Rainer Sauerborn

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.

Seasonal variations of household costs of illness in Burkina Faso

This paper assesses the seasonal variations of the time and financial costs of illness for rural households in Burkina Faso. It is based on a multiple round survey of 566 households, which included a time allocation study. The economic parameters of households which influence health seeking behavior changed substantially between the dry and rainy seasons: revenues fell in the rainy season and were exceeded by expenditures. Household production was at its peak in the rainy season resulting in significantly higher opportunity costs of time. At the same time illness perception changed: in the rainy season, significantly fewer illness episodes were perceived, and of those, the proportion perceived as severe decreased over-proportionally. Households shifted their healer choice in the rainy season away from high cost treatment, such as the hospital and dispensary, to low cost home treatment. For all these reasons, households incurred significantly fewer costs of illness in the rainy season (27% of dry season costs). Household health care expenditures were reduced to 1/6 of dry season levels, the time costs incurred by healthy household members to tend to the sick was reduced to 1/5 and the time costs of work incapacity due to sickness fell to about 1/2 of dry season levels. The authors stress the need to carry out research in all relevant seasons when studying health seeking behavior and the household costs of illness in order to avoid serious seasonal bias. They suggest policy options to increase health care utilization in the rainy season by reducing the financial and time costs of access to health care. Finally, the authors put forward a hypothesis to be tested by future research: They argue that the cognitive (changes in illness perception) and behavioral changes (different health care seeking) reflect the high opportunity costs of time and the low availability of cash households face during the rainy season. The paper discusses the negative implication that untreated illness has on the health status of household members.

Low utilization of community health workers: results from a household interview survey in Burkina Faso.

A representative household survey was carried out in order to study the utilization of community health workers (CHW) in relation to other sources of health care. We found three main results: (1) For mild diseases, villagers consulted their CHW only in 8.8% of mild diseases, in 69% the family remained the main provider of primary care. (2) In the case of serious diseases, which the CHW was supposed to identify and refer, the villagers bypassed the CHW in 96.5%. The professional health worker were consulted directly in the majority of serious disease. (3) Sick infants were not taken to the CHW for treatment. (4) No pattern of referral between professional and CHWs could be traced. Severity of disease and perceived effectiveness of the treatment were the most important determinants of health seeking behavior. Availability, distance, and cost of travel and drugs were important service related determinants. Individual and household characteristics such as income, ethnicity, and household size were only weakly associated with choice of curative care. Reasons for the low utilization of CHWs are outlined and policy implications discussed.

One hundred and eighteen years of the German health insurance system: are there any lessons for middle- and low-income countries?

A number of low and middle income countries (LMICs) are considering social health insurance (SHI) for adoption into their social and economic environment or striving to sustain and improve already existing SHI schemes. SHI was first introduced in Germany in 1883. An analysis of the German system from its inception up to today may yield lessons relevant to other countries. Such an analysis, however, is largely lacking, especially with regard to LMICs. This paper attempts to fill this gap. For each of the following lessons, it considers if and under which conditions they may be of relevance to LMICs. First, small, informal, voluntary health insurance schemes may serve as learning models for fund administration and solidarity, but in order to achieve universal coverage government action is needed to formalise these schemes and to introduce a principle of compulsion. Once compulsory health insurance exists for some people, incremental expansion of coverage to other regions and social groups may be feasible to achieve universality. Second, in order to ensure sustainability of SHI, the mandated benefit package should be adapted incrementally in accordance with changing needs, values and economic circumstances. Third. in a pluralistic SHI system equity, as well as risk pooling and spreading, can be enhanced if funds merge. The optimal number of funds, however, will depend on the stage of development of the SHI system as well as on other objectives of the system, including choice and competition. A risk equalisation scheme may prevent the adverse effects of risk selection, if competition between insurance funds is introduced into the system. Fourth, as an alternative to both state and market regulation, self-governance may serve as a source of stability and sustainability as well as a means of decentralising and democratising a health care system. Finally, costs can be successfully contained in a fee-for-service system, if cost-escalating provider behaviour is constrained by either political pressure or technical means.

