Colloquium for Systematic Reviews in International Development Dhaka

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1 Community-Based Health Insurance Schemes: A Systematic Review Anagaw Derseh Pro. Arjun S. Bed Dr. Robert Sparrow Colloquium for Systematic Reviews in International Development Dhaka 13 December 2012

2 Introduction More than half of health expenditure in poor countries is covered by out-of-pocket (OOP) payments incurred by households (Meghan, 2010). Increased expenditure caused by the need to cope with injury and illness has been identified as one of the main factors responsible for driving vulnerable households further into poverty (WHO, 2000). As shown in Figure 1 (based on surveys conducted in 59 countries), there is a direct and strong relationship between the share of OOP payment for health services and the share of households incurred catastrophic health care expenditure. It also shows that households in developing countries are more exposed to the risk of catastrophic health care expenditure as compared to developed countries.

3 Figure1: The relation between the share of households with catastrophic expenditures and percentage of out-of-pocket payment in total health expenditures (OOP% THE), based on surveys in 59 countries

4 Introduction Due to the limited ability of publicly financed health systems in developing countries to provide adequate access to health care and the shortcomings of informal coping strategies to provide financial protection against health shocks, a large number of communitybased health financing schemes, have been established in several low and middle income countries. CBHI schemes are non-profit initiatives built upon the principles of social solidarity and designed to provide financial protection against the impoverishing effects of health expenditure for households in the informal sector.

5 Introduction Matching the roll-out of these schemes, theoretical and especially empirical studies which examine their impact on outcomes - such as utilization of healthcare, financial protection, resource mobilization and social exclusion have flourished. Existing reviews of this body of work are provided by Jakab and Krishnan (2001), Preker et al. (2002) and Ekman (2004). Based on 45 published and unpublished works, Jakab and Krishnan (2001) conclude that there is convincing evidence that community health financing schemes are able to mobilize resources to finance healthcare needs, albeit there is substantial variation across schemes. They also argue that the schemes are effective in terms of reaching low-income groups although the ultra-poor are often excluded

6 Introduction Preker et al. (2002), reach a similar conclusion and point out that there is strong evidence that CBHIs are successful at mobilizing resources, enabling access to care for the poor and providing financial protection. However, the findings from the two studies are based on narrative reviews and they fail to assess the over all message or develop stylized facts. Unlike the these two papers, Ekman (2004) provides a systematic review of the literature based on 36 studies conducted between 1980 and 2002.

7 Introduction Ekman (2004) finds that while CBHI do provide financial protection for low income groups and mobilize resource for health providers. But the magnitude of the effect is low and the lowest income groups are excluded from enrollment. Moreover, there is no evidence that the schemes are associated with an increase in the quality of the care. On a methodological note, Ekman (2004) concludes that the evidence base to develop stylized facts is questionable and only five studies included in his review may be considered of high-quality However, it should be also noted that the conclusions of Ekman (2004) review are based on arbitrarily assigned quality grading scales

8 Objective of the current review The aim of this review is to provide an updated and systematic assessment of studies that have examined the impact of CBHI on various outcomes of interest. The specific objectives of the study are to: examine the impact of community-based financing on healthcare service utilization, OOP expenditure, inclusion of lower income groups, and adverse selection in enrolment examine the extent to which variations in outcomes may be related to key scheme design characteristics an issue which has policy implications but which has not been systematically investigated assesse the research methodology and comment on the potential effects of the study design on the empirical findings

9 Conducting the review This systematic review applies the following study protocols to assess the literature on the impact of CBHI schemes: The specific research aim: CBHI impact papers which deals with access to schemes, and their effect on health care utilization and financial protection Source of the data: published and unpublished papers between 1995 and 2012 located through a search of 6 databases and WHO website Key searching words used: community health financing, microinsurance, OOP payment and community insurance, communitybased health insurance. This generated a large number of papers (in several hundreds) Then titles and abstracts were examined and introductions and conclusions were perused for suitability of inclusion. Using this approach 108 potential papers were selected and passed to the second round for intensive reading.

10 Conducting the review.. Specific selection criteria: an examination of the impact of nonprofit community health financing schemes that serve population in the informal sector (urban and rural) of low and middle income countries. This restriction led to the exclusion of 16 out of the 108 papers. Type of data: micro data at the household or individual level (led to the exclusion of 9 studies). Research method: evaluate the effect of community health insurance mainly using quantitative and statistical analysis. Studies relying mainly on qualitative studies were included provided they used at least some statistical information (12 studies excluded). findings based on value judgement and self-perception without using any data were also excluded (6 studies excluded).

11 Conducting the review.. Outcome measures: utilization of health care (outpatient and inpatient) services, financial protection (OOP healthcare payments and catastrophic health expenditure), and social exclusion in enrolment and service utilization (19 studies excluded). The imposition of these criteria led to a list of 46 papers (32 published and 14 unpublished) that were retained for the review. After paper selection, the papers were read and carefully scrutinized. A data extraction template was developed to collect information from each paper Analysis: to assess the overall message emerging from the studies, univariate and bivariate distributions were constructed. These are used to construct stylized facts.

