Dissertations / Theses on the topic 'Community-based health insurance'

Includes bibliographical references (leaves 119-124).
Community-Based Health Insurance Schemes are new forms of health financing that can increase resources available for a national health system. These schemes are often regarded as not feasible. Evidence from recent experiences however; show that , if they are appropriately designed and managed they can be feasible and sustainable. The successes achieved by such schemes in Ghana motivated the government to make them a mandatory system of health financing. The main objective is that every resident of Ghana shall belong to a health insurance scheme that adequately covers him or her against "cash and carry" (i.e. user fees) in order to obtain access to a defined package of acceptable quality needed health services without having to pay at the point of receiving service. This study sought to undertake a critical comparative study of the performance of voluntary and mandatory community health financing schemes in Ghana and assess their prospects and challenges in their effort to improve efficiency, equity and the schemes' sustainability. The study, a qualitative one, employed descriptive survey techniques to evaluate the ability of schemes to finance their activities from their own sources and mechanisms put in place to cater for the poor and vulnerable, i.e. to evaluate with sustainability and equity respectively. The study also considered control measures to minimize cost escalation to assess efficiency. Focus group discussions, key informant interviews and document reviews were used to examine performance of voluntary and mandatory schemes in meeting those criteria. The study found that both voluntary and mandatory schemes were not self-sustainable due to low coverage and inadequate funds mobilized by the schemes. The main reasons for the general low enrolments are poverty, poor quality health service and limited benefit packages. The study showed that including out-patient (OPD) services in the benefit package and quality improvements in health service improve members' acceptability of insurance hence increase membership rates which will eventually increase schemes' sustainability. Efficient and effective administration of risk equalization fund will help reduce differences in districts' ability to raise revenue owing to different levels of economic activities as well as local morbidities. The study showed further that small community-based health insurance schemes (CBHIS) could be sub-district level financial intermediaries for the District Health Insurance Schemes. It was found in this study that a practical means testing mechanism to declare one poor in order to quality for exemption from contribution should be adopted. The study also suggests that alternative reimbursement mechanisms to fee-for-service need to be considered. The study suggests further research on equity in access and means testing. Such study should consider coming up with mechanisms for identifying the very poor in the communities and to put in place workable and sustainable measure to tackle the financial barriers to health care they face.

Universal coverage is a core health system goal which can be met through a variety of health financing mechanisms. The focus of this PhD is on one of these mechanisms, community-based health insurance (CBHI). CBHI aims to provide financial protection from the cost of seeking health care through voluntary prepayment by community members; typically it is not-for-profit and aims to be community owned and controlled. Despite its popularity with international policymakers and donors, CBHI has performed poorly in most low and middle income countries. The overarching objective of this PhD is therefore to understand the determinants of low enrolment and high drop-out in CBHI. The PhD builds on the existing literature, which employs mainly economic and health system frameworks, by critically applying social capital theory to the analysis of CBHI. A mixed-methods multiple case study research design is used to investigate the relationship between CBHI, bonding and bridging social capital at micro and macro levels and active community participation. The study focuses on Senegal, where CBHI is a component of national health financing policy. The results suggest that CBHI enrolment is determined by having broader social networks which provide solidarity, risk pooling, financial protection and financial credit. Active participation in CBHI may prevent drop-out and increase levels of social capital. Overall, it seems CBHI is likely to favour individuals who already possess social, economic, cultural and other forms of capital and social power. At the macro level, values (such as voluntarism, trust and solidarity) and power relations inhering in social networks of CBHI stakeholders are also found to help explain low levels of CBHI enrolment at the micro level. The results imply the need for a fundamental overhaul of the current CBHI model. It is possible that the needed reforms would require local institutions to develop new capacities and resources that are so demanding that alternative public sector policies such as national social health insurance might emerge as a preferable alternative.

