Abstract
Community-based Health Insurance (CBHI) schemes are recommended for providing financial risk protection to low-income informal workers in Bangladesh. We assessed the problem of adverse selection in a pilot CBHI scheme in this context. In total, 1292 (646 insured and 646 uninsured) respondents were surveyed using the Bengali version of the EuroQuol-5 dimensions (EQ-5D) questionnaire for assessing their health status. The EQ-5D scores were estimated using available regional tariffs. Multiple logistic regression was applied for predicting the association between health status and CBHI scheme enrolment. A higher number of insured reported problems in mobility (7.3%; p = 0.002); self-care (7.1%; p = 0.000) and pain and discomfort (7.7%; p = 0.005) than uninsured. The average EQ-5D score was significantly lower among the insured (0.704) compared to the uninsured (0.749). The regression analysis showed that those who had a problem in mobility (OR = 1.65; 95% CI: 1.25–2.17); self-care (OR = 2.29; 95% CI: 1.62–3.25) and pain and discomfort (OR = 1.43; 95% CI: 1.13–1.81) were more likely to join the scheme. Individuals with higher EQ-5D scores (OR = 0.46; 95% CI: 0.31–0.69) were less likely to enroll in the scheme. Given that adverse selection was evident in the pilot CBHI scheme, there should be consideration of this problem when planning scale-up of these kind of schemes.
Highlights
Out-of-pocket (OOP) healthcare payment is the predominant financing mechanism in many low- and middle-income countries (LMICs) [1]
When adjusting for confounding factors with multiple regression models, we found that the individuals with higher EuroQuol-5 dimensions (EQ-5D) scores were about half as likely to enroll in Community-based Health Insurance (CBHI) scheme
Our findings were similar to a previous study conducted in China, which found the presence of adverse selection in the Rural Mutual Health Care scheme [14]
Summary
Out-of-pocket (OOP) healthcare payment is the predominant financing mechanism in many low- and middle-income countries (LMICs) [1]. It is a source of 48% of total healthcare expenditure in low-income countries [2]. This high reliance on OOP healthcare payment results in catastrophic healthcare expenditure and impoverishment in LMICs [2]. The World Health Organization suggested increasing dependency on innovative prepayment healthcare financing mechanisms with the provision of risk pooling for mitigating this problem [3]. Res. Public Health 2018, 15, 242; doi:10.3390/ijerph15020242 www.mdpi.com/journal/ijerph
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