Background
Developing nations are increasingly interested in exploring alternative healthcare financing systems to improve health coverage, accessibility, and financial protection to achieve universal health coverage (UHC). In the early 1980s, many developing countries introduced alternative cost recovery public health financing via a user fee system [
1]. However, user fees limit healthcare-seeking ability, particularly for those living in the countryside. Many commentators, therefore have been calling for an effective prepaid health financing mechanism to eliminate financial barriers associated with healthcare access [
2]. Health insurance has been proven effective at increasing access to healthcare and protecting individuals and families from catastrophic health expenditures. The underlying modality of health insurance allows beneficiaries to pay for healthcare in advance to avoid out-of-pocket expenditure at the point of care. Social health insurance (SHI) is a form of health insurance usually provided by a central government and sometimes by non-government organizations (NGOs) at a community level [
3]. SHI in low-and-middle-income countries (LMICs) which rely heavily on taxes may face implementation barriers due to inadequate tax collection, low institutional capacity to collect taxes, and a large informal sector workforce. Another form of health insurance is community-based health insurance (CBHI) which proliferated throughout developing countries, especially in Africa in the early 1990s [
4]. CBHI schemes are also referred to as mutual health insurance schemes, local health insurance, micro-health insurance, and medical aid societies or medical aid schemes [
5]. These insurance schemes are typically managed by local NGOs, hospitals, civil society organizations, or organized cooperative societies with community participation in their management [
6]. The primary objective of CBHI schemes is to mobilize local resources to provide quality healthcare services and increase healthcare accessibility in deprived areas [
7]. Ghana, Rwanda, Japan, and China started with CBHI and then reformed their health financing system by integrating CBHI schemes into national health insurance; however, their journey to form national health insurance from the CBHI schemes was not straightforward [
5,
8‐
10]. Mali, Senegal, and India are exploring a similar CBHI scaling-up strategy [
10].
Historically, Bangladesh had a tax-based healthcare system; however, the dearth of government capacity and financial protection schemes has resulted in a severe burden of out-of-pocket health expenditures [
11]. In Bangladesh, CBHI exists mainly as a form of micro-health insurance initiated by microfinance institutes, NGOs, and hospital/healthcare providers. CBHI in Bangladesh is mainly affiliated with microfinance institutes, where microfinance operators launched health insurance for their borrowers to ensure their well-being. In the late 1990s and early 2000s, microfinance institutions began offering health insurance to their borrowers [
12]. The pioneer organizations for CBHI are Gonoshasthaya Kendra, Ad-din, Grameen Kalyan, Bangladesh Rural Advancement Committee (BRAC), Diabetic Association of Bangladesh, Sajida Foundation, Dhaka Community Hospital, Shakti, Nari Uddug Kendra, Dushtha Shasthya Kendra, Integrated Development Foundation, Society for Social Services and International Centre for Diarrhoeal Disease Research Bangladesh [
12,
13]. We might broadly categorize CBHI based on the types of insurance providers: (i) provider-based model, in which private health facilities commence health insurance and offer healthcare from their health facilities; (ii) microfinance-based model, where microfinance organizations manage insurance programs for their borrowers; and (iii) non-microfinance-based model, where NGOs launch health insurance for the organized community or specified geographic areas without any link with microfinance [
13]. In a provider-based model, private health facilities act as both insurers and providers, similarly, most microfinance institutions also use their health facilities to provide healthcare [
13,
14]. Non-microfinance NGOs most often buy health care from private healthcare providers, but some also buy insurance packages from insurance companies [
13]. The insurance company then provides health care from its contracted health facilities [
15]. Enrolment is generally compulsory in a microfinance-based model for their borrowers, whilst provider-based and non-microfinance-based models allow voluntary enrollment. Most CBHI schemes treat the family/household as an enrollment unit. CBHI offers discounts for poor and vulnerable communities and has a greater emphasis on maternal and child healthcare. However, most of these schemes are highly dependent on external funding and/or provide cross-subsidies to recover fund gaps although some of these schemes are evidence to cover a certain amount of operational cost [
12]. They also offered discounts on medicine and pathological tests however, most of them do not have referral systems. CBHI has been shown in several studies to enhance healthcare utilization among the rural poor and lessen out-of-pocket healthcare spending in Bangladesh [
16‐
18].
