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Lourenço L, Weber L, Garcia L, Ramos V, Souza J. Machine Learning Algorithms to Estimate Propensity Scores in Health Policy Evaluation: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:1484. [PMID: 39595751 PMCID: PMC11593605 DOI: 10.3390/ijerph21111484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2024] [Revised: 10/25/2024] [Accepted: 11/05/2024] [Indexed: 11/28/2024]
Abstract
(1) Background: Quasi-experimental design has been widely used in causal inference for health policy impact evaluation. However, due to the non-randomized treatment used, there is great potential for bias in the assessment of the results, which can be reduced by using propensity score (PS) methods. In this context, this article aims to map the literature concerning the use of machine learning (ML) algorithms for propensity score estimation. (2) Methods: A scoping review was carried out in the PubMed, EMBASE, ACM Digital Library, IEEE Explore, LILACS, Web of Science, Scopus, Compendex, and gray literature (ProQuest and Google Scholar) databases, based on the PRISMA-ScR guidelines. This scoping review aims to identify ML models and their accuracy and the characteristics of studies on causal inference for health policy impacts, with a specific focus on PS estimation using ML. (3) Results: Seven studies were included in the review from 3018 references searched. In general, tree-based ML models were used for PS estimation. Most of the studies did not show or mention the performance metrics of the selected models, focusing instead on discussing the treatment effects under analysis. (4) Conclusions: Despite important aspects of model development and evaluation being under-reported, this scoping review provides insights into the recent use of ML algorithms in health policy impact evaluation.
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Affiliation(s)
- Luís Lourenço
- Department of Knowledge Engineering, Federal University of Santa Catarina, Florianópolis 88035-972, Brazil (V.R.)
| | - Luciano Weber
- Department of Knowledge Engineering, Federal University of Santa Catarina, Florianópolis 88035-972, Brazil (V.R.)
| | | | - Vinicius Ramos
- Department of Knowledge Engineering, Federal University of Santa Catarina, Florianópolis 88035-972, Brazil (V.R.)
| | - João Souza
- Department of Knowledge Engineering, Federal University of Santa Catarina, Florianópolis 88035-972, Brazil (V.R.)
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Hasan MZ, Ahmed S, Mehdi GG, Ahmed MW, Arifeen SE, Chowdhury ME. The effectiveness of a government-sponsored health protection scheme in reducing financial risks for the below-poverty-line population in Bangladesh. Health Policy Plan 2024; 39:281-298. [PMID: 38164712 PMCID: PMC11423846 DOI: 10.1093/heapol/czad115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 11/09/2023] [Indexed: 01/03/2024] Open
Abstract
The Government of Bangladesh is piloting a non-contributory health protection scheme called Shasthyo Surokhsha Karmasuchi (SSK) to increase access to quality essential healthcare services for the below-poverty-line (BPL) population. This paper assesses the effect of the SSK scheme on out-of-pocket expenditure (OOPE) for healthcare, catastrophic health expenditure (CHE) and economic impoverishment of the enrolled population. A comparative cross-sectional study was conducted in Tangail District, where the SSK was implemented. From August 2019 to March 2020, a total of 2315 BPL households (HHs) (1170 intervention and 1145 comparison) that had at least one individual with inpatient care experience in the last 12 months were surveyed. A household is said to have incurred CHE if their OOPE for healthcare exceeds the total (or non-food) HH's expenditure threshold. Multiple regression analysis was performed using OOPE, incidence of CHE and impoverishment as dependent variables and SSK membership status, actual BPL status and benefits use status as the main explanatory variables. Overall, the OOPE was significantly lower (P < 0.01) in the intervention areas (Bangladeshi Taka (BDT) 23 366) compared with the comparison areas (BDT 24 757). Regression analysis revealed that the OOPE, CHE incidence at threshold of 10% of total expenditure and 40% of non-food expenditure and impoverishment were 33% (P < 0.01), 46% (P < 0.01), 42% (P < 0.01) and 30% (P < 0.01) lower, respectively, in the intervention areas than in the comparison areas. Additionally, HHs that utilized SSK benefits experienced even lower OOPE by 92% (P < 0.01), CHE incidence at 10% and 40% threshold levels by 72% (P < 0.01) and 59% (P < 0.01), respectively, and impoverishment by 27% at 10% level of significance. These findings demonstrated the significant positive effect of the SSK in reducing financial burdens associated with healthcare utilization among the enrolled HHs. This illustrates the importance of the nationwide scaling up of the scheme in Bangladesh to reduce the undue financial risk of healthcare utilization for those in poverty.