The thesis offers three primary contributions to the evidence base on demand for community-based health insurance (CB HI): (i) a review of the literature; (ii) an extended analytical framework to guide empirical investigations of demand for CBHI; and (iii) applied analyses to test the hypothesis regarding the relevance and fit of the proposed extension, and explore central positive and normative questions related to demand for CBHI by low-income groups in India and Nigeria. Chapter 2 offers an appraisal of the empirical and theoretical literature on demand for CBHI. Consequently, it proposes an extended analytical framework, which includes vectors of covariates at the household, CBHI, community, and state levels. More importantly, it proposes to test the relevance of social capital in models for demand estimation of CBHI. This extension places the central thrust of the thesis at the intersection of insurance theory and development economics. Chapter 3 exploits cross-sectional household data to apply the proposed extended framework to draw inferences on the nature of demand for micro insurance in India. Results from discrete choice and linear models show that the additional vectors have an impact on choice. While our social capital measures are not robust, the model statistics suggest that the community vector plays a role in demand. Chapter 4 explores demand to understand the market potential of a pilot in Lagos. The analysis draws on household and provider data. The results are more robust in terms of the number of significant covariates and their economic effects than those found in India. As a result, there is stronger and more decomposed evidence on the importance of the extended sets of covariates. Heckman, bivariate and multivariate models show significant effects for the CBHI and community vectors that have larger marginal effects than those observed in the household vector. The investigation offers a methodological insight into the double bounded dichotomous choice contingent valuation method. The evidence from these empirical analyses corroborates the relevance of the extended framework. We found that using the individual and household-level vector alone to estimate demand for CBHI is detached from reality and leads to model misspecification. Although the analyses are hampered by data limitations, the economic effects of the additional vectors are substantial. Understanding the role of social capital could improve the impact of community-based interventions. While there is evidence of interest in insurance even among the poor, the economic size of contributions from low-income groups in absolute terms is limited. However, their individual and household efforts are not negligible, as the stated reservation prices constitute a significant share of their household consumption. These facts imply that, while low-income households value insurance and coverage is demanded, their financial constraints may constitute a price barrier if the premiums are not subsidized. The thesis identifies critical gaps for future investigation: (i) combining analytical approaches (ii) improving measurement of factors; (iii) expanding the geographic scope of research on CB HI, especially in countries where community-based resource mobilization is a policy priority, in order to improve the external validity of findings and, consequently the value of information for design and policy making.

People´s access to safe health care is not as common as one might think. Today with new and different health insurances and improved health policies people should in theory have safe health care. Although numerous of health insurances exist, targeting large parts of populations, there are still many issues with them. The Behavioural Model of Health Services Use and Separate Spheres are the two theories that are used in this study. Where Separate Spheres describes men´s and women´s separate worlds, their responsibilities in them and how it effects them and the Behavioural Model of Health Services Use, which describes factors that either impede or enable people’s access to health care utilization. This study´s purpose is to see what different perceptions men and women have about the insurance and how these perceptions can affect families’ choice to enroll to the insurance. The study uses a qualitative approach and is based on semi-structured interviews. Results in this study showed that men and women have very different perceptions about the insurance. Men want the insurance because they want to save money and decrease health expenses. While women wants the insurance for their children to always have access to health care. The roles between men and women in households are significant and their different responsibilities affect their priorities and perceptions.

Includes bibliographical references (leaves 83-92).
One major challenge facing the international development community is how to finance and provide health care for the large informal sector in low and middle income countries. This is as a result of the inability of the traditional tax systems in most of these countries to generate the needed revenue to help meet the health needs of the citizens. In recent times, many countries in developing countries are increasingly depending on Community Based Insurance Schemes (CBHIS) as an alternative health care financing mechanism. In Ghana. the universal tax funded system of health care introduced in 1957 soon alter independence could not be sustained because of economic recession in the 1970's and 1980's forcing the government to introduce user fees in all public health institutions. User fees resulted in a decline in utilization of health services especially the poor and vulnerable group. This situation forced many communities to set up CBHIS meant to cover user fees charged at the health facilities. The success of some of these schemes and the fact that many Ghanaians do not have insurance cover led the government to introduce a National Health Insurance Scheme (NHIS) which is mandatory for all citizens. The law mandates all formal sector workers to contribute part of their social security contribution to the National Health Insurance Fund as premium, thus making it compulsory for them. Those in the informal sector are however required to voluntarily pay directly into their district schemes. Also, even though a proposal has been made to exempt the poor, no mechanism has been determined to identify poor households for subsidy. This study sought to undertake a critical evaluation of the role of CBHIS under the NHIS in extending health care coverage to the large informal sector (who are about 70% of the active labour force) in Ghana. Specifically, the study sought to determine factors that affect enrolment, to determine a practical mechanism to identify the poor and to gain an understanding of how other countries have increased health insurance coverage.

