Factors that affect the uptake of community-based health insurance in low-income and middle-income countries : a systematic protocol

Many people residing in low-income and middle-income countries (LMICs) are regularly exposed to catastrophic healthcare expenditure. It is therefore pertinent that LMICs should finance their health systems in ways that ensure that their citizens can use needed healthcare services and are protected from potential impoverishment arising from having to pay for services. Ways of financing health systems include government funding, health insurance schemes and out-of-pocket payment. A health insurance scheme refers to pooling of prepaid funds in a way that allows for risks to be shared. The health insurance scheme particularly suitable for the rural poor and the informal sector in LMICs is community-based health insurance (CBHI), that is, insurance schemes operated by organisations other than governments or private for-profit companies. We plan to search for and summarise currently available evidence on factors associated with the uptake of CBHI, as we are not aware of previous systematic reviews that have looked at this important topic

Community-based health insurance and social protection policy

Of all the risks facing poor households, health risks pose the greatest threat to their lives and livelihoods. A health shock adds health expenditures to the burden of the poor precisely at the time when they can afford it the least.One of the ways that poor communities manage health risks, in combination with publicly financed health care services, are community-based health insurance schemes (CBHIs). These are small scale, voluntary health insurance programs, organized and managed in a participatory manner. They are designed to be simple and affordable, and to draw on resources of social solidarity and cohesion to overcome problems of small risk pools, moral hazard, fraud, exclusion and cost-escalation. Less than 10 percent of the informal sector population in the developing nations has health coverage from a CBHI, but the number of such schemes is growing rapidly. On average, CBHIs recover between a quarter to a half of health service costs. As a social protection device, they have been shown to be effective in reducing out-of-pocket payments of their members, and in improving access to health services. Many schemes do fail. Problems, such as weak management, poor quality government health services, and the limited resources that local population can mobilize to finance health care, can impede success.Health Economics&Finance,Health Monitoring&Evaluation,Poverty Assessment,Safety Nets and Transfers,Insurance&Risk Mitigation

Dealing with Internal Inconsistency in Double-Bounded Dichotomous Choice: An Application to Community-Based Health Insurance

Contingent valuation method is commonly used in the field of health economics in an attempt to help policy maker in taking decisions. The use of the double-bounded dichotomous choice format results in a substantial gain in statistical efficiency over the single bounded dichotomous choice format. Yet, this efficiency gain comes at the cost of biasness known as internal inconsistency. This paper aims at reducing this internal inconsistency in double-bounded dichotomous choice by using the certainty calibration technique in a community-based health insurance study. Findings confirm the internal inconsistency between the initial and the follow-up responses and the statistical efficiency gains of the double-bounded dichotomous choice over the single-bounded dichotomous choice. Furthermore, the use of certainty calibration reduces this internal inconsistent pattern in responses and still maintains efficiency gain. We further discuss the policy implications.Contingent valuation; internal inconsistency; certainty calibration; community-based health insurance

Partnering with Medicaid to Advance and Sustain the Goals of the Child Welfare System

The purpose of this paper is to serve as a practical guide for child welfare directors who are looking to expand or sustain services for the children and families that they serve. This paper focuses on ways to partner with Medicaid to leverage opportunities to provide high quality services for children in child welfare who have behavioral health needs. It also includes information that will provide a foundational understanding of the behavioral health needs of children involved with the child welfare system, with an emphasis on describing child behavior through the lens of child development, adaptive functioning, and trauma; the services that can effectively address those behavioral and trauma related responses that can disrupt a child's skills and abilities; and, examples from states and counties who are providing these services and supports

Willingness to pay for community-based health insurance in Nigeria: do economic status and place of residence matter?

