Do risk sharing mechanisms improve access to health services in low and middle-income

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1 August 2008 SUPPORT Summary of a systematic review Do risk sharing mechanisms improve access to health services in low and middle-income countries? The introduction of user charges in many low and middle-income countries has been proposed as a strategy to increase revenues. But delayed treatment, catastrophic health expenditures and impoverishment are among the detrimental effects attributed to them. To reduce these risks, mechanisms allowing payment of care in advance or risk pooling have been increasingly advocated. Key messages Only one study was found that describes the impact of community-based health insurance schemes in Rwanda. Based on routine data collected at facility level, it seems that the introduction of these mechanisms may have increased utilization of care. But weaknesses in the design of the study limit the scope and validity of its findings. Who is this summary for? People making decisions concerning use of rish sharing mechanisms to improve access to health care. This summary includes: Key findings from research based on a systematic review Considerations about the relevance of this research for low and middleincome countries Not included: Recommendations Additional evidence not included in the systematic review Detailed descriptions of interventions or their implementation This summary is based on the following systematic review: Lagaarde M, Palmer N. Evidence from systematic reviews to inform decision making regarding financing mechanisms that improve access to health services for poor people. A policy brief prepared for the International Dialogue on Evidence-Informed Action to Achieve Health Goals in Developing Countries (IDEAHealth). Geneva: Alliance for Health Policy and Systems Research, ealthfinancingbrief.pdf What is a systematic review? A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies. SUPPORT an international collaboration funded by the EU 6th Framework Programme to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low and middle-income Glossary of terms used in this report: ions.htm Background references on this topic: See back page

2 Background Risk protection mechanisms include community-based insurance, social or private health insurance and pre-payment schemes. They all share the particularity of involving prospective payments for health care as opposed to payment at the point of delivery. In all of the schemes funds are collected in advance. Pre-payment schemes are individual forms of health financing and offer no opportunity for risk pooling, in contrast to community-based insurance that allows pooling across all beneficiaries of the scheme. Unlike community-based insurance, social health insurance is a compulsory scheme, whose coverage may vary from a specific large group (e.g. formal employees) to the whole population of a country. Social insurance schemes are usually mainly based on payroll contribution, from employers and employees. Increasingly support for such risk protection mechanisms has been voiced on grounds of their theoretical capacity to protect vulnerable people and alleviate financial constraints to accessing health services. How this summary was prepared After searching widely for systematic reviews that can help inform decisions about health systems, we have selected ones that provide information that is relevant to low and middle-income The methods used to assess the quality of the review and to make judgements about its relevance are described here: ods.htm Knowing what s not known is important A good quality review might not find any studies from low and middleincome countries or might not find any well-designed studies. Although that is disappointing, it is important to know what is not known as well as what is known. About the systematic review underlying this summary Review objective: To assess the effectiveness of risk protection mechanisms in improving access to care in low and middle income What the review authors searched for What the review authors found Interventions Participants Settings Outcomes Randomised trials, interrupted time-series analyses or controlled before-after studies that include interventions related to prepayment schemes, community-based insurance or social insurance. Populations who would potentially access health services - either well delineated (e.g. members of a health insurance scheme, pregnant women targeted by a voucher scheme) or more broadly defined. Studies taking place in low and middleincome Primary outcomes: changes in access to care or healthcare expenditure. Secondary outcomes: equity and patient outcomes. Date of most recent search: January controlled before-after study that evaluated communitybased health insurance. Health districts in Rwanda - primary care and some secondary health services. Rwanda Limitations: This is a good quality systematic review with only minor limitations. Health utilization outcomes measured by utilization of all available services in health centres (as curative outpatient visits, prenatal care visits, deliveries) and in hospitals. Lagaarde M, Palmer N. Evidence from systematic reviews to inform decision making regarding financing mechanisms that improve access to health services for poor people. A policy brief prepared for the International Dialogue on Evidence-Informed Action to Achieve Health Goals in Developing Countries (IDEAHealth). Geneva: Alliance for Health Policy and Systems Research, Background 2

3 Summary of findings The review included one controlled before-after study that evaluated a communitybased health insurance scheme in Rwanda. Enrolment in the scheme was voluntary and allowed access to a benefit package which included all preventive and curative services provided in the health centre, including essential drugs (as listed by the Ministry of Health). The only relevant outcomes collected before and after the beginning of the programme were monthly routine data from facilities located in the intervention and control districts. Health utilization outcomes measured by utilization of all available services in health centres (curative outpatient visits, prenatal care visits, deliveries, family planning, vaccinations, laboratory, hospitalization admissions and days) and in hospitals (curative outpatient visits, curative inpatient visits, deliveries, laboratory and radological tests, hospitalisation by ward, hospitalisation days). The volume of essential drugs prescribed in health centres and hospitals was also monitored. There is low quality evidence that community-based health insurance can increase utilization of health care. About quality of evidence (GRADE) High: Further research is very unlikely to change our confidence in the estimate of effect. Moderate: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. : Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low: We are very uncertain about the estimate. For more information, see last page. Community-based health insurance (CBHI) versus no intervention Patients or population: Health districts in Rwanda Settings: Primary and secondary care Intervention: Community-based health insurance Comparison: No intervention Outcomes CBHI districts Absolute changes from baseline Control districts Absolute difference between CBHI & control districts Quality of the evidence (GRADE) Curative consultations per capita % + 6.8% % Total number of deliveries in healthcare centres % - 5.1% % Total number of prenatal care consultations + 21% % % Total number of vaccinations % + 13% % GRADE: GRADE Working Group grades of evidence (see above and last page) Summary of findings 3