Gaps in financial access remain stark in the largest part of developing countries and have relevant consequences on poor households’ economic decisions, such as credit, saving and risk management. Lack of availability of formal financial services provided by either the market or public authorities (e.g in case of health insurance) have been compensated by the activity of informal groups, associations and arrangements. Old and new forms of community-based groups have been largely documented in most of developing countries and are shown to be active in several crucial economic domains. They have different levels of institutionalization as they can simply rely on social norms or can have rules and a certain degree of formalization concerning e.g. selection criteria, enforcement, sanctions. They all have in common the voluntary participation of people from the same community (village, neighbourhood, people of the same profession), the delivery of services to members, the non-profit character, the underpinning values of solidarity and mutual help. Some examples of community-based groups in Sub-Saharan Africa are analysed in this thesis: Rotating Saving and Credit Associations (roscas), funeral groups and mutual health organizations (MHOs). The importance of studying community-based arrangements lies in the premise that interventions at the level of a local community can deliver more effective and equitable development. Moreover, examining the mechanics of the informal market is very important for two reasons. First, the strength of the informal market is important for measuring and predicting how effective specific formal sector interventions could be, in the perspective of scaling-up. Second, lessons learned in the informal markets can help shape policy in the formal (Karlan and Morduch 2009). In chapter 1, drawing on data from a household survey in urban Benin1, we examine membership in two types of informal groups that display the characteristics of a commitment device: rotating savings and credit associations (roscas) and funeral groups. We investigate whether agents displaying time-inconsistent preferences are sophisticated enough to commit themselves through taking part in such groups. We provide evidence indicating that women who are hyperbolic are more likely to join these groups and to save more through them, but men displaying similar preferences appear naïve with regards membership. Moreover, we find that hyperbolic agents, irrespective of their gender, tend to restrain consumption of frivolous goods to a larger extent. Furthermore, weak evidence is provided that microcredit can be used as a device to foster self-discipline. We also ensure that our results cannot be explained by intrahousehold conflict issues. The second chapter largely draws on Bonan J, Dagnelie O., LeMay-Boucher P. and Tenikue M. (2012) “Is it all about Money? A Randomized Evaluation of the Impact of Insurance Literacy and Marketing Treatments on the Demand for Health Microinsurance in Senegal”, Working Papers 216, University of Milano-Bicocca, Department of Economics. It is based on a field work we carried out in Spring-Summer 2010 in Thies, Senegal, which I coordinated and supervised. The chapter presents experimental evidence on mutual health organizations (MHOs) in the area of Thiès, Senegal. Despite their benefits, in some areas there remain low take-up rates. We offer an insurance literacy module, communicating the benefits from health microinsurance and the functioning of MHOs, to a randomly selected sample of households. The effects of this training, and three cross-cutting marketing treatments, are evaluated using a randomized control trial. We find that our various marketing treatments have a positive and significant effect on health insurance adoption, increasing take-up by around 35%. Comparatively the insurance literacy module has a negligible impact on the take up decisions. We attempt at providing different contextual reasons for this result. The third chapter is an extension of the second and draws on the same dataset. We measure the willingness to pay (WTP) for MHOs premiums in a Senegalese urban context. WTP valuations can help both policy makers and existent MHOs in better understanding the characteristics of the demand of microinsurance products. This chapter considers the role of individual and household socio-economic determinants of willingness to pay for a health microinsurance product and add to the previous literature evidence of the role of income, wealth and risk preferences on individual WTP. We find that richer, more wealthy and more risk-averse head of households are more likely to reveal a higher WTP for health microinsurance. Conscious of the potential limits of our elicitation strategy (bidding game), we incorporate the existent literature on the effects of ‘preferences anomalies’ (Watson and Ryan 2007) and estimate WTP accounting for structural shift in preferences (Alberini et al. 1997), anchoring effect (Herriges and Shogren 1996) and the two effects together (Whitehead 2002). We find evidence of slight underestimation of the median WTP if preferences anomalies are not taken into consideration. However, the extent of such difference is far from being relevant. Previous results on the determinants of WTP are robust to the effect of such preference anomalies. We also provide an analysis of the predictive power of WTP on the actual take-up of insurance following our offering of membership to a sample of 360 households. WTP appears to have a positive and significant impact on actual take-up.

