Objective
Access to healthcare is mostly contingent on out-of-pocket spending (OOPS) by health se... more Objective Access to healthcare is mostly contingent on out-of-pocket spending (OOPS) by health seekers, particularly in low- and middle-income countries (LMICs). This would require many LMICs to raise enough funds to achieve universal health insurance coverage. But, are individuals or households willing to pay for health insurance, and how much? What factors positively affect WTP for health insurance?We wanted to examine the evidence for this, through a review of the literature. Methods We systematically searched databases up to February 2016 and included studies of individual or household WTP for health insurance. Two authors appraised the identified studies. We estimated the WTP as a percentage of GDP per capita, and adjusted net national income per capita of each country. We used meta-analysis to calculate WTP means and confidence intervals, and vote-counting to identify the variables that more often affected WTP. Result 16 studies (21 articles) from ten countries met the inclusion criteria. The mean WTP of individuals was 1.18% of GDP per capita and 1.39% of adjusted net national income per capita. The corresponding figures for households were 1.82% and 2.16%, respectively. Increases in family size, education level and income were consistently correlated with higher WTP for insurance, and increases in age were correlated with reduced WTP. Conclusions The WTP for healthcare insurance among rural households in LMICs was just below 2% of the GPD per capita. The findings demonstrate that in moving towards universal health coverage in LMICs, governments should not rely on households' premiums as a major financing source and should increase their fiscal capacity for an equitable health care system using other sources
Background: Of the estimated 30 million construction workers in India 51% are women, however, the... more Background: Of the estimated 30 million construction workers in India 51% are women, however, there are no studies on pregnant women living on construction sites in the Indian population. Objective: The present study was conducted to collect information on health access and challenges of pregnant women living on construction sites in Mumbai, Navi Mumbai, and Thane. Material and Methods: Participants were pregnant women living on construction sites, and were recruited from 13 construction sites. A mixed methods study, using both quantitative survey and focus group discussions, was conducted to understand the usage of ANC, delivery, and PNC, and financing aspects to pregnancy-related healthcare utilization among these women. Results: In the survey, a total of 72 pregnant women were interviewed. The average age of respondents was found to be 22 years (±49SD). A total of 76% of these women had utilized the health facilities for their antenatal checkups (ANC) with majority (65%) utilizing private health facilities. Among women who had a delivery within last 2 years, borrowings from other family members and contractors, and use of current savings, was the most common form of financing of both ANC and delivery expenses. 16 women were found to be working at the time of data collection during their current pregnancy, and during the FGDs, it was mentioned that the women tend to work till seventh month of pregnancy. Conclusion: These findings underscore the need for considering various contextual factors in ensuring better living and maternal health access services for such women living on construction sites. Abstract International Journal of Medical Science and Public Health Online 2016.
To assess the direct costs involved in treatment of children receiving intensive care in a univer... more To assess the direct costs involved in treatment of children receiving intensive care in a university-affiliated teaching hospital and its associated implications on the children's families, in rural India. It was a prospective observational study for cost-analysis using questionnaire based interviews and billing records data collection for admissions to the PICU over 27 consecutive months (January 2010 through March 2012). A total of 784 children were admitted to the unit during the assessment period. Full details of 633 children were included for analysis. The average length of stay was 6.16 d, average hospital expenditure was US$185.67, average hospital expenses per day was US$44.00, average pharmacy expenditure was US$109.67 and average pharmacy expenditure per day was US$20.62 per patient. Children who were ventilated had approximately 61 % more expense per day as compared to non-ventilated ones. Boys and those with health insurance reported higher length of stay. Linear hi...
Studies have suggested that human milk feeding decreases the incidence of retinopathy of prematur... more Studies have suggested that human milk feeding decreases the incidence of retinopathy of prematurity (ROP); however, conflicting results have been reported. The aim of this meta-analysis was to pool currently available data on incidence of ROP in infants fed human milk versus formula. Medline, PubMed, and EBSCO were searched for articles published through February 2015. Longitudinal studies comparing the incidence of ROP in infants who were fed human milk and formula were selected. Studies involving donor milk were not included. Two independent reviewers conducted the searches and extracted data. Meta-analysis used odds ratios (ORs), and subgroup analyses were performed. Five studies with 2208 preterm infants were included. Searches including various proportions of human milk versus formula, any-stage ROP, and severe ROP were defined to pool data for analyses. For any-stage ROP, the ORs (95% confidence intervals [CIs]) were as follows: exclusive human milk versus any formula, 0.29 (...
