Background
Methods
Literature searches
Analysis of data
Results
Reference | Type of paper | Main findings pertinent to the present analysis | |
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Nigeria
| |||
Adinma, 2010 [21] | Descriptive cross-sectional study with interventional component carried out in 120 women of reproductive age at Obionu Health Centre, Igboukwu | Benefit shown for integration of maternal health services into CBHI schemes | |
Dienye, 2011 [22] | Questionnaire cross-sectional survey of 229 surgical patients who consented to the study | Patients paid for care mostly with personal savings; most were unaware of the NHIS. When informed, 84.3% were willing to enrol. Information must be disseminated to promote acceptance of CBHI in rural areas | |
Onwujekwe, 2010 [23] | Questionnaire survey of 3070 households selected by simple random sampling. Contingent valuation was used to determine WTP using the bidding game format. Correlations between socioeconomic status and geographic locations with WTP were investigated. Log-ordinary least squares was used to examine the construct validity of elicited WTP | Economic status and place of residence influence WTP for CBHI membership. Consumer awareness should be promoted, and government or donor subsidies are needed to ensure success and sustainability | |
Onwujekwe, 2010 [24] | Questionnaire survey of 3070 households selected by simple random sampling. Focus group discussions were used to collect qualitative data, which was then examined for links between benefit package preferences with socioeconomic status and geographic residence of the respondents | Rural and poorer households preferred comprehensive packages; urban dwellers and the better off preferred more basic packages. Long-term viability must be promoted by quick access to care and benefits, and reduction in cost of treatment | |
Onwujekwe, 2009 [25] | Questionnaire survey of 971 respondents in two communities selected by simple random sampling. Data analysis examined socioeconomic status, differences in enrolment levels, utilisation, willingness to renew registration, and payments | Highlighted the need for subsidies to ensure enrolment and equitable risk protection among the very poor | |
Onwujekwe, 2011 [26] | Questionnaire survey of 3070 randomly selected households. Head of household or most senior member interviewed, and acceptability of CBHI scored on a scale of 1 to 10 | Greatest willingness to enrol detected among the poorest households. Less poor groups may be more aware of shortcomings in programmes, and may therefore be more likely to express distrust and cynicism about the success of the scheme | |
Senegal, Mali & Ghana
| |||
Jütting, 2003 [27] | Senegal | Survey of 346 randomly selected households (2860 persons): 70% members and 30% non-members. Models used to examine impact of CBHI on health care use and expenditure | Members more likely to use facilities than non-members, and pay substantially less when they do. The very poorest households do not enrol, however: cost of participation must be reduced by lowering of prices or addition of subsidies |
Ouimet, 2007 [12] | Senegal | Study of all Senegal CBHI providers, including interviews with subscribers and promoters, logistical analysis of links between subscribers and organisations and composite indicators representing values | Showed conflicts between promoter and subscriber values |
Smith, 2008 [28] | Senegal; Mali; Ghana | Data from three household surveys carried out by USAID-funded Partners for Health Reformplus. After presentation of descriptive statistics, multiple regression was used to estimate relationships between CBHI membership and access to formal maternal health services | CBHI membership is positively associated with maternal health service use. CBHI is a potential demand-side mechanism to increase maternal health care access, but complementary supply-side interventions to improve quality of and geographic access to care are also critical |
Rwanda
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Bucagu, 2012 [19] | Rwanda | Systematic review of literature, national policy documents and three Demographic & Health Surveys (2000, 2005 and 2010) to identify health system factors driving maternity service improvements | CBHI identified as a primary factor, together with better leadership and governance |
Schmidt, 2006 [29] | Rwanda | Analysis of data from six household surveys | The goals of maximising health revenue and maximising participation in CBHI are mutually exclusive. The top three quartiles of the Rwandan population were able to contribute US$1 per capita per year, but subsidies were recommended to extend coverage to the poorest quartile |
