salud y el bajo nivel asociado de utilización de los servicios de salud. CBHI es un acuerdo de pago por adelantado, establecido a nivel del hogar y dirigido principalmente a los sectores informales en áreas rurales. Después de una exitosa implementación piloto de 3 años, el gobierno etíope decidió expandir la implementación del esquema CBHI. Ha recibido un gran interés entre los miembros de la comunidad, especialmente aquellos que viven con enfermedades crónicas y perciben un estado de salud familiar deteriorado. La baja inscripción en el esquema fue la barrera para su expansión inicial debido a la poca conciencia y los conceptos erróneos sobre el programa, las limitaciones financieras para pagar las primas y la insatisfacción con los servicios de salud. Los juicios sobre el éxito de la política CBHI y las implicaciones futuras en Etiopía pueden tener que considerar tanto la experiencia de aprendizaje con perspectivas de amplio alcance como los logros de los objetivos de la política.
CITATIONS 6 READS 555 4 authors, including: Some of the authors of this publication are also working on these related projects: Involvement of cytoskeleton in the chemotaxis of cells without peripheral motile organelles View project Lichen biotechnology View project Rocio Santiago
Background
Poor health care financing remains a major challenge to health service utilization among the lower socioeconomic society. Consequently, countries have designed different health insurance programs to overcome financial barriers against health services utilization. Similarly, Ethiopia has been implementing community-based health insurance programs since 2011 to improve health care financing system. However, only a small number of people are enrolled which might be attributed to lack of willingness towards the program and the reasons for this remained under reported. This study was intended to examine willingness to join the community-based health insurance program and its associated factors in South Wollo, Northeast Ethiopia.
Method
A community-based cross-sectional study was conducted among 421 households. A multistage systematic random sampling technique was employed to recruit the study households. Data were entered into EpiData version 3.1 and was exported into SPSS version 24.0 for analysis. Bivariable and multivariable logistic regression analysis with a backward elimination method was performed to identify the determinants of willingness to join community-based health insurance. Finally, a statistically significant level was declared at a p-value of less than 0.05.
Results
Two hundred and ninety-three [73.6% (95%CI:68.8%-77.9%)] households were willing to join community-based health insurance programs. Being male headed household (AOR:0.2, 95%CI: 0.07–0.58), being a member of Idir (AOR:0.46, 95%CI: 0.25-.84), absence of chronic illness in the household (AOR: 0.31, 95%CI: 0.13–0.77), and family size < 4 (AOR: 0.18, 95% CI:0.08–0.41) were barriers to join community-based health insurance program whereas rural residency (AOR:1.9, 95% CI: 1.09–3.32), perceived quality health services (AOR:2.96, 95%CI:1.4–6.24), and having positive attitude (AOR:4.1, 95%CI:2.32–7.22) and good knowledge to programs (AOR:2.62, 95%CI:1.43–4.8) were enabling factors.
Conclusion
Nearly three-fourths of the households were willing to join community-based health insurance programs. However, different household and health service-related factors affected their willingness. The ministry of health with the regional and woreda health offices should work towards improving the quality of health services, conduct program advocacy and community sensitization towards the program, and build trust with the community.
The COVID-19 pandemic has result in unprecedented challenges for the manufacturing and service sectors. Further, it has also tremendously affected the global healthcare sector, which is seen in the surge of demand in personal protective equipment, ventilators, masks, medicines, etc. Furthermore, according to Menear (2020), the world population is projected to be at least 8.5 billion people by 2050, including a much higher elderly population. This calls for an urgent, critical evaluation and upgrade of the healthcare sector. In this regard, an implementation of Industry 4.0 (I4.0) technologies is proposed to fulfill the sector’s current and future needs. A detailed and systematic review has been conducted using PRISMA, which highlights the various I4.0 technologies for the early detection, control, and management of the healthcare supply chain as a whole. Finally, it is imperative that I4.0 be properly implemented for better management of the global healthcare sector. The study also highlights policy implications for stakeholders.
