Hengjin Dong

Drop-out analysis of community-based health insurance membership at Nouna, Burkina Faso

OBJECTIVES This study aims to identify the reasons why enrolled people decide not to renew their membership in following years. METHODS Household survey is used to collect information on the factors influencing dropping out from community-based health insurance (CBI). Information from CBI agency databank is used to describe the general situation of enrolment and drop-out. RESULTS Since the launch of CBI the enrolment rate has been low ranging from 5.2% to 6.3%. The drop-out rate, however, has been high ranging from 30.9% to 45.7%. It is found, by the multivariate analysis, that female household head, higher age or lower education of a household head, lower number of illness episodes in the past three months, fewer children or elderly in a household, poor perceived health care quality, less seeking care in the past month positively effected on drop-out, increasing the rate. However, the household six-month expenditure and the distance to the contracted health facility did not have the hypothesised sign. In contrast, a higher household expenditure and a shorter distance to the contracted health facility increased the drop-out. CONCLUSIONS High drop-out rates endanger the sustainability of CBI not only because they reduce the size of the insurance pool, but also because they bear a negative impact on further enrolment and drop-out. The drop-out rate in the scheme of the Nouna Health District, Burkina Faso, is very high. The reasons for drop-out may be related to affordability, health-needs and health demand, quality of care, household head and household characteristics. This study represents a valuable attempt towards further increasing the sustainability of CBI schemes, by understanding not what motivates people to first enrol in CBI, but what motivates them to renew membership year after year.

The effect of community-based health insurance on the utilization of modern health care services: evidence from Burkina Faso.

OBJECTIVE To quantify the impact of community-based health insurance (CBI) on utilization of health care services in rural Burkina Faso. METHODS Propensity score matching was used to minimise the observed baseline differences in the characteristics of insured and uninsured groups such that the observed difference in healthcare utilisation could generally be attributed to the CBI. RESULTS Compared with those who were not enrolled in the CBI, the overall increase in outpatient visits given illness in the insured group was about 40% higher, while the differential effect on utilization of inpatient care between insured and non-insured groups was insignificant. Not only were the very poor less likely to enroll in CBI, but even once insured, they were less likely to utilize health services compared to their wealthier counterparts. CONCLUSIONS The overall effect of CBI on health care utilization is significant and positive but the benefit of CBI is not equally enjoyed by all socioeconomic groups. The policy implications are: (a) there is a need to subsidize the premium to favor the enrolment of the very poor; and (b) various measures need to be placed in order to maximize the populations capacity to enjoy the benefits of insurance once insured.

Step-wedge cluster-randomised community-based trials: An application to the study of the impact of community health insurance

BackgroundWe describe a step-wedge cluster-randomised community-based trial which has been conducted since 2003 to accompany the implementation of a community health insurance (CHI) scheme in West Africa. The trial aims at overcoming the paucity of evidence-based information on the impact of CHI. Impact is defined in terms of changes in health service utilisation and household protection against the cost of illness. Our exclusive focus on the description and discussion of the methods is justified by the fact that the study relies on a methodology previously applied in the field of disease control, but never in the field of health financing.MethodsFirst, we clarify how clusters were defined both in respect of statistical considerations and of local geographical and socio-cultural concerns. Second, we illustrate how households within clusters were sampled. Third, we expound the data collection process and the survey instruments. Finally, we outline the statistical tools to be applied to estimate the impact of CHI.ConclusionWe discuss all design choices both in relation to methodological considerations and to specific ethical and organisational concerns faced in the field. On the basis of the appraisal of our experience, we postulate that conducting relatively sophisticated trials (such as our step-wedge cluster-randomised community-based trial) aimed at generating sound public health evidence, is both feasible and valuable also in low income settings. Our work shows that if accurately designed in conjunction with local health authorities, such trials have the potential to generate sound scientific evidence and do not hinder, but at times even facilitate, the implementation of complex health interventions such as CHI.

The two faces of enhancing utilization of health-care services: determinants of patient initiation and retention in rural Burkina Faso.