La couverture universelle de santé est aujourd’hui au coeur du financement de la santé. Dans ce contexte, le développement des mécanismes d’assurance et l’amélioration de l’efficience constituent des enjeux majeurs pour garantir l’équité dans l’accès et le financement des services de santé. La transition vers la couverture universelle de santé s’appuie sur la combinaison des fonds d’équité de santé et de l’assurance santé communautaire au Cambodge et sur le développement de l’assurance santé communautaire en Chine avec le Nouveau Système de Coopératives Médicales Rurales. Alors que les modalités du financement de la santé changent, l’utilisation des ressources devient un enjeu central et on doit alors s’interroger sur leur efficience dans le contexte de la couverture universelle de santé. C’est l’objet de cette thèse qui s’articule autour de quatre chapitres. Le chapitre I analyse les enjeux du financement de la santé dans les pays en développement dans le contexte de la couverture universelle de santé, montrant pourquoi la problématique de l’efficience en constitue l’une des interrogations centrales. La thèse se concentre alors sur l’étude de l’efficience des établissements de santé au travers de trois chapitres. Le chapitre II porte sur la mesure de l’efficience technique via l’analyse d’enveloppement des données. Les chapitres III et IV présentent des études de cas portant respectivement sur l’activité et l’efficience des centres de santé de la province de Takéo au Cambodge et des hôpitaux municipaux de la préfecture de Weifang en Chine dans le contexte des réformes orientées vers la couverture universelle de santé
Universal health coverage is at the heart of health financing. In such context, the development of insurance mechanisms and the improvement of efficiency are major stakes to insure equity in access and financing of health care services. In Cambodia, the transition to universal health coverage relies on a combination of health equity funds and community-based health insurance while in China it relies on the development of community-based health insurance with the New Rural Cooperative Medical Scheme. The composition of health financing evolves and thus, the utilization of resources becomes a central issue. So, as it proposed in this thesis, we have to examine the efficiency in the context of universal health coverage. The chapter I analyses the issues of health financing in developing countries in the context of universal health coverage and underlines why the efficiency is the central issue. The thesis then concentrates on the study of efficiency through three chapters. Chapter II details the data envelopment analysis to estimate technical efficiency. Chapters III and IV respectively study the activity and efficiency of health centers of Takeo province in Cambodia and townships hospitals of Weifang prefecture in China, in the context of reforms oriented to universal health coverage

