Essays on evaluating a community based health insurance scheme in rural Ethiopia

__Abstract__ Since the late 1990s, in a move away from user fees for health care and with the aim of creating universal access, several low and middle income countries have set up community-based health insurance (CBHI) schemes. Following this approach, in June 2011, with the aim of enhancing access to health care and reducing the burden of out-of-pocket health care expenditure, the Government of Ethiopia rolled out a pilot CBHI scheme. The scheme caters to rural households and urban informal sector workers in 13 districts located in four main regions (Tigray, Amhara, Oromiya, and SNNP) of the country. The main aims of this thesis are to assess the factors that drive initial scheme uptake and contract renewal and to identify the impact of CBHI on utilization of care and financial protection. As a prelude to an assessment of these issues, the thesis also provides a systematic review of the literature on CBHI schemes and uses five clinical vignettes to assess the demand for modern health care in rural Ethiopia. The thesis uses data obtained from various sources: three waves of a household panel survey, a health facility survey and qualitative information gathered through focus group discussions and key informant interviews

Firm Heterogeneity and Development: A Meta Analysis of FDI Productivity Spill-overs

abstract: In order to assess the relationship between economic development and firm heterogeneity, this paper studies productivity levels in the context of FDI. We illustrate that developing and emerging countries show a lot of variation in the extent of heterogeneity of their populations of firms. Heterogeneity is a bit stronger at per capita GDP levels below $10.000, but also remains substantial at higher levels of development We take stock of the rich literature on FDI-spill-overs analysing econometric studies on FDI spill-over effects that were published over the period 1983-2008 and deal with national studies in 30 developing countries and emerging markets. One important finding is that these studies tend to ignore two sources of heterogeneity: exports and – especially – R&D. We use a meta-analysis to correct for differences in research design (including regional effects, sample size and level of aggregation) and investigate the spill-over effects of foreign firms on domestic firms. Focusing on the effect of firm heterogeneity on productivity, we investigate several sources of heterogeneity including firm size (production share), internationalization (both exports and foreign ownership) and labour quality. We observe positive, and significant effects for heterogeneity in terms of labour quality, size and export as 44% –66% of the coefficients are significant and positive and less than 9% of the coefficients are negative and significant. This robustness contrasts with contradictory findings for foreign ownership where 63% of the coefficients are insignificant or negative. At another level this study identifies research design factors that influence the reported findings on FDI spill-over analysis

Community-Based Health Insurance Schemes

Due to the limited ability of publicly financed health systems in developing countries to provide adequate access to health care, community-based health financing has been proposed as a viable option. This has led to the implementation of a number of Community- Based Health Insurance (CBHI) schemes, in several developing countries. To assess the ability of such schemes in meeting their stated objectives, this study systematically reviews the existing empirical evidence on three outcomes – access to schemes, effect on health care utilization and effect on financial protection. In addition to collating and summarizing the evidence we analyse the link between key scheme design characteristics and their effect on outcomes and comment on the role that may be played by study characteristics in influencing outcomes. The review shows that the ultra-poor are often excluded and at the same time there is evidence of adverse selection. The bulk of the studies find that access to CBHI is associated with increased health care utilization, especially with regard

Containing the spread of COVID-19 in Ethiopia

Ethiopia has a low although rising number of confirmed COVID-19 cases. Despite these low figures, stringent measures have been implemented since mid-March. In this viewpoint we describe the prevention and preparation measures taken in Ethiopia and comment on the consequences, challenges and strengths of the measures, keeping in mind the Ethiopian context

The impact of Ethiopia’s pilot community based health insurance scheme on healthcare utilization and cost of care

In recent years there has been a proliferation of Community Based Health Insurance (CBHI) schemes designed to enhance access to modern health care services and provide financial protection to workers in the informal and rural sectors. In June 2011, the Government of Ethiopia introduced a pilot CBHI scheme in rural parts of the country. This paper assesses the impact of the scheme on utilization of modern health care and the cost of accessing health care. It adds to the relatively small body of work that provides a rigorous evaluation of CBHI schemes. We find that enrolment leads to a 30 to 41 percent increase in utilization of outpatient care at public facilities, a 45 to 64 percent increase in the frequency of visits to public facilities and at least a 56 percent decline in the cost per visit to public facilities. The effects of the scheme on out-of-pocket spending are not as clear. The impact on utilization and costs combined with a high uptake rate of almost 50 percent within two years of scheme establishment, suggests that this scheme has the potential to meet the goal of universal access to health care

