Does community-based health insurance affect lifestyle and timing of treatment seeking behavior?:Evidence from Ethiopia

Objectives: This paper aims to investigate the effects of enrollment in the Ethiopian community-based health insurance (CBHI) scheme on household preventive care activities and the timing of treatment-seeking behavior for illness symptoms. There is growing concern about the financial sustainability of CBHI schemes in developing countries. However, few empirical studies have identified potential contributors, including ex-ante and ex-post moral hazards. Methods: We implement a household fixed-effect panel data regression model, drawing on three rounds of household survey data collected face to face in districts where CBHI scheme is operational and in districts where it is not operational in Ethiopia. Results: The findings show that enrolment in CBHI does not significantly influence household behaviour regarding preventive care activities such as water treatment before drinking and handwashing before meals. However, CBHI significantly increases delay in treatment-seeking behaviour for diseases symptoms. Particularly, on average, we estimate about 4‒6 h delay for malaria symptoms, a little above 4 h for tetanus, and 10‒11 h for tuberculosis among the insured households. Conclusions: While there is evidence that CBHI improve the utilization of outpatient or primary care services, our study suggests that insured members may wait longer before visiting health facilities. This delay could be partly due to moral hazard problems, as insured households, particularly those from rural areas, may consider the opportunity costs associated with visiting health facilities for minor symptoms. Overall, it is essential to identify the primary causes of delays in seeking medical services and implement appropriate interventions to encourage insured individuals to seek early medical attention.</p

Mixed Methods EvAluation of the high-volume low-complexity Surgical hUb pRogrammE (MEASURE) : a mixed methods study protocol

ABSTRACT INTRODUCTION: The waiting list for elective surgery in England recently reached over 7.8 million people and waiting time targets have been missed since 2010. The high-volume low complexity (HVLC) surgical hubs programme aims to tackle the backlog of patients awaiting elective surgery treatment in England. This study will evaluate the impact of HVLC surgical hubs on productivity, patient care and the workforce. METHODS AND ANALYSIS: This 4-year project consists of 6 inter-linked work packages (WPs) and is informed by the Consolidated Framework for Implementation Research. WP1: Mapping current and future HVLC provision in England through document analysis, quantitative datasets (e.g., Hospital Episodes Statistics) and interviews with national service leaders. WP2: Exploring the effects of HVLC hubs on key performance outcomes, primarily the volume of low-complexity patients treated, using quasi-experimental methods. WP3: Exploring the impact and implementation of HVLC hubs on patients, health professionals and the local NHS through approximately nine longitudinal, multi-method qualitative case studies. WP4: Assessing productivity of HVLC surgical hubs using the Centre for Health Economics NHS productivity measure and Lord Carter’s operational productivity measure. WP5: Conducting a mixed-methods appraisal will assess the influence of HVLC surgical hubs on the workforce using: qualitative data (WP3) and quantitative data (e.g. NHS England’s workforce statistics and intelligence from WP2). WP6: Analysing the costs and consequences of HVLC surgical hubs will assess their achievements in relation to their resource use to establish value for money. A Patient and Public Involvement Group (PPI) will contribute to study design and materials. ETHICS AND DISSEMINATION: The study has been approved by the East Midlands – Nottingham Research Ethics Committee 23/EM/0231. Dissemination plans include multiple academic and non-academic outputs (e.g. Peer-reviewed journals, conferences, social media) and a continuous, feedback-loop of findings to key stakeholders (e.g. NHS England) to influence policy development. STUDY REGISTRATION: Researchregistry9364

Essay on Children’s Health, Fertility Decisions, and Household Dependency on Transfer Income in Developing Countries