Over the last few decades, increased use of computers has resulted in higher work related musculo... more Over the last few decades, increased use of computers has resulted in higher work related musculoskeletal disorders (WRMSDs). Published systematic literature reviews (SLRs) have focused on physical aspects of preventive interventions and health promotion. The present systematic literature review aims to assess the clinical effectiveness and economic burden of injury prevention and health promotion wellness programs for professional computer users, in preventing WRMSDs using bio-psychosocial model of assessment and intervention.
In this report, an attempt towards developing comprehensive guidelines for health services for st... more In this report, an attempt towards developing comprehensive guidelines for health services for street children in Mumbai city has been made. Attempts were made to use approaches involving all the actors involved in the delivery of health services to the street child, i.e. public health facility staff, private care providers, NGOs, policy makers, and street children themselves. Review of government policies and programmes aimed at health and nutrition, labour, education, housing, protection, survival, etc, were also conducted. The report has been prepared by using results of both quantitative and qualitative surveys at community level. Attempts were also made to understand the issues of service providers in ensuring the reach of health services to the street children. Two workshops were held with various stakeholders (NGOs, Preventive & Social Medicine Department of Municipal Hospitals, Street Children and Medical Personnel) where the preliminary findings of the report were shared an...
The objective of the baseline survey was to gather information on demographic characteristics of ... more The objective of the baseline survey was to gather information on demographic characteristics of the surveyed blocks; costs associated with out-patient care, hospitalisation, and maternity; understand involuntary non-treatment in order to structure a Community-Based Health Insurance (CBHI) scheme in Rajnandgaon district of state of Chhattisgarh. Another objective of the study is to have baseline indicators for a before-and-after evaluation in comparison with endline study at the end of 18-months of project period.
This paper aims to quantify the extent to which an attribute affects the decision making process ... more This paper aims to quantify the extent to which an attribute affects the decision making process at both individual and group level for a community based health insurance (CBHI) scheme launched among tribal population of M Rampur block in Kalahandi district, Odisha. Other methods for measuring the willingness to pay (WTP) for CBHI focus on its numerical value, while discrete choice analysis quests the impact of each attribute affecting the WTP. Utility maximisation approach has been used under the assumption that individuals are rational and maximise their perceived utility from the alternative following socio-economic constraints, like income and education. Analysis has been performed using mixed logit modelling incorporating conditional as well as multinomial logit models because of the dependency of both the choice specific and the individualistic attributes of the choice maker on the decision making process. The results evaluate the numerical value for the trade-off which individuals face during plan selection among the alternatives’ features as well as the impact of income, awareness and other personal attributes on preferences. Results shows that even the illiterate and innumerate individuals are able to make a justified decision. This choice modelling provides a tool for CBHI schemes’ efficient designing, evaluation and fabrication.
The objective of the baseline survey was to gather information on morbidity; costs associated wit... more The objective of the baseline survey was to gather information on morbidity; costs associated with hospitalisation and out-patient care; and understand knowledge, attitude and practices of people with regard to malaria and maternal health in order to structure a Community-Based Health Insurance (CBHI) scheme in Kalahandi district of Orissa.
This paper reports on two voluntary, contributory, contextualised, community-based health
insura... more This paper reports on two voluntary, contributory, contextualised, community-based health
insurance (CBHI) schemes, launched in Dhading and Banke (Nepal) in 2011. The implementation
followed a four-stage process: initiating (baseline survey), involving (awareness generation and
engaging community in benefit-package-design), launch (enrolment and training of selected
community members) and post-launch (viable claims ratio, settled within satisfactory time, sustainable
affiliation). Both schemes were successful on four key parameters: effective planning;
affiliation (grew from 0 to ~10,000) and renewals (>65 per cent); claims ratio (~50 per cent); and
promptness of claim settlement (~23 days). This model succeeded in implementing CBHI with
zero premium subsidies or subsidised health-care costs. The successful operation relied in large
part on the fact that members trust that they can enforce this contract. Considerable insurance
education and capacity development is necessary before the launch of the CBHI, and for sustainable
operations as well as for scaling.