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Affiliation(s)
- Md Zahid Hasan
- Health Systems and Population Studies Division, icddr,b, Dhaka 1212, Bangladesh
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Worsley Building, Clarendon Way, Leeds LS2 9NL, UK
- Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, University of Leeds, Worsley Building, Clarendon Way, Leeds LS2 9NL, UK
| | - Sayem Ahmed
- Health Economics and Health Technology Assessment, School of Health and Wellbeing, University of Glasgow, 90 Byres Road, Glasgow G12 8TB, UK
- Centre for Health Economics and Medicines Evaluation, Bangor University, Ardudwy, Normal Site, Holyhead Road, Gwynedd, Wales LL57 2PZ, UK
| | - Gazi Golam Mehdi
- Health Systems and Population Studies Division, icddr,b, Dhaka 1212, Bangladesh
| | | | - Shams El Arifeen
- Maternal and Child Health Division, icddr,b, Dhaka 1212, Bangladesh
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Marye DM, Debalkie Atnafu D, Belayneh M, Takele Alemu A. User Fee Exemption Policy Significantly Improved Adherence to Maternal Health Service Utilization in Bahir Dar City, Northwest Ethiopia: A Comparative Cross-Sectional Study. CLINICOECONOMICS AND OUTCOMES RESEARCH 2023; 15:775-785. [PMID: 38106643 PMCID: PMC10722901 DOI: 10.2147/ceor.s431488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 12/06/2023] [Indexed: 12/19/2023] Open
Abstract
Background Increasing free and skilled delivery is a top priority in the global effort to reduce maternal and newborn mortality. Reducing user-fees through exemption policy has contributed to universal health coverage. However, there is scant evidence regarding the effect of exempted maternal services on adherence to utilization in Ethiopia. Thus, this study aimed to assess the effect of fee exemption policy on adherence to maternal health service utilization and its predictors. Methods A community-based comparative cross-sectional study was conducted in Bahir Dar City. A two-stage multistage sampling was employed; 497 women participated. Data were collected by face-to-face interview; entered and cleaned using Epi-Data 3.1. SPSS version 25 was used for further analysis. Bivariable and multivariable logistic regression models were computed to assess the association between explanatory and outcome variables. An adjusted odds ratio with a 95% confidence interval was used to interpret the degree of association. The effect of fee exemption policy on adherence to maternal health service utilization was measured by propensity score matching. Results The overall adherence to maternal service utilization was 54.2%. Factors associated with adherence to maternal health service utilization were pregnancy complications [AOR: 4.1, 95% CI (2.32, 7.28)], secondary and above education [AOR: 4.6, 95% CI (1.38, 15.08)], early ANC1 booking [AOR: 3.1, 95% CI (1.83, 5.16)], autonomous women [AOR: 2.1, 95% CI (1.02, 4.39)], user fee exemption [AOR: 2.3, 95% CI (1.20, 4.47)] and high parity [AOR: 0.39, 95% CI (0.2, 0.75)]. User fee exemption induced a 22.7% increment in adherence to maternal service utilization (ATET=0.227, t=2.13). Conclusion User fee exemption policy significantly improved adherence to maternal health service utilization. Promoting a fee exemption policy through third-party financing can enhance maternal health service utilization adherence in hard-to-reach settings of Ethiopia by targeting mothers with higher pregnancies, no complications, no autonomy, and less education.
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Affiliation(s)
- Demlie Mekonnen Marye
- Department of Health System Management and Health Economics, School of Public Health, Bahir Dar University, Bahir Dar, Ethiopia
| | - Desta Debalkie Atnafu
- Department of Health System Management and Health Economics, School of Public Health, Bahir Dar University, Bahir Dar, Ethiopia
- International Centre for Evidence in Disability, London School of Hygiene and Tropical Medicine, London, UK
| | - Melesse Belayneh
- Department of Health System Management and Health Economics, School of Public Health, Bahir Dar University, Bahir Dar, Ethiopia
| | - Ayenew Takele Alemu
- Department of Public Health, College of Medicine and Health Sciences, Injibara University, Injibara, Ethiopia
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Fetene SM, Mengistu MY, Aschalew AY. Effectiveness and impact of community-based health insurance on health service utilization in northwest Ethiopia: a quasi-experimental evaluation. Front Public Health 2023; 11:1078462. [PMID: 38026288 PMCID: PMC10679351 DOI: 10.3389/fpubh.2023.1078462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 10/24/2023] [Indexed: 12/01/2023] Open
Abstract
Background Addressing the health challenges of lower socioeconomic groups in Ethiopia is still a huge problem. In that regard, the government piloted the community-based health insurance (CBHI) in 2011 in a few districts and subsequently scaled up. However, the effectiveness of the program on the utilization of health services and its impact was not well explored. Thus, we aimed to evaluate the effectiveness of CBHI toward health services' utilization and its impact in northwest Ethiopia. Methods A quasi-experimental matched comparison group evaluation design with sequential explanatory mixed methods was employed. To evaluate the CBHI program, the effectiveness and impact dimensions from the Organization for Economic Cooperation and Development framework were used. A multistage sampling technique was used to select a total of 332 households enrolled in the CBHI program; 341 comparison households who did not enroll in the program were also randomly selected. A structured interviewer-administrated questionnaire was used to evaluate the effectiveness and impact of CBHI on health service utilization. The Propensity score matching model was employed for the estimation of the effect of the CBHI program on health service utilization. Challenges for program achievement toward health service utilization were explained through qualitative data and these were then analyzed thematically. Results The evaluation showed 1.3 visits per capita per year of health service utilization among CBHI members. Households enrolled in CBHI increased health service utilization by 6.9 percentage points (ATT = 0.069; 95% CI: 0.034, 0.114). There was an improvement in health service utilization after the introduction of CBHI, however, there are challenges: (i) shortage of human resources, (ii) out-of-stock of drugs and medical supplies, and (iii) long waiting times for service and reimbursement claims. These issues limit the success of the program toward health service utilization. Conclusion The CBHI program contributed to health service utilization improvement among CBHI members. However, the utilization rate of health services among CBHI members is still less than the target stated for the program and also the WHO recommendation. Therefore, the findings of this evaluation can be used by program implementers, policy makers, and other stakeholders to overcome the identified challenges and to increase the success of the program.