My doctoral thesis consists of three chapters. Chapter 1 titled ‘The impact of Ethiopian Community-Based Health Insurance on children's health outcomes’ is a joint work with Prof. Martina Celidoni and Prof. Lorenzo Rocco, both from the University of Padova. Publicly financed Community Based-Health Insurance (CBHI) schemes are typically implemented in developing countries to foster healthcare utilization and improve health outcomes among low-income households. Using the Demographic and Health Survey from 2005 to 2016, we estimate the effects of the Ethiopian CBHI on children's health. Difference-in-differences estimates show that CBHI reduced mortality and the probability of being underweight among children under five. We also find that CBHI significantly reduces wasting, a measure of short-term nutritional deficiency or health conditions, but not stunting, known to be an indicator of long-term chronic malnutrition. Potential mechanisms underlying our results are improved maternal health, access to health care, nutrition, and a reduced risk of poverty. Chapter 2 titled ‘Does Community-Based Health Insurance affect women’s fertility decisions’ is a solo paper. This chapter focuses on estimating the effect of the Ethiopian CBHI on fertility decisions. CBHI might influence fertility through a number of channels, including improving children's survival and income, reduced costs of children's health and pregnancy, adoption of family planning strategies, and women empowerment. These mechanisms can have contrasting effects on fertility and the resulting direction and size of the effect is an empirical question. Based on data from the Ethiopian Demographic and Health Survey, estimates show that women, exposed to CBHI, have a lower probability of having a child than women in the control region. The underlying channels underpinning this finding are increases in modern contraception use, resulting from increased healthcare use, improvements in economic conditions and child survival, and the woman's intention to delay childbearing by at least two years. This reduction is mainly observed in rural, urban, and middle-aged (25-34) women. Chapter 3 titled ‘Rural development projects and transfer income: A step toward economic independence?’ is co-authored with Athur Mabiso (a senior economist at IFAD). The International Fund for Agricultural Development (IFAD) invested over USD 7.1 billion in rural development projects between 2007 and 2021. Using data collected from comparable treated and control households in 25 countries between 2019 and 2021, we investigate its effect on household reliance on transfer income. We implement an inverse probability weighting empirical strategy to further balance treated and control households based on observable characteristics. We find a 2-percentage point reduction in the share of transfer income - extensive margin - and a 16.4\% reduction in the amount of transfer income- intensive margin - for the treated households. Contemporaneous increases in gross income, income from crops and livestock are observed among the treated households implying that the project-promoted productive economic activities translated to less dependence on transfer income. We also show some heterogeneous effects by the gender of household head. These findings point to the potential role of rural development projects in reducing dependence on social protection transfers and offering a pathway to economic independence among the rural poor and vulnerable, including those headed by females.My doctoral thesis consists of three chapters. Chapter 1 titled ‘The impact of Ethiopian Community-Based Health Insurance on children's health outcomes’ is a joint work with Prof. Martina Celidoni and Prof. Lorenzo Rocco, both from the University of Padova. Publicly financed Community Based-Health Insurance (CBHI) schemes are typically implemented in developing countries to foster healthcare utilization and improve health outcomes among low-income households. Using the Demographic and Health Survey from 2005 to 2016, we estimate the effects of the Ethiopian CBHI on children's health. Difference-in-differences estimates show that CBHI reduced mortality and the probability of being underweight among children under five. We also find that CBHI significantly reduces wasting, a measure of short-term nutritional deficiency or health conditions, but not stunting, known to be an indicator of long-term chronic malnutrition. Potential mechanisms underlying our results are improved maternal health, access to health care, nutrition, and a reduced risk of poverty. Chapter 2 titled ‘Does Community-Based Health Insurance affect women’s fertility decisions’ is a solo paper. This chapter focuses on estimating the effect of the Ethiopian CBHI on fertility decisions. CBHI might influence fertility through a number of channels, including improving children's survival and income, reduced costs of children's health and pregnancy, adoption of family planning strategies, and women empowerment. These mechanisms can have contrasting effects on fertility and the resulting direction and size of the effect is an empirical question. Based on data from the Ethiopian Demographic and Health Survey, estimates show that women, exposed to CBHI, have a lower probability of having a child than women in the control region. The underlying channels underpinning this finding are increases in modern contraception use, resulting from increased healthcare use, improvements in economic conditions and child survival, and the woman's intention to delay childbearing by at least two years. This reduction is mainly observed in rural, urban, and middle-aged (25-34) women. Chapter 3 titled ‘Rural development projects and transfer income: A step toward economic independence?’ is co-authored with Athur Mabiso (a senior economist at IFAD). The International Fund for Agricultural Development (IFAD) invested over USD 7.1 billion in rural development projects between 2007 and 2021. Using data collected from comparable treated and control households in 25 countries between 2019 and 2021, we investigate its effect on household reliance on transfer income. We implement an inverse probability weighting empirical strategy to further balance treated and control households based on observable characteristics. We find a 2-percentage point reduction in the share of transfer income - extensive margin - and a 16.4\% reduction in the amount of transfer income- intensive margin - for the treated households. Contemporaneous increases in gross income, income from crops and livestock are observed among the treated households implying that the project-promoted productive economic activities translated to less dependence on transfer income. We also show some heterogeneous effects by the gender of household head. These findings point to the potential role of rural development projects in reducing dependence on social protection transfers and offering a pathway to economic independence among the rural poor and vulnerable, including those headed by females