Allegri, M. D.

Parmar, D.

Sauerborn, R.

Savadogo, G.

Souares, A.

City Research Online

Parmar, D., Allegri, M. D., Souares, A., Savadogo, G. & Sauerborn, R. (2011). Equity impact of community-based health insurance (2004-2008). Paper presented at the 3rd International Conference on Health Financing in Developing and Emerging Countries (CERDI), 11-05-2011 - 13-05-2011, Université d’Auvergne, France. City Research OnlineOriginal citation: Parmar, D., Allegri, M. D., Souares, A., Savadogo, G. & Sauerborn, R. (2011). Equity impact of community-based health insurance (2004-2008). Paper presented at the 3rd International Conference on Health Financing in Developing and Emerging Countries (CERDI), 11-05-2011 - 13-05-2011, Université d’Auvergne, France. Permanent City Research Online URL: http://openaccess.city.ac.uk/4134/ Copyright & reuseCity University London has developed City Research Online so that its users may access the research outputs of City University London's staff. Copyright © and Moral Rights for this paper are retained by the individual author(s) and/ or other copyright holders.  All material in City Research Online is checked for eligibility for copyright before being made available in the live archive. URLs from City Research Online may be freely distributed and linked to from other web pages. Versions of researchThe version in City Research Online may differ from the final published version. Users are advised to check the Permanent City Research Online URL above for the status of the paper.EnquiriesIf you have any enquiries about any aspect of City Research Online, or if you wish to make contact with the author(s) of this paper, please email the team at publications@city.ac.uk.Equity impact of community-based health insurance(2004-2008)Divya Parmar, Manuela de Allegri, Aurélia Souares, Germain Savadogo, Rainer SauerbornInstitute of Public Health   Heidelberg, GermanyCentre de Recherche en Santé de  NounaBurkina FasoEquity in health financing• Equity is an ethical principle• Health care should be: 1. financed according to ability-to-pay• Horizontal Equity: those who have the same ability-to-pay should pay the same • Vertical Equity: those with greater ability-to-pay should pay more 2. accessed according to need Reference: Culyer (1995)The studyData source: Household panel survey 2004-2008 (n=4695 individuals)Equity focus: • SES (poor vs. non-poor): Asset-based SES index was created by Principal Components Analysis (PCA). Data on ownership of household assets (durable goods and livestock) and housing conditions were used. Quartile 1 (Q1) was considered as ‘poor’.• Gender (women vs. men)• Age (children vs. adults)Equity at 2 levels:1. Equity in enrolment: Are the vulnerable groups enrolling into CBHI?2. Equity in utilization: Are the vulnerable groups utilizing healthcare?CBHI design & equity• Poor: Premium subsidies for poor (Q1) households in every village, since 2007  • Women: No specific benefits. – Deliveries not covered by CBHI – Government: ANC free and since 2007, 80% subsidy on deliveries at public facilities• Children: Premium subsidies, since the beginning(2004)– Government: Essential immunizations, malaria treatment & consultations Variable OR SEMale 0.886 0.187Child 0.456 0.132***Poor 0.274 0.090***Near 0.985 0.197Household Size 1.027 0.011**Ethnicity_Bwaba 0.961 0.235Literate 1.974 0.403***Year2005 1.792 0.436**Year2006 0.890 0.216Year2007 2.775 0.644***Year2008 1.524 0.366*Equity in enrolmentDependent variable: CHI (0,1)*** p<0.01, ** p<0.05, * p<0.1Only those individuals who were offered CBHI were included (n=4695)– No gender effect– Children less likely to enroll– Poor less likely to enroll Equity in enrolment: impact of subsidiesEquity improvedPoor enrolling more after subsidy0.2.4.6.81Cumulative share in enrolment0 .2 .4 .6 .8 1Cumulative share of eligible (ranked by SES, poorest first)Years 2004-2006 (Before subsidy)Years 2007-2008 (After subsidy)Line of equalityConcentration curves: Before & after subsidyVariable OR SEMale 0.876 0.130Child 0.565 0.175*Poor 0.499 0.115***CHI 2.182 0.531***Near 1.454 0.212**Household Size 1.016 0.009*Ethnicity_Bwaba 1.155 0.183Literate 1.545 0.230***Year2005 1.904 0.231Year2006 0.723 0.181Year2007 0.826 0.212Year2008 0.733 0.185Equity in utilization– No gender effect– Children less likely to utilize– Poor less likely to utilizeDependent variable: Facility care (0,1)*** p<0.01, ** p<0.05, * p<0.1Only those individuals who reported being sick in the previous month at the time of the survey were included (n=1710)Variable OR SEMale 0.876 0.130Child 0.565 0.175*Poor 0.499 0.115***CHI 2.182 0.531***Near 1.454 0.212**Household Size 1.016 0.009*Ethnicity_Bwaba 1.155 0.183Literate 1.545 0.230***Year2005 1.904 0.231Year2006 0.723 0.181Year2007 0.826 0.212Year2008 0.733 0.185Equity in utilization– No gender effect– Children less likely to utilize– Poor less likely to utilizeBut, are enrolled poor women and children utilizing care more than the non-enrolled?Equity in utilization: SESUtilization slightly more among poor who enrolled (CC above line of equality for poorest) Utilization by enrolment status0.2.4.6.81Cummulative share of facility use0 .2 .4 .6 .8 1Cummulative share of sick (ranked by SES, poorest first)CBHI==0CBHI==1Line of equalityEquity in utilization: genderAmong women: utilization more among poor women who enrolled(CC above line of equality)Among men: no difference in utilization for poor(For non-poor, utilization slightly less for enrolled)Women, by enrolment status0.2.4.6.81Cumulative share of facility use0 .2 .4 .6 .8 1Cumulative share of sick (ranked by SES, poorest first)CBHI=0CBHI=1Line of equalityMen, by enrolment status0.2.4.6.81Cumulative share of facility use0 .2 .4 .6 .8 1Cumulative share of sick (ranked by SES, poorest first)CBHI=0CBHI=1Line of equalityEquity in utilization: ageAmong children: utilization more among poor children who enrolled(CC above line of equality)Among adults: utilization more among poor adults who enrolled(CC above line of equality for poor)Children, by enrolment status Adults, by enrolment status0.2.4.6.81Cumulative share of facility use0 .2 .4 .6 .8 1Cumulative share of sick (ranked by SES, poorest first)CBHI==0CBHI==1Line of equality0.2.4.6.81Cumulative share of facility use0 .2 .4 .6 .8 1Cumulative share of sick (ranked by SES, poorest first)CBHI==0CBHI==1Line of equalityResults1. Equity in enrolment– Poor: enrolment increased after subsidy (still pro-rich)– Children less likely to enroll– No gender effect2. Equity in utilization– Poor: slight increase in utilization for those that enrolled– Women: pro-poor effect for those that enrolled– Children: pro-poor effect for those that enrolledNote:  Shows the status with and without CBHI; but does not mean that CBHI caused changes in utilizationImplications for National Health Insurance• Poor: Premium subsidy essential but not enough– Less likely to enroll. Even after enrolling less likely to utilize care– Other costs, health awareness, behavior at health facilities, sensitization….• Children: Premium subsidy essential but not enough – Less likely to enroll. However, once enrolled utilize care– Continue free/subsidized services for children at health facilities– Sensitization to increase enrolment • Women: Premium subsidies not essential– Continue free/subsidized maternal care at health facilitiesThank youDivya ParmarParmar@uni-heidelberg.deInstitute of Public HealthHeidelberg UniversityGermany

Equity impact of community-based health insurance (2004-2008)

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