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Affiliation(s)
- Samrawit Mihret Fetene
- Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Eze P, Ilechukwu S, Lawani LO. Impact of community-based health insurance in low- and middle-income countries: A systematic review and meta-analysis. PLoS One 2023; 18:e0287600. [PMID: 37368882 DOI: 10.1371/journal.pone.0287600] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 06/08/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND To systematically evaluate the empirical evidence on the impact of community-based health insurance (CBHI) on healthcare utilization and financial risk protection in low- and middle-income countries (LMIC). METHODS We searched PubMed, CINAHL, Cochrane CENTRAL, CNKI, PsycINFO, Scopus, WHO Global Index Medicus, and Web of Science including grey literature, Google Scholar®, and citation tracking for randomized controlled trials (RCTs), non-RCTs, and quasi-experimental studies that evaluated the impact of CBHI schemes on healthcare utilization and financial risk protection in LMICs. We assessed the risk of bias using Cochrane's Risk of Bias 2.0 and Risk of Bias in Non-randomized Studies of Interventions tools for RCTs and quasi/non-RCTs, respectively. We also performed a narrative synthesis of all included studies and meta-analyses of comparable studies using random-effects models. We pre-registered our study protocol on PROSPERO: CRD42022362796. RESULTS We identified 61 articles: 49 peer-reviewed publications, 10 working papers, 1 preprint, and 1 graduate dissertation covering a total of 221,568 households (1,012,542 persons) across 20 LMICs. Overall, CBHI schemes in LMICs substantially improved healthcare utilization, especially outpatient services, and improved financial risk protection in 24 out of 43 studies. Pooled estimates showed that insured households had higher odds of healthcare utilization (AOR = 1.60, 95% CI: 1.04-2.47), use of outpatient health services (AOR = 1.58, 95% CI: 1.22-2.05), and health facility delivery (AOR = 2.21, 95% CI: 1.61-3.02), but insignificant increase in inpatient hospitalization (AOR = 1.53, 95% CI: 0.74-3.14). The insured households had lower out-of-pocket health expenditure (AOR = 0.94, 95% CI: 0.92-0.97), lower incidence of catastrophic health expenditure at 10% total household expenditure (AOR = 0.69, 95% CI: 0.54-0.88), and 40% non-food expenditure (AOR = 0.72, 95% CI: 0.54-0.96). The main limitations of our study are the limited data available for meta-analyses and high heterogeneity persisted in subgroup and sensitivity analyses. CONCLUSIONS Our study shows that CBHI generally improves healthcare utilization but inconsistently delivers financial protection from health expenditure shocks. With pragmatic context-specific policies and operational modifications, CBHI could be a promising mechanism for achieving universal health coverage (UHC) in LMICs.
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Affiliation(s)
- Paul Eze
- Department of Health Policy and Administration, Penn State University, University Park, PA, United States of America
| | - Stanley Ilechukwu
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Health Projects, South Saharan Social Development Organization (SSDO), Independence Layout, Enugu, Nigeria
| | - Lucky Osaheni Lawani
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
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Oladosu AO, Khai TS, Asaduzzaman M. Factors affecting access to healthcare for young people in the informal sector in developing countries: a systematic review. Front Public Health 2023; 11:1168577. [PMID: 37427290 PMCID: PMC10327819 DOI: 10.3389/fpubh.2023.1168577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 05/18/2023] [Indexed: 07/11/2023] Open
Abstract
Background Young people are increasingly seeking employment in the informal sector due to increasing global unemployment. However, the precarious nature of work in the informal sectors, coupled with the high risk of occupational hazards, calls for a greater need for effective healthcare for informal sector workers, particularly young people. In addressing the health vulnerabilities of informal workers, systematic data on the determinants of health is a persistent challenge. Therefore, the objective of this systematic review was to identify and summarise the existing factors that affect access to healthcare among young people from the informal sector. Methods We searched six data databases (PubMed, Web of Science, Scopus, ProQuest, Crossref, and Google Scholar), which was followed by hand searching. Then we screened the identified literature using review-specific inclusion/exclusion criteria, extracted data from the included studies and assessed study quality. Then we presented the results in narrative form, though meta-analysis was not possible due to heterogeneity in the study design. Results After the screening, we retrieved 14 studies. The majority were cross-sectional surveys and were conducted in Asia (n = 9); four were conducted in Africa, and one in South America. Samples ranged in size from 120 to 2,726. The synthesised results demonstrate that problems of affordability, availability, accessibility, and acceptability of healthcare were barriers to young informal workers seeking healthcare. We found social networks and health insurance as facilitators of access for this group of people. Conclusion To date, this is the most comprehensive review of the evidence on access to healthcare for young people in the informal sector. Our study finding highlights the key gaps in knowledge where future research could further illuminate the mechanisms through which social networks and the determinants of access to healthcare could influence the health and well-being of young people and thus inform policy development.
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Affiliation(s)
| | - Tual Sawn Khai
- School of Graduate Studies, Lingnan University, Hong Kong, Hong Kong SAR, China
- Research Affiliate, Refugee Law Initiative (RLI), School of Advanced Study, University of London, London, United Kingdom
| | - Muhammad Asaduzzaman
- Department of Community Medicine and Global Health, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
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Nsiah-Boateng E, Musah M, Akuamoah CD, Asenso-Boadi F, Andoh-Adjei FX, Boye BO. Effect of mobile phone-based health insurance contribution payment system on retention of coverage in the National Health Insurance Scheme in Ghana: an evaluation study. BMC Health Serv Res 2023; 23:239. [PMID: 36906560 PMCID: PMC10007802 DOI: 10.1186/s12913-023-09236-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 03/02/2023] [Indexed: 03/13/2023] Open
Abstract
BACKGROUND Ghana introduced a mobile phone-based contribution payment system in its national health insurance scheme (NHIS) in December 2018 to improve the process of enrolment. We evaluated the effect of this digital health intervention on retention of coverage in the Scheme, one year after its implementation. METHODS We used NHIS enrolment data for the period, 1 December 2018-31 December 2019. Descriptive statistics and propensity-score matching method were performed to examine a sample of 57,993 members' data. RESULTS Proportion of members who renewed their membership in the NHIS via the mobile phone-based contribution payment system increased from 0% to 8.5% whilst those who did so through the office-based system only grew from 4.7% to 6.4% over the study period. The chance of renewing membership was higher by 17.4 percentage points for users of the mobile phone-based contribution payment system, compared to those who used the office-based contribution payment system. The effect was greater for the informal sector workers, males and the unmarried. CONCLUSIONS The mobile phone-based health insurance renewal system is improving coverage in the NHIS particularly for members who hitherto were less likely to renew their membership. Policy makers need to devise an innovative way for new members and all member categories to enrol using this payment system to accelerate progress towards attainment of universal health coverage. Further study needs to be conducted using mixed-method design with inclusion of more variables.