London: EPPI-Centre, Social Science Research Unit, Institute of Education, University of London, 2013
"The penetration of commercial or public contributory health insurance to the informal sector is ... more "The penetration of commercial or public contributory health insurance to the informal sector is very poor and the scaling of successful local interventions of Community-based health insurance (CBHI) seems to be one of the promising
approaches to remedy this situation. However, the existing information about the determinants of such success is lacking. There is no coherent understanding of an ideal way to implement and sustain such local efforts. Lately, there has been a
proliferation of thinking about the demand for insurance and medical care, and some attempts have been made to understand demand for voluntary health insurance like CBHI in low-income countries (ILO, 2002).There seems to be few literatures pertaining to the patterns of uptake of such insurance. Evidence on
determinants of enrolment with CBHI comes mostly from recent econometric modelling to predict influences of individual and household characteristics on enrolment decisions (Ito and Kono, 2010; Morsink and Geurts, 2011; Bonan et al., 2012). A few qualitative studies inform and complement studies on determinants of enrolment (Criel and Waelkens, 2003; De Allegri et al., 2006; Basaza et al., 2008), while others used mixed method approaches (Ozawa and Walker, 2009). The research question for the proposed systematic review is the identification of key parameters that determine the uptake of voluntary and community-based health insurance in low- and middle-income countries. Our review will also cover factors affecting re-enrolment in CBHI schemes. We will follow a search strategy,
using online databases related to thematic areas in the objective including social science, economics and medical science. We will search specific electronic databases which will be further supplemented by hand searching, citation tracking,
and personal communication including grey literature.
The determinants of CBHI uptake would be assessed using a broad evidence base (including both quantitative and qualitative). We plan on using the PROGRESS-Plus framework of Kavanagh et al. (2008) so as to interpret the data through an equity
lens viz. Place of Residence, Ethnicity, Occupation, Gender, Religion, Education, Social Capital (including peer experience with insurance, and specifically claims), Socio-economic position (SEP), Age, Disability, Sexual orientation, other vulnerable groups (e.g. disabled, HIV/AIDS, etc.). We will supplement this with topic-specific determinants such as previous exposure to insurance, having followed insurance education campaigns, and financial literacy in general (i.e. previous experience with microfinance in the broad sense – credit and savings). For all included studies
in addition to describing their study design, we will also assess their quality. We will assess the quality of included studies using checklist (Waddington et al., 2012), making judgments on the adequacy of reporting, data collection, presentation,
analysis and conclusions drawn. It is important to assess the methodological quality of individual studies (i.e. validity assessment) as it may affect both the results of the individual studies and ultimately the conclusions reached from the body of
studies. A success of this project is also linked to our ability to collecting the information that is scattered in many data sources, analysis of the data and translation of this analysis to a set of coherent general guidelines for successful implementation of
voluntary health insurance among the poor in low income countries. Through the identification of groups particularly within South and South East Asia that are working on CBHI as well as through the course of the review; We aim to emphasize
the creation of knowledge translation tools e.g. websites, policy briefs, newspapers, articles that can reach the end-line users such as policy-makers, donors and civil society organizations through conference presentations, policy briefs and contributing to the updating and maintenance of existing webpages. This would be enabled by an advisory group comprising of policy-makers, donors,
methodology expert and other researchers active in the area of initiatives for pro-poor insurance coverage in LMIC."
Although quality health facilities in Mumbai and Pune are plenty, slum dwellers do not benefit fu... more Although quality health facilities in Mumbai and Pune are plenty, slum dwellers do not benefit fully from these. Next to financial barriers, low quality treatment and discrimination form major hurdles to entering public care. A lot of them prefer to buy services from ill-qualified private providers. Without social protection in health (SPH), their predicament often boils down to the uneasy choice between forgoing treatment and risking impoverishment. Currently, some SPH interventions try to protect poor urbanites and increase their access to quality care. This article provides more insight into the health service encounter experienced by female slum dwellers. Using data from focus group discussions with members of three SPH interventions and in-depth interviews with providers, challenges faced by the women during their health seeking process are discussed. By using Bourdieu's theoretical concepts on field, capitals and habitus, this study shows that a more subtle reproduction of social inequities and domination in the medical field forces slum dwellers to either forgo treatment, buy ineffective care from private providers, or passively accept the abuse in the public sector. These insights demonstrate the need for transformative SPH interventions to address the power imbalances in society that create and sustain the social vulnerability of poor people when seeking health.
