Reduction of catastrophic health care expenditures by a community-based health insurance scheme in Gujarat,India: current experiences and challenges

OBJECTIVE: To assess the Self Employed Women's Association's Medical Insurance Fund in Gujarat in terms of insurance coverage according to income groups, protection of claimants from costs of hospitalization, time between discharge and reimbursement, and frequency of use. METHODS: One thousand nine hundred and thirty claims submitted over six years were analysed. FINDINGS: Two hundred and fifteen (11%) of 1927 claims were rejected. The mean household income of claimants was significantly lower than that of the general population. The percentage of households below the poverty line was similar for claimants and the general population. One thousand seven hundred and twelve (1712) claims were reimbursed: 805 (47%) fully and 907 (53%) at a mean reimbursement rate of 55.6%. Reimbursement more than halved the percentage of catastrophic hospitalizations (>10% of annual household income) and hospitalizations resulting in impoverishment. The average time between discharge and reimbursement was four months. The frequency of submission of claims was low (18.0/1000 members per year: 22-37% of the estimated frequency of hospitalization). CONCLUSIONS: The findings have implications for community-based health insurance schemes in India and elsewhere. Such schemes can protect poor households against the uncertain risk of medical expenses. They can be implemented in areas where institutional capacity is too weak to organize nationwide risk-pooling. Such schemes can cover poor people, including people and households below the poverty line. A trade off exists between maintaining the scheme's financial viability and protecting members against catastrophic expenditures. To facilitate reimbursement, administration, particularly processing of claims, should happen near claimants. Fine-tuning the design of a scheme is an ongoing process - a system of monitoring and evaluation is vital.     

The role of community-based health insurance within the health care financing system: a framework for analysis

There is increasing advocacy for community-based health insurance (CBHI) schemes as part of a broader solution to health care financing problems in low-income countries, but to date there is very limited understanding of how CBHI schemes interact with other elements of a health care financing system. This paper aims to set out a preliminary conceptual framework for understanding such interactions, and highlights the kind of research questions raised by such a framework. A basic conceptual map of a CBHI scheme is developed, and extensions added to this map that incorporate (1). effects upon non-members of schemes, (2). government subsidies to providers, (3). government subsidies to schemes, and (4). issues raised by the existence of multiple risk-pooling schemes in a particular context. The utility of a broader approach to analyzing/assessing CBHI schemes is illustrated through examination of two policy issues, namely (1). coordination of CBHI risk pools and government risk pools, and (2). equity implications of CBHI schemes and the role of government subsidies in such schemes. It is concluded that there is a strong need for empirical work to explore how CBHI schemes and the broader health care financing system interact, and that even if individual schemes achieve their own objectives (in terms of equity, efficiency etc.), this does not necessarily imply that such objectives will be achieved at the system level.     

Providing health care to Latino immigrants: community-based efforts in the rural midwest

We examined case studies of 3 rural Midwestern communities to assess local health care systems' response to rapidly growing Latino populations. Currently, clinics provide free or low-cost care, and schools, public health, social services, and religious organizations connect Latinos to the health care system. However, many unmet health care needs result from lack of health insurance, limited income, and linguistic and cultural barriers. Targeted safety net funding would help meet Latino health care needs in rural communities with limited resources.     

Dynamic process of adverse selection: evidence from a subsidized community-based health insurance in rural China

This article examines the changes of adverse selection over time during a 3-year subsidized, voluntary-based Community Health Insurance (CHI) scheme in rural China. The data came from a 4-year longitudinal social experimental study (2002-2006) on the CHI in Fengsan Township, Guizhou Province of China. A panel of 8198 observations (average of 2730 individuals) was analyzed using random effect logit model. We found that the effect of health status on the enrollment choice of the CHI scheme was significant. People with chronic condition history, with fair health, and with poor health were more likely to enroll in the scheme than those without chronic condition and with good health status. In addition, we found that almost all of the interaction terms of the health status variables and CHI wave variable were not significant, which indicates that the effects of adverse selection have not significantly changed over time. Furthermore, people with medium income and high income were more likely to enroll in the scheme compared to those with low income. This shows that adverse selection persisted in the subsequent enrollments of the CHI scheme, even with the government subsidy to the premium. However, adverse selection did not become more or less severe over time and worked through to a steady state. In addition, inequity of enrollment still exists under the current premium subsidy policy. Based on the findings, relevant policy implications are put forward to further improve the CHI scheme.     