OBJECTIVE: We examine socio-economic status (SES) and geographic differences in willingness of respondents to pay for community-based health insurance (CBHI). METHODS: The study took place in Anambra and Enugu states, south-east Nigeria. It involved a rural, an urban and a semi-urban community in each of the two states. A pre-tested interviewer-administered questionnaire was used to collect information from a total of 3070 households selected by simple random sampling. Contingent valuation was used to elicit willingness to pay (WTP) using the bidding game format. Data were examined for correlation between SES and geographic locations with WTP. Log ordinary least squares (OLS) was used to examine the construct validity of elicited WTP. RESULTS: Generally, less than 40% of the respondents were willing to pay for CBHI membership for themselves or other household members. The proportions of people who were willing to pay were much lower in the rural communities, at less than 7%. The average that respondents were willing to pay as a monthly premium for themselves ranged from 250 Naira (US$1.7) in a rural community to 343 Naira (US$2.9) in an urban community. The higher the SES group, the higher the stated WTP amount. Similarly, the urbanites stated higher WTP compared with peri-urban and rural dwellers. Males and people with more education stated higher WTP values than females and those with less education. Log OLS also showed that previously paying out-of-pocket for health care was negatively related to WTP. Previously paying for health care using any health insurance mechanism was positively related to WTP. CONCLUSION: Economic status and place of residence amongst other factors matter in peoples' WTP for CBHI membership. Consumer awareness has to be created about the benefits of CBHI, especially in rural areas, and the amount to be paid has to be augmented with other means of financing (e.g. government and/or donor subsidies) to ensure success and sustainability of CBHI schemes

Health Security for rural poor: study of community based health insurance

ABSTRACT For many people living in developing nations, illness represents a permanent threat to their income earning capacity and, therefore, their livelihood .Health insurance has been progressively more recognized as a tool to finance healthcare provision in the developing world. The high demand for good quality healthcare and the extreme underutilization of existing health services have given rise to the need for community health insurance—an arrangement that may both increase access to healthcare as well as theoretically improve its quality. While alternative forms of healthcare financing have been scrutinized, the option of insurance seems to be promising as it offers the opportunity to pool risk by converting unpredictable healthcare costs into fixed annual premiums. The typical dialogue surrounding health financing cites three main types of insurance as viable options to provide care. First is social health insurance, a practice initiated in several European countries where the working population of society provides health funds for the entire population, working and non-working. Social health insurance utilizes basic socialist principles to hold all sections of society accountable for the good of the community. The next type of insurance model is private health insurance, a structure that generally prevails in capitalist societies. Private insurance favors those who can afford to pay regular premiums, i.e. the middle class and the wealthy. Private insurance, therefore, inherently excludes the poor and only provides benefits to paying members. Finally, and most notable in discussing health for the rural poor, is community-based health insurance (CBHI). Studies conducted in various developing countries, including India, show that community-based health insurance (CBHI) schemes are highly effective in reaching poor populations. According to Friends of Women's World Banking, CBHI is defined as "any not-for-profit insurance scheme that is aimed primarily at the informal sector and formed on the basis of a collective pooling of health risks, and the members participate in its management." Such schemes frequently function in conjunction with healthcare providers or community organizations, such as local religious institutions, self-help groups (SHGs), or non-governmental organizations (NGOs).CBHI requires that people make a small contribution (i.e. pay a premium), which is then pooled to provide benefits, such as medical costs, to those within the pool who may need assistance. Unlike social or private health insurance schemes, CBHI is distinct in that it is generally initiated and managed by the community it benefits. This characteristic of CBHI is particularly important as it entails that the features of any specific CBHI scheme tailor to the local needs of the people. Against this background, the present paper attempts to analyze the Public Private Partnership [PPP] model in Health Insurance. As an example of the above-examined PPP, Chaitanya and HDFC-Chubb General Insurance, located in the Pune district of Maharashtra is taken as case study. Chaitanya and HDFC have recently joined in an endeavor attempting to provide CBHI coverage to SHG -women and their families in the Chaitanya field area. Founded in 1993, Chaitanya focuses on the establishment and strengthening of SHGs and development through micro-finance programs. Chaitanya's work has motivated the formation of the Grameen Mahila Swayamsiddha Sangha, the first independent federation of SHGs in Maharashtra. Currently, Chaitanya also carries out developmental activities including water & sanitation, agriculture, livelihood, and health. HDFC Bank and Chubb Corporation, USA entered a venture together in 2002 to jointly offer general insurance services. Specifically, HDFC-Chubb GIC offers a rural initiatives program tailored to meet the needs of the rural poor and offer insurance services at reduced costs.hEALTH SECURITY; POOR; INSURANCE

Magnitude of Out of Pocket Health Expenditures and Associated Factors Among Civil Servants