Objective
Access to healthcare is mostly contingent on out-of-pocket spending (OOPS) by health se... more Objective Access to healthcare is mostly contingent on out-of-pocket spending (OOPS) by health seekers, particularly in low- and middle-income countries (LMICs). This would require many LMICs to raise enough funds to achieve universal health insurance coverage. But, are individuals or households willing to pay for health insurance, and how much? What factors positively affect WTP for health insurance?We wanted to examine the evidence for this, through a review of the literature. Methods We systematically searched databases up to February 2016 and included studies of individual or household WTP for health insurance. Two authors appraised the identified studies. We estimated the WTP as a percentage of GDP per capita, and adjusted net national income per capita of each country. We used meta-analysis to calculate WTP means and confidence intervals, and vote-counting to identify the variables that more often affected WTP. Result 16 studies (21 articles) from ten countries met the inclusion criteria. The mean WTP of individuals was 1.18% of GDP per capita and 1.39% of adjusted net national income per capita. The corresponding figures for households were 1.82% and 2.16%, respectively. Increases in family size, education level and income were consistently correlated with higher WTP for insurance, and increases in age were correlated with reduced WTP. Conclusions The WTP for healthcare insurance among rural households in LMICs was just below 2% of the GPD per capita. The findings demonstrate that in moving towards universal health coverage in LMICs, governments should not rely on households' premiums as a major financing source and should increase their fiscal capacity for an equitable health care system using other sources
Background: Of the estimated 30 million construction workers in India 51% are women, however, the... more Background: Of the estimated 30 million construction workers in India 51% are women, however, there are no studies on pregnant women living on construction sites in the Indian population. Objective: The present study was conducted to collect information on health access and challenges of pregnant women living on construction sites in Mumbai, Navi Mumbai, and Thane. Material and Methods: Participants were pregnant women living on construction sites, and were recruited from 13 construction sites. A mixed methods study, using both quantitative survey and focus group discussions, was conducted to understand the usage of ANC, delivery, and PNC, and financing aspects to pregnancy-related healthcare utilization among these women. Results: In the survey, a total of 72 pregnant women were interviewed. The average age of respondents was found to be 22 years (±49SD). A total of 76% of these women had utilized the health facilities for their antenatal checkups (ANC) with majority (65%) utilizing private health facilities. Among women who had a delivery within last 2 years, borrowings from other family members and contractors, and use of current savings, was the most common form of financing of both ANC and delivery expenses. 16 women were found to be working at the time of data collection during their current pregnancy, and during the FGDs, it was mentioned that the women tend to work till seventh month of pregnancy. Conclusion: These findings underscore the need for considering various contextual factors in ensuring better living and maternal health access services for such women living on construction sites. Abstract International Journal of Medical Science and Public Health Online 2016.
To assess the direct costs involved in treatment of children receiving intensive care in a univer... more To assess the direct costs involved in treatment of children receiving intensive care in a university-affiliated teaching hospital and its associated implications on the children's families, in rural India. It was a prospective observational study for cost-analysis using questionnaire based interviews and billing records data collection for admissions to the PICU over 27 consecutive months (January 2010 through March 2012). A total of 784 children were admitted to the unit during the assessment period. Full details of 633 children were included for analysis. The average length of stay was 6.16 d, average hospital expenditure was US$185.67, average hospital expenses per day was US$44.00, average pharmacy expenditure was US$109.67 and average pharmacy expenditure per day was US$20.62 per patient. Children who were ventilated had approximately 61 % more expense per day as compared to non-ventilated ones. Boys and those with health insurance reported higher length of stay. Linear hi...
Studies have suggested that human milk feeding decreases the incidence of retinopathy of prematur... more Studies have suggested that human milk feeding decreases the incidence of retinopathy of prematurity (ROP); however, conflicting results have been reported. The aim of this meta-analysis was to pool currently available data on incidence of ROP in infants fed human milk versus formula. Medline, PubMed, and EBSCO were searched for articles published through February 2015. Longitudinal studies comparing the incidence of ROP in infants who were fed human milk and formula were selected. Studies involving donor milk were not included. Two independent reviewers conducted the searches and extracted data. Meta-analysis used odds ratios (ORs), and subgroup analyses were performed. Five studies with 2208 preterm infants were included. Searches including various proportions of human milk versus formula, any-stage ROP, and severe ROP were defined to pool data for analyses. For any-stage ROP, the ORs (95% confidence intervals [CIs]) were as follows: exclusive human milk versus any formula, 0.29 (...
Over the last few decades, increased use of computers has resulted in higher work related musculo... more Over the last few decades, increased use of computers has resulted in higher work related musculoskeletal disorders (WRMSDs). Published systematic literature reviews (SLRs) have focused on physical aspects of preventive interventions and health promotion. The present systematic literature review aims to assess the clinical effectiveness and economic burden of injury prevention and health promotion wellness programs for professional computer users, in preventing WRMSDs using bio-psychosocial model of assessment and intervention.
