Using community wealth ranking to identify the poor for subsidies: a case study of community-based health insurance in Nouna, Burkina Faso

Factors Contributing to Low Adherence to Community-Based Health Insurance in Rural Nyanza District, Southern Rwanda

Background

Community-based health insurance (CBHI) schemes are an emerging mechanism for providing financial protection against health-related poverty. In Rwanda, CBHI is being implemented across the country, and it is based on four socioeconomic categories of the “Ubudehe system”: the premiums of the first category are fully subsidized by government, the second and third category members pay 3000 frw, and the fourth category members pay 7000 frw as premium. However, low adherence of community to the scheme since 2011 has not been sufficiently studied.

Objective

This study aimed at determining the factors contributing to low adherence to the CBHI in rural Nyanza district, southern Rwanda.

Methodology

A cross-sectional study was conducted in nine health centers in rural Nyanza district from May 2017 to June 2017. A sample size of 495 outpatients enrolled in CBHI or not enrolled in the CBHI scheme was calculated based on 5% margin of error and a 95% confidence interval. Logistic regression was used to identify the determinants of low adherence to CBHI.

Results

The study revealed that there was a significant association between long waiting time to be seen by a medical care provider and between health care service provision and low adherence to the CBHI scheme (P value < 0.019) (CI: 0.09107 to 0.80323). The estimates showed that premium not affordable (P value < 0.050) (CI: 0.94119 to 9.8788) and inconvenient model of premium payment (P value < 0.001) (CI: 0.16814 to 0.59828) are significantly associated with low adherence to the CBHI scheme. There was evidence that the socioeconomic status as measured by the category of Ubudehe (P value < 0.005) (CI: 1.4685 to 8.93406) increases low adherence to the CBHI scheme.

Conclusion

This study concludes that belonging to the second category of the Ubudehe system, long waiting time to be seen by a medical care provider and between services, premium not affordable, and inconvenient model of premium payment were significant predictors of low adherence to CBHI scheme.

Street-level workers' inadequate knowledge and application of exemption policies in Burkina Faso jeopardize the achievement of universal health coverage: evidence from a cross-sectional survey

BACKGROUND

Street-level workers play a key role in public health policies in Africa, as they are often the ones to ensure their implementation. In Burkina Faso, the State formulated two different user-fee exemption policies for indigents, one for deliveries (2007), and one for primary healthcare (2009). The objective of this study was to measure and understand the determinants of street-level workers' knowledge and application of these exemption measures.

METHODS

We used cross-sectional data collected between October 2013 and March 2014. The survey targeted 1521 health workers distributed in 498 first-line centres, 18 district hospitals, 5 regional hospitals, and 11 private or other facilities across 24 districts. We used four different random effects models to identify factors associated with knowledge and application of each of the above-mentioned exemption policies.

RESULTS

Only 9.2% of workers surveyed knew of the directive exempting the worst-off, and only 5% implemented it. Knowledge and application of the delivery exemption were higher, with 27% of all health workers being aware of the delivery exemption directive and 24.2% applying it. Mobile health workers were found to be consistently more likely to apply both exemptions. Health workers who were facility heads were significantly more likely to know about the indigent exemption for primary health care and to apply it. Health workers in districts with higher proportions of very poor people were significantly more likely to know about and apply the delivery exemption. Nearly 60% of respondents indicated either 5% or 10% as the percentage of people they would deem adequate to target for exemption.

CONCLUSION

This quantitative study confirmed earlier qualitative results on the importance of training and informing health workers and monitoring the measures targeting equity, to ensure compliance with government directives. The local context (e.g., hierarchy, health system, interventions) and the ideas that street-level workers have about the policy instruments can influence their effective implementation. Methods for remunerating health workers and health centres also need to be adapted to ensure equity measures are applied to achieve universal healthcare.

Identifying the poor for premium exemption: a critical step towards universal health coverage in Sub-Saharan Africa

Premium exemption for the poor is a critical step towards achieving universal health coverage in sub-Saharan Africa due to the large proportion of the population living in extreme poverty who cannot pay premium. However, identifying the poor for premium exemption has been a big challenge for SSA countries. This paper is a succinct review of four methods available for identifying the poor, outlining the ideal conditions under which each of the methods should be used and the drawbacks associated with using each of the methods.