Post insurance reforms of India witnessed new insurance products in the health sector which were not available before the reforms. The share of health care expenditure to GDP is very low in India compared to other developing nations. Due to the exponential increase in the health care segment, the demand for health insurance product increased. As the demand for health care services is increasing in India it becomes important to study the factors which induce the demand for health insurance. Due to the absence of proper health care system in India, private health care system emerges very strongly and cost per head in health care is increasing very fast. It has become very difficult for lower-middle and middle-class people to afford the cost of health care. This has improved the awareness level of having health insurance to protect them from any unforeseen health cost in near future. I assume and propose that rising cost of health insurance would help people to understand the importance of unforeseen risk in case of health cost and induce to purchase health insurance products. As the cost of health seems to be rising so far In India people are becoming more conscious of health insurance purchase. The change in lifestyle encourages people to take treatment at high-end hospitals. This factor and the rising inflation are making individuals purchase health insurance. The outcome of this study would help the insurers and financial policy makers formulate proper strategies to increase the penetration of health insurance.
Health microinsurance aims to provide financial protection to the poor by reducing their need to use the costlier risk management strategies. Present study is an impact assessment of a Government of India sponsored health coverage scheme (Rashtriya Swasthya Bima Yojana). The study has been conducted by including three north-Indian states. The scheme has been assessed in terms of financial protection. Overall the health coverage scheme has been successful in reducing the hospital expenditure of the poor households together with improving their fund mobilization and smoothing the household consumption at the time of health shock.
Key words: Financial protection, Fund mobilization, Health Microinsurance, Rashtria Swasthya Bima Yojana and.
Background: In a push for universal health coverage, Ethiopia introduced two insurance schemes in 2010. Yet coverage rates remain very low. To encourage greater adoption, policymakers require a better understanding of who chooses to enroll and which promotional efforts are most effective in encouraging enrollment.
Objective: Using nationally representative Demographic and Health Surveys, this research assessed the social determinants of health insurance coverage, including media exposure, in
Ethiopia from 2011-2016.
Methods: This research analyzed health insurance coverage and other sociodemographic and media exposure variables using multivariable logistic regression model.
Results: Health insurance coverage increased 3.30 times from 1.48% in 2011 to 4.89% in 2016.
In both years, coverage was associated with higher education, older age, higher wealth levels, and exposure to newspaper and television. Compared to those with no exposure to newspaper, those with newspaper exposure at least once a week were 1.80 times (2011) and 1.86 times
(2016) more likely to be insured. Similar results were obtained for television exposure.
Conclusion: Initiatives that target the poor and less educated will be necessary if Ethiopia is to achieve universal health coverage. This research suggests that, to date, newspaper and television mediums have been effective promotion mechanisms for growing enrollment.
Yopougon-Sicogi est un quartier de la commune de Yopougon, situé dans le district d’Abidjan en Côte d’Ivoire. C’est un quartier planifié et bâti, qui regorge une forte concentration humaine. Il dispose également de plusieurs structures sanitaires reparties sur de faibles superficies qui offrent une diversité de services d’offre de soins. Cependant, malgré la proximité des populations avec ces établissements de soins (100% de la population se situent à moins de 2 km de ces établissements sanitaires) et leur multitude de services d’offre de soins, le taux de fréquentation de l’ensemble de ces structures de santé (8,89% en 2010; 10,41% en 2013; 9,28% en 2014) n’a jamais dépassé la norme recommandée par l’OMS qui est de 50% de fréquentation. Face à cette situation, la question principale qui en résulte est de savoir, quels sont les facteurs socio-spatiaux qui influencent l’accès et le recours des populations aux structures sanitaires de Yopougon-Sicogi. Ainsi, la présente étude a pour objectif d’analyser les différents facteurs socio-spatiaux qui influencent l’accès et le recours des populations aux structures sanitaires de Yopougon-Sicogi. L’étude caractérisée de géographie des micro-espaces, a porté sur un échantillon de 181 chefs de ménages et 269 clients (patients) déterminés à partir de la formule de Fisher sur la base d’un sondage stratifié. Des données qualitatives et quantitatives ont été recueillies grâce aux interviews avec les autorités sanitaires et promoteurs des infrastructures de santé, et aussi à l’aide de deux types de questionnaires : l’un destiné aux chefs de ménages et l’autre aux clients. Des analyses descriptives, spatiales, bivariées et multivariées ont été faites. Le test d’indépendance du Khi-2 et le test de Cramer ont été effectués. Le modèle de régression logistique a été également construit. Tous ont permis d’identifier les facteurs socio-spatiaux dont dépendant l’accès et le recours aux structures sanitaires de Yopougon-Sicogi. Aussi, le modèle de distribution spatiale de ces établissements sanitaires à