Climate variability and increase in intensity and magnitude of dengue incidence in Singapore

Introduction: Dengue is currently a major public health burden in Asia Pacific Region. This study aims to establish an association between dengue incidence, mean temperature and precipitation, and further discuss how weather predictors influence the increase in intensity and magnitude of dengue in Singapore during the period 2000–2007. Materials and methods: Weekly dengue incidence data, daily mean temperature and precipitation, and the midyear population data in Singapore during 2000–2007 were retrieved and analyzed. We employed a time series Poisson regression model including time factors such as time trends, lagged terms of weather predictors, considered autocorrelation, and accounted for changes in population size by offsetting. Results: The weekly mean temperature and cumulative precipitation were statistically significant related to the increases of dengue incidence in Singapore. Our findings showed that dengue incidence increased linearly at time lag of 5–16 and 5–20 weeks succeeding elevated temperature and precipitation, respectively. However, negative association occurred at lag week 17–20 with low weekly mean temperature as well as lag week 1–4 and 17–20 with low cumulative precipitation. Discussion: As Singapore experienced higher weekly mean temperature and cumulative precipitation in the years 2004–2007, our results signified hazardous impacts of climate factors on the increase in intensity and magnitude of dengue cases. The ongoing global climate change might potentially increase the burden of dengue fever infection in near future.

Climate change and health: on the latest IPCC report

www.thelancet.com Vol 383 April 5, 2014 1185 The Intergovernmental Panel on Climate Change (IPCC) released its latest report on March 31, 2014. This report was the second instalment of the Fifth Assessment Report, prepared by Working Group 2, on impacts, vulnerability, and adaptation to climate change. In this Comment, we, as contributors to the chapter on human health, explain how the IPCC report was prepared and highlight important fi ndings. The IPCC reviews and assesses the scientifi c published work on climate change. As an intergovernmental body composed of members of the UN, the IPCC does not undertake research itself; instead it appoints Working Groups who assess the work. This assessment means more than simply to summarise the state of knowledge: Working Groups are asked to weigh what has been written (in both peer-reviewed publications and grey literature), to make judgments about likelihood and uncertainty, and to fl ag important emerging issues. The focus for Working Group 2 was mainly, but not exclusively, on what had been written since the previous assessment in 2007; papers were eligible for inclusion if they were published, or accepted for publication, before Aug 31, 2013. The Working Groups were required to highlight what might be relevant to policy, but did not recommend policies. The Fifth Assessment Report Working Group 1 reported on the physical science of climate change in September, 2013 (appendix). Working Group 3, concerned with mitigation (ie, reduction of greenhouse gas emissions), will release its report in April, 2014. The scale of the enterprise is remarkable—indeed, reports by the IPCC together probably represent the largest scientifi c assessment exercise in history. There are 310 authors and review editors in Working Group 2, and an even greater number of contributing authors who have added to the report from their areas of special expertise. In addition to health, Working Group 2 examined natural and managed resources (eg, fresh water, coastal systems, and food production), human settlements, and other aspects of wellbeing such as security and livelihoods. The report (30 chapters) will be published in two volumes, and includes integrated assessments of impacts and adaptation in nine geographic regions and an overarching summary for policy makers. Work on the Fifth Assessment Report began 5 years ago (appendix) and aspects of the IPCC process distinguish its assessments from other reviews and scientifi c publications. One diff erence is the substantial role of member states in determination of, in the initial stages, the scope of the reports and the membership of writing groups. At the beginning of each round of assessment, meetings organised by the IPCC decide on the structure of the reports, including the number of chapters and the topics to be covered, and then member states nominate potential authors. The fi nal decision about authors is made by a subgroup from the IPCC, the Bureau, on the basis of scientifi c merit and the necessary institutional and disciplinary perspectives for each chapter, seeking, at the same time, to achieve a balance of representation by gender and region. Once appointed, the IPCC authors work independently; government input occurs as part of the peer review process. However, the member states must approve and sign off on the fi nal report. Thus, the IPCC assessments are the outputs of many iterative interactions between scientists and policy makers. Another feature of the IPCC process is the intensity of peer review. There were four rounds of review for the Fifth Assessment Report, two of which involved hundreds of self-nominated experts and scientists appointed by member-state governments. Each round generated an enormous number of comments, questions, and requests for change. For instance, the IPCC received 1009 reviewer comments just on the second-order draft of chapter 11 (human health). Two dedicated review editors per chapter are charged with ensuring that the authors consider each comment seriously and, if they reject it, that they do so with good reasons. Both the comments and the chapter authors’ responses will be published on the IPCC website. The IPCC does not prescribe how chapter groups should gather and interpret the scientifi c work, partly because conventions and practice diff er among disciplines. Contributors to the health chapter used many strategies to identify relevant published work. Due to the breadth of the topic, including the range of health outcomes and exposure pathways, the chapter team decided that one systematic review would not be possible. Climate change and health: on the latest IPCC report