12 Review results 1. Social exclusion 61 percent of the papers (11 out of 18) find statistically significant evidence to support the claim that the ultra-poor are excluded from CBHI schemes. Even when such households become members, they tend to use healthcare services less intensively as compared to higher income groups potentially due to their inability to afford copayments and other related costs (transportation and forgone income). 2. Adverse selection About 67 percent (6 out of 9) of the studies find evidence that individuals suffering from chronic health conditions are more likely to join CBHI schemes as compared to those in good health.

13 Review results.. 3. Utilization of healthcare services Consistent with the results of previous reviews our analysis shows that 74 percent of the studies (26 out of 35) find positive and statistically significant CBHI membership effects on health care utilization The effect differs across the type of health care services: 75 percent of the studies find an effect on outpatient care while the corresponding figure for inpatient care is 64 percent. 4. Financial protection the schemes have registered strong evidence (88% of the cases) in preventing catastrophic health expenditure. 41 percent of such studies conclude that the schemes have not achieved success in reducing OOP healthcare payments

14 Review results.. 5. Scheme characteristics and scheme effects Variations in the relative performance of different CBHI schemes could be a result of the manner in which such schemes are designed and operated. Government-run schemes are more successful at creating access to health care (79 percent) and reducing OOP health spendings (78 percent) as compared to community-run schemes (69 percent and 43 percent respectively ). However, government run schemes are less successful at social inclusion. 86 percent of studies (6 out of 7) showing that government-schemes tend to exclude the ultra-poor as compared to 50 percent (5 out of 10) in the case of community-run NGOsupported schemes.

15 Review results.. Access to external funds appears to be positively associated with increase in utilization (81 percent of the studies while it is 75 percent for those schemes with out support) and reduction in OOP expenses (70 percent while it is 50 percent for the schemes with out support). All 9 schemes in which communities have a role in programme design and implementation are associated with an increase in access to healthcare and in reducing OOP expenditure (4 out of 5) while the corresponding figures for schemes without such participation are 55 percent (6 out of 11) and 25 percent (1 out of 4) respectively. Participation of members in management and supervision activities is also linked with increases in access to healthcare service (7 out of 7) and providing financial protection.

16 Study characteristics and scheme effects Reading of the papers raises several concerns, especially if the aim is to identify the causal impact of the schemes on various outcomes. First, previous studies reveal that CBHI enrolment is often a voluntary choice and there is clear evidence of exclusion of the ultrapoor and the higher enrolment of individuals with existing medical conditions. However, most studies do not account for this pattern of self-selection and hence ignores the consequences of estimating the impact of CBHI on health care use and financial protection based on self-selected samples For instance, only 6 papers out of 43 studies on utilization tried to control for observed and unobserved factors that may influence scheme uptake (selection effects) using techniques such as difference-in-difference (DID), Instrumental Variables (IV), and Heckman selection models.

17 Study characteristics and scheme effects The common approach is to ignore (unobserved) selection effects but control for a range of observed characteristics which may have a bearing on outcomes and on scheme uptake ( 19 out of 43 studies on health care utilization) and to use research techniques such as OLS, logit/probit, and PSM. Second, the bulk of the studies rely on cross-section data for their analysis. For instance, only 2 of the 16 studies on OOP health care spending apply regression methods have used panel data. Thus, such studies could not do dynamic analyses and fail to control for unobserved heterogeneity. Third, a key determinant that may influence participation in CBHIs and scheme effectiveness is the availability and quality of healthcare facilities. While about half of the studies (13 out of 25) on health care use control for the availability of health care, there are very few examples (3 out of 25) of studies that control for the quality of care. Most studies (71-86 percent) which did not control for health supply factors report significant result than those (65-67 percent) which did. Which is potentially due to the effect of unobserved factor.

18 Study characteristics and scheme effects There has been a clear improvement in the quality of the literature after the review by Ekman (2004). For instance, about 35 of the 43 papers now use regression analysis or report statistical significance compared to the Ekman review (16 out of 36). However, the burden of proof needed to obtain convincing effects has also risen since 2004 and based on current standards a convincing causal analysis of interventions such as the CBHI calls for the use of baseline and follow up data, information on treatment and valid controls and the use of appropriate statistical methods to control for the endogenous nature of CBHI participation.

19 Conclusion The review shows that the ultra-poor are often excluded from accessing CBHI schemes. Even if they do enrol, the lowest income groups are less likely to use health care services. This suggests the need to subsidise premiums or introduce fee waivers criteria for the poorest of the poor There is also considerable evidence that individuals with poor health conditions are more likely to enrol which could create problem on the financial sustainability of the scheme. The bulk of the studies report that access to CBHI is associated with increased health care utilization, especially with regard to the use of relatively cheaper outpatient care services as opposed to inpatient care The schemes also appear to mitigate catastrophic healthcare expenditure. However, there is no strong evidence showing the effectiveness of the scheme in reduce OOP health spending which implies the need to expand health facilities and reduce indirect costs of health care utilization.

20 Conclusions The review suggests that the effectiveness of the schemes, among other things, depends on factors related to the deign and implementation of the scheme. From a methodological and policy perspective, future work on such schemes needs to push the envelope by attempting to gather and analyse longitudinal data (baseline and follow up) and to control for unobserved heterogeneity which may be driving scheme uptake and outcomes. It is also important to consider for the quality and availability of health facilities while examining the impact of the schemes on outcomes of interest. Increase in the quality of the evidence base is essential in order to judge whether community-based schemes are a viable long-term health financing strategy.

21 Thank you!!!

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