travers l’espace du quartier et les raisons justifiant leur faible fréquentation ont été identifiés. Les résultats montrent que, les sept structures sanitaires existantes sur l’espace de Yopougon-Sicogi sont exclusivement tournées vers l’offre de soins privée. Leur inégale répartition sur cet espace a été influencée par la proximité de l’hôpital général, la présence des marchés, la rareté d’établissement sanitaire dans les quartiers voisins, le réseau routier du quartier et surtout à cause des insuffisances liées aux textes de lois régissant l’organisation des structures de santé privées. Aussi, l’échelle de distribution spatiale de ces infrastructures de santé obtenue n’est pas calquée sur une hiérarchie des lieux centraux. Le schéma triangulaire obtenu, reste propre au quartier et à l’offre de soins de santé privée. Les résultats montrent en outre que, les variables : sexe, âge, taille du ménage, profession, revenu, niveau d’étude, coût des soins, confiance au personnel médical, qualité de soins, type de service se sont avérées déterminantes dans l’utilisation de ces infrastructures de santé (khi-2 cal > khi-tab). Mais, la valeur du V de Cramer a montré que les variables fortement liées au recours à ces structures de santé sont l’âge et le coût des soins (V= 5,2 et v= 6,4). L’étude a montré aussi que, 89% des ménages ne fréquentent pas ces structures sanitaires. Les raisons de leurs faibles intérêts restent liées à l’inadéquation entre l’offre de services de soins disponible et les besoins de soins exprimés, au manque de confiance au personnel soignant ainsi que leur proximité avec l’hôpital général de la commune.Toutefois, pour réduire toutes formes d’inégalités sanitaires en Côte d’Ivoire, cette étude recommande une collaboration entre spécialistes de la santé et des sciences sociales.
The rate of maternal mortality in Nigeria remains high despite recent worldwide success in reducing it. Data from the World Bank suggests that maternal mortality rate (MMR) is about 917 per 100,000 for Nigeria and this is only second to India globally. Hence, in this study, we investigate the research question of to what extent can community health insurance influence maternal health in Nigeria by looking at aspects of maternal health such as health seeking behaviors of, and demand for maternal healthcare services among women in Nigeria The data utilized for the study was sourced from the 2013 Nigeria Demographic and Health Survey (NDHS), while estimations were done using Propensity Score Matching and Nearest Neighbor Matching. The result from the estimations shows that the average treatment effect on the treated (ATT) reveals that participating in a Community Health Insurance (CHI) scheme improves the health seeking behavior of a woman by about 17% compared to when she does not participate. The result further reveals that those who participated in the scheme were likely to have 58% increased antenatal care visits compared to when they do not participate. This study concludes that CHI is protective of maternal health. It is likely to improve health seeking behavior of women in Nigeria by reducing out-of-pocket payment for health services. Further recommendations are also discussed.
This paper proposes a way to improve health provision for populations that are usually excluded from access to health services. It starts out from a short description of who the excluded are, and what they are excluded from. The paper then looks at the major policy statements elaborated at the international level, and proceeds to propose the missing dimension. Next, based on field testing and analysis of several tens of pilot cases, the paper proposes a concept for group-based health insurance, or “micro-insurance”, and explains its rationale and its components. Lastly, the paper proposes a strategy to implement this concept.
. The poor are the principal beneficiaries of universal access to social services. . Instead of thinking in terms of supply, we need to meet the demand for services from the poor. . Policies should be judged by their outcomes rather than by the amount of resources employed. . Coherent, long-term and participatory policy are needed to escape from the poverty trap.
This paper proposes a new definition and conceptual framework for Social Protection grounded in Social Risk Management. The concept repositions the traditional areas of Social Protection (labor market intervention, social insurance and social safety nets) in a framework that includes three strategies to deal with risk (prevention, mitigation and coping), three levels of formality of risk management (informal, market-based, public) and many actors (individuals, households, communities, NGOs, governments at various levels and international organizations) against the background of asymmetric information and different types of risk. This expanded view of Social Protection emphasizes the double role of risk management instruments—protecting basic livelihood as well as promoting risk taking. It focuses specifically on the poor since they are the most vulnerable to risk and typically lack appropriate risk management instruments, which constrains them from engaging in riskier but also higher return activities and hence gradually moving out of chronic poverty. Copyright Kluwer Academic Publishers 2001
This report presents information on the credit constraints that poor rural households face ... in nine countries of Asia and Africa (Bangladesh, Cameroon, China, Egypt, Ghana, Madagascar, Malawi, Nepal, and Pakistan). It uses this information to make the case for appropriate public intervention in strengthening rural financial markets and draws conclusions about areas where public resources may best be spent" Preface.