Health care financing in Uganda: the role of social health insurance

PURPOSE: The purpose of this article is to explore the feasibility of introducing a social health insurance (SHI) scheme in Uganda from the perspectives of a targeted population of respondents in Kampala, Uganda. DESIGN/METHODOLOGY/APPROACH: Out of 100 questionnaires distributed to a random sample of Ugandans, 74 were returned, yielding a 74 percent response rate. FINDINGS: Results show that all Ugandans surveyed support the introduction of SHI. Some are willing to contribute financially and most believe that the Ugandan government should make this benefit available to all Ugandans. While there is a great deal of support for introducing SHI, several respondents noted that cost sharing, in whatever form taken, is burdensome on people with lower incomes and has disastrous consequences for the delivery and utilization of health services among the poor. ORIGINALITY/VALUE: A larger study exploring Ugandans' perspectives may provide valuable information on how Africans can begin to design a workable health financing structure to promote better access to health care for the most vulnerable groups in society.     

Social capital and farmer's willingness-to-join a newly established community-based health insurance in rural China

In 2002, China announced a new funding strategy that would reestablish community-based health insurance (CHI) in rural areas, whereby the Chinese government will entice farmers' participation by providing each participant an annual subsidy of 10-20 Yuan (US 1.25-2.50 dollars). However, there is no evidence demonstrating how many farmers would be willing-to-join (WTJ) such newly developed government subsidized voluntary-based CHI scheme and what factors influence farmers' willingness-to-join. In this study, we examine the probability of farmers' willingness-to-join such CHI under the different scenarios of government subsidy and individual contribution, and also explore factors that influence farmers' willingness-to-join with the emphasis on social capital. The study is based on data collected from a 2002 household survey conducted in Fengsan Township, located in China's Guizhou Province. Logistic regression is used in the analysis. The findings from this study show that even with the government subsidy to the premium, the probability of WTJ the new voluntary-based CHI only reach 50%. The results also indicate that community level social capital, as measured by reciprocity index, and individual level social capital, as measured by trust index, are significantly and positively associated with the probability of farmers' WTJ newly developed government subsidized CHI. Policy recommendations have been made based on those findings.     

The role of traditional healers in community-based HIV care in rural Lesotho

Traditional healers provide a substantial proportion of health care in resource-poor settings, including countries with high burdens of HIV in sub-Saharan Africa. Traditional healers have played many roles in HIV care, but some biomedical providers view them as obstacles in providing HIV treatment. This is a qualitative study exploring the roles played by traditional healers in a community-based program rolling out antiretroviral therapy (ART) in two rural communities in Lesotho. Seventeen traditional healers took part in interviews focus groups, and participant observation sessions over a 2 years period. Data showed they provided a wide range of HIV services prior to the ART rollout. Baseline knowledge regarding HIV was high, but healers reported mixed emotions about the planned ART rollout. Joint meetings were held between biomedical providers and traditional healers, and a collaborative model of care resulted. Traditional healers took on a variety of roles in the ART rollout, including HIV prevention activities, HIV testing, monitoring patients, and participating in joint learning sessions. All of the traditional healers underwent HIV testing and 7/17 (41.2%) tested positive for the disease, of whom four were eligible for and enrolled in ART. Healers expressed an appreciation for the collaboration with biomedical providers and being paid for their referrals. However, some expressed concern about the biomedical providers’ lack of understanding of HIV in the local context. This research shows that traditional healers can provide a variety of community-based HIV services and are not obstacles for advancing care in the communities they serve.     

