Health insurance affordability and the quality of life among low Socioeconomic Status (SES) individuals in Low- and Middle-Income Countries (LMICs)

 Preamble:

Whereas the right to health is a fundamental human right, it remains inaccessible to many, especially those of low socioeconomic status (SES) in low- and middle-income countries (LMICs); and whereas the affordability of health insurance is a critical factor that can enhance or impede access to necessary healthcare services; we recognize that the ability to obtain health insurance plays a pivotal role in determining the quality of life for individuals and families within these communities.

Acknowledging that the lack of affordable health insurance options leads to a disproportionate burden of disease and financial hardship on low SES populations; and understanding that the provision of affordable health insurance is not only a matter of social justice but also an investment in the social and economic development of LMICs; we hereby emphasize the significance of health insurance affordability as a determinant of health outcomes and overall quality of life.

It is imperative to address the barriers to health insurance affordability with the aim of achieving Universal Health Coverage (UHC) and ensuring that all individuals, irrespective of their socioeconomic status, have access to the healthcare they require without suffering financial hardship.

 

Healthcare Utilization:

• Community-based health insurance (CBHI) schemes in LMICs have been shown to substantially improve healthcare utilization, particularly for outpatient services¹.

This domain is now examined as follows:

Healthcare Utilization:

• Increased Access to Services: CBHI schemes have been instrumental in increasing access to healthcare services. By providing a financial safety net, these schemes enable individuals, especially those from low socioeconomic backgrounds, to seek medical attention without the fear of prohibitive costs.
• Outpatient Services: There is a notable increase in the utilization of outpatient services among CBHI members. This is crucial because regular outpatient care can prevent the escalation of diseases and reduce the need for more expensive inpatient care.
• Preventive Care: CBHI often includes preventive services, which can lead to early detection and treatment of illnesses, contributing to better long-term health outcomes.
• Equity in Health: By making healthcare more affordable, CBHI schemes promote equity in health. They ensure that low-income families receive the same level of care as their higher-income counterparts, thus working towards reducing health disparities.
• Community Empowerment: These schemes often involve community members in their governance, which can empower communities to take charge of their health needs and foster a sense of ownership and responsibility.

Challenges and Considerations:

• Sustainability: For CBHI schemes to be sustainable, they must balance the cost of premiums with the benefits provided. This requires careful financial management and often, support from external funding.
• Quality of Care: While CBHI improves access to services, the quality of care is also a critical factor. There must be a focus on improving the standards of care alongside increasing utilization.
• Awareness and Education: Educating the community about the benefits of health insurance and how to use it effectively is essential for maximizing utilization.
• Integration with National Policies: CBHI schemes should be integrated with national health policies to ensure they complement other health financing mechanisms and contribute to the broader goal of universal health coverage.

In conclusion, CBHI schemes have a positive impact on healthcare utilization in LMICs, particularly for outpatient services. They play a vital role in improving access to healthcare, promoting preventive care, and achieving equity in health. However, the sustainability and quality of care provided under these schemes are areas that require ongoing attention and improvement.

 

 

 

 

2. Financial Risk Protection:
• CBHI schemes have improved financial risk protection in 24 out of 43 studies, indicating that insured households had lower out-of-pocket health expenditure and a reduced incidence of catastrophic health expenditure¹.

 

Financial Risk Protection is discussed in details as follows:

• Reduction in Out-of-Pocket Expenditure: The studies indicate that CBHI schemes have been effective in reducing out-of-pocket health expenditure for insured households. This is a significant benefit, as high out-of-pocket costs can deter individuals from seeking necessary medical care.
• Lower Incidence of Catastrophic Health Expenditure: Catastrophic health expenditure occurs when a household’s total out-of-pocket health expenses exceed a certain proportion of their income, leading to financial hardship. CBHI schemes have been shown to protect against such financial risks, thereby safeguarding families from falling into poverty due to health-related expenses.
• Improved Economic Stability: By mitigating the financial risks associated with healthcare costs, CBHI schemes contribute to the economic stability of households. This allows families to allocate their resources to other essential needs, such as education and nutrition, which can further improve their quality of life.
• Enhanced Health Equity: Financial risk protection is a key component of health equity. CBHI schemes help level the playing field by ensuring that low-income households have the same opportunity to access healthcare services as those with higher incomes, without the burden of disproportionate costs.