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Affiliation(s)
- Eric Nsiah-Boateng
- National Health Insurance Authority, Accra, Ghana. .,Ministry of Health, Accra, Ghana. .,School of Public Health, University of Ghana, Accra, Ghana.
| | - Mariam Musah
- National Health Insurance Authority, Accra, Ghana
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Alemayehu YK, Dessie E, Medhin G, Birhanu N, Hotchkiss DR, Teklu AM, Kiros M. The impact of community-based health insurance on health service utilization and financial risk protection in Ethiopia. BMC Health Serv Res 2023; 23:67. [PMID: 36683041 PMCID: PMC9869550 DOI: 10.1186/s12913-022-09019-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 12/30/2022] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Evidence on the effectiveness of community-based health insurance (CBHI) in low-income countries is inconclusive. This study assessed the impact of CBHI on health service utilization and financial risk protection in Ethiopia. METHODS We conducted a comparative cross-sectional study nested within a larger national household survey in 2020. Data was collected from three groups of households-CBHI member households (n = 1586), non-member households from CBHI implementing woredas (n = 1863), and non-member households from non-CBHI implementing woredas (n = 789). Indicators of health service utilization, out-of-pocket health spending, catastrophic health expenditure, and impoverishment due to health spending among CBHI members were compared with non-members from CBHI implementing woredas and households from non-CBHI implementing woredas. Propensity score matching (PSM) was used to account for possible selection bias. RESULTS The annual number of OPD visits per capita among CBHI member households was 2.09, compared to 1.53 among non-member households from CBHI woredas and 1.75 among households from non-CBHI woredas. PSM estimates indicated that CBHI members had 0.36 (95% CI: 0.25, 0.44) and 0.17 (95% CI: -0.04, 0.19) more outpatient department (OPD) visits per capita per year than their matched non-member households from CBHI-implementing and non-CBHI implementing woredas, respectively. CBHI membership resulted in a 28-43% reduction in annual OOP payments as compared to non-member households. CBHI member households were significantly less likely to incur catastrophic health expenditures (measured as annual OOP payments of more than 10% of the household's total expenditure) compared to non-members (p < 0.01). CONCLUSION CBHI membership increases health service utilization and financial protection. CBHI proves to be an important strategy for promoting universal health coverage. Implementing CBHI in all woredas and increasing membership among households in woredas that are already implementing CBHI will further expand its benefits.
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Affiliation(s)
| | - Ermias Dessie
- World Health Organization – Ethiopia, Addis Ababa, Ethiopia
| | | | - Negalign Birhanu
- grid.411903.e0000 0001 2034 9160Department of Health Policy and Management, Institute of Health, Jimma University, Jimma, Ethiopia
| | - David R. Hotchkiss
- grid.265219.b0000 0001 2217 8588School of Public Health and Tropical Medicine, Tulane University, New Orleans, USA
| | | | - Mizan Kiros
- grid.414835.f0000 0004 0439 6364Ministry of Health, Addis Ababa, Ethiopia
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Sheikh N, Tagoe ET, Akram R, Ali N, Howick S, Morton A. Implementation barriers and remedial strategies for community-based health insurance in Bangladesh: insights from national stakeholders. BMC Health Serv Res 2022; 22:1200. [PMID: 36153512 PMCID: PMC9508716 DOI: 10.1186/s12913-022-08561-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 09/12/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Community-based health insurance (CBHI) is a part of the health system in Bangladesh, and overcoming the obstacles of CBHI is a significant policy concern that has received little attention. The purpose of this study is to analyze the implementation barriers of voluntary CBHI schemes in Bangladesh and the strategies to overcome these barriers from the perspective of national stakeholders.
Methods
This study is exploratory qualitative research, specifically case study design, using key informant interviews to investigate the barriers of CBHI that are faced during the implementation. Using a topic guide, we conducted thirteen semi-structured in-depth interviews with key stakeholders directly involved in the CBHI implementation process. The data were analyzed using the Framework analysis method.
Results
The implementation of CBHI schemes in Bangladesh is being constrained by several issues, including inadequate population coverage, adverse selection and moral hazard, lack of knowledge about health insurance principles, a lack of external assistance, and insufficient medical supplies. Door-to-door visits by local community-health workers, as well as regular promotional and educational campaigns involving community influencers, were suggested by stakeholders as ways to educate and encourage people to join the schemes. Stakeholders emphasized the necessity of external assistance and the design of a comprehensive benefits package to attract more people. They also recommended adopting a public–private partnership with a belief that collaboration among the government, microfinance institutions, and cooperative societies will enhance trust and population coverage in Bangladesh.
Conclusions
Our research concludes that systematically addressing implementation barriers by including key stakeholders would be a significant reform to the CBHI model, and could serve as a foundation for the planned national health protection scheme for Bangladesh leading to universal health coverage.