Although CBHI schemes offer financial protection against healthcare costs to a group of people, the literature indicates that such a financing strategy is not much effective in the advancement of achieving UHC goals [
7]. The key grounds for this argument are adverse selection, moral hazard and heavy reliance on external subsidy challenge scheme implementation [
4,
7]. Major barriers of CBHI relate to conventional health insurance, including a small risk pooling, limited technical and organizational knowledge, low service coverage capacity, poor quality of care, and inadequate service providers [
4].
Although there is substantial literature on CBHI in Africa and Asia, there are few studies in Bangladesh [
14]. Most of the Bangladeshi literature focuses on the impact of CBHI on healthcare access and out-of-pocket spending and investigates the factors that influence enrollment and renewal [
19‐
21]. Hence, this study aims to explore the implementation barriers of CBHI in Bangladesh, and strategies to overcome these barriers. Bangladesh is behind other countries in the journey to UHC and the adoption of CBHI as a mechanism of financing for healthcare. The Government of Bangladesh plans to reform healthcare financing, and CBHI is an integral part of the adopted healthcare financing strategy 2012–2032 [
11]. To secure healthcare for the massive informal sector, the government strategy relies heavily on CBHI. In this context, it is crucial to understand CBHI's implementation barriers since this will benefit policymakers in their efforts to implement a healthcare financing strategy, particularly targeting the informal sector.
Discussion
Our research examines the barriers to implementing CBHI in Bangladesh and stakeholders' views on strategies to overcome these barriers. One of the key issues of CBHI schemes discussed by our participants is insufficient population coverage. Low enrolment and renewal rates were also noted as barriers to the successful implementation of CBHI, which they believe is due to the voluntary nature of membership. CBHIs are often small in size because they are designed to target a specific geographic area. Such schemes are more prone to implementation issues since they have limited risk diversification opportunities due to small membership pools. Previous studies indicate that awareness and understanding of the CBHI concept, trust in scheme management, perceived quality of care, and socio-demographic characteristics all play a role in households' decision to join and stay in the scheme [
20,
21,
30,
31].
To encourage individuals to join CBHI, our interviewees suggested door-to-door visits, health education sessions, campaigns, and financial assistance to the destitute. Previous studies have discovered that door-to-door visits, health education sessions, and campaigns have an effective influence on increasing enrolment and renewal [
33‐
41]. Similarly, providing some form of financial assistance to disadvantaged households could make it more affordable for them to join CBHI [
29,
33,
34,
36,
42,
43]. Our stakeholders also talked about providing additional performance-based monetary incentives to CHWs to motivate them to visit more households and recruit new members. Previous research in Bangladesh has shown that monetary incentives positively impact CHW’s retention and intervention success [
44,
45]. Our interviewees also suggested incorporating non-health benefits in the benefits package to encourage their membership renewal. In Bangladesh, several schemes have attempted to implement non-health benefits in CBHI among informal workers [
18] and ready-made garment workers [
46]. However, the impact of non-health benefits is yet undetermined in Bangladesh. According to a study in Vietnam, the inclusion of non-health benefits did attract more individuals and stimulated the expansion of the social health insurance scheme [
47]. Similarly, another research suggested that countries must push beyond the health sector to achieve UHC, and social health insurance schemes may need to incorporate non-health benefits to get maximum insurance coverage [
48]. The inclusion of non-health benefits may serve as an incentive for Bangladeshi informal workers to join and renew CBHI memberships.