Socioeconomic inequalities of outpatient and inpatient service utilization in China: personal and regional perspectives

BACKGROUND

China's health system has shown remarkable progress in health provision and health outcomes in recent decades, however inequality in health care utilization persists and poses a serious social problem. While government pro-poor health policies addressed affordability as the major obstacle to equality in health care access, this policy direction deserves further examination. Our study examines the issue of health care inequalities in China, analyzing both regional and individual socioeconomic factors associated with the inequality, and provides evidence to improve governmental health policies.

METHODS

The China Health and Nutrition Survey (CHNS) 1991-2011 data were used to analyze the inequality of health care utilization. The random effects logistic regression technique was used to model health care utilization as the dependent variable, and income and regional location as the independent variables, controlling for individuals' age, gender, marital status, education, health insurance, body mass index (BMI), and period variations. The dynamic trend of 1991-2011 regional disparities was estimated using an interaction term between the regional group dummy and the wave dummy.

RESULTS

The probability of using outpatient service and inpatient services during the previous 4 weeks was 8.6 and 1.1% respectively. Compared to urban residents, suburban (OR: 0.802, 95% CI: 0.720-0.893), town (OR: 0.722, 95% CI: 0.648-0.804), rich (OR: 0.728, 95% CI: 0.656-0.807) and poor village (OR: 0.778, 95% CI: 0.698-0.868) residents were less likely to use outpatient service; and rich (OR: 0.609, 95% CI: 0.472-0.785) and poor village (OR: 0.752, 95% CI: 0. 576-0.983) residents were less likely to use inpatient health care. But the differences between income groups were not significant, except the differences between top and bottom income group in outpatient service use.

CONCLUSION

Regional location was a more important factor than individual characteristics in determining access to health care. Besides demand-side subsidies, Chinese policy makers should pay enhanced attention to health care resource allocation to address inequity in health care access.

Characterisation of the rural indigent population in Burkina Faso: a screening tool for setting priority healthcare services in sub-Saharan Africa

BACKGROUND

In Africa, health research on indigent people has focused on how to target them for services, but little research has been conducted to identify the social groups that compose indigence. Our aim was to identify what makes someone indigent beyond being recognised by the community as needing a card for free healthcare.

METHODS

We used data from a survey conducted to evaluate a state-led intervention for performance-based financing of health services in two districts of Burkina Faso. In 2015, we analysed data of 1783 non-indigents and 829 people defined as indigents by their community in 21 villages following community-based targeting processes. Using a classification tree, we built a model to select socioeconomic and health characteristics that were likely to distinguish between non-indigents and indigents. We described the screening performance of the tree using data from specific nodes.

RESULTS

Widow(er)s under 45 years of age, unmarried people aged 45 years and over, and married women aged 60 years and over were more likely to be identified as indigents by their community. Simple rules based on age, marital status and gender detected indigents with sensitivity of 75.6% and specificity of 55% among those 45 years and over; among those under 45, sensitivity was 85.5% and specificity 92.2%. For both tests combined, sensitivity was 78% and specificity 81%.

CONCLUSION

In moving towards universal health coverage, Burkina Faso should extend free access to priority healthcare services to widow(er)s under 45, unmarried people aged 45 years and over, and married women aged 60 years and over, and services should be adapted to their health needs.

ETHICS CONSIDERATIONS

The collection, storage and release of data for research purposes were authorised by a government ethics committee in Burkina Faso (Decision No. 2013-7-066). Respondent consent was obtained verbally.

Inequitable Access to Health Care by the Poor in Community-Based Health Insurance Programs: A Review of Studies From Low- and Middle-Income Countries

The poor lack equitable access to health care in community-based health insurance schemes. Flexible installment payment plans, subsidized premiums, and elimination of co-pays can increase enrollment and use of health services by the poor.

Background:

Out-of-pocket payments for health care services lead to decreased use of health services and catastrophic health expenditures. To reduce out-of-pocket payments and improve access to health care services, some countries have introduced community-based health insurance (CBHI) schemes, especially for those in rural communities or who work in the informal sector. However, there has been little focus on equity in access to health care services in CBHI schemes.