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Hasan MZ, Ahmed MW, Mehdi GG, Khan JAM, Islam Z, Chowdhury ME, Ahmed S. Factors affecting the healthcare utilization from Shasthyo Suroksha Karmasuchi scheme among the below-poverty-line population in one subdistrict in Bangladesh: a cross sectional study. BMC Health Serv Res 2022; 22:885. [PMID: 35804366 PMCID: PMC9270808 DOI: 10.1186/s12913-022-08254-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 06/24/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Financing healthcare through out-of-pocket (OOP) payment is a major barrier in accessing healthcare for the poor people. The Health Economics Unit (HEU) of the Ministry of Health and Family Welfare of the government of Bangladesh has developed Shasthyo Suroksha Karmasuchi (SSK), a health protection scheme, with the aim of reducing OOP expenditure and improving access of the below-poverty-line (BPL) population to healthcare. The scheme started piloting in 2016 at Kalihati sub-district of Tangail District. Our objective was to assess healthcare utilization by the enrolled BPL population and to identify the factors those influencing their utilization of the scheme. METHOD A cross-sectional household survey was conducted from July to September 2018 in the piloting sub-district. A total of 806 households were surveyed using a semi-structured questionnaire. Information on illness and sources of healthcare service were captured for the last 90 days before the survey. Multiple logistic regression models were applied to determine the factors related to utilization of healthcare from the SSK scheme and other medically trained providers (MTPs) by the SSK members for both inpatient and outpatient care. RESULT A total of 781 (24.6%) people reported of suffering from illness of which 639 (81.8%) sought healthcare from any sources. About 8.0% (51 out of 639) of them sought healthcare from SSK scheme and 28.2% from other MTPs within 90 days preceding the survey. Households with knowledge about SSK scheme were more likely to utilize healthcare from the scheme and less likely to utilize healthcare from other MTPs. Non-BPL status and suffering from an accident/injury were significantly positively associated with utilization of healthcare from SSK scheme. CONCLUSION Among the BPL population, healthcare utilization from the SSK scheme was very low compared to that of other MTPs. Effective strategies should be in place for improving knowledge of BPL population on SSK scheme and the benefits package of the scheme should be updated as per the need of the target population. Such initiative can be instrumental in increasing utilization of the scheme and ultimately will reduce the barriers of OOP payment among BPL population for accessing healthcare.
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Affiliation(s)
- Md Zahid Hasan
- Health Systems and Population Studies Division, Health Economics and Financing, icddr,b, 68 Shahid Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh. .,Leeds Institute of Health Sciences, University of Leeds, 6 Clarendon Way, Woodhouse, LS2 9NL, Leeds, UK.
| | - Mohammad Wahid Ahmed
- Health Systems and Population Studies Division, Health Economics and Financing, icddr,b, 68 Shahid Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Gazi Golam Mehdi
- Health Systems and Population Studies Division, Health Economics and Financing, icddr,b, 68 Shahid Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Jahangir A M Khan
- Health Economics and Policy Unit, School of Public Health and Community Medicine, University of Gothenburg, Medicinaregatan 18A, 405 30, Gothenburg, Sweden
| | - Ziaul Islam
- Health Systems and Population Studies Division, Health Economics and Financing, icddr,b, 68 Shahid Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Mahbub Elahi Chowdhury
- Health Systems and Population Studies Division, Health Economics and Financing, icddr,b, 68 Shahid Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Sayem Ahmed
- Health Economics and Health Technology Assessment (HEHTA), Institute of Health & Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, UK
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Lee J, Di Ruggiero E. How does informal employment affect health and health equity? Emerging gaps in research from a scoping review and modified e-Delphi survey. Int J Equity Health 2022; 21:87. [PMID: 35725451 PMCID: PMC9208971 DOI: 10.1186/s12939-022-01684-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 05/31/2022] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION This article reports on the results from a scoping review and a modified e-Delphi survey with experts which aimed to synthesize existing knowledge and identify research gaps on the health and health equity implications of informal employment in both low- and middle-income countries (LMICs) and high-income countries (HICs). METHODS The scoping review included peer-reviewed articles published online between January 2015 and December 2019 in English. Additionally, a modified e-Delphi survey with experts was conducted to validate our findings from the scoping review and receive feedback on additional research and policy gaps. We drew on micro- and macro-level frameworks on employment relations and health inequities developed by the Employment Conditions Knowledge Network to synthesize and analyze existing literature. RESULTS A total of 540 articles were screened, and 57 met the eligibility criteria for this scoping review study, including 36 on micro-level research, 19 on macro-level research, and 13 on policy intervention research. Most of the included studies were conducted in LMICs while the research interest in informal work and health has increased globally. Findings from existing literature on the health and health equity implications of informal employment are mixed: informal employment does not necessarily lead to poorer health outcomes than formal employment. Although all informal workers share some fundamental vulnerabilities, including harmful working conditions and limited access to health and social protections, the related health implications vary according to the sub-groups of workers (e.g., gender) and the country context (e.g., types of welfare state or labour market). In the modified e-Delphi survey, participants showed a high level of agreement on a lack of consensus on the definition of informal employment, the usefulness of the concept of informal employment, the need for more comparative policy research, qualitative health research, and research on the intersection between gender and informal employment. CONCLUSIONS Our results clearly identify the need for more research to further understand the various mechanisms through which informal employment affects health in different countries and for different groups of informal workers.
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Affiliation(s)
- Juyeon Lee
- Dalla Lana School of Public Health, Division of Social and Behavioural Health Sciences, University of Toronto, 155 College Street, Room 408, M5T 3M7 Toronto, ON Canada
| | - Erica Di Ruggiero
- Dalla Lana School of Public Health, Division of Social and Behavioural Health Sciences, University of Toronto, 155 College Street, Room 408, M5T 3M7 Toronto, ON Canada
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Ahmed S, Hasan MZ, Ali N, Ahmed MW, Haq E, Shabnam S, Chowdhury M, Gahan B, Bousquet C, Khan JAM, Islam Z. Effectiveness of health voucher scheme and micro-health insurance scheme to support the poor and extreme poor in selected urban areas of Bangladesh: An assessment using a mixed-method approach. PLoS One 2021; 16:e0256067. [PMID: 34723992 PMCID: PMC8559931 DOI: 10.1371/journal.pone.0256067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 07/29/2021] [Indexed: 11/19/2022] Open
Abstract
Background National healthcare financing strategy recommends tax-based equity funds and insurance schemes for the poor and extreme poor living in urban slums and pavements as the majority of these population utilise informal providers resulting in adverse health effects and financial hardship. We assessed the effect of a health voucher scheme (HVS) and micro-health insurance (MHI) scheme on healthcare utilisation and out-of-pocket (OOP) payments and the cost of implementing such schemes. Methods HVS and MHI schemes were implemented by Concern Worldwide through selected NGO health centres, referral hospitals, and private healthcare facilities in three City Corporations of Bangladesh from December 2016 to March 2020. A household survey with 1,294 enrolees, key-informant interviews, focus group discussions, consultative meetings, and document reviews were conducted for extracting data on healthcare utilisation, OOP payments, views of enrolees, and suggestions of implementers, and costs of services at the point of care. Results Healthcare utilisation including maternal, neonatal and child health (MNCH) services, particularly from medically trained providers, was higher and OOP payments were lower among the scheme enrolees compared to corresponding population groups in general. The beneficiaries were happy with their access to healthcare, especially for MNCH services, and their perceived quality of care was fair enough. They, however, suggested expanding the benefits package, supported by an additional workforce. The cost per beneficiary household for providing services per year was €32 in HVS and €15 in MHI scheme. Conclusion HVS and MHI schemes enabled higher healthcare utilisation at lower OOP payments among the enrolees, who were happy with their access to healthcare, particularly for MNCH services. However, they suggested a larger benefits package in future. The provider’s costs of the schemes were reasonable; however, there are potentials of cost containment by purchasing the health services for their beneficiaries in a competitive basis from the market. Scaling up such schemes addressing the drawback would contribute to achieving universal health coverage.