Moral hazard is a recognized threat that leads to high benefit consumption and obstructs voluntary CBHI implementation in Bangladesh. Due to the voluntary nature of the schemes, they are sensitive to adverse selection, in which high-risk and sick people are more likely to purchase health insurance than low-risk and healthy people [
49]. Adverse selection is a threat to financial viability because it limits the potential for risk-sharing from healthy to sick people, forcing insurers to raise premiums to adjust costs when they face high claims. Low-risk persons are more likely to leave a scheme as a result of the increased premiums due to the expected low healthcare costs relative to their CBHI contribution, resulting in further adverse selection [
50]. Adverse selection has been documented in CBHI schemes in India [
51], China [
52], and Africa [
49]. Participants also emphasized the moral hazard problem, which states that once people are insured, they are more prone to overuse medical services. This might be due to either a lack of concern for one's health after joining a scheme or deliberate deceitfulness by consumers. Introducing group coverage, mandatory membership, and waiting periods are recognized techniques to overcome the problem of adverse selection; however, claim limits and copayments could lessen moral hazard [
53]. Further research is suggested to explore the effectiveness of those strategies on moral hazard and adverse selection.
Our interviewees noted that the progress of CBHI schemes is significantly impacted due to high startup and administrative costs. The establishment of CBHI is costly as it necessitates new infrastructure, staff recruitment, and the development of procedures and regulations before receiving significant premiums, making it difficult to recoup expenses. Studies conducted in Bangladesh stated that none of the CBHI with voluntary membership could recover their operating costs and heavily rely on subsidies [
13,
15]. Stakeholders stated that CBHI requires regular marketing and awareness campaigns and efforts to collect premiums, creating additional administrative and financial barriers. The most costly administrative task of CBHI in Tanzania was revenue collection comprising marketing and registration activities [
54]. Interviewees also acknowledged how they are challenged by the absence of additional monetary assistance from the government or donor agencies. Since premium and co-payment arrangements are insufficient, the financial viability of such schemes is a major concern.
Furthermore, due to the COVID-19 crisis, external funding for CBHI appears to be becoming increasingly difficult in the future. Interviewees advised adopting an automated computerized system and a mobile banking payment system to reduce workload and administrative costs. In the health insurance market, new technology and innovation, such as automation [
55] and mobile money payment [
56] are very effective in decreasing manual workload, time, and transition costs, but we see no evidence that this can entirely obviate the need for external financial support. Our participants also highlighted the need for a risk fund allocation for CBHI and the need for seed money to get a CBHI off the ground.
Our study found that scheme features, i.e., benefits package, could be a challenging factor to attract the target population. Due to a limited risk pool and inadequate population coverage, most benefit packages are not adequately designed to cover all medical expenses. As a result, insured members frequently have to spend a large amount of out-of-pocket money for medical diagnostics and medication as a co-payment. Our interviewees discussed the importance of including medicine in the benefits package and designing the benefit package to meet people's healthcare needs and preferences. The scheme should be affordable to the poor while also appealing to the wealthy, cover both inpatient and outpatient services, and provide a choice of public and private providers. The benefits packages which can address the needs of a community, are equitable, and provide outpatient services are likely to increase enrollment [
57‐
59]. On the other hand, low membership is attributed to chronic disease exclusion [
60], a high premium amount [
60], and limited disease coverage [
57]. Our participants advised that benefit packages be designed using research-based knowledge to attract more customers.
While people do not understand the concepts of medical insurance, they are more likely to decline to join or continue a CBHI policy. According to our study, the community's awareness of health insurance, socio-cultural beliefs, social norms, and healthcare-seeking patterns could impede CBHI implementation. The concept of health insurance is unfamiliar in Bangladesh, particularly among the disadvantaged rural population. Low enrolment in CBHI appears to be a strong sign that the targeted rural populace does not realize the value of an advance payment, i.e., purchasing a specific measure of assurance against an unpredictable future event. A review article on CBHI articulated that proper understanding of the concept and principles of health insurance has a positive impact on enrolment and renewal in different countries such as Afghanistan, Cameroon, China, Ghana, Guatemala, India, Kenya, Nigeria, the Philippines, Tanzania, and Uganda [
31]. Interviewees suggested a promotional campaign, awareness-building activities such as door-to-door visits, and health education sessions in the community with the involvement of local community health workers and influential personnel to promote the insurance scheme by educating people.
