ASC – Publicaties niet-programma gebonde

Alemu, G.

Bedi, A.S.

Dekker, M.

Mebratie, A.

Sparrow, R.

Yilma, Z.

Leiden University Scholary Publications

  www.ascleiden.nl ASC Infosheet 23 The Impact of Ethiopia’s Community-Based Health Insurance on Household Economic Welfare:A Policy Brief  Zelalem Yilma, Anagaw Mebratie, Robert Sparrow, Marleen Dekker, Getnet Alemu & Arjun Bedi  This infosheet is based on data collected for an impact evaluation of a Community-Based Health Insurance (CBHI) scheme that was introduced in Ethiopia in June 2011. The CBHI scheme is being imple-mented on a pilot basis  in 13 dis-tricts/woredas in four regional states. The objective of the scheme is to remove fi-nancial barriers and increase health-service utilization; improve the quality of care by increasing resources for health facilities and mobilize additional re-sources for the health sector. The re-search project conducted household sur-veys in 2011, 2012 and 2013 (baseline and two follow-up surveys) and facility-level surveys in 2011 and 2014. Qualita-tive data were also collected using key informant interviews, focus-group discus-sions and event history analysis. As a prelude to national coverage, the Ethiopian government introduced a pilot Community- Based Health Insurance scheme in thirteen woredas across the four main regional states in June 2011. The scheme’s primary aims included the provision of financial protection against unexpected healthcare costs and the en-hancement of access to modern healthcare. This policy brief assesses the impact of the scheme on household eco-nomic welfare: consumption, income, indebtedness and livestock.  Health insurance principally addresses out-of-pocket health expenditure, which is one of the two main sources of house-hold financial stress related to illness. The second is reduced income due to a household member’s declining capacity to work. While health insurance schemes are not designed to curb this source of vulnerability, they can protect the house-hold’s agricultural income by facilitating an early recovery and reducing pressure on it to reallocate resources meant for productive purposes, for example, by buying fertilizers and high-value seeds and covering medical expenses. By reduc-ing reliance on potentially harmful coping responses, such as borrowing at high rates, health insurance schemes can pro-tect a household’s economic welfare in both the short and long term.  My wife is sick with a modern illness, TB. She gets sick again and again and goes to health facilities quite often. I spent around Birr 5000 on her health. Her ill-ness has affected our harvest. Because of health expenses, I couldn’t buy inputs (high-yield seeds and fertilizer) on time and this has reduced my output. [Male respondent, Oumbulo Tenkaka Kebele of SNNPR. Interview: 11 February 2013]   ASC Infosheet 23/2015 www.ascleiden.nl My daughter had a stomach complaint for more than a week. I took her to a traditional healer but she didn’t get better. Then I took her to a health centre. I spent Birr 300 on that. Due to her illness, I didn’t work in my vegetable garden. As I used the money I put aside for seeds, I ran out of cash to buy seeds so I couldn’t grow vegetables. Although, after some time, I worked off-farm (digging sand and selling it) and planted vegetables, I do not expect as much output as I planted late. [Male respondent, Jara Damuwa Kebele of SNNPR. Interview: 15 February 2013]    The four regions studied in the research pro-gramme in rural Ethiopia   Three rounds of a household panel da-taset were collected in March/April 2011, 2012 and 2013. The first was collected a few months before the launch of the CBHI scheme and served as a baseline in this survey. It included sixteen districts locat-ed across Ethiopia’s four main regions: Amhara, Oromiya, Tigray and SNNPR. The three districts in each region that imple-mented the CBHI pilot and one selected non-pilot district were included. The non-pilot districts were chosen based on crite-ria similar to those used to select the pilot districts. A two-stage sampling design was applied in the districts and villages and households were selected using random sampling. The total sample size in the first round was 1632 households (9455 indi-viduals), of which 98% and 97% were suc-cessfully resurveyed in 2012 and 2013 respectively.   Photo 1 The CBHI scheme’s ID and membership card  Photo: Zelalem Yilma   CBHI uptake was 41% in the sample in April 2012 and 48% in 2013, which is rela-tively high compared to what has been found in other African countries. Benefit packages, registration fees, premiums and premium payment methods are simi-lar within regions but vary slightly be-tween regions. On average, premiums for core household members (parents and underage children) amount to about 1-ASC Infosheet 23/2015 www.ascleiden.nl 1.4% of monthly non-medical household expenditures The results of this survey suggest a non-random uptake, i.e. uptake in some groups is higher than in other groups. At the baseline, households that subse-quently take up CBHI have higher crop output and income, are more likely to have borrowed, have larger outstanding loans and bigger livestock holdings than households that do not have insurance. But few differences in consumption were noted. A naive comparison of post-intervention outcomes would probably overestimate the impact of CBHI on in-come and livestock and underestimate the impact on indebtedness. We have, therefore, estimated a level model that controls for both observed and unob-served differences that do not change over time.    