One of the most sizable and least predictable shocks to economic opportunities in developing countries is major illness. We investigate the extent to which families are able to insure consumption against major illness using a unique panel data set from Indonesia that combines excellent measures of health status with consumption information. We find that there are significant economic costs associated with major illness, and that there is very imperfect insurance of consumption over illness episodes. These estimates suggest that public disability insurance or subsidies for medical care may improve welfare by providing consumption insurance.
The majority of Sub-Saharan African citizens - informal sector workers and the rural population - have never had access to wage-based social health insurance or privately run health insurance. As a response to the lack of social security, to the negative side-effects of user fees introduced in the eighties and to persistent problems with health care financing, non-profit, voluntary community-based health insurance (CBHI) schemes for urban and rural self-employed and informal sector workers have recently emerged. CBHI seems to be a promising attempt to improve access to health care, health outcomes and social protection in the case of illness. Given the unique ethnic, lingual and cultural diversity within African nations, the CBHI approach may be particularly valuable because it allows adaptation to local conditions. The actual implementation of CBHI schemes in Sub-Saharan Africa has had mixed results so far, with viability and acceptance largely depending on design and management of the scheme, community participation, regulations at the level of the health care provider, quality of services and on the socio-economic and cultural context. Small-scale health insurance can supplement other sources of finance rather than being a substitute for them. Further research is required to identify appropriate measures and instruments to overcome the identified limitations of CBHI schemes.
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This article develops and uses methodologies to evaluate the impact of publicly-financed health insurance programmes on the use of health care. Using univariate and bivariate probit estimation techniques, the study tests and corrects for endogeneity resulting from selection bias. Potential endogeneity arises from the choice to be insured, eligibility for insurance, and differences in individuals’ health status.The setting for the study is the country of Ecuador. The General Health Insurance (GHI) programme, which primarily covers workers in the formal sector of the economy, is found to have a strong positive association with the use of curative health care after correcting for selection bias, but no significant effect on the use of preventive care. Individuals with severe illnesses who are eligible for GHI have a preference for private health care, and self-select out of the GHI programme. The Seguro Campesino Social (SSC) programme, directed at farming populations, has positive but insignificant associations with both curative and preventive care. Copyright © 1999 John Wiley & Sons, Ltd.
Although the Bamako Initiative from its very beginning was caught up in wider debates about the potential equity impact of any form of user financing, to date there has been little empirical investigation of this impact. This three-country study, undertaken in Benin, Kenya and Zambia in 1994/95, was initiated to add to the body of relevant evidence. It sought to understand not only what had been the equity impacts of community financing activities in these countries but also how they had been brought about. As a result, it investigated equity primarily through consideration of the design of these financing activities and through the perceptions of different actors, within a limited number of purposively selected geographical areas in each country, about their strengths and weaknesses. Additional data on utilization were either collected during the course of the study (Kenya) or drawn from other available studies (Benin and Zambia). Key issues considered in the studies' assessment of equity were the extent to which both relative and absolute affordability gains were achieved, as well as as an influence over both the distributional and procedural justice of the financing activities, the pattern of decision-making. Across countries there was evidence of relative affordability gains in Benin and Kenya, but Kenyan gains were not sustained over time and no such gains were identified in Zambia. In addition, no country had given attention either to the issue of absolute affordability, through the implementation of effective exemption mechanisms to protect the poorest from the burden of payment, or to the establishment of community decision-making bodies that effectively represented the interests of all groups including the poorest. Overall, therefore, although the Benin Bamako Initiative programme might be judged as successful in terms of what appear to be its own equity objectives, the other two countries' schemes had clear equity problems even in these terms. The experience across countries also highlights the unresolved question of whether equity is concerned with the greatest good for the greatest number or with promoting the interests of the most disadvantaged. Copyright © 2000 John Wiley & Sons, Ltd.
This paper describes existing social security systems in developing countries and analyses their institutional strengths and weaknesses. To this end, it identifies four main providers of social security, namely the State, the market, member-based organizations, and private households. Given the strengths and weaknesses of each system, the paper explores the possibilities of a public-private partnership which should be based on the use of local information on the one hand while profiting from possibilities of risk sharing and risk pooling on the other.