In Ethiopia, as other developing countries, public health care is provided at nominally low prices and free to those that does not afford to pay. But the health care consumer population is still to make considerable amount of out-of-pocket health expenditure for various reasons. A cross sectional quantitative study from January to May 2013 was done. Study population was civil servants in Debre Markos town. A total of 467 study participants were selected by using simple random sampling method. Data were collected by trained high school graduates and then the collected data were entered into a computer by using Epi-Data version 3.1 and analysis was performed by using SPSS version 16 for windows. Possible associations between out of pocket health expenditure and its predictors were analyzed by using both bivariate and multivariate analysis. The mean age of the study participants were 41 years. Majorities were between 25 and 44 years of age, 258 (55.2%). The level of education among the study participants indicated that most 380 (81.4%) were graduates of higher education (HE) and majority were Orthodox Christian which accounted 446 (95.5%) followed by Muslims 13 (2.8%). To put it briefly, the study identified that the median of out of pocket health care expenditure accounted 8.26% of total household income. Health status of the household (with or without chronic illness), debt on any of the household, house on construction owned by any household member, educational fee for at least one member of the household and predominantly used health institution were the associated factors that have significant impact on household out of pocket health expenditure. There is economic burden as a result of health care at household level. Based on the results, the recommendation was introducing social health insurance for all civil servant employees in the study area

Expression of Trichoderma reesei cellulases CBHI and EGI in Ashbya gossypii

To explore the potential of Ashbya gossypii as a host for the expression of recombinant proteins and to assess whether protein secretion would be more similar to the closely related Saccharomyces cerevisiae or to other filamentous fungi, endoglucanase I (EGI) and cellobiohydrolase I (CBHI) from the fungus Trichoderma reesei were successfully expressed in A. gossypii from plasmids containing the two micron sequences from S. cerevisiae, under the S. cerevisiae PGK1 promoter. The native signal sequences of EGI and CBHI were able to direct the secretion of EGI and CBHI into the culture medium in A. gossypii. Although CBHI activity was not detected using 4- methylumbelliferyl-β-D-lactoside as substrate, the protein was detected by Western blot using monoclonal antibodies. EGI activity was detectable, the specific activity being comparable to that produced by a similar EGI producing S. cerevisiae construct. More EGI was secreted than CBHI, or more active protein was produced. Partial characterization of CBHI and EGI expressed in A. gossypii revealed overglycosylation when compared with the native T. reesei proteins, but the glycosylation was less extensive than on cellulases expressed in S. cerevisiae.Fundação para a Ciência e a Tecnologia (FCT

Equity Implications of Health Sector User Fees\ud in Tanzania : Do we Retain the User Fee or do we Set the User F(r)ee?

