Assessing effectiveness of a community based health insurance in rural Burkina Faso

BMC Health Services Research, Volume 12, No. 1, Year 2012

Interpretação

Background: Financial barriers are a recognized major bottleneck of access and use of health services. The aim of this study was to assess effectiveness of a community based health insurance (CBHI) scheme on utilization of health services as well as on mortality and morbidity. Methods. Data were collected from April to December 2007 from the Nounas Demographic Surveillance System on overall mortality, utilization of health services, household characteristics, distance to health facilities, membership in the Nouna CBHI. We analyzed differentials in overall mortality and selected maternal health process measures between members and non-members of the insurance scheme. Results: After adjusting for covariates there was no significant difference in overall mortality between households who could not have been members (because their area was yet to be covered by the stepped-wedged scheme), non-members but whose households could have been members (areas covered but not enrolled), and members of the insurance scheme. The risk of overall mortality increased significantly with distance to health facility (35% more outside Nouna town) and with education level (37% lower when at least primary school education achieved in households). Conclusion: There was no statistically significant difference in overall mortality between members and non-members. The enrolment rates remain low, with selection bias. It is important that community based health insurances, exemptions fees policy and national health insurances be evaluated on prevention of deaths and severe morbidities instead of on drop-out rates, selection bias, adverse selection and catastrophic payments for health care only. Effective social protection will require national health insurance. © 2012 Hounton et al.; licensee BioMed Central Ltd. The surveys and data extraction were conducted from April to December May 2007. The study site is Nouna health district (Figure 2), a remote and rural health district situated in the North West of Burkina Faso. The area is characterized by dry weather with a mean annual rainfall of about 800 mm resulting in dry savannah vegetation. In early 1990s, a Demographic Surveillance System (DSS) was established by the Nouna Health Research Centre. The original DSS area covered 39 villages (~population about 26 000 inhabitants) and has been progressively extended to cover 58 villages and Nouna town, with a population of about 72 000 people. The density of population is about 35 individuals per square km. The population is distributed in roughly 9,500 households and composed of 65% of a rural people and 35% of Nouna semi-urban town people. The population is essentially young with children less than 15 years of age representing about 48% of the total population, and only 6.2% above 60 years of age. The inhabitants are mostly subsistence farmers and/or cattle keepers. Illiteracy is extremely high, over 80%. Location of Nouna DSS, Burkina Faso (Photo credit: Dr Bocar Kouyate). The Nouna CBHI was launched in 2004 and was developed by the Nouna Health Research Centre in collaboration with the University of Heidelberg (Germany) as an operational research to study how to improve community access and uptake of health services and how to meet the need of the poor within Nouna health district. The scheme was progressively introduced since 2004 using a stepped-wedged design after almost two years of preparation. In 2004 only one third of the targeted areas was covered by the intervention, followed by another third in 2005, and the last third in 2006. The preparation phase involved structural meetings with key stakeholders, administrative clearance, several studies on barriers and facilitators of implementing such strategies, scenarios of benefit packages, valuation of health outcomes willingness-to-pay for the scheme, population revenue and affordable premium and has been extensively described elsewhere [6,17-20]. The benefit package included the minimum package of primary care services available in the district including antenatal care, laboratory exams, hospitalization fees, and transportation for emergencies. Members of the scheme are individual and families from covered health areas within the demographic surveillance system (DSS) who paid the enrolment fee (0.4 USD), and annual premium (3 USD per individual 15 years and older and 2 USD per individual less than 15 years of age). By improving perceived quality of care, by reducing out-of-pocket and by ensuring financial protection reduces the overall delay (mainly first and second), the Nouna CBHI is expected to improving utilization of quality health services and reduction of mortality and morbidity (Figure 3). Thus, we can assume if the Nouna CBHI is effective one could expect a higher utilization of health services (including but not limited to antenatal care, institutional delivery, malaria, etc.) among household members of the Nouna CBHI versus non-members. The improved utilization of health services could result in a lower mortality risk (screening, early diagnostic, access to emergency treatment) in members compared to non-members which we sought to investigate after adjusting for important determinants such as education, distance to health services and household asset ownership. Conceptual model of the Nouna community based health insurance scheme. Data were extracted from longitudinal household surveys at the Nouna Demographic Surveillance Site. The household survey sample size was 1,504 households at the time of the study, half of which were from Nouna town and the other half from surrounding villages; data were extracted on household characteristics, births, deaths and age at death, distance from village to health centers and to Nouna district hospital. In addition, a prospective survey was administered to women with experience of delivery during the last 12 months prior to the survey (April – May 2007) and data were collected on place of delivery, membership in the Nouna Community Based Health Insurance, age of the mother, anemia [21], average distance from village to health centre, and assets ownership. Anemia was selected as this morbidity has not been investigated at the time the study was designed. Descriptive statistics and regression analyses (logistic regression and Poisson regression) were performed to assess the association of overall mortality, utilization of health services, and institutional delivery by membership to the Nouna CBHI adjusting for important covariates. We used a Poisson regression with computed person-time of all deaths (person-time of years spent before death in the DSS, since the DSS started) to investigate whether there is any mortality advantage (lower mortality risk) to any sub group and by any of the selected covariates, and assess whether there is an overall lower mortality risk among members versus non-members and by selected covariates. This method was used because the distribution of deaths is probably skewed and the person-time variable consists of non-negative integers. The dependent variable was the person-time of all deaths in the Nouna DSS and membership in the Nouna CBHI, educational level, age, asset ownership, place the explanatory variables. Dummy variables were created reflect the time spent in the scheme. Study was approved by ethical review boards of Centre MURAZ and the Nouna Health Research Centre (Burkina Faso).

