Abstract
Out-of-pocket payments for health care services lead to decreased use of health services and catastrophic health expenditures. To reduce out-of-pocket payments and improve access to health care services, some countries have introduced community-based health insurance (CBHI) schemes, especially for those in rural communities or who work in the informal sector. However, there has been little focus on equity in access to health care services in CBHI schemes. We searched PubMed, Web of Science, African Journals OnLine, and Africa-Wide Information for studies published in English between 2000 and August 2014 that examined the effect of socioeconomic status on willingness to join and pay for CBHI, actual enrollment, use of health care services, and drop-out from CBHI. Our search yielded 755 articles. After excluding duplicates and articles that did not meet our inclusion criteria (conducted in low- and middle-income countries and involved analysis based on socioeconomic status), 49 articles remained that were included in this review. Data were extracted by one author, and the second author reviewed the extracted data. Disagreements were mutually resolved between the 2 authors. The findings of the studies were analyzed to identify their similarities and differences and to identify any methodological differences that could account for contradictory findings. Generally, the rich were more willing to pay for CBHI than the poor and actual enrollment in CBHI was directly associated with socioeconomic status. Enrollment in CBHI was price-elastic-as premiums decreased, enrollment increased. There were mixed results on the effect of socioeconomic status on use of health care services among those enrolled in CBHI. We found a high drop-out rate from CBHI schemes that was not related to socioeconomic status, although the most common reason for dropping out of CBHI was lack of money to pay the premium. The effectiveness of CBHI schemes in achieving universal health coverage in low- and middle-income countries is questionable. A flexible payment plan where the poor can pay in installments, subsidized premiums for the poor, and removal of co-pays are measures that can increase enrollment and use of CBHI by the poor.
Highlights
Global Health: Science and Practice 2017 | Volume 5 | Number 2 most likely to be ill and less able to afford to pay for health care.[4,5] To ensure that the poor have access to health care when they need it and that they are protected from catastrophic health expenses, health systems need to be financed by either tax or prepayment schemes.[1,3] The prepayment scheme should lead to a large risk pool and enough money in the health system to cross-subsidize the sick and the poor
The full text of the remaining 77 articles were evaluated in more detail, of which 34 were excluded because they did not include analysis based on socioeconomic status
A more recent survey in southwest Ethiopia in 2013 showed that households in the highest wealth quintile were more than 4 times more willing to join the community-based health insurance (CBHI) compared with households in the second wealth quintile.[29]
Summary
Global Health: Science and Practice 2017 | Volume 5 | Number 2 most likely to be ill and less able to afford to pay for health care.[4,5] To ensure that the poor have access to health care when they need it and that they are protected from catastrophic health expenses, health systems need to be financed by either tax or prepayment schemes.[1,3] The prepayment scheme should lead to a large risk pool and enough money in the health system to cross-subsidize the sick and the poor. While health insurance schemes are the norm in high-income countries, the story is different in low-income countries.[1,3]. There is a push to encourage countries to provide access to basic health care for all their citizens through prepayment or tax schemes. Out-of-pocket payments for health care services lead to decreased use of health services and catastrophic health expenditures. To reduce out-of-pocket payments and improve access to health care services, some countries have introduced community-based health insurance (CBHI) schemes, especially for those in rural communities or who work in the informal sector. There has been little focus on equity in access to health care services in CBHI schemes
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