Dhillon, 2012 [30] | Rwanda | Investigation of the impact of subsidising CBHI enrolment, removing point-of-service co-payments, and improving service delivery on health facility utilisation rates in Mayange, a rural area containing approximately 25,000 people | Improvement of service delivery and reduced financial barriers (elimination of copayments and increased subsidies) increases health facility utilisation under CBHI |
Schneider, 2006 [31] | Rwanda | Cross-sectional household survey data collected in 2000 in the context of the introduction of CBHI: 3139 households (354 insured and 2785 uninsured) - 14,574 individuals in total. Analysis via an indirect standardisation approach used to measure health inequality | Substantial inequality in utilisation linked to user fees - these were linked to horizontal inequity in service use across scheme members. In addition, benefit packages need to be large enough to protect households against catastrophic expenditure |
Logie, 2008 [18] | Rwanda | Descriptive review summarising three health system developments introduced by the Rwandan government to lower barriers to care: coordination of donors and external aid with government policy, and monitoring the effectiveness of aid; a country-wide independent CBHI scheme; and the introduction of a performance-based pay initiative | Annual fee too expensive for the very poor and insufficient to fund basic care - extra central funding and donor contributions needed. Addition of contributions from other insurance schemes and exemptions for the poor recommended |
Uganda
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Basaza, 2010 [13] | Uganda | Semi-structured interviews with senior Ministry of Health staff and District Health Officers - qualitative study | Revealed gaps in knowledge and understanding of schemes among Ministry of Health and District Health Office staff. Also highlighted OOP expenditure as a problem |
Basaza, 2007 [32] | Uganda | Case study of two CBHI schemes: review of scheme records, key informant interviews and exit polls with both insured and non-insured patients | Various demand and supply side factors identified |
Basaza, 2008 [33] | Uganda | Reasons for low enrolment were investigated in two different models of CBHI. Focus group discussions and in-depth interviews were carried out with members and non-members to acquire more insight and understanding in people’s perception of CHI, in reasons for joining/not joining and in the possibilities for increased enrolment. | Highlighted scheme design problems, ability to pay premiums, poor quality of care, trust, etc. |
Kyomugisha, 2009 [34] | Uganda | Qualitative descriptive cross-sectional study: focus group discussions with scheme members and non-members (158 participants) | Schemes were not sustainable because of small budgets, low enrolment and lack of government support. Effect of abolition of user fees on scheme enrolment was minimal. Governments should ensure that quality does not suffer when user fees are removed, and schemes need substantial support to build sustainability |
Burkina Faso
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De Allegri, 2006 [35] | Burkina Faso | In-depth interviews with 32 heads of households in Nouna District, BF | Previously neglected factors, such as institutional rigidities and socio-cultural practices, are important in shaping the decision to enrol |
Dong, 2003 [15] | Burkina Faso | WTP study: household survey involving 2414 individuals and 705 household heads. Take-it-or-leave-it (TIOLI) and bidding game methods used to determine WTP | Pointed out the importance of considering differences between the theoretical and real markets, and between WTP and the costs of benefit packages |
Dong, 2004 [16] | Burkina Faso | WTP survey: random sample of 698 household heads interviewed with bidding game method. | Decision makers need to consider WTP when setting enrolment units and premiums |
Dong, 2004 [17] | Burkina Faso | Focus group discussions carried out after a pilot based on three key informant interviews; followed by a household survey (160 households). Qualitative survey with costings; the bidding game method was used to determine WTP and feasibility of running CBHI+ | Subsidies highlighted; household characteristics influenced preferences |
Dong, 2009 [36] | Burkina Faso | Survey of 756 rural and 553 urban households. logistic regression was used to study the influence of individual and household factors on CBHI drop-outs | Drop-out rates influenced by affordability, health needs and health demand, quality of care, and household head and household characteristics |
Parmar, 2012 [37] | Burkina Faso | 4-year study of adverse selection and targeted subsidies. CBHI was randomly offered to 41 villages and 1 town (Nouna) during 2004–6, with premium subsidies offered to poor households in 2007. Data were subsequently collected by household panel survey from randomly selected households (n = 6795); fixed effect models were applied | Targeted subsidies may increase coverage but may also increase adverse selection. Such subsidies for the very poor or other high-risk groups must be accompanied by strategies to bridge the financial gap created by adverse selection and thus assist sustainability |