AI Digest

Study Justification:

– Financial barriers are a major obstacle to accessing and using health services.
– The aim of this study was to assess the effectiveness of a community-based health insurance (CBHI) scheme in improving utilization of health services and reducing mortality and morbidity.
– The study was conducted in rural Burkina Faso, where access to healthcare is limited.

Study Highlights:

– Data was collected from April to December 2007 from the Nounas Demographic Surveillance System.
– The study analyzed overall mortality, utilization of health services, household characteristics, distance to health facilities, and membership in the Nouna CBHI.
– After adjusting for covariates, there was no significant difference in overall mortality between members and non-members of the insurance scheme.
– The risk of overall mortality increased with distance to health facility and education level.
– The study highlights the importance of evaluating community-based health insurances, exemptions fees policy, and national health insurances on prevention of deaths and severe morbidities.

Study Recommendations:

– The study recommends evaluating community-based health insurances, exemptions fees policy, and national health insurances on prevention of deaths and severe morbidities instead of drop-out rates, selection bias, adverse selection, and catastrophic payments for healthcare only.
– Effective social protection will require a national health insurance.

Key Role Players:

– Researchers and data collectors
– Nouna Health Research Centre
– University of Heidelberg (Germany)
– Ethical review boards of Centre MURAZ and the Nouna Health Research Centre

Cost Items for Planning Recommendations:

– Research and data collection expenses
– Administrative clearance
– Meetings with key stakeholders
– Studies on barriers and facilitators
– Benefit package development
– Valuation of health outcomes
– Determining affordable premiums
– Population revenue assessment

Força da prova

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong, but there are some areas for improvement. The study design is described, and data were collected from a Demographic Surveillance System. The analysis includes adjusting for covariates. However, the abstract does not provide specific results or statistical significance for the main outcomes. To improve the evidence, the abstract should include the specific findings and statistical significance for overall mortality, utilization of health services, and selected maternal health process measures. Additionally, it would be helpful to include the sample size and any limitations of the study.