Moreover, medical treatment loans mentioned by our interviewee could be a feasible variation of community health insurance in Bangladesh. Microfinance scheme borrowers can apply for medical loans for themselves and their family members who have medical needs. The microfinance institute will allow them to pay the debts in instalments. Further research is needed to explore the community’s response, acceptability, and the prospect of a medical loan-based micro health insurance scheme.
Trust in insurance providers and consumer satisfaction, influenced by perceived healthcare quality, were mentioned by respondents as barriers to CBHI implementation. The availability and efficiency of healthcare personnel, their attitude or engagement with patients, and health facility features all play a role in how people perceive healthcare quality [
30]. Low-quality healthcare because of insufficient or unavailability of healthcare professionals and drug supplies during patients' visiting hours, infrastructural features, and health professionals' negative attitudes were identified as significant barriers to CBHI implementation in our study. Low-quality healthcare and healthcare providers’ inefficient technical proficiency were barriers to enrolment and membership renewal in Rwanda [
61]. Another study in Benin reported that approximately 30% of members drop out of a scheme due to the providers’ negative attitudes and behaviours [
37]. Most of the stated reasons for dissatisfaction were long waiting queues, providers’ negative attitude and efficiency, reimbursement rates, membership fees, drug quality, and treatment variation among socio-economic classes [
30]. The capacity to provide high-quality healthcare services based on the needs of enrollees would boost their satisfaction and build trust over time. Our interviewees suggested paramedics, telehealth services, and online consultation to improve the healthcare supply. Incentives and training are proposed to motivate health professionals and the provision of high-quality medicines to ensure consumer satisfaction and trust.
The distance between a household and a health facility is an important indicator of inequality in terms of healthcare accessibility. A long distance has been cited as a barrier to implementing CBHI in Bangladesh, potentially discouraging the target population from participating. According to studies, low enrolment has been linked to high travel costs due to great distances [
37,
61]. A study in Bangladesh also found that households close to health facilities were 2.7 times more likely to renew their membership [
21], which could be due to the information gap and travel expenditure to access healthcare services. To solve the issue of long distances, one of our participants suggested setting up a satellite clinic; however, satellite clinics are only effective for outpatient healthcare services. Collaboration between public and private providers could open up possibilities to receive healthcare from nearby facilities, making healthcare more accessible. Although our study gathers experience from Bangladesh, our findings, broader discussion, and suggested strategies apply to other low-resource contexts and are useful to policymakers.
Limitations
Although the study was qualitative, it may have benefited from quantitative insights as well as scheme beneficiaries’ participation. However, it was challenging to explore the beneficiaries’ perceptions of CBHI because of COVID-19 restrictions. Secondly, our study only included health insurance schemes whose information was available in the literature, which could be a source of bias given that successful schemes are more likely to be documented [
14]. Furthermore, we may have lost some information because some of the interviews were disrupted due to a poor internet connection. Despite these limitations, we believe this study provides a comprehensive understanding of the implementation barriers of CBHI in Bangladesh.
Conclusion
This qualitative study examines the barriers to implementing CBHI in Bangladesh from the viewpoints of insurance providers, researchers, and policymakers, including respondents from several active and recently closed schemes, as well as researchers and policymakers. The key barriers to CBHI implementation are insufficient population coverage, adverse selection, moral hazard, high startup and administrative costs, lack of knowledge of health insurance modalities, inadequate healthcare supplies, insurer trust, and the distance to travel to health facilities.
The CBHI in Bangladesh could serve as a foundation for the planned National Health Security Act towards UHC. Bangladesh is the birthplace of microfinance, and we have seen several integrations between health insurance and microfinance schemes. However, public–private partnership initiatives are necessary to reach a significant portion of the target population. Microfinance institutes and cooperative societies working at the grassroots level in Bangladesh can be prospective partners because they already have a well-organized and trusted platform. Our findings strongly suggest that policymakers should support CBHI schemes in technical and financial aspects and establish a distinct body to investigate the efficacy of public–private (i.e., NGO, microfinance, and cooperative societies) partnered approaches to CBHI in Bangladesh.
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