Does Community-Based Health Insurance Protect Women from Financial Catastrophe After Cesarean Section? A Prospective Study from a Rural Hospital in Rwanda

BackgroundThe implementation of community-based health insurance in (CBHI) in Rwanda has reduced out of pocket (OOP) spending for the >79% of citizens who enroll in it but the effect for surgical patients is not well described. For all but the poorest citizens who are completely subsidized, the OOP (out of pocket) payment at time of service is 10%. However, 55.5% of the population is below the international poverty line meaning that even this copay can have a significant impact on a family’s financial health. The aim of this study was to estimate the burden of OOP payments for cesarean sections in the context of CBHI and determine if having it reduces catastrophic health expenditure (CHE). MethodsThis study is nested in a larger randomized controlled trial of women undergoing cesarean section at a district hospital in Rwanda. Eligible patients were surveyed at discharge to quantify household income and routine monthly expenditures and direct and indirect spending related to the hospitalization. This was used in conjunction with hospital billing records to calculate the rate of catastrophic expenditure by insurance group. ResultsAbout 94% of the 340 women met the World Bank definition of extreme poverty. Of the 330 (97.1%) with any type of health insurance, the majority (n=310, 91.2%) have CBHI. The average OOP expenditure for a cesarean section and hospitalization was $9.36. The average cost adding transportation to the hospital was $19.29. 164 (48.2%) had to borrow money and 43 (12.7%) had to sell possessions. The hospital bill alone was a CHE for 5.3% of patients. However, when including transportation costs, 15.4% incurred a CHE and including lost wages, 22.6%. ConclusionTo ensure universal health coverage (UHC), essential surgical care must be affordable. Despite enrollment in universal health insurance, cesarean section still impoverishes households in rural Rwanda, the majority of whom already lie below the poverty line. Although CBHI protects against CHE from the cost of healthcare, when adding in the cost of transportation, lost wages and caregivers, cesarean section is still often a catastrophic financial event. Further innovation in financial risk protection is needed to provide equitable UHC.

Client satisfaction on community based health insurance scheme and associated factors at Boru Meda Hospital, Northeast, Ethiopia: institutional based cross-sectional study

Background Community-based health insurance systems are usually voluntary and characterized by community members pooling funds and protecting themselves against the high costs of seeking medical care and treatment for illness. Client satisfaction with health service provision during the implementation of health insurance schemes has often been neglected. This study aimed to determine client satisfaction with the community-based health insurance scheme and associated factors. Methods An institutional-based cross-sectional study design was applied from February 22–March 11 /2019. A total of 420 study participants were included in the study using a systematic random sampling technique. Data were collected using a pretested semi-structured interviewer-administered questionnaire with a patient exit interview. Bivariate and multivariate logistic regression analyses were used to identify factors associated with Community-based Health Insurance of client satisfaction. Statistical significance was decided at a p-value less than 0.05. Result A total of 420 community-based health insurance clients of health service users participated in the study with a 100% response rate. The overall client satisfaction was 80% at 95% Cl (76.1, 83.9), respondents who have perceived that partially or none availability of prescribing drugs were 0.09 times less likely satisfied as compared to full availability of prescribing drugs (AOR =0.09; 95% Cl: (0.04, 0.19)). Besides, study participants waiting time to consult service providers within 30 min were more satisfied than those who were delayed 60 min and above (AOR =3.16; 95% Cl: (1.19, 8.41)). Conclusion Community-based health insurance client satisfaction provided in the present study was 80% indicating low proportion. Full availability of prescribing drugs, clients renewed their community-based health insurance membership, and preference of clients to use the hospital for future health care need were positively associated with client satisfaction while the perception of waiting time before physician consultation negatively affected client’s satisfaction. Therefore, the hospital management members and service providers need to give attention to reduce waiting time preceding consultation, improve drug availability, and sustain the hospital preference by the client.

Willingness to Join Community-Based Health Insurance and Its Associated Factors among Households in West Gojjam Zone, North Mecha Woreda ,Amhara region, Ethiopia

Background Community-based health insurance schemes are becoming increasingly recognized as a potential strategy to achieve universal health coverage in developing countries. Ethiopia is a low income country with more of health spending out of pocket payment by households. Health insurance is also expected to provide financial protection because it reduces the financial risk associated with falling ill. Therefore; financial risk in the absence of health insurance is equal to the out-of-pocket expenditures because of illness. Method Cross-sectional community based study design was conducted by using a pretested structured questionnaire. Multi-stage cluster, simple random and systematic sampling techniques was used to select 296 households as study units which were allocated to the kebeles proportionately. The sampled households were selected using simple random sampling technique. Bivariate and multivariate logistic regression was used for analysis of variables and 95% confidence level and P value <0.05 was used to measure strength of association. Results A total of 296 sampled study participants, 285 participated in this study with a response rate of 96.3%.From this, (90.9%) were willing to join and (89.8%) of them were willingness to pay CBHI. the benefits of join the scheme were as follows, (86.8%) were reduce OOP expenditure, (8.3%) of them improve health status, (2.3%) were reduce the risk of severity and (2.6%) foster productivity. Conclusions This study showed that the proportion of willingness to join CBHI was higher than the findings of others study in the country and it is encouraging for planned strategy to expanding the scheme throughout the country. The main challenges utilization of health services in government health institutions were absence of available medicine, poor service delivery, lack of enough laboratory, health professional’s lack of good behavior and shortage of ambulance services. To alleviate such problem the government should be encourage access to health services.