Resumo

The surveys and data extraction were conducted from April to December May 2007. The study site is Nouna health district (Figure 2), a remote and rural health district situated in the North West of Burkina Faso. The area is characterized by dry weather with a mean annual rainfall of about 800 mm resulting in dry savannah vegetation. In early 1990s, a Demographic Surveillance System (DSS) was established by the Nouna Health Research Centre. The original DSS area covered 39 villages (~population about 26 000 inhabitants) and has been progressively extended to cover 58 villages and Nouna town, with a population of about 72 000 people. The density of population is about 35 individuals per square km. The population is distributed in roughly 9,500 households and composed of 65% of a rural people and 35% of Nouna semi-urban town people. The population is essentially young with children less than 15 years of age representing about 48% of the total population, and only 6.2% above 60 years of age. The inhabitants are mostly subsistence farmers and/or cattle keepers. Illiteracy is extremely high, over 80%. Location of Nouna DSS, Burkina Faso (Photo credit: Dr Bocar Kouyate). The Nouna CBHI was launched in 2004 and was developed by the Nouna Health Research Centre in collaboration with the University of Heidelberg (Germany) as an operational research to study how to improve community access and uptake of health services and how to meet the need of the poor within Nouna health district. The scheme was progressively introduced since 2004 using a stepped-wedged design after almost two years of preparation. In 2004 only one third of the targeted areas was covered by the intervention, followed by another third in 2005, and the last third in 2006. The preparation phase involved structural meetings with key stakeholders, administrative clearance, several studies on barriers and facilitators of implementing such strategies, scenarios of benefit packages, valuation of health outcomes willingness-to-pay for the scheme, population revenue and affordable premium and has been extensively described elsewhere [6,17-20]. The benefit package included the minimum package of primary care services available in the district including antenatal care, laboratory exams, hospitalization fees, and transportation for emergencies. Members of the scheme are individual and families from covered health areas within the demographic surveillance system (DSS) who paid the enrolment fee (0.4 USD), and annual premium (3 USD per individual 15 years and older and 2 USD per individual less than 15 years of age). By improving perceived quality of care, by reducing out-of-pocket and by ensuring financial protection reduces the overall delay (mainly first and second), the Nouna CBHI is expected to improving utilization of quality health services and reduction of mortality and morbidity (Figure 3). Thus, we can assume if the Nouna CBHI is effective one could expect a higher utilization of health services (including but not limited to antenatal care, institutional delivery, malaria, etc.) among household members of the Nouna CBHI versus non-members. The improved utilization of health services could result in a lower mortality risk (screening, early diagnostic, access to emergency treatment) in members compared to non-members which we sought to investigate after adjusting for important determinants such as education, distance to health services and household asset ownership. Conceptual model of the Nouna community based health insurance scheme. Data were extracted from longitudinal household surveys at the Nouna Demographic Surveillance Site. The household survey sample size was 1,504 households at the time of the study, half of which were from Nouna town and the other half from surrounding villages; data were extracted on household characteristics, births, deaths and age at death, distance from village to health centers and to Nouna district hospital. In addition, a prospective survey was administered to women with experience of delivery during the last 12 months prior to the survey (April – May 2007) and data were collected on place of delivery, membership in the Nouna Community Based Health Insurance, age of the mother, anemia [21], average distance from village to health centre, and assets ownership. Anemia was selected as this morbidity has not been investigated at the time the study was designed. Descriptive statistics and regression analyses (logistic regression and Poisson regression) were performed to assess the association of overall mortality, utilization of health services, and institutional delivery by membership to the Nouna CBHI adjusting for important covariates. We used a Poisson regression with computed person-time of all deaths (person-time of years spent before death in the DSS, since the DSS started) to investigate whether there is any mortality advantage (lower mortality risk) to any sub group and by any of the selected covariates, and assess whether there is an overall lower mortality risk among members versus non-members and by selected covariates. This method was used because the distribution of deaths is probably skewed and the person-time variable consists of non-negative integers. The dependent variable was the person-time of all deaths in the Nouna DSS and membership in the Nouna CBHI, educational level, age, asset ownership, place the explanatory variables. Dummy variables were created reflect the time spent in the scheme. Study was approved by ethical review boards of Centre MURAZ and the Nouna Health Research Centre (Burkina Faso).

Materiais

N/A

Inovações

Based on the provided information, here are some potential innovations that could be used to improve access to maternal health:

1. Mobile health clinics: Implementing mobile health clinics that can travel to remote areas, such as the Nouna health district in Burkina Faso, to provide maternal health services. This would help overcome the barrier of distance to health facilities.

2. Telemedicine: Introducing telemedicine services to enable pregnant women in rural areas to consult with healthcare professionals remotely. This would improve access to medical advice and reduce the need for travel.

3. Community health workers: Training and deploying community health workers who can provide basic maternal health services, education, and support in remote areas. This would help bridge the gap between healthcare facilities and the community.

4. Financial incentives: Offering financial incentives, such as subsidies or cash transfers, to encourage pregnant women to seek antenatal care and deliver in healthcare facilities. This would address the financial barriers mentioned in the study.

5. Health education programs: Implementing comprehensive health education programs that focus on maternal health, including topics such as prenatal care, nutrition, and birth preparedness. This would empower women with knowledge and encourage them to seek appropriate care.

6. Partnerships with traditional birth attendants: Collaborating with traditional birth attendants to improve their skills and knowledge on safe delivery practices. This would ensure that women who prefer to deliver at home have access to trained attendants who can provide safe and hygienic care.

7. Strengthening health infrastructure: Investing in the improvement and expansion of healthcare facilities in rural areas, including the availability of essential equipment and supplies for maternal health services.