In this report, an attempt towards developing comprehensive guidelines for health services for st... more In this report, an attempt towards developing comprehensive guidelines for health services for street children in Mumbai city has been made. Attempts were made to use approaches involving all the actors involved in the delivery of health services to the street child, i.e. public health facility staff, private care providers, NGOs, policy makers, and street children themselves. Review of government policies and programmes aimed at health and nutrition, labour, education, housing, protection, survival, etc, were also conducted. The report has been prepared by using results of both quantitative and qualitative surveys at community level. Attempts were also made to understand the issues of service providers in ensuring the reach of health services to the street children. Two workshops were held with various stakeholders (NGOs, Preventive & Social Medicine Department of Municipal Hospitals, Street Children and Medical Personnel) where the preliminary findings of the report were shared an...
The objective of the baseline survey was to gather information on demographic characteristics of ... more The objective of the baseline survey was to gather information on demographic characteristics of the surveyed blocks; costs associated with out-patient care, hospitalisation, and maternity; understand involuntary non-treatment in order to structure a Community-Based Health Insurance (CBHI) scheme in Rajnandgaon district of state of Chhattisgarh. Another objective of the study is to have baseline indicators for a before-and-after evaluation in comparison with endline study at the end of 18-months of project period.
This paper aims to quantify the extent to which an attribute affects the decision making process ... more This paper aims to quantify the extent to which an attribute affects the decision making process at both individual and group level for a community based health insurance (CBHI) scheme launched among tribal population of M Rampur block in Kalahandi district, Odisha. Other methods for measuring the willingness to pay (WTP) for CBHI focus on its numerical value, while discrete choice analysis quests the impact of each attribute affecting the WTP. Utility maximisation approach has been used under the assumption that individuals are rational and maximise their perceived utility from the alternative following socio-economic constraints, like income and education. Analysis has been performed using mixed logit modelling incorporating conditional as well as multinomial logit models because of the dependency of both the choice specific and the individualistic attributes of the choice maker on the decision making process. The results evaluate the numerical value for the trade-off which individuals face during plan selection among the alternatives’ features as well as the impact of income, awareness and other personal attributes on preferences. Results shows that even the illiterate and innumerate individuals are able to make a justified decision. This choice modelling provides a tool for CBHI schemes’ efficient designing, evaluation and fabrication.
The objective of the baseline survey was to gather information on morbidity; costs associated wit... more The objective of the baseline survey was to gather information on morbidity; costs associated with hospitalisation and out-patient care; and understand knowledge, attitude and practices of people with regard to malaria and maternal health in order to structure a Community-Based Health Insurance (CBHI) scheme in Kalahandi district of Orissa.
This paper reports on two voluntary, contributory, contextualised, community-based health
insura... more This paper reports on two voluntary, contributory, contextualised, community-based health
insurance (CBHI) schemes, launched in Dhading and Banke (Nepal) in 2011. The implementation
followed a four-stage process: initiating (baseline survey), involving (awareness generation and
engaging community in benefit-package-design), launch (enrolment and training of selected
community members) and post-launch (viable claims ratio, settled within satisfactory time, sustainable
affiliation). Both schemes were successful on four key parameters: effective planning;
affiliation (grew from 0 to ~10,000) and renewals (>65 per cent); claims ratio (~50 per cent); and
promptness of claim settlement (~23 days). This model succeeded in implementing CBHI with
zero premium subsidies or subsidised health-care costs. The successful operation relied in large
part on the fact that members trust that they can enforce this contract. Considerable insurance
education and capacity development is necessary before the launch of the CBHI, and for sustainable
operations as well as for scaling.
London: EPPI-Centre, Social Science Research Unit, Institute of Education, University of London, 2013
"The penetration of commercial or public contributory health insurance to the informal sector is ... more "The penetration of commercial or public contributory health insurance to the informal sector is very poor and the scaling of successful local interventions of Community-based health insurance (CBHI) seems to be one of the promising
approaches to remedy this situation. However, the existing information about the determinants of such success is lacking. There is no coherent understanding of an ideal way to implement and sustain such local efforts. Lately, there has been a
proliferation of thinking about the demand for insurance and medical care, and some attempts have been made to understand demand for voluntary health insurance like CBHI in low-income countries (ILO, 2002).There seems to be few literatures pertaining to the patterns of uptake of such insurance. Evidence on
determinants of enrolment with CBHI comes mostly from recent econometric modelling to predict influences of individual and household characteristics on enrolment decisions (Ito and Kono, 2010; Morsink and Geurts, 2011; Bonan et al., 2012). A few qualitative studies inform and complement studies on determinants of enrolment (Criel and Waelkens, 2003; De Allegri et al., 2006; Basaza et al., 2008), while others used mixed method approaches (Ozawa and Walker, 2009). The research question for the proposed systematic review is the identification of key parameters that determine the uptake of voluntary and community-based health insurance in low- and middle-income countries. Our review will also cover factors affecting re-enrolment in CBHI schemes. We will follow a search strategy,
using online databases related to thematic areas in the objective including social science, economics and medical science. We will search specific electronic databases which will be further supplemented by hand searching, citation tracking,
and personal communication including grey literature.