Methods:

We searched PubMed, Web of Science, African Journals OnLine, and Africa-Wide Information for studies published in English between 2000 and August 2014 that examined the effect of socioeconomic status on willingness to join and pay for CBHI, actual enrollment, use of health care services, and drop-out from CBHI. Our search yielded 755 articles. After excluding duplicates and articles that did not meet our inclusion criteria (conducted in low- and middle-income countries and involved analysis based on socioeconomic status), 49 articles remained that were included in this review. Data were extracted by one author, and the second author reviewed the extracted data. Disagreements were mutually resolved between the 2 authors. The findings of the studies were analyzed to identify their similarities and differences and to identify any methodological differences that could account for contradictory findings.

Results:

Generally, the rich were more willing to pay for CBHI than the poor and actual enrollment in CBHI was directly associated with socioeconomic status. Enrollment in CBHI was price-elastic—as premiums decreased, enrollment increased. There were mixed results on the effect of socioeconomic status on use of health care services among those enrolled in CBHI. We found a high drop-out rate from CBHI schemes that was not related to socioeconomic status, although the most common reason for dropping out of CBHI was lack of money to pay the premium.

Conclusion:

The effectiveness of CBHI schemes in achieving universal health coverage in low- and middle-income countries is questionable. A flexible payment plan where the poor can pay in installments, subsidized premiums for the poor, and removal of co-pays are measures that can increase enrollment and use of CBHI by the poor.

Poverty identification for a pro-poor health insurance scheme in Tanzania: reliability and multi-level stakeholder perceptions

Background

Many low income countries have policies to exempt the poor from user charges in public facilities. Reliably identifying the poor is a challenge when implementing such policies. In Tanzania, a scorecard system was established in 2011, within a programme providing free national health insurance fund (NHIF) cards, to identify poor pregnant women and their families, based on eight components. Using a series of reliability tests on a 2012 dataset of 2,621 households in two districts, this study compares household poverty levels using the scorecard, a wealth index, and monthly consumption expenditures.

Methods

We compared the distributions of the three wealth measures, and the consistency of household poverty classification using cross-tabulations and the Kappa statistic. We measured errors of inclusion and exclusion of the scorecard relative to the other methods. We also gathered perceptions of the scorecard criteria through qualitative interviews with stakeholders at multiple levels of the health system.

Findings

The distribution of the scorecard was less skewed than other wealth measures and not truncated, but demonstrated clumping. There was a higher level of agreement between the scorecard and the wealth index than consumption expenditure. The scorecard identified a similar number of poor households as the “basic needs” poverty line based on monthly consumption expenditure, with only 45 % errors of inclusion. However, it failed to pick up half of those living below the “basic needs” poverty line as being poor. Stakeholders supported the inclusion of water sources, income, food security and disability measures but had reservations about other items on the scorecard.

Conclusion

In choosing poverty identification strategies for programmes seeking to enhance health equity it’s necessary to balance between community acceptability, local relevance and the need for such a strategy. It is important to ensure the strategy is efficient and less costly than alternatives in order to effectively reduce health disparities.

From institutionalization of user fees to their abolition in West Africa: a story of pilot projects and public policies

This article analyzes the historical background of the institutionalization of user fees and their subsequent abolition in West Africa. Based on a narrative review, we present the context that frames the different articles in this supplement. We first show that a general consensus has emerged internationally against user fees, which were imposed widely in Africa in the 1980s and 1990s; at that time, the institutionalization of user fees was supported by evidence from pilot projects funded by international aid agencies. Since then there have been other pilot projects studying the abolition of user fees in the 2000s, but these have not yet had any real influence on public policies, which are often still chaotic. This perplexing situation might be explained more by ideologies and political will than by insufficient financial capacity of states.

Health insurance and child mortality in rural Burkina Faso

Background

Micro health insurance schemes have been implemented across developing countries as a means of facilitating access to modern medical care, with the ultimate aim of improving health. This effect, however, has not been explored sufficiently.

Objective

We investigated the effect of enrolment into community-based health insurance on mortality in children under 5 years of age in a health and demographic surveillance system in Nouna, Burkina Faso.