Impact of Ethiopia’s Community Based Health Insurance on household economic welfare

In 2011, the Government of Ethiopia launched a pilot Community-Based Health Insurance (CBHI) scheme. This paper uses three rounds of household survey data, collected before and after the introduction of the CBHI pilot, to assess the impact of the scheme on household consumption, income, indebtedness and livestock holdings. We find that enrolment leads to a 5 percentage point – or 13 percent – decline in the probability of borrowing and is associated with an increase in household income. There is no evidence that enrolling in the scheme affects consumption or livestock holdings. Our results show that the scheme reduces reliance on potentially harmful coping responses such as borrowing. This paper adds to the relatively small body of work which rigorously evaluates the impact of CBHI schemes on economic welfare

The Effect of Ethiopia’s Community-Based Health Insurance Scheme on Revenues and Quality of Care

Ethiopia’s Community-Based Health Insurance (CBHI) scheme was established with the objectives of enhancing access to health care, reducing out-of-pocket expenditure (OOP), mobilizing financial resources and enhancing the quality of health care. Previous analyses have shown that the scheme has enhanced health care access and led to reductions in OOP. This paper examines the impact of the scheme on health facility revenues and quality of care. This paper relies on a difference-in-differences approach applied to both panel and cross-section data. We find that CBHI-affiliated facilities experience a 111% increase in annual outpatient visits and annual revenues increase by 47%. Increased revenues are used to ameliorate drug shortages. These increases have translated into enhanced patient satisfaction. Patient satisfaction increased by 11 percentage points. Despite the increase in patient volume, there is no discernible increase in waiting time to see medical professionals. These results and the relatively high levels of CBHI enrollment suggest that the Ethiopian CBHI has been able to successfully negotiate the main stumbling block—that is, the poor quality of care—which has plagued similar CBHI schemes in Sub-Saharan Afric

Self-reported health care seeking behavior in rural Ethiopia: Evidence from clinical vignettes

Between 2000 and 2011, Ethiopia rapidly expanded its health-care infrastructure recording an 18-fold increase in the number of health posts and a 7-fold increase in the number of health centers. However, annual per capita outpatient utilization has increased only marginally. The extent to which individuals forego necessary health care, especially why and who foregoes care are issues that have received little attention in the context of low-income countries. This paper uses five clinical vignettes covering a range of context-specific child and adult-related diseases to explore the health-seeking behavior of rural Ethiopian households. We find almost universal preference for modern care. There is a systematic relationship between socioeconomic status and choice of providers mainly for adult-related conditions with households in higher consumption quintiles more likely to seek care in health centers, private/NGO clinics as opposed to health posts. Similarly, delays in care-seeking behavior are apparent mainly for adult-related conditions. The differences in care seeking behavior between adult and child related conditions may be attributed to the recent spread of health posts which have focused on raising awareness of maternal and child health. Overall, the analysis suggests that the lack of health-care utilization is not driven by the inability to recognize health problems or due to a low perceived need for modern care but due to other factors

Healthcare-seeking behaviour in rural Ethiopia: Evidence from clinical vignettes

__Abstract__ Objectives: To investigate the determinants of healthcare-seeking behaviour using five contextrelevant clinical vignettes. The analysis deals with three issues: whether and where to seek modern care and when to seek care. Setting: This study is set in 96 villages located in four main regions of Ethiopia. The participants of this study are 1632 rural households comprising 9455 individuals. Primary and secondary outcome measures: Probability of seeking modern care for symptoms related to acute respiratory infections/pneumonia, diarrhoea, malaria, tetanus and tuberculosis. Conditional on choosing modern healthcare, where to seek care (health post, health centre, clinic and hospital). Conditional on choosing modern healthcare, when to seek care (seek care immediately, the next day, after 2 days, between 3 days to 1 week, a week or more). Results: We find almost universal preference for modern care. Foregone care ranges from 0.6% for diarrhoea to 2.5% for tetanus. There is a systematic relationship between socioeconomic status and choice of providers mainly for adult-related conditions with households in higher consumption quintiles more likely to seek care in health centres, private/Non-Government Organization (NGO) clinics as opposed to health posts. Delays in care-seeking behaviour are apparent mainly for adult-related conditions and among poorer households. Conclusions: The analysis suggests that the lack of healthcare utilisation is not driven by the inability to recognise health problems or due to a low perceived need for modern care