Continued Adherence to Community-Based Health Insurance Scheme in Two Districts of Northeast Ethiopia: Application of Accelerated Failure Time Shared Frailty Models

Background: The sustainability of a voluntary community-based health insurance scheme depends to a greater extent on its ability to retain members. In low- and middle-income countries, high rate of member dropout has been a great concern for such schemes. Although few studies had investigated the factors influencing dropout decisions, none of these looked into how long and why members adhere to the scheme. The purpose of this study was to determine the factors affecting time to drop out while accounting for the influence of cluster-level variables. Methods: A community-based cross-sectional study was conducted among 1232 rural households who have ever been enrolled in two community-based health insurance schemes. A household survey was conducted using a mobile data collection platform. The Kaplan-Meier estimates were used to compare the time to drop out among subgroups. To identify predictors of time to drop out, a multivariable analysis was done using the accelerated failure time shared frailty models. The degree of association was assessed using the acceleration factor (δ) and statistical significance was determined at 95% confidence interval. Results: Results of the multivariable analysis revealed that marital status of the respondents (δ=1.614; 95% CI: 1.221–2.134), household size (δ=1.167; 95% CI: 1.012–1.344), presence of chronic illness (δ=1.421; 95% CI: 1.163–1.736), hospitalization history (δ=1.308; 95% CI: 1.120–1.529), higher perceived quality of care (δ=1.323; 95% CI: 1.101–1.589), perceived risk protection (δ=1.220; 95% CI: 1.029–1.446), and higher trust in the scheme (δ=1.729; 95% CI: 1.428–2.095) were significant predictors of time to drop out at p-value < 0.05. Conclusions: The study identified evidence suggestive of adverse selection in the schemes. The fact that larger households remain in the scheme indicates the need to reconsider the premium level in line with household size to attract small size households. Issues that are under the control of the scheme and the healthcare system can be adjusted to increase membership adherence. Resolving problems related to the quality of health care can be a cross-cutting area of ​​intervention to retain members by building trust in the scheme and enhancing the risk protection ability of the schemes.

Determinants of Enrolment for Community Based Health Insurance Scheme among Agro-pastoralist communities of Aw-barre District in Somali region of Ethiopia: Unmatched case control study.

BackgroundEthiopia launched community-based health insurance scheme in 2011 as part of the revised health care financing strategy to ensure universal health coverage and implementation has started in most part of the country since the launching of the scheme. However, the roll out of the scheme started in Somali Region in 2020—much later the rest of the country. The aim of this study was to assess determinants of enrollment of community-based health insurance among households in Awbarre Woreda, Somali Region, EthiopiaMethodsCommunity based unmatched case control study using a mixed approach of quantitative and qualitative methods was conducted between March and April 2021 and the study participants were selected using multi-stage sampling technique. The quantitative method used interviewer administered structured questionnaire among 216 participants (54 enrolled and 162 non-enrolled), while the qualitative method used key informant interview and focus group discussions in two rural and two urban kebeles of the woreda. The quantitative data was analyzed using SPSS version 20 and thematic analysis was used for the qualitative data. Multivariable logistic regression was used to determine the determinants of enrollment for the community-based health insurance and statistical significance was set at p value of <5%. Result Awareness about CBHI scheme AOR = 9.41(1.16,76.19), households income AOR = 2.73(0.77, 9.57); and being a member of community-based solidarity groups AOR = 2.88(1.17, 7.12) were the determinants for CBHI enrollment and reaffirmed by the qualitative findings. ConclusionsThe enrollment for community-based insurance was determined by being well informed about the scheme, household income, and being a member of solidarity groups at community level. Given the early stage of implementation, enhancing sensitization of the community about the scheme using various community platforms, promotion of the existing community based solidarity groups/associations, diligent targeting of the poor households/indigents and ensuring linkage with any existing social protection program would help to increase enrolment for the scheme.