Inequality in willingness-to-pay for community-based health insurance

The purpose was to provide information for devising community-based health insurance (CBI) policies that reduce inequality in enrolment and further inequality in access to health services. A two-stage cluster sampling was used in the household survey. Inequalities in willingness-to-pay (WTP) for CBI are examined by expenditure quintile using data collected from a household survey. Interviews were conducted with 2414 individuals, 705 of whom were household heads. A bidding game method was used to elicit WTP. Individuals and households were assigned to 6-month expenditure quintiles. We found that mean and median individual WTP for CBI was significantly higher for higher spending quintiles, as was mean and median household WTP. The curves of cumulative percentage of individual and household WTP shifted rightwards for higher quintiles, implying that at any given premium the lower the quintile the lower the uptake of CBI. The Gini coefficient for individual WTP and household WTP was 0.15 and 0.08, respectively, and for individual 6-month expenditure and household 6-month expenditure is 0.68 and 0.63, respectively. The results imply that the premium needs to be adjusted for income; otherwise, a lower proportion of poor people will enrol in CBI and without exemptions or subsidies the poor will have less access to health services than the rich. Thus, exemptions and subsidies for the poor for enrolling in CBI are an important issue for decision-makers with an objective of improving equity of health and helping the poor to break out of the cycle of poverty. Since the distribution of WTP by household is less unequal than the distribution of WTP by individuals, the household might be a better unit of enrolment in terms of equity than the individual.     

Impact of community-based health insurance on utilisation of preventive health services in rural Uganda: a propensity score matching approach

International Journal of Health Economics and Management - The effect of voluntary health insurance on preventive health has received limited research attention in developing countries, even when...     

Understanding consumers' preferences and decision to enrol in community-based health insurance in rural West Africa

This paper presents a qualitative investigation of consumers' preferences regarding the single elements of a community-based health insurance (CBI) scheme recently implemented in a rural region in west Africa. The aim is to provide adequate policy-guidance to decision makers in low and middle income countries by producing an in-depth understanding of how consumers' preferences may affect decision to participate in such schemes. Although it has long been suggested that feeble levels of participation may very well be an expression of consumers' dissatisfaction with scheme design, little systematic efforts have so far been channelled towards supporting such argument with empirical evidence. Consumers' preferences were explored through means of 32 individual interviews with household heads. Analysis used the method of constant comparison and was conducted by two independent researchers. Data from 10 focus group discussions provided an additional valuable source of triangulation. Findings suggest that decision to enrol is closely linked to whether the single elements of the scheme match consumers' needs and expectations. In particular, consumers justified decision to join or not to join the insurance scheme in relation to their preference for the unit of enrolment, the premium level and the payment modalities, the benefit package, the health service provider network and the CBI managerial structure. The discussion of the findings focuses on how understanding consumers' preferences and incorporating them in the design of a CBI scheme may result in increased participation rates, ensuring that poor populations gain better access to health services and enjoy greater protection against the cost of illness.     

In-home health education for family day care providers: A rural community-based project

An in-home consultation program for educating rural family day care providers about child health and safety is described. Three home visits were made to forty-eight providers. For the first two visits, a public health nurse assessed provider needs and presented information. Topics most frequently requested by providers were about controlling infections, first aid and safety practices, infectious diseases, and skin problems. Evaluation of provider satisfaction was conducted on the third visit by an independent evaluator. All providers reported satisfaction with the delivery of information. Level of health knowledge was also assessed. The majority of providers were informed at least minimally about maintaining a healthy environment for their day care children. Nurses, however, observed providers using practices that could place themselves and children at risk for spread of fecal/oral and direct contact illnesses. Providers with some education beyond high school, particularly in child development, were likely to know more about injury prevention. Mandated preventive child health training was recommended for family day care providers.This project was made possible by a grant from The Sierra Foundation, a private, independent foundation committed to supporting health and health-related activities in northern California (#81124). The author would like to thank Valley Oak Children's Services, Children's Home Society of Yuba City, Kathy Dahlgren, Jane Rysberg, Deborah Harter, Elizabeth Van Laan, the reviewers, and the Associate Editor Susan Kontos for their various contributions.     

Rebalancing health systems toward community-based care: The role of subsectoral politics

There has been increased policy discourse urging a “rebalancing” of health systems from institutionally-based to community-based approaches. This paper offers an analysis of the subsectoral dynamics that condition opportunities to strengthen community-based care relative to acute care. We report on the results of a policy study in Ontario, Canada that explored factors impacting on the capacity to expand community-based care. In so doing, we highlight the challenges associated with the community subsector’s ability to develop ‘critical’ status and challenge the dominance of the acute subsector. We conclude that attempts to rebalance health systems toward community-based care should begin by understanding that health care is not a monolithic policy sector, but rather a collection of proximate policy sub-sectors, inclusive of community care, acute care, and institutional care, each with their own internal characteristics and dynamics that impact sectoral directions.     