Much of the literature on group lending focuses on its high repayment rates rather than its goal of promoting borrower welfare. Most studies that attempt to measure the impact of group lending neglect the issues of self-selection and endogenous program placement, thus leading to biased estimates of impact. One reason for this neglect is the lack of data that would allow for identification of impact. This paper surmounts these problems by using data from a quasi-experiment conducted in Northeast Thailand in 1995–1996. Program participants were identified in six control villages 1 year prior to receiving loans. Surveys were then conducted of these “control” members, “treatment” members in eight older program villages, and nonmembers in both types of village. This survey design allows for straightforward estimation of impact. The results indicate that program loans are having little impact although “naive” estimates of impact that fail to account for self-selection and endogenous program placement significantly overestimate impact.
This paper presents IV estimates of the returns to schooling for Honduran males by exploiting the variation in the availability of schooling at the time individuals were eligible to commence their education. The IV estimates are significantly higher than OLS estimates. The higher rate of return estimates are driven by the greater schooling attainment and the higher marginal returns for individuals from more privileged family backgrounds. In line with studies for developed countries, we conclude that, when estimating rates of return to education for developing countries, it is important to account for the endogeneity of educational attainment. [JEL J31, J24, O15]
This is the twenty-first in the annual series assessing major development issues. This report acknowledges that knowledge, not capital, is the key to sustained economic growth and improvements in human well-being. It distinguishes between two sorts of knowledge: knowledge about technology, called technical knowledge or simply know-how, and knowledge about attributes, that is, knowledge about products, processes, or institutions. The report focuses on the relationship between the unequal distribution in know-how (knowledge gaps) across and within countries and the difficulties posed by having incomplete knowledge of attributes (information problems). In the first of three parts, the report discusses the importance of knowledge to development, and the risks and opportunities that the information revolution poses for developing countries. It then examines three critical steps that developing countries must take to narrow knowledge gaps: acquiring knowledge, absorbing knowledge, and communicating knowledge. Part 2 discusses the nature and extent of information problems, specific information problems, and three areas where information problems are most severe, namely in financial information, in environmental research, and in listening to the poor. Part 3 summarizes what knowledge and information requirements mean for developing government and international institution policies.
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Community based health insurance is an emerging and promising concept that has attracted the attention of policy makers as it addresses health care challenges faced by the poor. This paper discusses solutions to important incentive problems in micro-health insurance schemes which threaten their sustainability. In particular, three issues are explored: (i) if defining household as unit of insurance always mitigates adverse selection problem; (ii) how ex ante moral hazard problem can be circumvented through group insurance contract; and (iii) how to set incentives for scheme managers. Various public policies are discussed that help to set appropriate incentives to better manage health insurance schemes in low-income country environments.
Following the success of a controlled trial of insecticide-impregnated bednets in reducing mortality in children. The Gambia started a National Impregnated Bednet Programme (NIBP) in 1992. The objectives of this programme were to introduce impregnated bednets into all primary health care (PHC) villages and to establish a system of cost recovery over a three-year period. During the initial phase of the programme, when insecticide was given out free, a high uptake was achieved. However, after small user charges were introduced in 1993, coverage dropped to a low level. In 1994, different systems of insecticide distribution and permethrin formulations were tried in an attempt to improve coverage. A nationwide cross-sectional survey carried out during the 1994 rainy season measured coverage by distribution channel, as well as the knowledge, attitudes and practices of health workers and villagers during the intervention. Overall, only 16% of bednets were impregnated in 1994, compared to 80% when the insecticide was offered free of charge in previous years. Lack of money was the major reason given by villagers for not impregnating their bednets in 1994. Use of impregnated bednets was higher in areas where the sale of permethrin emulsion by village health workers was supplemented by the sale of insecticide in individual packages through shops. In villages where insecticide was distributed free to women with small children through governmental mother and child health (MCH) services, higher levels of coverage were achieved among women and young children than in villages where other distribution systems were used. We conclude that the sale of insecticide through the private sector may increase bednet impregnation rates in African communities, and that the free distribution of insecticide through MCH services may be an effective way of targeting young children, the group most at risk of malaria.