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.

Housing conditions and Plasmodium falciparum infection: protective effect of iron-sheet roofed houses.

BackgroundIdentification and better understanding of potential risk factors for malaria are important for targeted and cost-effective health interventions. Housing conditions have been suggested as one of the potential risk factors. This study aims to further investigate this risk factor, and is focused on the effect of the type of roof on Plasmodium falciparum infection among children below five years in the North West of Burkina Faso.MethodsIn a cross-sectional study design, 661 children aged six to 60 months were randomly selected from three rural and one semi-urban site at the end of the rainy season (November 2003). The children were screened for fever and tested for Plasmodium falciparum infection. In addition, data on bed net use and house characteristics was collected from the household were each child lived. Using adjusted odds ratios, children living in house roofed with iron-sheet were compared with those in house with mud or grass roof.ResultsOverall P. falciparum infection prevalence was 22.8 % with a significant variation between (Chi-square, p < 0.0001). The prevalence in Cissé (33.3 %) and Goni (30.6 %) were twice times more than in Nouna (15.2 %) and Kodougou (13.2 %). After adjusting for age, sex, use of bed net and housing conditions, children living in houses with mud roofs had significantly higher risk of getting P. falciparum infection compared to those living in iron-sheet roofed houses (Odds Ratio 2.6; 95% Confidence Interval, 1.4–4.7).ConclusionThese results suggest that house characteristics should be taken into consideration when designing health intervention against P. falciparum infection and particular attention should be paid to children living in houses with mud roofs.

Examining out-of-pocket expenditure on health care in Nouna, Burkina Faso: implications for health policy

OBJECTIVE To examine household out‐of‐pocket expenditure on health care, particularly malaria treatment, in rural Burkina Faso.

Households' perception of climate change and human health risks: A community perspective

BackgroundBangladesh has been identified as one of the most vulnerable countries in the world concerning the adverse effects of climate change (CC). However, little is known about the perception of CC from the community, which is important for developing adaptation strategies.MethodsThe study was a cross-sectional survey of respondents from two villages--one from the northern part and the other from the southern part of Bangladesh. A total of 450 households were selected randomly through multistage sampling completed a semi-structure questionnaire. This was supplemented with 12 focus group discussions (FGDs) and 15 key informant interviews (KIIs).ResultsOver 95 percent of the respondents reported that the heat during the summers had increased and 80.2 percent reported that rainfall had decreased, compared to their previous experiences. Approximately 65 percent reported that winters were warmer than in previous years but they still experienced very erratic and severe cold during the winter for about 5-7 days, which restricted their activities with very destructive effect on agricultural production, everyday life and the health of people. FGDs and KIIs also reported that overall winters were warmer. Eighty point two percent, 72.5 percent and 54.7 percent survey respondents perceived that the frequency of water, heat and cold related diseases/health problems, respectively, had increased compared to five to ten years ago. FGDs and KIIs respondents were also reported the same.ConclusionsRespondents had clear perceptions about changes in heat, cold and rainfall that had occurred over the last five to ten years. Local perceptions of climate variability (CV) included increased heat, overall warmer winters, reduced rainfall and fewer floods. The effects of CV were mostly negative in terms of means of living, human health, agriculture and overall livelihoods. Most local perceptions on CV are consistent with the evidence regarding the vulnerability of Bangladesh to CC. Such findings can be used to formulate appropriate sector programs and interventions. The systematic collection of such information will allow scientists, researchers and policy makers to design and implement appropriate adaptation strategies for CC in countries that are especially vulnerable.