Photo 2 The pilot CBHI scheme provides financial protection against unexpected healthcare costs and aims to enhance access to mod-ern healthcare, such as this health centre   Photo: Marleen Dekker    Figure 1 shows a comparison of the in-sured and uninsured households for a number of outcome variables related to borrowing and loans, production, income and consumption. With the exception of consumption, differences in these out-come variables  were found at a descrip-tive level. When controlling for household and regional characteristics in regression analysis, some of the effects remain. CBHI appeared to have a negative impact on the probability of having outstanding loans. This effect ranged between 4% and 5% depending on the methods used and the control groups, which translates to about 13% of baseline values. The result suggests that CBHI members are less like-ly to resort to borrowing to finance any medical treatment their household mem-bers may require. There are also negative coefficients for the amount of outstand-ing loans although these are imprecise. Estimates for all types of livestock are not statistically significant. While there was evidence of some positive impact on in-come, the results provided no evidence that CBHI affected household consump-tion.    Figure 1  Selected outcome variables by insurance status by year   0 .1 .2 .3 .4201320122011Proportion of indebted0 200 400 600 800 1,000201320122011Outstanding loan0 5,000 10,000 15,000201320122011Crop output0 5,000 10,000 15,000201320122011Total income0 100 200 300 400 500201320122011Total consumption0 100 200 300 400201320122011Food consumptionuninsuredinsuredASC Infosheet 23/2015 www.ascleiden.nl Overall, the main benefit of the scheme was found to be its effect on re-ducing the need to borrow. This may have longer-term benefits and reduce vulnera-bility to other forms of shocks. A related study found a marked impact on increas-ing healthcare utilization. These two sets of results, namely the lower probability of borrowing and increased healthcare utili-zation, provide support for the govern-ment’s recent move to extend the CBHI pilot to 161 districts. However, a nation-wide scale-up requires an examination of the scheme’s financial sustainability.   The information presented here is based on a paper entitled ‘Impact of Ethiopia’s Community-Based Health Insurance on Household Economic Welfare’ that was published in 2014 as ISS Working Paper No. 590.   Authors contact details  Getnet Alemu: Addis Ababa University          galemu2001@yahoo.com Arjun S. Bedi: International Institute of Social Studies, Erasmus University Rotterdam & School of Foreign Service-Qatar, Georgetown University bedi@iss.nl Marleen Dekker: African Studies Centre, Leiden University MDekker@ascleiden.nl Anagaw Mebratie: International Institute of So-cial Studies, Erasmus University Rotterdam mebratie@iss.nl Robert Sparrow: Crawford School of Public Policy, Australian National University                       robert.sparrow@anu.edu.au Zelalem Yilma: International Institute of Social Studies, Erasmus University Rotterdam     debebe@iss.nl  The authors acknowledge the generous financial support of the Netherlands Organisation for Sci-entific Research (NWO-WOTRO): grant no. W07.45.103.00.   More information on the project can be found at: http://www.ossrea.net/index.php?option=com_content&view=article&id=764&Itemid=177  Related Publications  Mebratie, A., R. Sparrow, G. Alemu & A.S. Bedi (2013) ‘Community-Based Health Insurance Schemes: A Systematic Review’. ISS Working Paper No. 568.Mebratie, A.D., R. Sparrow, Z. Yilma, D. Abebaw, G. Alemu & A.S. Bedi (2013) ‘Impact of Ethiopian Pilot Community-Based Health Insurance Scheme on Health Care Utili-zation: A Household Panel Data Analysis’. The Lancet 381: S92.  Mebratie, A., R. Sparrow, Z. Yilma, D. Abebaw, G. Alemu & A.S. Bedi (2014) ‘The Impact of Ethi-opia’s Pilot Community Based Health Insur-ance Scheme on Healthcare Utilization and Cost of Care’. ISS Working Paper No. 593. Mebratie, A., R. Sparrow, Z. Yilma, G. Alemu & A.S. Bedi (2014) ’Dropping Out of Ethiopia’s Community-Based Health Insurance Scheme’. ISS Working Paper No. 591. Mebratie, A., R. Sparrow, Z. Yilma, G. Alemu & A.S. Bedi (2013) ‘Enrolment in Ethiopia’s Community Based Health Insurance Scheme’. ISS Working Paper No. 578. Mebratie, A.D., E. van de Poel, Z. Yilma, D. Abebaw, G. Alemu & A.S. Bedi (2014) ‘Healthcare-Seeking Behaviour in Rural Ethio-pia: Evidence from Clinical Vignettes’. BMJ Open 4: 1-12. Yilma, Z., D. Anagaw. A. Mebratie, R. Sparrow, M. Dekker, G. Alemu & A.S. Bedi (2014) ‘Channels of Impoverishment due to Ill Health in Rural Ethiopia’. ISS Working Paper No. 592. Yilma, Z. , A. Mebratie, R. Sparrow, D. Abebaw, M. Dekker, G. Alemu & A.S. Bedi (2014) ‘Cop-ing with Shocks in Rural Ethiopia’. Journal of Development Studies 50(7): 1009-1024. Yilma, Z., A. Mebratie, R. Sparrow, M. Dekker, G. Alemu & A.S. Bedi (2014) ’Impact of Ethiopia’s Community-Based Health Insurance on Household Economic Welfare’. ISS Working Paper No. 590.  

The impact of Ethiopia's community-based health insurance on household economic welfare: a policy brief

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The impact of Ethiopia's community-based health insurance on household economic welfare: a policy brief

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