\ud Early 2004, Research for Poverty Alleviation (REPOA) commissioned ETC Crystal to examine the equity implications of health sector user fees in Tanzania, with particular reference to proposed and actual charges at dispensary and health centre level. This year, Tanzania will review its Poverty Reduction Strategy. With the findings of the user fee study, REPOA aims at making a valuable contribution to the review process and provide country-specific insight into one of the most debated issues in health financing. The focus and design of the study was formulated in close cooperation with the Research and Analysis Working Group of REPOA. The strategies for data collection comprised: (1) a comprehensive literature analysis literature, (2) semi-structured interviews with resource persons from the government of Tanzania, multi- and bilateral donors, research institutes and NGOs in Dar Es Salaam, and (3) a case study in Kagera Region, including both document analysis and semi-structured interviews with resource persons from the MOH, NGOs, FBOs, health workers and health care consumers from vulnerable and poor population groups. The study team developed multiple tools for data collection and analysis including: (1) a data matrix for categorisation and identification of key issues, (2) guidelines for the interviews in Dar Es Salaam, (3) guidelines for data collection and interviews in Kagera Region, and (4) a tool for the analysis of poverty reduction strategy documents. A total number of 170 user fee-related documents were assessed, including those covering the experience from neighbouring countries. Seventy-nine resource persons participated in the study. Resources generated by user fees and their use at hospital, district council and PHC levels. The study team found that reliable, transparent user fee income data for district, hospital and PHC level were difficult to obtain. Based on what information is available, the team concludes that revenues raised from user fees at the hospital level have been lower than what has been projected. Furthermore, the data reflect huge variations between facilities and a decline in the revenues from cost sharing. The reasons of the reported decline are unclear. The data reflecting the contribution of user fees and CHF to the health budget at district council level show huge variations as well. The reported user fee income proportion for the district health budget was on average 10.5%. The study team could not establish how the income from cost sharing and the CHF was re-distributed by the council to PHC facilities or priority areas. A worrying finding was that some councils did not spend all health resources in the health sector. The study team observes an urgent need for: (1) more accurate and comprehensive record keeping at local council level, and (2) more costing and tracking studies to obtain a better insight into cost sharing and expenditures and to adequately inform policy making. Contribution of user fees and CHFs to the health resource envelope. The study team concludes that the national projections of the cost sharing schemes do not reflect an accurate picture, since the data are based on the inaccurate financial data received from the districts. It is likely that the actual and projected data on user fees, CHFs and HSF are underestimations of the real income collected at the different facility levels. This means that the MOH faces a loss of income that cannot be redistributed to the health sector. It also implies that people (both wealthy and poor) are likely pay more than what is officially reported. The actual potential and use of the non-reported user fees are not known. The total contribution of the cost sharing schemes (excluding NHIF) to the national health resource envelope for FY03/04 is 1.67 Billion Tshs. This equals a contribution of 0.6% to the overall budget for the health sector. In total, this is US$1.56 million. Given the size of the total health budget (US$ 260 million), it can be concluded that the officially reported user fees contribute a small proportion only. The actual revenue generated does not meet the initial expectations. Contribution of revenues generated to improved services. The study team found limited positive evidence that user fees in Tanzania have in general achieved their original objectives of sustainability, drug availability, quality of care, equity and access for the poor. More specifically, the study team found that government-run PHC facilities appeared to face severe shortages of drugs and supplies. In addition, user fees were not always retained at PHC level, but deposited in the HSF account which mainly benefits the purchase of supplies for the district hospital. Positive results were seen for reinvestment of CHF funds. In total, 50% of the health workersand patients reported improvements in drugs availability, diagnostic facilities and maintenance. However, equity criteria for the distribution of available resources from the user fee income to PHC level are not systematically followed. Impact of user fees on access to health services. The study team concludes that presently, the user fees in Tanzania are regressive and contribute to substantial exclusion, self exclusion and increased marginalisation. The team has collected evidence which shows that user fees have disproportionally affected access to health care for poor and vulnerable population groups, more specifically: (1) pregnant women from poor households, (2) under-five children from poor households, (3) orphans and especially double orphans, (4) widows, (5) people older than 60 years, (6) people with disabilities, and (7) AIDS patients. Further extension of fees to dispensary and health centre level. Also at the PHC level, the study team found that fees have negatively impacted the use of health care by the rural poor population, particularly women and children. Given the importance of the public PHC facilities for poor people (government health centres are the main choice for out-patient care for the poor), the study team expects that the further extension of user fees to PHC level without effective exemption and waiver mechanisms will contribute to further exclusion and selfexclusion. Effectiveness of exemption and waiver mechanisms. The study team identifies the ineffectiveness of the present exemption and waiver mechanisms as the core problem in the user fee debate in Tanzania. A functional exemption and waiver system is actually non-existent putting vulnerable and poor people at risk by practically denying them access to public health\ud services. This applies both to (1) the exemption and waiver system in health facilities and (2) the exemption mechanisms instituted for the CHFs. In both situations, poor people just do not receive the exemptions to which they are entitled to! Revenue collection appears to prevail over protecting the poor and vulnerable. Some hospitals have even tried to hide the waivers in their statistics in order to have, on paper, a better performance with their user fee income. The study team recommends that, should the government of Tanzania decide to maintain its user fee policy, priority is given to the design of an effective exemption and waiver system combined with: (1) sufficient resources to compensate for the unknown money lost (since it not recorded