The determinants of CBHI uptake would be assessed using a broad evidence base (including both quantitative and qualitative). We plan on using the PROGRESS-Plus framework of Kavanagh et al. (2008) so as to interpret the data through an equity
lens viz. Place of Residence, Ethnicity, Occupation, Gender, Religion, Education, Social Capital (including peer experience with insurance, and specifically claims), Socio-economic position (SEP), Age, Disability, Sexual orientation, other vulnerable groups (e.g. disabled, HIV/AIDS, etc.). We will supplement this with topic-specific determinants such as previous exposure to insurance, having followed insurance education campaigns, and financial literacy in general (i.e. previous experience with microfinance in the broad sense – credit and savings). For all included studies
in addition to describing their study design, we will also assess their quality. We will assess the quality of included studies using checklist (Waddington et al., 2012), making judgments on the adequacy of reporting, data collection, presentation,
analysis and conclusions drawn. It is important to assess the methodological quality of individual studies (i.e. validity assessment) as it may affect both the results of the individual studies and ultimately the conclusions reached from the body of
studies. A success of this project is also linked to our ability to collecting the information that is scattered in many data sources, analysis of the data and translation of this analysis to a set of coherent general guidelines for successful implementation of
voluntary health insurance among the poor in low income countries. Through the identification of groups particularly within South and South East Asia that are working on CBHI as well as through the course of the review; We aim to emphasize
the creation of knowledge translation tools e.g. websites, policy briefs, newspapers, articles that can reach the end-line users such as policy-makers, donors and civil society organizations through conference presentations, policy briefs and contributing to the updating and maintenance of existing webpages. This would be enabled by an advisory group comprising of policy-makers, donors,
methodology expert and other researchers active in the area of initiatives for pro-poor insurance coverage in LMIC."
Although quality health facilities in Mumbai and Pune are plenty, slum dwellers do not benefit fu... more Although quality health facilities in Mumbai and Pune are plenty, slum dwellers do not benefit fully from these. Next to financial barriers, low quality treatment and discrimination form major hurdles to entering public care. A lot of them prefer to buy services from ill-qualified private providers. Without social protection in health (SPH), their predicament often boils down to the uneasy choice between forgoing treatment and risking impoverishment. Currently, some SPH interventions try to protect poor urbanites and increase their access to quality care. This article provides more insight into the health service encounter experienced by female slum dwellers. Using data from focus group discussions with members of three SPH interventions and in-depth interviews with providers, challenges faced by the women during their health seeking process are discussed. By using Bourdieu's theoretical concepts on field, capitals and habitus, this study shows that a more subtle reproduction of social inequities and domination in the medical field forces slum dwellers to either forgo treatment, buy ineffective care from private providers, or passively accept the abuse in the public sector. These insights demonstrate the need for transformative SPH interventions to address the power imbalances in society that create and sustain the social vulnerability of poor people when seeking health.
Uploads
Access to healthcare is mostly contingent on out-of-pocket spending (OOPS) by health seekers, particularly in low- and middle-income countries (LMICs). This would require many LMICs to raise enough funds to achieve universal health insurance coverage. But, are individuals or households willing to pay for health insurance, and how much? What factors positively affect WTP for health insurance?We wanted to examine the evidence for this, through a review of the literature.
Methods
We systematically searched databases up to February 2016 and included studies of individual or household WTP for health insurance. Two authors appraised the identified studies. We estimated the WTP as a percentage of GDP per capita, and adjusted net national income per
capita of each country. We used meta-analysis to calculate WTP means and confidence intervals, and vote-counting to identify the variables that more often affected WTP.
Result
16 studies (21 articles) from ten countries met the inclusion criteria. The mean WTP of individuals was 1.18% of GDP per capita and 1.39% of adjusted net national income per capita. The corresponding figures for households were 1.82% and 2.16%, respectively. Increases in family size, education level and income were consistently correlated with higher WTP for insurance, and increases in age were correlated with reduced WTP.