Design

We analysed the effect of health insurance enrolment on child mortality with a Cox regression model. We adjusted for variables that we found to be related to the enrolment in health insurance in a preceding analysis.

Results

Based on the analysis of 33,500 children, the risk of mortality was 46% lower in children enrolled in health insurance as compared to the non-enrolled children (HR=0.54, 95% CI 0.43–0.68) after adjustment for possible confounders. We identified socioeconomic status, father's education, distance to the health facility, year of birth, and insurance status of the mother at time of birth as the major determinants of health insurance enrolment.

Conclusions

The strong effect of health insurance enrolment on child mortality may be explained by increased utilisation of health services by enrolled children; however, other non-observed factors cannot be excluded. Because malaria is a main cause of death in the study area, early consultation of health services in case of infection could prevent many deaths. Concerning the magnitude of the effect, implementation of health insurance could be a major driving factor of reduction in child mortality in the developing world.

Using a community-based definition of poverty for targeting poor households for premium subsidies in the context of a community health insurance in Burkina Faso

Background

One of the biggest challenges in subsidizing premiums of poor households for community health insurance is the identification and selection of these households. Generally, poverty assessments in developing countries are based on monetary terms. The household is regarded as poor if its income or consumption is lower than a predefined poverty cut-off. These measures fail to recognize the multi-dimensional character of poverty, ignoring community members’ perception and understanding of poverty, leaving them voiceless and powerless in the identification process. Realizing this, the steering committee of Nouna’s health insurance devised a method to involve community members to better define ‘perceived’ poverty, using this as a key element for the poor selection. The community-identified poor were then used to effectively target premium subsidies for the insurance scheme.

Methods

The study was conducted in the Nouna’s Health District located in northwest Burkina Faso. Participants in each village were selected to take part in focus-group discussions (FGD) organized in 41 villages and 7 sectors of Nouna’s town to discuss criteria and perceptions of poverty. The discussions were audio recorded, transcribed and analyzed in French using the software NVivo 9.

Results

From the FGD on poverty and the subjective definitions and perceptions of the community members, we found that poverty was mainly seen as scarcity of basic needs, vulnerability, deprivation of capacities, powerlessness, voicelessness, indecent living conditions, and absence of social capital and community networks for support in times of need. Criteria and poverty groups as described by community members can be used to identify poor who can then be targeted for subsidies.

Conclusion

Policies targeting the poorest require the establishment of effective selection strategies. These policies are well-conditioned by proper identification of the poor people. Community perceptions and criteria of poverty are grounded in reality, to better appreciate the issue. It is crucial to take these perceptions into account in undertaking community development actions which target the poor. For most community-based health insurance schemes with limited financial resources, using a community-based definition of poverty in the targeting of the poorest might be a less costly alternative.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-014-1335-4) contains supplementary material, which is available to authorized users.

Analysis of agency relationships in the design and implementation process of the equity fund in Madagascar

Background

There are large gaps in the literature relating to the implementation of user fee policy and fee exemption measures for the poor, particularly on how such schemes are implemented and why many have not produced expected outcomes. In October 2003, Madagascar instituted a user fee exemption policy which established “equity funds” at public health centres, and used medicine sales revenue to subsidise the cost of medicine for the poor. This study examines the policy design and implementation process of the equity fund in Madagascar in an attempt to explore factors influencing the poor equity outcomes of the scheme.

Methods

This study applied an agency-incentive framework to investigate the equity fund policy design and implementation practices. It analysed agency relationships established during implementation; examined incentive structures given to the agency relationships in the policy design; and considered how incentive structures were shaped and how agents responded in practice. The study employed a case-study approach with in-depth analysis of three equity fund cases in Madagascar’s Boeny region.

Results

Policy design problems, triggering implementation problems, caused poor equity performance. These problems were compounded by the re-direction of policy objectives by health administrators and strong involvement of the administrators in the implementation of policy. The source of the policy design and implementation failure was identified as a set of principal-agent problems concerning: monitoring mechanisms; facility-based fund management; and the nature and level of community participation. These factors all contributed to the financial performance of the fund receiving greater attention than its ability to financially protect the poor.