properly), and (2) a serious effort to make it work. However, there is substantial evidence that exemption and waiver systems do not guarantee increased access to health services for poor people unless major adjustments in the design, implementation and funding for adequate exemption and waiver systems take place. In the light of recent developments in Uganda and Kenya, it seems a much more realistic approach to compare the costs of (1) the suspension of user fees at PHC level against the required costs for (2) improved exemption and waiver systems or (3) improved NSHIF approaches in the contest of abolishment of fees and to opt for the most pro-poor and cost-effective approach within the shortest possible time frame. The potential and impact of Community Health Funds. The introduction of the CHF has not provided the expected benefits for poor people. There are a number of constraints the study team thinks should be urgently addressed, including the delays in the introduction of the CHFs and the weak management at the district and lower levels. More importantly, the study team found that poor people often cannot afford to pay the CHF premium because it is too high and has to be paid at once. If membership of the CHF becomes compulsory and poor people are not effectively exempted from paying CHF premiums and co-payments, the impact of the CHF can be disastrous and lead to double exclusion of poor people. Another issue of concern is related to the link between user fees and the CHF. According to the CHF Act, the user fees paid at public health centres and dispensaries form a source of income to the CHF. The premium paid to the CHF will receive WB matching funds, putting pressure on the PHC facilities to raise income through user fees. This indicates a complicated dilemma since it means that if user fees will be suspended or abolished at PHC level, the CHFs will not be able to take off as planned and will not receive part of their required resources. This points to the need to assess the mix of financing mechanisms and their interactions, rather than look at them as stand-alone policies. Tanzania has opted for a system of multiple risk-pooling schemes for the health sector. There is an urgent need to review the ongoing processes and assess their impact on the overall health system and the vulnerable members of the population. Scenarios. Reviewing the available literature, the study team observes that the abolition of user fees for education in Tanzania, and for health in South Africa and Uganda, has had impressive results in terms of attendance and access. Recently, Kenya also decided to abolish user fees for health. However, when reviewing the stakeholder’s attitudes towards abolition, the study team concludes that the necessary support for such a decision seems to lacking in Tanzania at present. The study shows that Tanzania is at a cross road. Tanzania can opt for two strategic directions. One strategy can be to continue on the road of the multiple risk pooling strategies. The other strategy can be to follow the abolishment of user fees at either (1) all levels or (2) at PHC levels. Both strategies will require substantial support from external donors and will require major adjustments in the current funding mechanisms. However, given the negative equity implications for poor people with the multiple risk pooling systems and the complicated, time consuming, costly and unreliable administration that is required for user fee systems and CHF, evidence indicates that it seems a more pro-poor and pragmatic strategy to abolish the user fees for poor people either (1) temporarily till improved exemption and waiver systems have been designed and introduced or (2) as long as the poverty situation in Tanzania requires. In case Tanzania will opt for the continuation of a multiple risk pooling system, then a number of key conditions will have to be met in order to ensure access to health services for poor people. It will be crucial to assess the mix of financing mechanisms and their interactions rather than look at them as stand-alone policies. Considering the severe poverty situation in Tanzania, it is concerning to find that many stakeholders continue promoting and supporting user fees in the absence of effective exemption and waiver systems. This does not correspond with the commitment to reducing poverty in Tanzania as articulated in the PRS. Consequently, immediate political action is required. Abolition of user fees can be considered as a pro-poor option to reduce exclusion and self-exclusion among the poor and vulnerable. The studies illustrate, that the abolition of fees needs to be combined with considerable efforts in other areas, such as changed levels of funding (internally and externally), improvements in the allocation and disbursement of funds, improved human resource development, improved incentive schemes for health workers and improved quality of services. This indicates the importance of a broad, strong political support and donor support. The developments in Uganda and Kenya might have created a momentum for Tanzania to rethink the current multiple risk pooling strategies in the context of the PRS Review and to opt for more pro-poor health strategies. It should be noted that in the current political situation strengthening the existing exemption and waiver systems seems to be the most preferred scenario at this moment. However, in the light of all the constraints mentioned and in the context of positive developments in Uganda and recent decisions taken in Kenya, the study team would like to recommend to include the suspension of user fees at PHC level in the next PRS document for Tanzania as a real pro-poor health strategy for Tanzania. The study team considers the Poverty Reduction Strategy Review Process as an excellent opportunity to lobby the government and the development partners on these issues, and to demand that a specific Plan of Action is included in the second Poverty Reduction Strategy Paper. The study team hopes that the findings of this study will contribute in such a positive and constructive way to the Tanzania PRS Review Process. The outcomes of this study confirm that in Tanzania, user fees are an issue to be carefully (re)considered when designing national pro-poor health policies in Poverty Reduction Strategies. Considering the severe poverty situation in Tanzania, it is concerning to find that many stakeholders\ud continue promoting and supporting user fees in the absence of effective exemption and waiver systems. This does not correspond with the government’s commitment to reduce poverty in Tanzania. Consequently, immediate political action is required.\u

Enrolment in Ethiopia’s Community Based Health Insurance Scheme

In June 2011, the Government of Ethiopia rolled out a pilot Community Based Health Insurance (CBHI) scheme. This paper assesses scheme uptake. We examine whether the scheme is inclusive, the role of health status in inducing enrolment and the effect of the quality of health care on uptake. By December 2012, scheme uptake had reached an impressive 45.5 percent of target households. We find that a household’s socioeconomic status does not inhibit uptake and the most food-insecure households are substantially more likely to enrol. Recent illnesses, incidence of chronic diseases and self-a