It is important to note that the effectiveness of these innovations would need to be evaluated through rigorous research and monitoring to ensure their impact on improving access to maternal health.

AI Innovations Description

The recommendation to improve access to maternal health based on the study is to evaluate and strengthen the community-based health insurance (CBHI) scheme in rural Burkina Faso. The study found that there was no significant difference in overall mortality between members and non-members of the insurance scheme. However, the enrollment rates remain low, indicating a need for improvement.

To enhance the effectiveness of the CBHI scheme, the following steps can be taken:

1. Increase awareness and education: Conduct community outreach programs to educate the population about the benefits of the CBHI scheme and the importance of maternal health. This can include providing information on antenatal care, institutional delivery, and other essential services covered by the insurance.

2. Improve affordability: Assess the affordability of the CBHI scheme and adjust the premium rates accordingly. This can involve subsidizing the premiums for low-income households or implementing a sliding scale based on income levels.

3. Expand coverage: Work towards expanding the coverage of the CBHI scheme to reach more households in rural areas. This can be done by gradually extending the scheme to additional villages and ensuring that all eligible households have the opportunity to enroll.

4. Strengthen healthcare infrastructure: Address the issue of distance to health facilities by improving the accessibility and availability of healthcare services in rural areas. This can involve building more health centers or mobile clinics, as well as providing transportation options for emergency cases.

5. Address barriers to enrollment: Identify and address any barriers that prevent households from enrolling in the CBHI scheme. This can include addressing misconceptions or concerns about the scheme, simplifying the enrollment process, and ensuring that enrollment is easily accessible to all eligible households.

By implementing these recommendations, the CBHI scheme can be developed into an innovation that improves access to maternal health services in rural Burkina Faso.

AI Innovations Methodology

Based on the provided description, here are some potential recommendations to improve access to maternal health:

1. Increase awareness and education: Implement community-based education programs to raise awareness about the importance of maternal health and the available services. This can be done through workshops, community meetings, and outreach programs.

2. Improve transportation infrastructure: Enhance transportation networks to ensure that pregnant women can easily access healthcare facilities. This can include building roads, improving public transportation, and providing ambulances or other means of transportation for emergencies.

3. Strengthen healthcare facilities: Invest in improving the quality and capacity of healthcare facilities in rural areas. This can involve training healthcare workers, providing necessary medical equipment and supplies, and ensuring the availability of essential maternal health services.

4. Expand community-based health insurance: Increase the coverage and enrollment rates of community-based health insurance schemes to provide financial protection and reduce out-of-pocket expenses for maternal health services. This can be achieved through targeted awareness campaigns and subsidies for low-income households.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define indicators: Identify key indicators to measure the impact of the recommendations, such as the number of pregnant women accessing antenatal care, the percentage of institutional deliveries, and maternal mortality rates.

2. Collect baseline data: Gather data on the current status of maternal health access in the target area, including the number of healthcare facilities, transportation infrastructure, enrollment rates in health insurance schemes, and maternal health indicators.

3. Develop a simulation model: Create a simulation model that incorporates the identified recommendations and their potential impact on the selected indicators. This model should consider factors such as population demographics, geographical distribution, and socio-economic characteristics.

4. Input data and parameters: Input the collected baseline data into the simulation model, along with parameters related to the recommendations, such as the expected increase in awareness, the improvement in transportation infrastructure, and the expansion of health insurance coverage.

5. Run simulations: Run multiple simulations using different scenarios to assess the potential impact of the recommendations on the selected indicators. This can involve adjusting the parameters and inputs to test different assumptions and scenarios.

6. Analyze results: Analyze the simulation results to determine the potential impact of the recommendations on improving access to maternal health. This can include comparing the outcomes of different scenarios and identifying the most effective interventions.

7. Refine and validate the model: Continuously refine and validate the simulation model based on real-world data and feedback from stakeholders. This will ensure that the model accurately represents the complex dynamics of improving access to maternal health.

By following this methodology, policymakers and stakeholders can gain insights into the potential effectiveness of different recommendations and make informed decisions to improve access to maternal health in rural Burkina Faso.

Autor

Dima Health

Statistics:

Citations: 23

Identifiers:

DOI: 10.1186/1472-6963-12-363

Research Areas:

Community Interventions, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Social Determinants

Study Countries:

Burkina Faso

Study Design:

Cohort Study, Cross Sectional Study, randomised-control-trial

Study Approach:

Mixed-methods, Quantitative, Systematic Review

Participants Gender:

Female

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