Conclusion

The ability of exemption policies to protect the poor from user fees can be found in the details of the policy design and implementation; and implications of the policy design and implementation in a specific context determine whether a policy can realise its objectives. The equity fund experience in Madagascar, which illustrates the challenges of beneficiary identification, casts doubts on the application of the ‘targeting’ approach in health financing and raises issues to be considered in universal health policy formulation. The agency framework provides a useful lens through which to examine policy process issues.

Strategies for expanding health insurance coverage in vulnerable populations

BACKGROUND

Health insurance has the potential to improve access to health care and protect people from the financial risks of diseases. However, health insurance coverage is often low, particularly for people most in need of protection, including children and other vulnerable populations.

OBJECTIVES

To assess the effectiveness of strategies for expanding health insurance coverage in vulnerable populations.

SEARCH METHODS

We searched Cochrane Central Register of Controlled Trials (CENTRAL), part of The Cochrane Library. www.thecochranelibrary.com (searched 2 November 2012), PubMed (searched 1 November 2012), EMBASE (searched 6 July 2012), Global Health (searched 6 July 2012), IBSS (searched 6 July 2012), WHO Library Database (WHOLIS) (searched 1 November 2012), IDEAS (searched 1 November 2012), ISI-Proceedings (searched 1 November 2012),OpenGrey (changed from OpenSIGLE) (searched 1 November 2012), African Index Medicus (searched 1 November 2012), BLDS (searched 1 November 2012), Econlit (searched 1 November 2012), ELDIS (searched 1 November 2012), ERIC (searched 1 November 2012), HERDIN NeON Database (searched 1 November 2012), IndMED (searched 1 November 2012), JSTOR (searched 1 November 2012), LILACS(searched 1 November 2012), NTIS (searched 1 November 2012), PAIS (searched 6 July 2012), Popline (searched 1 November 2012), ProQuest Dissertation &Theses Database (searched 1 November 2012), PsycINFO (searched 6 July 2012), SSRN (searched 1 November 2012), Thai Index Medicus (searched 1 November 2012), World Bank (searched 2 November 2012), WanFang (searched 3 November 2012), China National Knowledge Infrastructure (CHKD-CNKI) (searched 2 November 2012).In addition, we searched the reference lists of included studies and carried out a citation search for the included studies via Web of Science to find other potentially relevant studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after (CBA) studies and Interrupted time series (ITS) studies that evaluated the effects of strategies on increasing health insurance coverage for vulnerable populations. We defined strategies as measures to improve the enrolment of vulnerable populations into health insurance schemes. Two categories and six specified strategies were identified as the interventions.

DATA COLLECTION AND ANALYSIS

At least two review authors independently extracted data and assessed the risk of bias. We undertook a structured synthesis.

MAIN RESULTS

We included two studies, both from the United States. People offered health insurance information and application support by community-based case managers were probably more likely to enrol their children into health insurance programmes (risk ratio (RR) 1.68, 95% confidence interval (CI) 1.44 to 1.96, moderate quality evidence) and were probably more likely to continue insuring their children (RR 2.59, 95% CI 1.95 to 3.44, moderate quality evidence). Of all the children that were insured, those in the intervention group may have been insured quicker (47.3 fewer days, 95% CI 20.6 to 74.0 fewer days, low quality evidence) and parents may have been more satisfied on average (satisfaction score average difference 1.07, 95% CI 0.72 to 1.42, low quality evidence).In the second study applications were handed out in emergency departments at hospitals, compared to not handing out applications, and may have had an effect on enrolment (RR 1.5, 95% CI 1.03 to 2.18, low quality evidence).

AUTHORS' CONCLUSIONS

Community-based case managers who provide health insurance information, application support, and negotiate with the insurer probably increase enrolment of children in health insurance schemes. However, the transferability of this intervention to other populations or other settings is uncertain. Handing out insurance application materials in hospital emergency departments may help increase the enrolment of children in health insurance schemes. Further studies evaluating the effectiveness of different strategies for expanding health insurance coverage in vulnerable population are needed in different settings, with careful attention given to study design.

Is the process for selecting indigents to receive free care in Burkina Faso equitable?