OBJECTIVE To explore the factors that determine whether a patient will initiate treatment within a system of health-care services, and the factors that determine whether the patient will be retained in the chosen system, in Nouna, rural Burkina Faso. METHODS The data used were pooled from four rounds of a household survey conducted in Nouna, rural Burkina Faso. The ongoing demographic surveillance system provided a sampling framework for this survey in which 800 households were sampled using a two-stage cluster sampling procedure. More than one treatment episode was observed for a single episode of illness per patient. The multinomial logit model was used to explore the determinants of patient initiation to systems of modern, traditional and home treatment, and a binary logit model was used to explore the determinants of patient retention within the chosen health-care provider system. FINDINGS The results suggest that the determinants of patient initiation and their subsequent retention are different. Household income, education, urban residence and expected competency of the provider are positive predictors of initiation, but not of retention, for modern health-care services. Only perceived quality of care positively predicted retention in modern health-care services. CONCLUSION Interventions focusing on patient initiation and patient retention are likely to be different. Policies directed at enhancing initiation for modern health-care services would primarily focus on reducing financial barriers, while those directed at increasing retention would primarily focus on attributes that improve the perceived quality of care.

A comparison of the reliability of the take-it-or-leave-it and the bidding game approaches to estimating willingness-to-pay in a rural population in West Africa

The test-retest reliability of the bidding game and the take-it-or-leave-it (TIOLI) approaches to eliciting willingness-to-pay (WTP) are compared. A random sample of households in the Nouna area of Burkina Faso were interviewed twice with an interval of around 4-5 weeks. One thousand one hundred and eight individuals were asked their individual WTP for community-based health insurance. Three hundred and forty eight of these individuals were household heads who were in addition asked about their WTP for health insurance for the whole household. Median and the mean WTP were higher in the test than in the retest. Despite these differences both methods displayed moderate to good reliability (kappa values ranged from 0.467 to 0.621, Spearman correlations ranged from 0.653 to 0.701 and Pearson correlations ranged from 0.593 to 0.675). There was some evidence that the bidding game was more reliable than the TIOLI method. This study is based on larger sample size than previous studies and also is one of the first studies of the reliability of WTP in a developing country.

The differences in characteristics between health-care users and non-users: implication for introducing community-based health insurance in Burkina Faso

The purposes of this study are to describe the characteristics of different health-care users, to explain such characteristics using a health demand model and to estimate the price-related probability change for different types of health care in order to provide policy guidance for the introduction of community-based health insurance (CBI) in Burkina Faso. Data were collected from a household survey using a two stage cluster sampling approach. Household interviews were carried out during April and May 2003. In the interviewed 7,939 individuals in 988 households, there were 558 people reported one or more illness episodes; two-thirds of these people did not seek professional care. Health care non-users display lower household income and expenditure, older age and lower perceived severity of disease. The main reason for choosing no-care and self-care was ‘not enough money’. Multinomial logistic regression confirms these observations. Higher household cash-income, higher perceived severity of disease and acute disease significantly increased the probability of using western care. Older age and higher price-cash income ratio significantly increased the probability of no-care or self-care. If CBI were introduced the probability of using western care would increase by 4.33% and the probability of using self-care would reduce by 3.98%. The price-related probability change of using western care for lower income people is higher than for higher income although the quantity changed is relatively small. In conclusion, the introduction of CBI might increase the use of medical services, especially for the poor. Co-payment for the rich might be necessary. Premium adjusted for income or subsidies for the poor can be considered in order to absorb a greater number of poor households into CBI and further improve equity in terms of enrolment. However, the role of CBI in Burkina Faso is rather limited: it might only increase utilisation of western health care by a probability of 4%.

Using community wealth ranking to identify the poor for subsidies: a case study of community-based health insurance in Nouna, Burkina Faso.

Access to health-care is low in developing countries. Poor people are less likely to seek care than those who are better off. Community-based health insurance (CBI) aims to improve healthcare utilisation by removing financial barriers, unfortunately CBI has been less effective in securing equity than expected. Poor people, who probably require greater protection from catastrophic health expenses, are less likely to enrol in such schemes. Therefore, it is important to implement targeted interventions so that the most in need are not left out. CBI has been offered to a district in Burkina Faso, comprising 7762 households in 41 villages and the district capital of Nouna since 2004. Community wealth ranking (CWR) was used in 2007 to identify the poorest quintile of households who were subsequently offered insurance at half the usual premium rate. The CWR is easy to implement and requires minimal resources such as interviews with local informants. As used in this study, the agreement between the key informants was more (37.5%) in the villages than in Nouna town (27.3%). CBI management unit only received nine complaints from villagers who considered that some households had been wrongly identified. Among the poorest, the annual enrolment increased from 18 households (1.1%) in 2006 to 186 (11.1%) in 2007 after subsidies. CWR is an alternative methodology to identify poor households and was found to be more cost and time efficient compared to other methods. It could be successfully replicated in low-income countries with similar contexts. Moreover, targeted subsidies had a positive impact on enrolment.