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Affiliation(s)
- Sayem Ahmed
- Mathematical Modelling Group, Oxford University Clinical Research Unit (OUCRU), Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Liverpool School of Tropical Medicine (LSTM), Liverpool, United Kingdom
- * E-mail:
| | - Md. Zahid Hasan
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Nausad Ali
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- Bangladesh Institute of Development Studies (BIDS), Agargaon, Dhaka, Bangladesh
| | - Mohammad Wahid Ahmed
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | | | | | | | | | | | - Jahangir A. M. Khan
- Liverpool School of Tropical Medicine (LSTM), Liverpool, United Kingdom
- Health Economics and Policy Unit, School of Public Health and Community Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ziaul Islam
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
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Kuwawenaruwa A, Wyss K, Wiedenmayer K, Metta E, Tediosi F. The effects of medicines availability and stock-outs on household's utilization of healthcare services in Dodoma region, Tanzania. Health Policy Plan 2020; 35:323-333. [PMID: 31942625 PMCID: PMC7152726 DOI: 10.1093/heapol/czz173] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2019] [Indexed: 12/14/2022] Open
Abstract
Low- and middle-income countries have been undertaking health finance reforms to address shortages of medicines. However, data are lacking on how medicine availability and stock-outs influence access to health services in Tanzania. The current study assesses the effects of medicine availability and stock-outs on healthcare utilization in Dodoma region, Tanzania. We conducted a cross-sectional study that combined information from households and healthcare facility surveys. A total of 4 hospitals and 89 public primary health facilities were surveyed. The facility surveys included observation, record review over a 3-month period prior to survey date, and interviews with key staff. In addition, 1237 households within the health facility catchment areas were interviewed. Data from the facility survey were linked with data from the household survey. Descriptive analysis and multivariate logistic regressions models were used to assess the effects of medicine availability and stock-outs on utilization patterns and to identify additional household-level factors associated with health service utilization. Eighteen medicines were selected as ‘tracers’ to assess availability more generally, and these were continuously available in ∼70% of the time in facilities across all districts over 3 months of review. The main analysis showed that household’s healthcare utilization was positively and significantly associated with continuous availability of all essential medicines for the surveyed facilities [odds ratio (OR) 3.49, 95% confidence interval (CI) 1.02–12.04; P = 0.047]. Healthcare utilization was positively associated with household membership in the community health insurance funds (OR 1.97, 95% CI 1.23–3.17; P = 0.005) and exposure to healthcare education (OR 2.75, 95% CI 1.84–4.08; P = 0.000). These results highlight the importance of medicine availability in promoting access to health services in low-income settings. Effective planning and medicine supply management from national to health facility level is an important component of quality health services.
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Affiliation(s)
- August Kuwawenaruwa
- Ifakara Health Institute, Plot 463, Kiko Avenue Mikocheni, PO Box 78 373, Dar es Salaam, Tanzania.,Swiss Tropical and Public Health Institute (Swiss TPH), Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Kaspar Wyss
- Swiss Tropical and Public Health Institute (Swiss TPH), Basel, Switzerland.,University of Basel, Basel, Switzerland.,Swiss Centre for International Health (SCIH), Basel, Switzerland
| | - Karin Wiedenmayer
- Swiss Centre for International Health (SCIH), Basel, Switzerland.,Health promotion and System Strengthening (HPSS), Dodoma, Tanzania
| | - Emmy Metta
- Ifakara Health Institute, Plot 463, Kiko Avenue Mikocheni, PO Box 78 373, Dar es Salaam, Tanzania.,School of Public Health and Social Sciences (SPHSS), Muhimbili University of Health and Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Fabrizio Tediosi
- Swiss Tropical and Public Health Institute (Swiss TPH), Basel, Switzerland.,University of Basel, Basel, Switzerland
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Pervin S, Ruma FI, Rahman K, Ferdous J, Ara R, Abu Syed MM, Goodman A. Adjuvant Hysterectomy in Patients With Residual Disease After Radiation for Locally Advanced Cervical Cancer: A Prospective Longitudinal Study. J Glob Oncol 2020; 5:1-7. [PMID: 30707665 PMCID: PMC6426523 DOI: 10.1200/jgo.18.00157] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The aim of the study was to evaluate the efficacy of hysterectomy in the control of pelvic disease in patients with post-irradiated residual cervical cancer. PATIENTS AND METHODS Forty patients were treated at either National Institute of Cancer Research and Hospital (NICRH) or Delta Cancer Hospital in Dhaka, Bangladesh, with International Federation of Gynecology and Obstetrics stage IIB to IIIB disease with residual disease after the following: either concurrent chemoradiation with or without brachytherapy, induction chemotherapy and external-beam radiotherapy (EBRT) with or without brachytherapy, or only EBRT. Patients were treated by either radical hysterectomy or extrafascial hysterectomy. RESULTS From 2009 to June 2013, 55 patients were evaluated for central residual disease on their presentations to NICRH or Delta Hospital. Patients with distant recurrences after primary radiation were excluded. Forty patients had invasive cancer on biopsy and underwent either radical hysterectomy or extrafascial hysterectomy. Surgery was performed 14 to 18 weeks after the initial treatment. Of the 29 women who underwent extrafascial hysterectomy, four (13.8%) developed recurrent disease, and one died; none of the 11 patients treated by radical hysterectomy experienced recurrences during the study period. Morbidity was increased in patients who underwent radical hysterectomy. Overall 90% of patients (36 of 40 patients) who underwent surgery had no evidence of disease at 5 years of follow-up. CONCLUSION Surgery is a viable treatment option for patients with residual cervical cancer after radiation. Radical hysterectomy after radiation is more morbid but has better tumor control than extrafascial hysterectomy.