Background

In Burkina Faso, patients are required to pay for healthcare. This constitutes a barrier to access for indigents, who are the most disadvantaged. User fee exemption systems have been created to facilitate their access. A community-based initiative was thus implemented in a rural region of Burkina Faso to select the worst-off and exempt them from user fees. The final selection was not based on pre-defined criteria, but rather on community members’ tacit knowledge of the villagers. The objective of this study was to analyze the equitable nature of this community-based selection process.

Method

Based on a cross-sectional study carried out in 2010, we surveyed 1,687 indigents. The variables collected were those that determine healthcare use according to the Andersen-Newman model (1969): sociodemographic variables; income; occupation; access to financial, food or instrumental assistance; presence of chronic illness; and disabilities related to vision, muscle strength, or mobility. Bivariate analyses and logistic regression were performed.

Results

User fee exemptions were given mainly to indigents who were widowed (OR = 1.40; CI 95% [1.10–1.78]), had no financial assistance from their household for healthcare (OR = 1.58; CI 95% [1.26–1.97], lived alone (OR = 1.28; CI 95% [1.01–1.63]), lived with their spouses, (OR = 2.00; CI 95% [1.35-2.96], had vision impairments (OR = 1.45; CI 95% [1.14–1.84]), or had poor muscle strength and good mobility (OR = 1.73; CI 95% [1.28–2.33]). The indigent selection was not determined by household income, self-reported chronic illness, or previous use of services.

Conclusion

The community selection process took into account factors related to social vulnerability and functional limitations. However, we cannot affirm that the selection process was perfectly equitable, as it was very restrictive due to the limited budget available and the State’s lack of engagement in this matter. Exemption processes should be temporary solutions, and the State should make a commitment to move toward universal healthcare coverage.

Protocol for the process evaluation of interventions combining performance-based financing with health equity in Burkina Faso

BACKGROUND

The low quality of healthcare and the presence of user fees in Burkina Faso contribute to low utilization of healthcare and elevated levels of mortality. To improve access to high-quality healthcare and equity, national authorities are testing different intervention arms that combine performance-based financing with community-based health insurance and pro-poor targeting. There is a need to evaluate the implementation of these unique approaches. We developed a research protocol to analyze the conditions that led to the emergence of these intervention arms, the fidelity between the activities initially planned and those conducted, the implementation and adaptation processes, the sustainability of the interventions, the possibilities for scaling them up, and their ethical implications.

METHODS/DESIGN

The study adopts a longitudinal multiple case study design with several embedded levels of analyses. To represent the diversity of contexts where the intervention arms are carried out, we will select three districts. Within districts, we will select both primary healthcare centers (n =18) representing different intervention arms and the district or regional hospital (n =3). We will select contrasted cases in relation to their initial performance (good, fair, poor). Over a period of 18 months, we will use quantitative and qualitative data collection and analytical tools to study these cases including in-depth interviews, participatory observation, research diaries, and questionnaires. We will give more weight to qualitative methods compared to quantitative methods.

DISCUSSION

Performance-based financing is expanding rapidly across low- and middle-income countries. The results of this study will enable researchers and decision makers to gain a better understanding of the factors that can influence the implementation and the sustainability of complex interventions aiming to increase healthcare quality as well as equity.

A community-based approach to indigent selection is difficult to organize in a formal neighbourhood in Ouagadougou, Burkina Faso: a mixed methods exploratory study

Background

In most African countries, indigents treated at public health centres are supposed to be exempted from user fees. In Africa, most of the available knowledge has to do with targeting processes in rural areas, and little is known about how to select the worst-off in an urban area. In rural communities of Burkina Faso, trials of participatory community-based selection of indigents have been effective. However, the process for selecting indigents in urban areas is not yet clear.

Methods

This study evaluates a community-funded participatory indigent selection process in both a formal (loti) and an informal (non-loti) neighbourhood in the urban setting of Burkina Faso’s capital. This was an exploratory study to evaluate the processes and effectiveness of participatory targeting. We conducted individual interviews (n = 26) and analyzed secondary qualitative data (eight focus groups, 16 individual interviews). We also used the results of a socioeconomic survey (carried out by the Ouaga HDSS in 2011) of all the households established in the areas, including those of selected indigents.

