Health systems research
Health insurance for universal coverage
Among the barriers preventing sick people from seeking care, the price of health care has been consistently shown to be crucial. In consideration of the vicious cycle between poverty and ill health alternative financing mechanisms, de-coupling payment from time of use and pooling risks, are needed to address the challenge of improved access to health care. Social health insurance has proven to be one powerful tool to achieve (near) universal coverage with adequate financial protection for all against health care costs in that beneficiaries are asked to pay according to their means while guaranteeing them the right to health services according to need. Unfortunately, since social health insurance is traditionally attached to the labor market the nationally organized expansion of social health insurance to the self-employed and non-formal sector is especially demanding in the context of developing and least-developed countries. But there are strong arguments in favour of universal coverage of health insurance that can be brought compulsory membership. It may be difficult to reach at nationwide consensus to accept the basic rule of social health insurance and it may not be feasible in low income setting where most of people are in informal sector and self-employed.
Heidelberg University, the Department of Tropical Hygiene and Public Health has been at the forefront of research in addressing the challenges faced by low- and middle-income countries in providing universal coverage to their population through Community-based Health Insurance (CBI). The Department is working with its collaborative partner, Nouna Health Research Center (CRSN), in Burkina Faso to provide scientific evidence for designing and implementing CBI in low-income countries.
Community-based insurance: enrolment behaviour and impact on demand, health status and poverty
D2 sub-project of SFB 544 Control of Tropical Infectious Diseases:
However efficacious existing and future health care interventions, such as vaccines and drugs, may be in clinical trials, they will not have an impact on population health, if health systems do not deliver them to those in need. Community-based insurance (CBI) has the potential to increase access to good quality health care. The D2 project provides scientific evidence to improve the design and implementation of such insurance. Furthermore, we will analyze the impact of the insurance scheme on utilisation of health care, health outcomes, household’s poverty and on quality of care.
CBI is implemented in a staggered fashion (step wedge design) as a cluster –randomized controlled community trial. Villages or groups of small villages or quarters of the town of Nouna are the population clusters. The following figure shows the design schematically.
- Figure 1. Timeline of the cluster-randomized trial with follow-up. Red triangle: time of proposal submission. The curves schematically represent the hypothetical increase in the proportion of all households who enrol in the three groups of clusters. Note the presence of potential increase and decrease (lack of renewal of enrolment in CBI.
The following table gives an overview of the study components and methods:
Table 1. Summary of study components
Objective | Hypothesis | Measurement | Analysis |
1. Enrolment behaviour | Both household perceptions and, provider behaviour constrain enrolment | Qualitative interviews
| Contextual and conceptual analysis, stakeholder mapping |
2. a) Insurance impact on utilisation | CBI leads to a moderate increase in utilisation | At the household level via self reported visits via HHS | Relative change in utilisation over time in the treatment group as compared to the control* |
2. b) Insurance impact on health status | CBI leads to a higher level of quality of life | At individual level using QALY measures based of EQ-5D and ratings scale | Relative change in utilisation over time in the treatment group as compared to the control* |
2. c) Insurance impact on poverty | CBI will prevent individuals from entering into health related poverty | At the individual level from the HHS, income and expenditure will be key economic indicators | Econometric techniques for testing structural differences between insured and uninsured** |
2. d) Insurance impact on quality of care | Patients will seek care early and take complete drug therapy. Providers will adhere to standards of care | Household survey, direct observation, user survey, blood chloroquine assay
Malaria as indicator disease. | Difference between enrolled and non-enrolled regarding: health care seeking delay, provider adherence to standards of care, treatment completion |
* Self selection is corrected for by using propensity score analysis which systematically chooses an appropriate control group that have the same likelihood of selection insurance than those who chose to participate in the treatment (i.e. CBI)
** Multiple linear regression using panel data is necessary as changes in poverty and health need to be measured over time and hence need a method to account for panel data.
Current data analysis (3-2007):
Currently we are doing impact evaluation of CBI on health services, utilization, quality of care, health system and poverty. It is believed that CBI has the potential to lower the financial barriers at the point of service use and hence it is likely to increase the demand for health care. However, the empirical evidence remains weak and there is a real paucity of community trials to assess the impact of CHI. The objective of this study is to detect any differences in the demand for health care between individuals who have enrolled in the community health insurance and those who have not.
Keeping membership year after year is a sign of sustainability. In order to provide information to keep membership stable, we analysed the drop-out rate and the reasons motivating the choice to leave the scheme after having been enrolled at least once in the scheme.
Drop-out analysis of community-based health insurance membership at Nouna, Burkina Faso
Targeting the poor
Out-of-pocket payments continue to be the most important means of financing health care in most developing countries. Large and unpredictable health payments can expose households to substantial risk and at their most extreme, can result in impoverishment. The poorest members of the community are the most concerned. The community based-insurance which was implemented in Nouna (Burkina Faso) in 2004, has the potential to prevent such health shocks by smoothening and avoiding asset loss. The enrolment rate was low especially among the poor people who are the most unable to pay the premium. The objective of this study was to determine the poorest of the population and to subsidize their premium enrolment to CBI.
German health insurance system
A number of low and middle income countries (LMICs) are considering social health insurance (SHI) for adoption into their social and economic environment or striving to sustain and improve already existing SHI schemes. SHI was first introduced in Germany in 1883. An analysis of the German system from its inception up to today may yield lessons relevant to other countries.
INsurance in TRANSition (INTRANS Project)
The overall objective of this research is to identify under what circumstances, and through what mechanisms, meso-level approaches such as Community-based Health Insurance (CHI) can contribute to achieving universal coverage in health care in the context of transition in health financing.