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Affiliation(s)
- Shahana Pervin
- National Institute of Cancer Research and Hospital, Dhaka, Bangladesh
| | | | - Khadija Rahman
- National Institute of Cancer Research and Hospital, Dhaka, Bangladesh
| | | | - Rifat Ara
- Bangabandhu Sheikh-Mujib Medical University, Dhaka, Bangladesh
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Khan JAM, Ahmed S, Sultana M, Sarker AR, Chakrovorty S, Rahman MH, Islam Z, Rehnberg C, Niessen LW. The effect of a community-based health insurance on the out-of-pocket payments for utilizing medically trained providers in Bangladesh. Int Health 2020; 12:287-298. [PMID: 31782795 PMCID: PMC7322207 DOI: 10.1093/inthealth/ihz083] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 08/07/2019] [Accepted: 08/09/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND We aimed to estimate the effect of the community-based health insurance (CBHI) scheme on the magnitude of out-of-pocket (OOP) payments for the healthcare of the informal workers and their dependents. The CBHI scheme was piloted through a cooperative of informal workers, which covered seven unions in Chandpur Sadar Upazila, Bangladesh. METHODS A quasi-experimental study was conducted using a case-comparison design. In total 1292 (646 insured and 646 uninsured) households were surveyed. Propensity score matching was done to minimize the observed baseline differences in the characteristics between the insured and uninsured groups. A two-part regression model was applied using both the probability of OOP spending and magnitude of such spending for healthcare in assessing the association with enrolment status in the CBHI scheme while controlling for other covariates. RESULTS The OOP payment was 6.4% (p < 0.001) lower for medically trained provider (MTP) utilization among the insured compared with the uninsured. However, no significant difference was found in the OOP payments for healthcare utilization from all kind of providers, including the non-trained ones. CONCLUSIONS The CBHI scheme could reduce OOP payments while providing better quality healthcare through the increased use of MTPs, which consequently could push the country towards universal health coverage.
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Affiliation(s)
- Jahangir A M Khan
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, United Kingdom
- Universal Health Coverage Programme, Health Systems and Population Studies Division, icddr, b, 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh
- Health Economics and Policy Research Group, Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Tomtebodavägen 18a, 171 65 Solna, Sweden
| | - Sayem Ahmed
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, United Kingdom
- Universal Health Coverage Programme, Health Systems and Population Studies Division, icddr, b, 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh
- Health Economics and Policy Research Group, Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Tomtebodavägen 18a, 171 65 Solna, Sweden
| | - Marufa Sultana
- Universal Health Coverage Programme, Health Systems and Population Studies Division, icddr, b, 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh
- Deakin Health Economics, School of Health and Social Development, Deakin University, 221 Burwood Highway Burwood VIC 3125 Melbourne, Australia
| | - Abdur Razzaque Sarker
- Health Economics and Financing Research, Population Studies Division, Bangladesh Institute of Development Studies (BIDS), E-17, Shahid Shahabuddin Shorok, Agargaon, Dhaka 1207, Bangladesh
| | - Sanchita Chakrovorty
- Universal Health Coverage Programme, Health Systems and Population Studies Division, icddr, b, 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh
- Department of Agricultural Economics, Purdue University, Room # 631, Krannert Building, 403 West State Street, West Lafayette, Indiana 47906, USA
| | - Mohammad Hafizur Rahman
- Health Economics Unit, Ministry of Health and Family Welfare, 14/2 Topkhana Road (3rd–4th Floor), Dhaka 1000, Bangladesh
| | - Ziaul Islam
- Universal Health Coverage Programme, Health Systems and Population Studies Division, icddr, b, 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh
| | - Clas Rehnberg
- Health Economics and Policy Research Group, Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Tomtebodavägen 18a, 171 65 Solna, Sweden
| | - Louis W Niessen
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, United Kingdom
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Nageso D, Tefera K, Gutema K. Enrollment in community based health insurance program and the associated factors among households in Boricha district, Sidama Zone, Southern Ethiopia; a cross-sectional study. PLoS One 2020; 15:e0234028. [PMID: 32484840 PMCID: PMC7266314 DOI: 10.1371/journal.pone.0234028] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 05/18/2020] [Indexed: 11/18/2022] Open
Abstract
Background In absence of any form of health insurance, out-of-pocket payments for health care lead to decreased use of health services and catastrophic health expenditures. Community-based health insurances has been promised financial model for informal sectors to reduce these problems in many countries. When this comes down to Ethiopia, in the South Nation Nationality People’s Region of the country established 52 schemes including Boricha district, the study area However, there has been little evidence about the enrollment status and the associated factors in the study area in particular elsewhere in general. Objective The study aims to assess the current enrollment status of households in community based health insurance and the associated factors in Boricha district of Sidama Zone, Southern Ethiopia. Methods and materials A community based cross-sectional study design was employed from February 01, 2019 to March 31, 2019, using a sample of 632 households. Data were collected using interviewer-administered pre-tested questionnaire and entered into EPI-Info 7and transported to SPSSversion20 for analysis. Multi-variable logistic regression analysis along with odds ratio and the corresponding 95% CI was conducted and significance was declared at P-value <0.05. Results Current enrollment status of households in community based health insurance was found to be 81 (12.8%). According to this study, educational status; secondary school& above[AOR = 2.749, 95%CI(1.142, 6.618)], timing of collecting premium [AOR = 0.433; 95% CI (0.196, 0.958)], family size ≥5, [AOR = 4.16;95%CI (1.337, 12.944)], no trust on scheme management[AOR = 0.272; 95%CI (0.140, 0.528)], lack of information [AOR = 0.086; 95%CI (0.026, 0.288)], dissatisfaction with health care service received[AOR = 0.303; 95%CI (0.171, 0.537)], no chronic illness in the family[AOR = 0.259; 95%C.I.(0.137, 0.488)] were factors significantly associated with current enrollment status in CBHI. Conclusions Households head’s education status, timing of premium collection, family size, no trust on scheme management, lack of information, services dissatisfaction and chronic illness in the family member were the identified factors associated with enrollment in CBHI in the study area. Therefore, to enhance the enrollment and sustainability of CBHI in the study area awareness creation, improving timing of premium collection, strengthening scheme management, improving quality of service are the areas that decision makers needs to intervene.