Results

The coverage of indigent targeting was very low: 0.33% (loti) and 0.22% (non loti). In the non loti neighbourhood, the level of poverty among people selected was higher than the mean level of the poor who were not selected. Some indigents selected in the loti neighbourhood were not among the worst-off. The process was difficult to organize in the loti neighbourhood; people knew each other less well and were not very available, and there were cases of collusion. The process worked well in the non loti neighbourhood.

Conclusions

This intervention research provides new evidence about the feasibility of a community-based selection process in an urban setting in Africa by comparing two different urban settings. The participatory community-based selection process appeared to be suitable for the non loti neighbourhood, but other targeting strategies need to be found for loti areas. Specific budgets need to be allocated to increase the coverage of indigent targeting.

Community-based health insurance programmes and the National Health Insurance Scheme of Nigeria: challenges to uptake and integration

BACKGROUND

Nigeria has included a regulated community-based health insurance (CBHI) model within its National Health Insurance Scheme (NHIS). Uptake to date has been disappointing, however. The aim of this study is to review the present status of CBHI in SSA in general to highlight the issues that affect its successful integration within the NHIS of Nigeria and more widely in developing countries.

METHODS

A literature survey using PubMed and EconLit was carried out to identify and review studies that report factors affecting implementation of CBHI in SSA with a focus on Nigeria.

RESULTS

CBHI schemes with a variety of designs have been introduced across SSA but with generally disappointing results so far. Two exceptions are Ghana and Rwanda, both of which have introduced schemes with effective government control and support coupled with intensive implementation programmes. Poor support for CBHI is repeatedly linked elsewhere with failure to engage and account for the 'real world' needs of beneficiaries, lack of clear legislative and regulatory frameworks, inadequate financial support, and unrealistic enrolment requirements. Nigeria's CBHI-type schemes for the informal sectors of its NHIS have been set up under an appropriate legislative framework, but work is needed to eliminate regressive financing, to involve scheme members in the setting up and management of programmes, to inform and educate more effectively, to eliminate lack of confidence in the schemes, and to address inequity in provision. Targeted subsidies should also be considered.

CONCLUSIONS

Disappointing uptake of CBHI-type NHIS elements in Nigeria can be addressed through closer integration of informal and formal programmes under the NHIS umbrella, with increasing involvement of beneficiaries in scheme design and management, improved communication and education, and targeted financial assistance.

Community concepts of poverty: an application to premium exemptions in Ghana's National Health Insurance Scheme

BACKGROUND

Poverty is multi dimensional. Beyond the quantitative and tangible issues related to inadequate income it also has equally important social, more intangible and difficult if not impossible to quantify dimensions. In 2009, we explored these social and relativist dimension of poverty in five communities in the South of Ghana with differing socio economic characteristics to inform the development and implementation of policies and programs to identify and target the poor for premium exemptions under Ghana's National Health Insurance Scheme.

METHODS

We employed participatory wealth ranking (PWR) a qualitative tool for the exploration of community concepts, identification and ranking of households into socioeconomic groups. Key informants within the community ranked households into wealth categories after discussing in detail concepts and indicators of poverty.

RESULTS

Community defined indicators of poverty covered themes related to type of employment, educational attainment of children, food availability, physical appearance, housing conditions, asset ownership, health seeking behavior, social exclusion and marginalization. The poverty indicators discussed shared commonalities but contrasted in the patterns of ranking per community.

CONCLUSION

The in-depth nature of the PWR process precludes it from being used for identification of the poor on a large national scale in a program such as the NHIS. However, PWR can provide valuable qualitative input to enrich discussions, development and implementation of policies, programs and tools for large scale interventions and targeting of the poor for social welfare programs such as premium exemption for health care.

Adverse selection in a community-based health insurance scheme in rural Africa: implications for introducing targeted subsidies

Background

Although most community-based health insurance (CBHI) schemes are voluntary, problem of adverse selection is hardly studied. Evidence on the impact of targeted subsidies on adverse selection is completely missing. This paper investigates adverse selection in a CBHI scheme in Burkina Faso. First, we studied the change in adverse selection over a period of 4 years. Second, we studied the effect of targeted subsidies on adverse selection.