Willingness to pay for hypothetical malaria vaccines in rural Burkina Faso.

Aims: This study aims to set priorities for anti-disease malaria vaccines by determining community preference in a hyperendemic area. Methods: A bidding game technique was used to elucidate willingness to pay in rural Burkina Faso and 2,326 adults were interviewed. Results: It is shown that there are significant differences between community preference for an anti-disease vaccine aimed at reducing pathology in pregnant women, and for a vaccine directed against childhood malaria. While the target population was willing to pay CFAfr 2101 for a vaccine against maternal malaria, its members were prepared to pay only CFAfr 1433 for a vaccine against childhood malaria. Conclusions: Whilst it is increasingly likely that anti-disease malaria vaccines will become available in the foreseeable future, lessons from the past suggest that a lack of acceptance and support from the intended recipients may lead to less than optimal compliance, and hence efficacy. For the planning of vaccine development and application strategies, it is therefore highly important to take community views into account. Here it is argued that such information could help researchers and funding agencies to set priorities for future vaccine research.

Efficiency of antenatal care and childbirth services in selected primary health care facilities in rural Tanzania: a cross-sectional study

BackgroundCost studies are paramount for demonstrating how resources have been spent and identifying opportunities for more efficient use of resources. The main objective of this study was to assess the actual dimension and distribution of the costs of providing antenatal care (ANC) and childbirth services in selected rural primary health care facilities in Tanzania. In addition, the study analyzed determining factors of service provision efficiency in order to inform health policy and planning.MethodsThis was a retrospective quantitative cross-sectional study conducted in 11 health centers and dispensaries in Lindi and Mtwara rural districts. Cost analysis was carried out using step down cost accounting technique. Unit costs reflected efficiency of service provision. Multivariate regression analysis on the drivers of observed relative efficiency in service provision between the study facilities was conducted. Reported personnel workload was also described.ResultsThe health facilities spent on average 7 USD per capita in 2009. As expected, fewer resources were spent for service provision at dispensaries than at health centers. Personnel costs contributed a high approximate 44% to total costs. ANC and childbirth consumed approximately 11% and 12% of total costs; and 8% and 10% of reported service provision time respectively. On average, unit costs were rather high, 16 USD per ANC visit and 79.4 USD per childbirth. The unit costs showed variation in relative efficiency in providing the services between the health facilities. The results showed that efficiency in ANC depended on the number of staff, structural quality of care, process quality of care and perceived quality of care. Population-staff ratio and structural quality of basic emergency obstetric care services highly influenced childbirth efficiency.ConclusionsDifferences in the efficiency of service provision present an opportunity for efficiency improvement. Taking into consideration client heterogeneity, quality improvements are possible and necessary. This will stimulate utilization of ANC and childbirth services in resource-constrained health facilities. Efficiency analyses through simple techniques such as measurement of unit costs should be made standard in health care provision, health managers can then use the performance results to gauge progress and reward efficiency through performance based incentives.

ISS-An Electronic Syndromic Surveillance System for Infectious Disease in Rural China

Background syndromic surveillance system has great advantages in promoting the early detection of epidemics and reducing the necessities of disease confirmation, and it is especially effective for surveillance in resource poor settings. However, most current syndromic surveillance systems are established in developed countries, and there are very few reports on the development of an electronic syndromic surveillance system in resource-constrained settings. Objective this study describes the design and pilot implementation of an electronic surveillance system (ISS) for the early detection of infectious disease epidemics in rural China, complementing the conventional case report surveillance system. Methods ISS was developed based on an existing platform ‘Crisis Information Sharing Platform’ (CRISP), combining with modern communication and GIS technology. ISS has four interconnected functions: 1) work group and communication group; 2) data source and collection; 3) data visualization; and 4) outbreak detection and alerting. Results As of Jan. 31st 2012, ISS has been installed and pilot tested for six months in four counties in rural China. 95 health facilities, 14 pharmacies and 24 primary schools participated in the pilot study, entering respectively 74256, 79701, and 2330 daily records into the central database. More than 90% of surveillance units at the study sites are able to send daily information into the system. In the paper, we also presented the pilot data from health facilities in the two counties, which showed the ISS system had the potential to identify the change of disease patterns at the community level. Conclusions The ISS platform may facilitate the early detection of infectious disease epidemic as it provides near real-time syndromic data collection, interactive visualization, and automated aberration detection. However, several constraints and challenges were encountered during the pilot implementation of ISS in rural China.