Within the overall aim of poverty alleviation, development efforts have included credit and self-employment programmes. In Bangladesh, the major beneficiaries of such group-based credit programmes are rural women who use the loans to initiate small informal income-generating activities. This paper explores the benefits of women's participation in credit programmes on their own health seeking. Using data from a sample of 1798 households from rural Bangladesh, conducted in 1991-1992 through repeated random sampling of 87 districts covered by Grameen Bank, Bangladesh Rural Advancement Committee (BRAC) and Bangladesh Rural Development Board (BRDB), this paper addresses the question: does women's participation in credit programmes significantly affect their use of formal health care? A non-unitary household preference model is suggested to test the hypothesis that women's empowerment through participation in these programmes results in greater control of resources for their own demand for formal health care. The analysis controls for endogeneity due to self-selection and other unobserved village level factors through the use of a weighted two stage instrumental variable approach with village level fixed effects. The findings indicate a positive impact of women's participation in credit programmes on their demand for formal health care. The policy simulations on the results of this study highlight the importance of credit programmes as a health intervention in addition to being a mechanism for women's economic empowerment.
Governments are constantly faced with competing demands for public funds, thereby necessitating careful use of scarce resources. In Egypt, the School Health Insurance Programme (SHIP) is a government subsidized health insurance system that targets school children. The primary goals of the SHIP include improving access and equity in access to health care for children while, at the same time, ensuring programme sustainability. Using the Egyptian Household Health Utilization and Expenditure Survey (1995), this paper empirically assesses the extent to which the SHIP achieves its stated goals. Our findings show that the SHIP significantly improved access by increasing visit rates and reducing financial burden of use (out-of-pocket expenditures). With regard to the success of targeting the poor, conditional upon being covered, the SHIP reduced the differentials in visit rates between the highest and lowest income children. However, only the middle-income children benefitted from reduced financial burden (within group equity). Moreover, by targeting the children through school enrollment, the SHIP increased the differentials in the average level of access between school-going children and those not attending school (overall equity). Children not attending school tend to be poor and living in rural areas. Our results also indicate that original calculations may underestimate the SHIP financial outlays, thereby threatening the long run financial sustainability of the programme.
Poor people lack access to health care with a negative impact on their dignity, human capital formation and their risk-management options. Recently an emerging movement of community-based health insurance schemes has attracted the attention of policy makers and researchers as it seems that these schemes target the poor more efficiently. Taking the example of community-based health insurance schemes in rural Senegal this paper identifies the factors explaining participation in these schemes. Using household survey data of non-members and members, we found that household income, religion, village characteristics and the belonging to a certain ethnic group exert the strongest influence on the probability of participation. From these findings, it follows that i) although the schemes reach the “poor” in general, the “poorest of the poor” within the villages find it financially difficult to participate; ii) social exclusion due to religion or ethnic group might persist. Several options ...
Les populations pauvres ont des difficultés à accéder aux soins de santé, ce qui a des répercussions négatives sur leur dignité, sur leur aptitude à gérer les risques et sur la formation du capital humain. Ces dernières années, des systèmes d’assurance de santé ont été créés au niveau des communautés, attirant l’attention des décideurs et des chercheurs par leur apparente efficacité à atteindre les pauvres. S’appuyant sur l’exemple d’un tel système en milieu rural au Sénégal, l’auteur identifie les facteurs responsables de la participation à ces mécanismes d’assurance de santé. Il ressort de l’analyse des données d’une enquête ménage auprès de membres et de non membres du système, que les principaux facteurs déterminants de la participation sont : le revenu, la religion, les spécificités villageoises et l’appartenance à tel ou tel groupe ethnique. On peut déduire de ces résultats que i) b
The authors estimate how cost sharing, the portion of the bill the patient pays, affects demand for medical services. The data come from a randomized experiment. A catastrophic insurance plan reduces expend itures 31 percent relative to zero out-of-pocket price. The price elasticity is approximately A0.2. The post-World War II growth in medical expenditures is either largely attributable to technological change induced by increased insurance coverage, a hypothesis that cannot be tested, or to factors other than increased insurance coverage. The authors reject the hypothesis that less favorable coverage of outpatient services increases total expenditure, e.g., by deterring preventive care. Coauthors are Joseph P. Newhouse, Naihua Duan, Emmett B. Keeler, Arleen Leibowitz, and M. Susan Marquis. Copyright 1987 by American Economic Association.