Souares, 2010 [38] | Burkina Faso | Community wealth ranking was used to identify the poorest quintile of households among 7762 in Nouna district who were then offered insurance at half the usual premium for 2007 | Annual enrolment increased from 18 households (1.1%) in 2006 to 186 (11.1%) in 2007 |
Cameroon
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Donfouet, 2011 [14] | Cameroon | Contingent valuation study based on survey of 410 rural households. Willingness to pay investigated | Substantial demand for CBHI in rural Cameroon, but social marketing strategies such as mass media campaigns are needed to raise awareness |
Guinea
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Criel, 2003 [39] | Guinea | Focus group discussions carried out to explore reasons for low enrolment | Poor quality of care highlighted as a factor |
Factor | Examples of countries where factors noteda | Issues identified and policy implications | References |
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Factors positively linked to uptake
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Provision of uniform benefit packages offering wide illness coverage | Ghana | Benefits should be predefined and comprehensive, with a good coverage of likely disease burden | |
Provision of services at accredited facilities helps to ensure uniformity of benefits offered | |||
Adequate public financing/realistic pricing | Ghana, Rwanda, Burkina Faso | Use of funds from taxation is necessary to allow funding to become progressive and to encourage/enable the less well-off to join through subsidies and fee exemptions | |
Targeted subsidies positively influenced enrolment in Nouna, BF, although there is also a danger of adverse selection | |||
Elimination or minimisation of copayments | Rwanda | Increases in subsidies to the point where copayments are eliminated could lead to as much as 100% coverage | |
User fees in Rwanda were found to be linked to substantial inequality in utilisation, with medical visits being more common among the more well-off uninsured | |||
Strong desire/willingness to join | Cameroon, Nigeria | Greatest willingness noted among poorest households in Nigeria | |
Policy makers should undertake research to determine WTP; social marketing can encourage participation | |||
Avoidance of focus on maximisation of health revenue | Rwanda | CBHI participation and a focus on the generation of healthcare revenues are mutually exclusive | Schmidt [29] |
Improvements in education and socioeconomic status | Burkina Faso | Enrolment in schemes may increase in line with social and economic progress and development over the long term | De Allegri [35] |
Provision of maternal healthcare benefits | Senegal, Mali, Ghana, Rwanda, Nigeria | Inclusion of maternal healthcare benefits promotes interest in CBHI as a demand-side driver, and CBHI is a primary contributor to strong maternal health services | |
Scheme organisers should ensure that packages are comprehensive, as excessive limitation discourages uptake | |||
Awareness of the limitations of traditional medicine | Burkina Faso | Noted in the Nouna, BF survey. Further research is needed, but this observation emphases the value of improved education and communication | De Allegri [35] |
Negative factors that discourage or limit uptake
| |||
Excessive requirement for OOP expenditure, inability to pay | Uganda, Burkina Faso, Guinea, Senegal, Nigeria | Major determinant of enrolment; even where implementation has been predominantly successful, the very poorest populations may still find participation financially difficult | |
OOP remains significant in healthcare systems in many countries (despite actions such as abolition of user fees in government institutions in Uganda) | |||
Regressive flat-rate payments are a problem in Nigeria, and inability to pay premiums is the single biggest obstacle in Uganda. There are no mechanisms in place to help those who cannot afford to join | |||
Ambiguous and contradictory healthcare funding policy is a significant problem that must be addressed | |||
Social exclusion due to religion or ethnicity | Senegal | Noted in Senegal, where the Roman Catholic Church supports the Mutuelles, and where Christians were reported in 2003 to be more likely than Moslems to enrol. In interviews, Moslems were under the mistaken impression that CBHI was open to Christians only | Jütting [27] |
Lack of legal framework or umbrella organisation | Guinea, Benin | Failure to provide any proper governance or official framework for CBHI schemes is linked to low enrolment | Soors [20] |
Lack of government (or donor) support | Uganda, Burkina Faso, Nigeria | Small budgets, low enrolment and lack of government support cause schemes to fail. Schemes need substantial support to build their sustainability; technical and policy decisions should account for this | |