4 Relevance of the review for low and middle-income countries Findings APPLICABILITY The only study included was done in Rwanda. Interpretation* Community-based health insurance schemes are complex to implement and sustain. They require technical skills to be designed, managed and implemented. In addition it has been claimed that strong trust from the community in the implementing organisation, or among those who manage the scheme is essential. EQUITY Overall, the included studies provided little data regarding differential effects of the interventions for disadvantaged populations. If those who are poorest are not able to afford the premiums, the potential to reduce inequities can be threatened. Inequities in the target population may be created if those who are better-off are more likely to enrol, and if the scheme is successful in improving access to care and financial protection to its members. COST-EFFECTIVENESS Overall the included studies provided little data regarding cost-effectiveness issues. Community-based health insurance schemes have rarely operated on a substantial scale. When they are designed or extended to cover a whole population, they may become social insurance mechanisms, with mandatory participation. MONITORING & EVALUATION Only one study was found evaluating a communitybased health insurance scheme and no studies were found that evaluated social health insurance. The impact of risk sharing mechanisms should be evaluated, if possible in pilots before undertaking large scale changes. Both intended outcomes and potential adverse effects should be measured. The one study that was included found variable changes in indicators of access to health care. Adequate monitoring of the impact of risk sharing mechanisms on access to care requires health information systems that may not be available in some settings. This can be addressed by using human resources to collect information, although this would increase the cost of monitoring. *Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low and middle-income For additional details about how these judgements were made see: Relevance of the review for low and middle-income countries 4

5 Additional information Related literature This systematic review is currently in press: Lagarde M, Palmer N. The impact of risk sharing mechanisms on access to health services in low and middle-income Cochrane Database of Systematic Reviews. The protocol for the systematic review above: The impact of health financing strategies on access to health services in low and middle-income countries (Protocol). Cochrane Database of Systematic Reviews 2006, Issue 3. This chapter summarizes the financing mechanisms of health systems: The world health report Health systems: improving performance. Chapter 5: Who pays health systems?. Geneva: WHO, Systematic review addressing the impact of community-based health insurance: Ekman B. Communitybased health insurance in low-income countries: a systematic review of the evidence. Health Policy Plan 2004; 19: Review: Creese A, Bennett S. Rural risk-sharing strategies. In: Schieber G (ed.). Innovations in Health Care Financing. Proceedings of a World Bank Conference. Washington, D.C: World Bank, 1997, pages This summary was prepared by García Marti Sebastían and Ciapponi Agustín. Institute for Clinical Effectiveness and Health Policy. Argentina Conflict of interest None declared. For details, see: Acknowledgements This summary has been peer reviewed by: Tracey Perez Koehlmoos, Bangladesh; Gabriel Rada, Chile. This summary should be cited as García Martí S, Ciapponi A. Does risk sharing mechanisms improve access to health services in low and middle income countries? A SUPPORT Summary of a systematic review. August About quality of evidence (GRADE) The quality of the evidence is a judgement about the extent to which we can be confident that the estimates of effect are correct. These judgements are made using the GRADE system, and are provided for each outcome. The judgements are based on the type of study design (randomised trials versus observational studies), the risk of bias, the consistency of the results across studies, and the precision of the overall estimate across studies. For each outcome, the quality of the evidence is rated as high, moderate, low or very low using the definitions on page 3. For more information about GRADE: SUPPORT collaborators: The Alliance for Health Policy and Systems Research (HPSR) is an international collaboration aiming to promote the generation and use of health policy and systems research as a means to improve the health systems of developing The Cochrane Effective Practice and Organisation of Care Group (EPOC) is a Collaborative Review Group of the Cochrane Collaboration: an international organisation that aims to help people make well informed decisions about health care by preparing, maintaining and ensuring the accessibility of systematic reviews of the effects of health care interventions. The Evidence-Informed Policy Netowrk (EVIPNet) is is an initiative to promote the use of health research in policymaking. Focusing on low and middleincome countries, EVIPNet promotes partnerships at the country level between policy-makers, researchers and civil society in order to facilitate both policy development and policy implementation through the use of the best scientific evidence available. For more information, see: To receive notices of new SUPPORT summaries, go to: etter/ To provide feedback on this summary, go to: Additional information 5