Conclusions
The WTP for healthcare insurance among rural households in LMICs was just below 2% of the GPD per capita. The findings demonstrate that in moving towards universal health coverage in LMICs, governments should not rely on households' premiums as a major financing source and should increase their fiscal capacity for an equitable health care system using other sources
insurance (CBHI) schemes, launched in Dhading and Banke (Nepal) in 2011. The implementation
followed a four-stage process: initiating (baseline survey), involving (awareness generation and
engaging community in benefit-package-design), launch (enrolment and training of selected
community members) and post-launch (viable claims ratio, settled within satisfactory time, sustainable
affiliation). Both schemes were successful on four key parameters: effective planning;
affiliation (grew from 0 to ~10,000) and renewals (>65 per cent); claims ratio (~50 per cent); and
promptness of claim settlement (~23 days). This model succeeded in implementing CBHI with
zero premium subsidies or subsidised health-care costs. The successful operation relied in large
part on the fact that members trust that they can enforce this contract. Considerable insurance
education and capacity development is necessary before the launch of the CBHI, and for sustainable
operations as well as for scaling.
approaches to remedy this situation. However, the existing information about the determinants of such success is lacking. There is no coherent understanding of an ideal way to implement and sustain such local efforts. Lately, there has been a
proliferation of thinking about the demand for insurance and medical care, and some attempts have been made to understand demand for voluntary health insurance like CBHI in low-income countries (ILO, 2002).There seems to be few literatures pertaining to the patterns of uptake of such insurance. Evidence on
determinants of enrolment with CBHI comes mostly from recent econometric modelling to predict influences of individual and household characteristics on enrolment decisions (Ito and Kono, 2010; Morsink and Geurts, 2011; Bonan et al., 2012). A few qualitative studies inform and complement studies on determinants of enrolment (Criel and Waelkens, 2003; De Allegri et al., 2006; Basaza et al., 2008), while others used mixed method approaches (Ozawa and Walker, 2009). The research question for the proposed systematic review is the identification of key parameters that determine the uptake of voluntary and community-based health insurance in low- and middle-income countries. Our review will also cover factors affecting re-enrolment in CBHI schemes. We will follow a search strategy,
using online databases related to thematic areas in the objective including social science, economics and medical science. We will search specific electronic databases which will be further supplemented by hand searching, citation tracking,
and personal communication including grey literature.
The determinants of CBHI uptake would be assessed using a broad evidence base (including both quantitative and qualitative). We plan on using the PROGRESS-Plus framework of Kavanagh et al. (2008) so as to interpret the data through an equity
lens viz. Place of Residence, Ethnicity, Occupation, Gender, Religion, Education, Social Capital (including peer experience with insurance, and specifically claims), Socio-economic position (SEP), Age, Disability, Sexual orientation, other vulnerable groups (e.g. disabled, HIV/AIDS, etc.). We will supplement this with topic-specific determinants such as previous exposure to insurance, having followed insurance education campaigns, and financial literacy in general (i.e. previous experience with microfinance in the broad sense – credit and savings). For all included studies
in addition to describing their study design, we will also assess their quality. We will assess the quality of included studies using checklist (Waddington et al., 2012), making judgments on the adequacy of reporting, data collection, presentation,
analysis and conclusions drawn. It is important to assess the methodological quality of individual studies (i.e. validity assessment) as it may affect both the results of the individual studies and ultimately the conclusions reached from the body of
studies. A success of this project is also linked to our ability to collecting the information that is scattered in many data sources, analysis of the data and translation of this analysis to a set of coherent general guidelines for successful implementation of
voluntary health insurance among the poor in low income countries. Through the identification of groups particularly within South and South East Asia that are working on CBHI as well as through the course of the review; We aim to emphasize
the creation of knowledge translation tools e.g. websites, policy briefs, newspapers, articles that can reach the end-line users such as policy-makers, donors and civil society organizations through conference presentations, policy briefs and contributing to the updating and maintenance of existing webpages. This would be enabled by an advisory group comprising of policy-makers, donors,
methodology expert and other researchers active in the area of initiatives for pro-poor insurance coverage in LMIC."
Access to healthcare is mostly contingent on out-of-pocket spending (OOPS) by health seekers, particularly in low- and middle-income countries (LMICs). This would require many LMICs to raise enough funds to achieve universal health insurance coverage. But, are individuals or households willing to pay for health insurance, and how much? What factors positively affect WTP for health insurance?We wanted to examine the evidence for this, through a review of the literature.
Methods
We systematically searched databases up to February 2016 and included studies of individual or household WTP for health insurance. Two authors appraised the identified studies. We estimated the WTP as a percentage of GDP per capita, and adjusted net national income per
capita of each country. We used meta-analysis to calculate WTP means and confidence intervals, and vote-counting to identify the variables that more often affected WTP.