The annexes in this volume examine the strengths and limitations of community-based health insurance (CBHI) schemes currently operating to meet basic health care needs of rural populations in East and Southern Africa. These CBHI operations have achieved limited successes in designing and implementing affordable, participatory, and sustainable health care financing mechanisms for populations with limited resources but great need for health services. The scheme information presented here focuses on "lessons learned" from these operations, and recommendations derived from these lessons learned are designed to assist the rural communities interested in establishing similar, workable risk-sharing and financing mechanisms. These types of health care financing systems offer promising alternatives to centralized health care system and promote community ownership in health care. Table of Contents v Table of Contents Acronyms.....................................................................
Health, education and poverty reduction OECD Development Centre Policy Brief No. 19. Paris: OECD Development Centre The Gambian National Impregnated Bednet Programme: evaluation of the 1994 cost recovery trial
- C Morrisson
- O M€ Uller
- K Cham
- S Jaffar
- B Greenwood
Morrisson, C. (2002). Health, education and poverty reduction. OECD Development Centre Policy Brief No. 19. Paris: OECD Development Centre. M€ uller, O., Cham, K., Jaffar, S., & Greenwood, B. (1996). The Gambian National Impregnated Bednet Programme: evaluation of the 1994 cost recovery trial. Social Science and Medicine, 43, 1–7.
The willingness to pay for medical care
- P Gertler
- J Van Der Gaag
Gertler, P., & Van der Gaag, J. (1990). The willingness to
pay for medical care. Baltimore/Washington, DC:
Johns Hopkins University Press/World Bank.
Social risk management: a new conceptual framework for social protection, and beyond. Social Protection Discus-sion Paper No. 0006 Social security systems in low income countries: concepts, constraints, and the need for cooperation
- R Holzmann
- S Jorgensen
Holzmann, R., & Jorgensen, S. (2000). Social risk management: a new conceptual framework for social protection, and beyond. Social Protection Discus-sion Paper No. 0006. Washington, DC: The World Bank. J€ utting, J. (2000). Social security systems in low income countries: concepts, constraints, and the need for cooperation. International Social Security Review, 53(4), 3–25.
Health financing for poor people: resource mobilization and risk sharing. Washington DC: The World Bank
- A Preker
Preker, A. (2004). Health financing for poor people:
resource mobilization and risk sharing. Washington
DC: The World Bank (in print).
Les mutuelles de santé rurales de la région de Thiès au Sénegal: des initiatives communautaires pour améliorer l’accès aux soins de santé
- J Tine
Tine, J. (2000). Les mutuelles de sant e rurales de la r egion de Thi es au S enegal: des initiatives commun-autaires pour am eliorer l'acc es aux soins de sant e. Bonn: Center for Development Research.
Design of incentives in community-based health insurance schemes. ZEF-Discussion Papers on Development Policy No. 63
- R Ahuja
- J Utting
Ahuja, R., & J€ u utting, J. (2003). Design of incentives in
community-based health insurance schemes. ZEF-Discussion Papers on Development Policy No. 63.
Bonn: Center for Development Research.
Contribution of mutual health organisations to financing delivery and access to health care: synthesis of research in nine West and Central African countries
- C Atim
Atim, C. (1998). Contribution of mutual health organisations to financing delivery and access to health care:
synthesis of research in nine West and Central African
countries. Bethesda: Abt Associates Inc.
Cost of illness, demand for medical care, and the prospect of community health insurance schemes in the rural areas of Ethiopia
- A Asfaw
Asfaw, A. (2003). Cost of illness, demand for medical
care, and the prospect of community health insurance
schemes in the rural areas of Ethiopia. Frankfurt:
Peter Lang Eds.
Macroeconomics and health: investing in health for economic development
- Cmh
CMH (2001). Macroeconomics and health: investing in
health for economic development. Report of the
Commission on Macroeconomics and Health. Geneva:
WHO.
Pr e esentation de mutuelles du
- M Garba
- V Cyr
Garba, M., & Cyr, V. (1998). Pr e esentation de mutuelles
du Sud Borgou et Zou Nord au B e enin. Paper
presented at the Seminaire--At e elier de CIDEF--Les Mutuelles de Sant e e en Afrique: Concept
Import e eou R e ealit e e
E Emergente? Experiences et Perspectives, Paris.
Women’s participation in rural credit programmes in Bangladesh and their demand for formal health care: is there a positive impact?
- Nada
Nada, P. (1999). Women's participation in rural credit
programmes in Bangladesh and their demand for
formal health care: is there a positive impact? Health
Economics and Econometrics, 8, 415-428.