Excessively rigid enrolment requirements or institutional rigidity | Uganda, Burkina Faso | Failure to recruit the required number of people in a village has been a key feature affecting schemes in Uganda (mandatory 60% of a group or 100 families per village) | |
Rules for group membership should reflect what is achievable | |||
Mismatch of values expressed by promoters and subscribers; failure to align the ‘real’ market with the theoretical one, and to match benefits with WTP | Senegal, Burkina Faso, Nigeria | Need to align expectations/needs of promoters (focus on financial sustainability) and subscribers (who look for sustainability and solidarity) | |
Increase participation of members in decision making; failure to engage beneficiary participation in Nigeria has been pinpointed as a major problem | |||
Ensure that prospective members are willing to pay for the benefits on offer, and that the market in any locality matches the theoretical one on which projections are based | |||
Lack of information | Uganda, Burkina Faso, Nigeria | Governments and promoters must ensure that schemes are properly and accurately publicised, and the public properly informed; lack of knowledge can lead to scepticism | |
Lack of information is a significant problem in Nigeria | |||
Authorities must ensure that government and health officials are fully informed about the packages on offer | |||
Poor quality of healthcare | Uganda, Guinea | Concerns relate to cleanliness, long queues before being seen, and lack of some prescribed medicines | |
Noted as the main reason for lack of interest in the Maliando Mutual Health Organisation in Conakry, Guinea | |||
Lack of trust; perception that schemes are unfair or even unnecessary; dislike of health care personnel and cultural resistance | Uganda | Belief that non-members are treated better in hospital than scheme members | |
Integrity of fund managers and transparency of operation: “Nothing is done to ensure that fund managers account to scheme members” (Ugandan interview respondent) | |||
Some members pay premiums continuously but never fall sick | |||
“I wasn’t bothered since I am young and not likely to fall sick”; “If I do not fall sick, I should not pay for someone else” (Ugandan survey respondents) | |||
Schemes must be fair, well run and affordable, and the public sufficiently well-informed to appreciate the need for coverage and mutuality | |||
High drop-out rates | Burkina Faso | Related to other factors noted in this table: affordability, health needs and demand, quality of care and household characteristics | Dong [36] |
Improve perception of schemes by heads of households, ensure that large households are able to maintain contributions (e.g. flexibility in payment options); ensure that service offered meets expectations (e.g. in line with education, etc.) |
CBHI schemes and their uptake in Nigeria and other SSA countries
Nigeria
Senegal, Mali and Ghana
Rwanda
East African Countries (Uganda, Tanzania, Kenya)
Burkina Faso
Cameroon
Other SSA Countries
Drivers of success and sustainability
Discussion
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Closer integration of CBHI with the formal sector under the existing NHIS umbrella, with improved regulation and guarantee of financial stability by central government. Government support via tax revenues is necessary to cover gaps and ensure sustainability.
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Elimination of regressive funding (flat rate payments).
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Elimination of unrealistic pricing and minimisation of OOP payments, equity of availability of benefit packages, and consideration of targeted public subsidies.
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Improved understanding of beneficiary needs by policymakers. Scheme benefits need to be comprehensive and easily understood, and administrators and providers trusted by beneficiaries. Evidence strongly suggests that current lack of confidence is being driven by lack of awareness and poor communication, which could be addressed through targeted information campaigns.
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Increased citizen participation in the organisation and running of schemes (the Nigerian model provides for member involvement). Information about the schemes available should be widely disseminated and understood.
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Ensuring transparency and monitoring of quality of service: communities may not be enrolling because of lack of information or misinformation, lack of trust and cultural resistance, or a perception that schemes are unfair and the standard of care is inadequate.
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Monitoring of risk sharing, claims-to-revenue ratios and operating costs to ensure long-term sustainability [51].