Challenges and Opportunities:

• Coverage and Benefit Design: One of the challenges facing CBHI schemes is the design of coverage and benefits. To enhance financial risk protection, schemes must cover a wide range of services and provide sufficient coverage levels to reduce out-of-pocket payments.
• Pooling of Risks: Effective risk pooling is essential for the success of CBHI schemes. By spreading the financial risk across a larger group, the impact of high-cost events on any single member is reduced.
• Scale and Sustainability: Achieving scale is important for the sustainability of CBHI schemes. Larger pools of insured members can lead to more stable and predictable financing, which is crucial for long-term viability.
• Integration with National Health Systems: Integrating CBHI schemes with national health systems can strengthen the overall health financing structure and ensure that financial risk protection is part of a comprehensive approach to healthcare.

Overall, CBHI schemes play a pivotal role in providing financial risk protection to low-income households in LMICs. They have been successful in reducing both out-of-pocket health expenditure and the incidence of catastrophic health expenditure, contributing to improved economic stability and health equity. However, there are challenges that need to be addressed to maximize the potential of these schemes, including coverage and benefit design, risk pooling, scale, and integration with national health systems.

 

 

 

 

3. Quality of Life:
• While CBHI generally improves healthcare utilization, it inconsistently delivers financial protection from health expenditure shocks. However, with context-specific policies and operational modifications, CBHI could be a promising mechanism for achieving universal health coverage (UHC) in LMICs¹.

Quality of Life is dissected in the following section:

• Inconsistent Financial Protection: Although CBHI schemes generally improve healthcare utilization, they have been inconsistent in delivering financial protection from health expenditure shocks. This inconsistency can be attributed to various factors, including limited coverage of services, inadequate benefit packages, and the financial vulnerability of the insured population.
• Impact on Quality of Life: The quality of life for individuals in LMICs is directly affected by their ability to access and afford healthcare. CBHI schemes can play a significant role in improving this aspect by reducing the financial barriers to healthcare services, which in turn can lead to better health outcomes and a higher standard of living.
• Potential for UHC: CBHI schemes have the potential to be a key mechanism for achieving Universal Health Coverage (UHC) in LMICs. UHC aims to ensure that all individuals and communities receive the health services they need without suffering financial hardship.

Strategies for Improvement:

• Context-Specific Policies: Implementing policies that are tailored to the specific needs and circumstances of the target population can enhance the effectiveness of CBHI schemes. This includes understanding the local healthcare landscape, cultural norms, and economic conditions. Accordingly, the following considerations are relevant:

• Tailored to Local Needs: Policies must be designed with a deep understanding of the local healthcare landscape. This includes recognizing the prevalent diseases, available healthcare facilities, and the capacity of local healthcare providers.
• Cultural Sensitivity: The success of CBHI schemes often hinges on their cultural acceptability. Policies should respect and align with local cultural norms and values, which can influence health-seeking behavior and attitudes towards insurance.
• Economic Adaptability: Economic conditions vary greatly across LMICs. Policies should be adaptable to the economic realities of the target population, such as income levels, employment patterns, and financial literacy.
• Inclusive Design: Effective policies should aim to include the most vulnerable populations, such as women, children, the elderly, and those with disabilities, ensuring that the CBHI schemes serve the entire community.

Strategic Implementation:

• Community Engagement: Engaging with community leaders and members in the policy design process can lead to more relevant and accepted health insurance schemes.
• Education and Communication: Clear communication and education about the benefits and workings of CBHI schemes are essential for their uptake and sustained use.
• Feedback Mechanisms: Establishing robust feedback mechanisms can help policymakers understand the impact of CBHI schemes and make necessary adjustments.
• Partnerships: Forming partnerships with local NGOs, healthcare providers, and international organizations can provide the support needed to implement context-specific policies effectively.