Le financement des soins de santé de qualité constitue un défi majeur pour les pays en développement. Malgré les efforts consentis pour améliorer l’offre des services de santé, une frange importante de la population n’a toujours pas accès aux soins de santé. La faible croissance économique, le manque des ressources, la corruption et les contraintes imposées au secteur public peuvent expliquer pourquoi la conception d’un système de financement des soins de santé est complexe. Au cours des deux dernières décennies, il y a eu une baisse de l'utilisation des services de santé après l'introduction du recouvrement des coûts dans les établissements de santé publics. Les personnes les plus touchées par cette politique sont les ménages à faibles revenus notamment dans les zones rurales qui sont le plus souvent vulnérables aux maladies. L'assurance communautaire a été proposée comme une alternative pour améliorer une meilleure accessibilité des ménages à faibles revenus aux soins de santé. L'assurance communautaire apparaît ainsi comme un outil de protection sociale pour un grand nombre de personnes qui, autrement, n'auraient pas une couverture face au risque maladie. Toutefois, un tel système d’assurance maladie ne peut avoir des effets à long terme que s’il existe une forte préférence des ménages pour une telle politique, et un capital social dans les zones rurales. Evaluer les préférences des ménages pour l'assurance communautaire est importante pour la formulation des recommandations de politique économique. Une connaissance adéquate des déterminants de la demande pour l'assurance communautaire est aussi essentielle pour l'élaboration de stratégies visant à accroître l’allocation des ressources, et à améliorer la qualité des services. La présente étude a pour objet d’évaluer les préférences des ménages pour l’assurance communautaire en milieu rural camerounais. L’usage de la méthode d’évaluation contingente suggère que les ménages à faibles revenus sont disposés à payer pour l’assurance communautaire. En outre, le capital social a un effet positif et significatif sur la demande. L’usage des doubles questions binaires pour évaluer des préférences des ménages est incompatible avec les incitations et sujets à un shift effect hétérogène expliqué par les caractéristiques intrinsèques des ménages. Les ménages très certains de leurs réponses ne sont pas sujets aux anomalies comportementales. Enfin, les préférences des ménages sont inter-indépendantes du fait des interactions spatiales expliquées par les normes sociales
The financing of quality healthcare is a major challenge for developing countries. Despite efforts to improve the provision of healthcare services, a significant proportion of the population does not always have access to healthcare services. Low economic growth, lack of economic resources, corruption and constraints on the public sector could explain why the design of a system of financing healthcare is complex. Over the past two decades, there has been a decline in the use of healthcare services after the introduction of cost recovery in public health facilities. Those most affected by this policy are low-income households particularly in rural areas that are most often vulnerable to diseases. The community-based health insurance has been proposed as an alternative to improve better access to low-income households to healthcare services. The community-based health insurance is thus a tool of social protection for many households who otherwise would not have formal insurance. However, such a health insurance scheme can have long-term effects if households have a strong preference for it, and there is social capital in rural areas. Assessing the preferences of households for the community-based health insurance is important for the formulation of policy recommendations. Adequate knowledge on the determinants of demand for the community-based health insurance is essential for developing strategies to increase resource allocation, and improve the quality of services. This study aims at assessing the preferences of households for community-based health insurance in rural areas of Cameroon. The use of contingent valuation method suggests that low-income households are willing to pay for the community-based health insurance. Furthermore, social capital has a positive and significant effect on the demand, and the use of double-bounded dichotomous choice to assess the preferences of households is incentive incompatible. We also found that there is heterogeneous shift effect in preferences anomalies and could be mostly explained by the salient characteristics of households. A striking result is that more certain households are not subjected to preference anomalies. Lastly, there is spatial dependence in the preferences of households explained by social norms

In 2007, at its 52nd Conference in Polokwane, the African National Congress (ANC) called for the implementation of a National Health Insurance (NHI) scheme. The announcement resulted in much debate, with critics voicing concerns about the state of the public health system, lack of consultation and the expense of a NHI scheme. However, little attention has been paid to the 
human resource (HR) needs, despite the fact that 57% of recurrent expenditure on health1 is on HR. This research aimed to identify the HR requirements to support the implementation of an effective and equitable health system funded by a NHI in South Africa. An overview of the current burden of disease and distribution of HR is provided. Through interviewing key stakeholders the study attempted to elicit information about factors which will hamper or assist in developing such a health system, specifically looking at the HR situation and needs. The research explores HR 
odels and proposes key HR requirements for implementation of a health system funded by a NHI in South Africa, including skills mix and projected numbers of health workers and 
proposes ways to improve the deficient HR situation. Exploratory qualitative research methods were used comprising in-depth individual interviews, with a purposive sample of key informants, including: public health professionals and health managers (working in rural and urban areas)
researchers
academics and NGO managers. The contents of the interviews were analysed to identify common responses about and suggestions for HR requirements within the framework of a NHI. 1 Personal communication Dr Mark Blecher, Director Social Services (Health), National Treasury, 17 July 2009 The literature review includes policy documents, position papers and articles from journals and bulletins. Key informants were asked to identify literature and research material to support recommendations. The research findings indicate that despite the South African Government&rsquo
s expressed commitment to Primary Health Care (PHC), the National Department of Health has continued to support and sustain a clinical model of health service delivery (Motsoaledi, 2010), primarily utilising doctors and nurses. The clinic based services are limited in their ability to reach community level, and, being focused on curative aspects, are often inadequate with regard to prevention, health promotion and rehabilitation services. While the curricula of health professionals have been through some changes, the training has continued to be curative in focus and the clinical training sites have not been significantly expanded to include peripheral sites. While there are many Community Health Workers in the country, they remain disorganised and peripheral to the public health system. The mid level worker category 
has not been fully explored. Finally there are no clear strategies for recruitment and retention of health workers in rural and under-resourced areas. In addition to the continued use of a clinical model, transformation of the health system hasbeen hampered by inadequate numbers of health workers, particularly in the rural and periurban townships and informal settlements. There is no clear strategy for addressing the critical 
health worker shortage in under-resourced areas, particularly rural areas. The last section makes recommendations, which will be submitted to the relevant task teams working on the NHI. It is intended that recommendations arising out of the research will influence the process and decisions about HRH within a NHI funded health system.