Result
16 studies (21 articles) from ten countries met the inclusion criteria. The mean WTP of individuals was 1.18% of GDP per capita and 1.39% of adjusted net national income per capita. The corresponding figures for households were 1.82% and 2.16%, respectively. Increases in family size, education level and income were consistently correlated with higher WTP for insurance, and increases in age were correlated with reduced WTP.
Conclusions
The WTP for healthcare insurance among rural households in LMICs was just below 2% of the GPD per capita. The findings demonstrate that in moving towards universal health coverage in LMICs, governments should not rely on households' premiums as a major financing source and should increase their fiscal capacity for an equitable health care system using other sources
insurance (CBHI) schemes, launched in Dhading and Banke (Nepal) in 2011. The implementation
followed a four-stage process: initiating (baseline survey), involving (awareness generation and
engaging community in benefit-package-design), launch (enrolment and training of selected
community members) and post-launch (viable claims ratio, settled within satisfactory time, sustainable
affiliation). Both schemes were successful on four key parameters: effective planning;
affiliation (grew from 0 to ~10,000) and renewals (>65 per cent); claims ratio (~50 per cent); and
promptness of claim settlement (~23 days). This model succeeded in implementing CBHI with
zero premium subsidies or subsidised health-care costs. The successful operation relied in large
part on the fact that members trust that they can enforce this contract. Considerable insurance
education and capacity development is necessary before the launch of the CBHI, and for sustainable
operations as well as for scaling.
approaches to remedy this situation. However, the existing information about the determinants of such success is lacking. There is no coherent understanding of an ideal way to implement and sustain such local efforts. Lately, there has been a
proliferation of thinking about the demand for insurance and medical care, and some attempts have been made to understand demand for voluntary health insurance like CBHI in low-income countries (ILO, 2002).There seems to be few literatures pertaining to the patterns of uptake of such insurance. Evidence on
determinants of enrolment with CBHI comes mostly from recent econometric modelling to predict influences of individual and household characteristics on enrolment decisions (Ito and Kono, 2010; Morsink and Geurts, 2011; Bonan et al., 2012). A few qualitative studies inform and complement studies on determinants of enrolment (Criel and Waelkens, 2003; De Allegri et al., 2006; Basaza et al., 2008), while others used mixed method approaches (Ozawa and Walker, 2009). The research question for the proposed systematic review is the identification of key parameters that determine the uptake of voluntary and community-based health insurance in low- and middle-income countries. Our review will also cover factors affecting re-enrolment in CBHI schemes. We will follow a search strategy,
using online databases related to thematic areas in the objective including social science, economics and medical science. We will search specific electronic databases which will be further supplemented by hand searching, citation tracking,
and personal communication including grey literature.
The determinants of CBHI uptake would be assessed using a broad evidence base (including both quantitative and qualitative). We plan on using the PROGRESS-Plus framework of Kavanagh et al. (2008) so as to interpret the data through an equity
lens viz. Place of Residence, Ethnicity, Occupation, Gender, Religion, Education, Social Capital (including peer experience with insurance, and specifically claims), Socio-economic position (SEP), Age, Disability, Sexual orientation, other vulnerable groups (e.g. disabled, HIV/AIDS, etc.). We will supplement this with topic-specific determinants such as previous exposure to insurance, having followed insurance education campaigns, and financial literacy in general (i.e. previous experience with microfinance in the broad sense – credit and savings). For all included studies
in addition to describing their study design, we will also assess their quality. We will assess the quality of included studies using checklist (Waddington et al., 2012), making judgments on the adequacy of reporting, data collection, presentation,
analysis and conclusions drawn. It is important to assess the methodological quality of individual studies (i.e. validity assessment) as it may affect both the results of the individual studies and ultimately the conclusions reached from the body of
studies. A success of this project is also linked to our ability to collecting the information that is scattered in many data sources, analysis of the data and translation of this analysis to a set of coherent general guidelines for successful implementation of
voluntary health insurance among the poor in low income countries. Through the identification of groups particularly within South and South East Asia that are working on CBHI as well as through the course of the review; We aim to emphasize
the creation of knowledge translation tools e.g. websites, policy briefs, newspapers, articles that can reach the end-line users such as policy-makers, donors and civil society organizations through conference presentations, policy briefs and contributing to the updating and maintenance of existing webpages. This would be enabled by an advisory group comprising of policy-makers, donors,
methodology expert and other researchers active in the area of initiatives for pro-poor insurance coverage in LMIC."