An Assessment of the Economic Feasibility of Selected Surgeries in the Obstetrics and Gynaecology Department under Community-Based Health Insurance (CBHI) in a Tertiary Care Hospital in South India

Community-Based Health Insurance (CBHI) is a form of micro health insurance targeted at low-income groups that permits for grouping of assets to tackle the expenses of future, uncertain, health-related circumstances. According to the International Labour Organisation, more than 80% of India’s employed nonagricultural population is in the informal sector, implying that they are possibly excluded from receiving health insurance benefits. This is where CBHI comes into play, wherein groups of people belonging to a community define the demand and benefits and pool their resources to provide financial protection to all their members. This study aims to scrutinize the package prices sanctioned by these schemes and compare them with the cost incurred by the hospital. The expense pattern of three surgeries in the Department of Obstetrics and Gynaecology was analysed under three insurance schemes: Arogya Bhagya Yojana, Arogya Karnataka, and Employees’ State Insurance Scheme. Methodology. A retrospective study was conducted in a 2,032-bedded tertiary care hospital in South India. Patients of abdominal hysterectomy, vaginal hysterectomy, and caesarean section surgeries covered by any of the insurance schemes mentioned above were a part of the inclusion criteria. The patient records were examined from the hospital’s Medical Records Department (MRD). The patients’ bills were assembled from the inpatient billing department to scrutinize all the expenses associated with each surgery. The variable costs include consumables, medicine, electricity and AC, diagnostics, blood bank materials, doctor’s fee, package differences, and others. In contrast, fixed costs include bed cost, equipment cost (purchase + annual maintenance cost), manpower cost-OT, manpower cost-nursing, and allocated indirect costs associated with the medical treatment. These were computed and compared with the package price of respective insurance schemes to determine if the schemes are profit-yielding schemes or loss-yielding schemes, using the data from the finance department. Results and Conclusion. It has been observed that the operating loss of the hospital for abdominal hysterectomy, vaginal hysterectomy, and caesarean section under CBHI schemes ranges between 7% and 36%. The highest loss was observed in Arogya Karnataka Scheme for caesarean section surgery (BPL patients). The amount received through these schemes is insufficient to cover the costs acquired by the hospital, let alone make a profit. However, under Arogya Bhagya and ESI Schemes, the hospital has made a profit in covering the variable costs for these surgeries. The study concludes that the hospital is running under loss due to the three Community-Based Health Insurance (CBHI) schemes.

Pooled coverage of community based health insurance scheme enrolment in Ethiopia: Systematic review and meta-analysis. (Preprint)

BACKGROUND Community Based Health Insurance (CBHI) is a type of health insurance program that provides financial protection against the cost of illness and improving access to health care services for communities engaged in the informal sector. In Ethiopia, the coverage of CBHI enrolment varies across regions and decision of household enrolment is affected by different factors. OBJECTIVE The aim of this systematic review and meta-analysis was to identify the pooled coverage of CBHI enrolment in Ethiopia to understand its policy implications. METHODS The systematic review and meta-analysis was done by adhering the PRISMA guideline with exhaustive search in PubMed/Medline, HINARI, SCOPUS and Google scholar complemented by manual search. Two authors independently selected studies, extracted data, and assessed quality of studies. The I2 test statistic was used to test heterogeneity among studies. The overall coverage of CBHI scheme was estimated by using random-effects model. RESULTS Among 269 identified, 17 studies were included in this meta-analysis and the overall coverage of CBHI scheme was 45% (95% CI 35%, 55%) in Ethiopia. The sub-group analysis shows higher enrolment rate 55.97(95%CI: 41.68, 69.77) in earlier (2016-2017) studies than recent 37.33(95%CI: 24.82, 50.77) studies (2018-2020). CONCLUSIONS The pooled coverage of CBHI enrolment is low in Ethiopia compared the national target of 80% set for 2020. It is also concentrated in only major regions of the country. Due attention to be given to improving geographic expansion of CBHI and to the declining coverages with in the CBHI implementing regions by addressing the main bottlenecks restraining coverages. CLINICALTRIAL Registration: the protocol of this systematic review and meta-analysis was published in PROSPERO with registration number: CRD42021252762

Factors affecting the uptake of community-based health insurance in Ethiopia: a systematic review

<p class="abstract">The goal of health care financing in Ethiopia is achieving universal health care coverage by community-based health insurance which was expected to cover more than eighty percent of the population. The aim was to minimize catastrophic out-of-pocket health service expenditure. We systematically reviewed factors affecting the uptake of community-based health insurance in Ethiopia. We searched various databases by 09 to 10 March 2019. We included articles regardless of their publication status with both quantitative and qualitative approaches. The factors determining the uptake of community-based health insurance in Ethiopia were found to be demographic and socio-economic, and health status, and health service-related issues. Among demographic and socio-economic factors, the report of the studies regarding gender and age was not consistent. However, income, education, community participation, marriage, occupation, and family size were found to be significant predictors and were positively related to the uptake of the scheme.<strong> </strong>Concerning health status and health service-related factors; illness experience, benefit package, awareness level, previous out of pocket expenditure for health care service, and health service status (quality, adequacy, efficiency, and coverage) were significantly and positively related but the premium amount, self-rated health status and bureaucratic complexity were found to be negative predictors. To achieve universal health care coverage through community-based health insurance, special attention should be given to community-based intervention.</p>