Community-Based Health Insurance (CBHI) in Rwanda was promulgated as the best alternative to address the financial barriers for accessibility to health care services for the poor population and the informal sector. The purpose of this study was to investigate whether CBHI reduce Out-of-pocket health expenses for their members as compared to non-members and to what extent CBHI provide financial protection for the poorest population. This research based itself on secondary source of data primarily collected for a prospective quasi-experimental design which evaluated the impact of Performance-Based Financing. The primary study had reported on the Out-Of-Pocket expenses for health by members and non-members of CBHI; residing in a sample of 1961 households; in addition to their demographics and socio-economic characteristics. The findings indicate that insured individuals were about 2.6 times more likely to utilize health care services than respondents without health insurance. It is also worth noting that households with health insurance coverage were less likely to experience a catastrophic health expenditure than households without health insurance (aOR: 0.744; 95% CI:[0.586 - 0.945]), and that the effect of health insurance coverage was higher in people living in poor households than in people living in middle or richer households
Health Studies
M.A. (Public Health)

Bibliography: leaves 268-317
The challenge of accessing affordable healthcare services in the developing countries prompted the promotion of community-based health insurance (CBHI) as an effective alternative. CBHI has been implemented in many countries of the South over the last three decades for the purpose of improving access and attaining universal health coverage. However, the sudden stoppage of a CBHI programme in rural Nigeria raised a lot of concerns about the suitability of the health financing scheme. Thus, this thesis examines the stoppage of the CBHI programme in rural Kwara, Nigeria. Premised on the health policy triangle as a conceptual framework, mixed methods approach was adopted for data collection. This involved 12 focus group discussions, 22 in-depth interviews, 32 key informant interviews and 1,583 questionaires. The study participants were community members, community leaders, healthcare providers, policymakers, international partner, health maintenance organisation officials and a researcher. Findings revealed that transnational actors relied on various resources (e.g. fund and ‘expertise’) and formed alliances with local actors to drive the introduction of the programme. As such, the design and implementation of the policy were dominated by international actors. Despite the sustainability challenges faced by the programme, the study found that it benefitted some of the enrolled community members. Though, even at the subsidised amount, enrolment premium was still a challenge for many. The main reasons for the stoppage of the programme are a paucity of fund and poor management. The stoppage of the programme, however, signified a point of reversal in the relative achievements recorded by the CBHI scheme because community members have deserted the healthcare facilities due to high costs of care. In view of these, the thesis notes that short-term policies often lead to temporary outcomes and suggests the need to repurpose the role of the state by introducing a long-term comprehensive healthcare policy – based on the reality of the nation – to provide equitable healthcare services for the citizenry irrespective of their capacity to pay.
Sociology
D. Phil. (Sociology)

碩士
銘傳大學
風險管理與保險學系碩士班
103
Due to the demand for Long term care has greatly increased, its urgent to promote Long term care system. Based on Ten-Year Plan for Long-term Care, the Long-term care insurance is expected to execute within a few years. This study based on Andersen behavioral model of health care utilization for analyzing the demand and recognition of the community-based care and home health care by sending questionnaires to the above 20 years-old citizens in Taipei. The study suggests that government should speed up the planning of long-term care insurance and commit to the development of community-based care and home health care, in order to achieve aging in place, maintaining independence and self-respect for the elderly. On the other hand, it can also assist people with disabilities in a better quality of life, and reduce the burden on the family with long-term care demands.