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Affiliation(s)
- Dawit Nageso
- Boricha District Health Office, Balela, Sidama, Ethiopia
- * E-mail:
| | - Kebede Tefera
- School of Public Health, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
| | - Keneni Gutema
- School of Public Health, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
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Ahmed S, Sarker AR, Sultana M, Roth F, Mahumud RA, Kamruzzaman M, Hasan MZ, Mirelman AJ, Islam Z, Niessen LW, Rehnberg C, Khan AA, Gyr N, Khan JAM. Do employer-sponsored health insurance schemes affect the utilisation of medically trained providers and out-of-pocket payments among ready-made garment workers? A case-control study in Bangladesh. BMJ Open 2020; 10:e030298. [PMID: 32132134 PMCID: PMC7059493 DOI: 10.1136/bmjopen-2019-030298] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 12/02/2019] [Accepted: 12/17/2019] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE We estimated the effect of an employer-sponsored health insurance (ESHI) scheme on healthcare utilisation of medically trained providers and reduction of out-of-pocket (OOP) expenditure among ready-made garment (RMG) workers. DESIGN We used a case-control study design with cross-sectional preintervention and postintervention surveys. SETTINGS The study was conducted among workers of seven purposively selected RMG factories in Shafipur, Gazipur in Bangladesh. PARTICIPANTS In total, 1924 RMG workers (480 from the insured and 482 from the uninsured, in each period) were surveyed from insured and uninsured RMG factories, respectively, in the preintervention (October 2013) and postintervention (April 2015) period. INTERVENTIONS We tested the effect of a pilot ESHI scheme which was implemented for 1 year. OUTCOME MEASURES The outcome measures were utilisation of medically trained providers and reduction of OOP expenditure among RMG workers. We estimated difference-in-difference (DiD) and applied two-part regression model to measure the association between healthcare utilisation, OOP payments and ESHI scheme membership while controlling for the socioeconomic characteristics of workers. RESULTS The ESHI scheme increased healthcare utilisation of medically trained providers by 26.1% (DiD=26.1; p<0.01) among insured workers compared with uninsured workers. While accounting for covariates, the effect on utilisation significantly reduced to 18.4% (p<0.05). The DiD estimate showed that OOP expenditure among insured workers decreased by -3700 Bangladeshi taka and -1100 Bangladeshi taka compared with uninsured workers when using healthcare services from medically trained providers or all provider respectively, although not significant. The multiple two-part models also reported similar results. CONCLUSION The ESHI scheme significantly increased utilisation of medically trained providers among RMG workers. However, it has no significant effect on OOP expenditure. It can be recommended that an educational intervention be provided to RMG workers to improve their healthcare-seeking behaviours and increase their utilisation of ESHI-designated healthcare providers while keeping OOP payments low.
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Affiliation(s)
- Sayem Ahmed
- Health Economics and Financing Research, Health Systems and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- Health Economics and Policy, Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Abdur Razzaque Sarker
- Health Economics and Financing Research, Health Systems and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- Department of Management Science, University of Strathclyde, Glasgow, UK
- Health Economics and Financing Research, Bangladesh Institute of Development Studies (BIDS), Dhaka, Bangladesh
| | - Marufa Sultana
- Deakin Health Economics, School of Health and Social Development, Deakin University, Melbourne, Victoria, Australia
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Felix Roth
- Swiss Micro Insurance Consultancy Group (SMCG), Basel, Switzerland
| | - Rashidul Alam Mahumud
- Health Economics and Financing Research, Health Systems and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- Health Economics and Policy Research, Centre for Health, Informatics and Economic Research, University of Southern Queensland, Toowoomba, Queensland, Australia
| | | | - Md Zahid Hasan
- Health Economics and Financing Research, Health Systems and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | | | - Ziaul Islam
- Health Economics and Financing Research, Health Systems and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Louis W Niessen
- Liverpool School of Tropical Medicine, Liverpool, UK
- Department of International Health, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Clas Rehnberg
- Health Economics and Policy, Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden
| | - Ak Azad Khan
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Niklaus Gyr
- Department of Internal Medicine, University of Basel, Basel, Switzerland
| | - Jahangir A M Khan
- Health Economics and Policy, Department of Learning, Informatics, Management and Ethics (LIME), Karolinska Institutet, Stockholm, Sweden
- Liverpool School of Tropical Medicine, Liverpool, UK
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