Methods

The study area, covering 41 villages and 1 town, was divided into 33 clusters and CBHI was randomly offered to these clusters during 2004–06. In 2007, premium subsidies were offered to the poor households. The data was collected by a household panel survey 2004–2007 from randomly selected households in these 33 clusters (n = 6795). We applied fixed effect models.

Results

We found weak evidence of adverse selection before the implementation of subsidies. Adverse selection significantly increased the next year and targeted subsidies largely explained this increase.

Conclusions

Adverse selection is an important concern for any voluntary health insurance scheme. Targeted subsidies are often used as a tool to pursue the vision of universal coverage. At the same time targeted subsidies are also associated with increased adverse selection as found in this study. Therefore, it’s essential that targeted subsidies for poor (or other high-risk groups) must be accompanied with a sound plan to bridge the financial gap due to adverse selection so that these schemes can continue to serve these populations.

Targeting accuracy and impact of a community-identified waiver card scheme for primary care user fees in Afghanistan

BACKGROUND

User fees are a known common barrier to using health services, particularly among the poor. When fees are present, many facilities have waiver systems for poor patients to exempt them from paying. Targeting waivers to patients who need them most has been a challenge, especially in fragile states, where relevant data are limited and trust in institutions is low.

METHODS

Community-based targeting of vulnerable households was piloted in Afghanistan and evaluated for its feasibility, accuracy and effect on care-seeking. Waiver cards were distributed to very poor and female-headed households in catchment areas of 26 facilities in 10 provinces of Afghanistan in 2005 as one component of a larger health financing study. Households were nominated by community leaders using general guidelines to support 15% of the poorest members. In most cases, waiver cards were pro-actively distributed to them. Targeting accuracy, perceptions, as well the cards' effects on utilization were evaluated in 2007 through household surveys, health facility data, and in-depth interviews and focus group discussions with facility staff and community leaders.

RESULTS

The waiver system was implemented quickly at all but one facility charging fees. Facility staff and community leaders reported favorable perceptions of implementation and targeting accuracy.However, an analysis of the asset index of beneficiaries indicated that although targeting was progressive, significant leakage and high levels of under-coverage occurred; 42% of cards were used by people in the wealthiest three quintiles, and only 19% of people in the poorest quintile received a card. Households with waiver cards reported higher rates of care-seeking for recent illnesses compared to those without cards (p = 0.02).

CONCLUSIONS

Community identification of beneficiaries is feasible in a fragile state. Several recommendations are discussed to improve targeting accuracy of a waiver card system in the future, in light of this research and other international experiences.

Low coverage but few inclusion errors in Burkina Faso: a community-based targeting approach to exempt the indigent from user fees

BACKGROUND

User fees were generalized in Burkina Faso in the 1990s. At the time of their implementation, it was envisioned that measures would be instituted to exempt the poor from paying these fees. However, in practice, the identification of indigents is ineffective, and so they do not have access to care. Thus, a community-based process for selecting indigents for user fees exemption was tested in a district. In each of the 124 villages in the catchment areas of ten health centres, village committees proposed lists of indigents that were then validated by the health centres' management committees. The objective of this study is to evaluate the effectiveness of this community-based selection.

METHODS

An indigent-selection process is judged effective if it minimizes inclusion biases and exclusion biases. The study compares the levels of poverty and of vulnerability of indigents selected by the management committees (n = 184) with: 1) indigents selected in the villages but not retained by these committees (n = 48); ii) indigents selected by the health centre nurses (n = 82); and iii) a sample of the rural population (n = 5,900).

RESULTS

The households in which the three groups of indigents lived appeared to be more vulnerable and poorer than the reference rural households. Indigents selected by the management committees and the nurses were very comparable in terms of levels of vulnerability, but the former were more vulnerable socially. The majority of indigents proposed by the village committees who lived in extremely poor households were retained by the management committees. Only 0.36% of the population living below the poverty threshold and less than 1% of the extremely poor population were selected.

CONCLUSIONS

The community-based process minimized inclusion biases, as the people selected were poorer and more vulnerable than the rest of the population. However, there were significant exclusion biases; the selection was very restrictive because the exemption had to be endogenously funded.