Outcome-Oriented Approach:

• Health Outcomes: The ultimate goal of context-specific policies should be to improve health outcomes. This means not just increasing healthcare utilization but also ensuring that the care received is effective and leads to better health.
• Financial Outcomes: Policies should also aim to improve financial outcomes by reducing the burden of healthcare costs and protecting against financial shocks due to illness.
• Quality of Life: By focusing on both health and financial outcomes, context-specific policies can contribute to an overall improvement in the quality of life for individuals and communities.

Overall, context-specific policies are crucial for the success of CBHI schemes in LMICs. They ensure that the schemes are well-suited to the unique needs and circumstances of the target population, leading to better health and financial outcomes and, ultimately, an enhanced quality of life.

 

 

• Operational Modifications: Making operational changes, such as simplifying enrollment processes, improving claims management, and enhancing service delivery, can help CBHI schemes provide more consistent financial protection and improve the quality of life for members.

• Simplifying Enrollment Processes: Streamlining the enrollment process can significantly increase participation in CBHI schemes. This could involve reducing paperwork, creating online platforms for easy registration, and providing assistance to help individuals understand and complete the enrollment process.
• Improving Claims Management: Efficient claims management is crucial for member satisfaction and trust in the scheme. This includes timely processing of claims, transparent communication regarding the status of claims, and minimizing the rejection of valid claims.
• Enhancing Service Delivery: Improving the quality and efficiency of healthcare service delivery can lead to better health outcomes and member satisfaction. This might involve training healthcare providers, upgrading healthcare facilities, and ensuring the availability of essential medicines and supplies.

Additional Considerations:

• Technology Integration: Utilizing technology can make operations more efficient. For example, mobile health (mHealth) applications can facilitate communication between members and CBHI managers, provide health education, and streamline the claims process.
• Feedback Systems: Establishing robust feedback systems allows members to voice their concerns and suggestions, which can inform continuous improvement of the CBHI scheme.
• Capacity Building: Investing in the capacity building of CBHI staff can improve their ability to manage the scheme effectively, from enrollment to claims processing and beyond.
• Partnerships with Healthcare Providers: Forming strong partnerships with healthcare providers ensures that members receive quality care and that providers understand the CBHI processes, leading to smoother service delivery.

Impact on Quality of Life:

• Access to Timely Care: Operational improvements can lead to quicker access to necessary healthcare services, which is vital for maintaining and improving health.
• Reduced Administrative Burden: Simplified processes reduce the administrative burden on members, allowing them to focus on their health rather than on bureaucratic hurdles.
• Financial Security: Efficient operational systems ensure that members receive the financial protection they expect, which can alleviate stress and contribute to a better quality of life.

In essence, operational modifications are key to enhancing the performance of CBHI schemes. By focusing on simplifying enrollment, improving claims management, and enhancing service delivery, CBHI schemes can provide more consistent financial protection and positively impact the quality of life for their members. These changes require a commitment to continuous improvement and a focus on the needs of the members.

• Strengthening Health Systems: Strengthening the underlying health systems is crucial for the success of CBHI schemes. This involves improving the quality and availability of healthcare services, training healthcare providers, and ensuring that health facilities are well-equipped.

Strengthening Health Systems is a multifaceted approach that is essential for the success of Community-based health insurance (CBHI) schemes. Let’s examine this domain:

• Improving Healthcare Quality and Availability:
• Quality Assurance Programs: Implementing quality assurance programs can help maintain high standards of care. These programs often include regular monitoring and evaluation of healthcare services.
• Infrastructure Development: Upgrading healthcare infrastructure is key to improving service delivery. This includes not only physical infrastructure like buildings and medical equipment but also technological infrastructure like health information systems.
• Supply Chain Management: Ensuring a reliable supply of medications and medical supplies prevents stockouts and ensures that healthcare providers can offer a full range of services.
• Training Healthcare Providers:
• Continuing Education: Ongoing training for healthcare providers ensures they stay up-to-date with the latest medical knowledge and practices.
• Skill Development: Specialized training programs can help healthcare workers develop new skills that are in demand, such as emergency care or surgery techniques.
• Incentive Structures: Creating incentive structures can motivate healthcare providers to deliver better care and to work in underserved areas.
• Well-Equipped Health Facilities:
• Medical Equipment: Providing modern and functional medical equipment is crucial for accurate diagnosis and effective treatment.
• Maintenance Programs: Regular maintenance of medical equipment ensures its longevity and reliability.
• Safe and Clean Environment: Facilities must adhere to safety and hygiene standards to prevent infections and ensure patient safety.
• Healthcare Financing:
• Sustainable Funding: Developing sustainable funding mechanisms, such as government subsidies or donor funding, can support the long-term operation of health systems.
• Efficient Use of Resources: Ensuring that resources are used efficiently can reduce waste and make health services more affordable.
• Policy and Governance:
• Regulatory Frameworks: Establishing clear regulatory frameworks can guide the operation of health systems and ensure compliance with national and international standards.
• Decentralization: Decentralizing health services can bring decision-making closer to the community level, making it more responsive to local needs.
• Community Involvement:
• Community Health Workers: Training and employing community health workers can extend the reach of health services, especially in rural or hard-to-reach areas.
• Public Awareness Campaigns: Educating the public about health issues and the importance of preventive care can lead to healthier behaviors and increased demand for health services.

By focusing on these areas, health systems can be strengthened to support the effective implementation of CBHI schemes. This, in turn, can lead to improved health outcomes, financial protection, and an enhanced quality of life for the community members they serve.

 

• Community Engagement: Engaging with the community to raise awareness about the benefits of CBHI and involving them in the decision-making process can lead to higher enrollment rates and better alignment of the schemes with the community’s needs.

 

Community Engagement plays a pivotal role in the success of Community-based health insurance (CBHI) schemes. Let’s examine its importance and implementation:

• Raising Awareness:
• Information Campaigns: Conducting information campaigns to educate the community about the benefits of CBHI can demystify insurance concepts and highlight the importance of financial protection against health risks.
• Local Media: Utilizing local media, including radio, newspapers, and social media, can help reach a wider audience and keep the community informed about CBHI schemes.
• Involving the Community in Decision-Making:
• Participatory Approaches: Adopting participatory approaches in the design and implementation of CBHI schemes ensures that the services provided align with the community’s needs and preferences.
• Feedback Loops: Establishing feedback loops where community members can share their experiences and provide input can lead to continuous improvement of the CBHI schemes.
• Building Trust:
• Transparency: Being transparent about how CBHI schemes operate, including premium collection, fund management, and claims reimbursement, builds trust within the community.
• Success Stories: Sharing success stories of individuals who have benefited from CBHI can encourage others to enroll and support the scheme.
• Cultural Sensitivity:
• Respecting Traditions: Understanding and respecting local traditions and integrating them into the CBHI framework can enhance acceptance and participation.
• Language and Communication: Communicating in the local language and using culturally appropriate messaging can make CBHI information more accessible and relatable.
• Community Leaders and Influencers:
• Engagement: Engaging with community leaders and influencers can facilitate the dissemination of information and encourage community members to participate in CBHI schemes.
• Endorsements: Endorsements from respected figures can lend credibility to CBHI schemes and motivate enrollment.
• Education and Capacity Building:
• Training Sessions: Organizing training sessions for community members on how to access and use CBHI services can empower them to take control of their health and finances.
• Health Literacy: Improving health literacy helps individuals make informed decisions about their health and insurance needs.
• Collaboration with Local Organizations:
• Partnerships: Forming partnerships with local NGOs, faith-based organizations, and community groups can extend the reach and impact of CBHI schemes.
• Joint Initiatives: Collaborative initiatives can pool resources and expertise, making CBHI schemes more robust and sustainable.