Management initiatives in a community-based health insurance scheme

Community-based health insurance (CBHI) schemes have developed in response to inadequacies of alternate systems for protecting the poor against health care expenditures. Some of these schemes have arisen within community-based organizations (CBOs), which have strong links with poor communities, and are therefore well situated to offer CBHI. However, the managerial capacities of many such CBOs are limited. This paper describes management initiatives undertaken in a CBHI scheme in India, in the course of an action-research project. The existing structures and systems at the CBHI had several strengths, but fell short on some counts, which became apparent in the course of planning for two interventions under the research project. Management initiatives were introduced that addressed four features of the CBHI, viz. human resources, organizational structure, implementation systems, and data management. Trained personnel were hired and given clear roles and responsibilities. Lines of reporting and accountability were spelt out, and supportive supervision was provided to team members. The data resources of the organization were strengthened for greater utilization of this information. While the changes that were introduced took some time to be accepted by team members, the commitment of the CBHI's leadership to these initiatives was critical to their success.     

Barriers to accessing benefits in a community-based insurance scheme: lessons learnt from SEWA Insurance, Gujarat

This paper seeks to examine barriers faced by members of a community-based insurance (CBI) scheme, which is targeted at poor women and their families, in accessing scheme benefits. CBI schemes have been developed and promoted as mechanisms to offer protection to poor families from the risks of ill-health, death and loss of assets. However, having voluntarily enrolled in a CBI scheme, poor households may find it difficult or impossible to access scheme benefits. The paper describes the results of qualitative research carried out to assess the barriers faced in accessing scheme benefits by members of the CBI scheme run by the Self-Employed Women's Association (SEWA) in Gujarat, India. The study finds that the members face a variety of different barriers, particularly in seeking hospitalization and in submitting insurance claims. Some of the barriers are rooted in factors outside the scheme's control, such as illiteracy and financial poverty amongst members, and inadequacies of the transportation and health care infrastructure. But other barriers relate to the scheme's design and management, for example, lack of clarity among scheme staff regarding the scheme's rules and processes, and requirements that claimants submit documents to prove the validity of their claims. The paper makes recommendations as to how SEWA Insurance can address some of the identified barriers and discusses the relevance of these findings to other CBI schemes in India and elsewhere.     

Quality of care for women undergoing a hysterectomy: effects of insurance and race/ethnicity

OBJECTIVE: We assessed the quality of hospital care for women who underwent a hysterectomy to compare Medicaid-covered women with privately insured women and minority women with White women. METHODS: We evaluated medical decisions, inpatient care, quality of inpatient care, and outcomes. RESULTS: Quality of hospital care was equivalent for Medicaid-covered women compared with privately insured women and for non-Hispanic Black women compared with White women. Medicaid-covered women (40%) and Black women (68%) were more likely to have a complication compared with privately insured women and White women, respectively. CONCLUSIONS: Increased complications after hysterectomy may result in increased economic burdens to Medicaid. Further studies of the racial/ethnic and sociodemographic issues are needed so that disparities may be adequately addressed.     

The feasibility of community-based health insurance in Burkina Faso

To ensure the acceptability of community-based insurance (CBI) by the community and its sustainability, a feasibility study of CBI was conducted in Burkina Faso, including preference for benefit package of CBI, costing of health services, costing of the benefit package and willingness-to-pay (WTP) for the package. Qualitative methods were used to collect information about preferences for the benefit package. Cost per unit health services, health demand obtained from household survey and physician-judged health needs were used to estimate the cost of the benefit package. The bidding game method was used to elicit household head's WTP for the package. We found that there were strong preferences for inclusion of high-cost healthservices such as operation, essential drugs and consultation fees in the benefit package. It is estimated that the cost of the package per capita was 1673 CFA (demand-based) and 9630 CFA (need-based), including 58% government subsidies (euro 1 = 655 CFA). The average household head with eight household members agreed to pay from 7500 (median) to 9769 CFA (mean) to join the CBI for his/her household. The WTP results were influenced by household characteristics, such as location, household size and age composition. Under certain assumptions (household as the enrolment unit, median household head's WTP as premium for the average household, 50% enrolment rate), it would be feasible to run CBI in Nouna, Burkina Faso if enrolees' health demand did not increase by more than 28% or if the underwriting of the initial losses was covered by extra funds.