By actively engaging with the community, CBHI schemes can achieve higher enrollment rates and ensure that the services provided meet the actual needs of the community. This engagement fosters a sense of ownership and responsibility among community members, leading to stronger, more effective health insurance systems that can significantly improve the quality of life for all members.

 

In conclusion, while CBHI schemes have shown promise in improving healthcare utilization and contributing to a better quality of life, there is a need for more consistent financial protection against health expenditure shocks. With the right context-specific policies and operational modifications, CBHI could indeed be a promising mechanism for advancing towards UHC in LMICs, ultimately enhancing the quality of life for low SES individuals.

Recommended Further Reading

1. Alatinga KA, Fielmua N. The Impact of Mutual Health Insurance Scheme on Access and Quality of Health Care in Northern Ghana: The Case of Kassena-Nankana East Scheme. J Sustain Dev. 2011;4(5):125–38.
2. Asfaw A, Braun J Von. Can community health insurance schemes shield the poor against the downside health effects of economic reforms? The case of rural Ethiopia. Health Policy (New York). 2004;70(1):97–108.
3. Atim C. Social movements and health insurance: A critical evaluation of voluntary, non-profit insurance schemes with case studies from Ghana and Cameroon. Soc Sci Med. 1999;48(7):881–96.
4. Atim C, Sock M. An External Evaluation of the Nkoranza Community Financing Health Insurance Scheme, Ghana. 2000.
5. Atnafu A, Gebremedhin T. Community-based health insurance enrollment and child health service utilization in Northwest Ethiopia: A cross-sectional case comparison study. ClinicoEconomics and Outcomes Research. 2020;12:435–44.
6. Bhat R, Menezes L, Avila C. Annapurna Pariwar Community/Mutual Health Insurance Program: A Case study in Maharashtra, India. 2017.
7. Blanchard-Horan C. Health microinsurance in Uganda: Affecting malaria treatment seeking behavior. International Journal of Public Administration. 2007;30(8–9):765–89.
8. Broomberg J, Price MR. The impact of the fee-for-service reimbursement system on the utilisation of health services. Part II. South African Medical Journal. 1990;78:133–6.
9. Carrin G, et al. The reform of the rural cooperative medical system in the People’s Republic of China: Interim experience in 14 pilot counties. Soc Sci Med. 1999;48(7):961–72.
10. Cheema AR, et al. Availability Does Not Mean Utilisation: Analysis of a Large Micro Health Insurance Programme in Pakistan. Glob J Health Sci. 2020;12(10):14–24.
11. Chemouni B. The political path to universal health coverage: Power, ideas and community-based health insurance in Rwanda. World Dev. 2018;106(June):87–98.
12. Chee G, Smith K, Kapinga A. Assessment of the Community Health Fund in Hanang District, Tanzania. 2002.
13. Criel B, Kegels G. A health insurance scheme for hospital care in Bwamanda district, Zaire: Lessons and questions after 10 years of functioning. Tropical Medicine and International Health. 1997;2(7):654–72.
14. Criel B, Van Der Stuyft P, Van Lerberghe W. The Bwamanda hospital insurance scheme: Effective for whom? Soc Sci Med. 1999;48(7):897–911.
15. Dekker M, Wilms A. Health Insurance and Other Risk-Coping Strategies in Uganda: The Case of Microcare Insurance Ltd. World Dev. 2010;38(3):369–78.
16. Desai S, Sinha T, Mahal A. Prevalence of hysterectomy among rural and urban women with and without health insurance in Gujarat, India. Reprod Health Matters. 2011;19(37):42–51.
17. Devadasan N, et al. Accord community health insurance—Increasing access to hospital care. Econ Polit Wkly. 2004;39(28):3189–94.
18. Devadasan N, et al. Community health insurance in Gudalur, India, increases access to hospital care. Health Policy Plan. 2010;25(2):145–54.
19. Eze P, Lawani O, Agu J, Acharya Y. Catastrophic health expenditure in sub-Saharan Africa: Systematic review and meta-analysis. Bull World Health Organ. 2022;100(5):337–51.