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      Community-Based Health Insurance Membership Dropout Rate and Associated Factors in Dera District, Northwest Ethiopia

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          Abstract

          Background

          Community-based health insurance is an emerging strategy for providing financial protection against health-related poverty. They have developed into alternative health financing mechanisms for out-of-pocket expenses in low- and middle-income countries. Hence, the aim of this study was to assess the drop-out rate of community-based health insurance membership and associated factors in Dera district, Northwest Ethiopia, 2020.

          Methods

          Through systematic random sampling techniques, a community-based cross-sectional study was conducted on 584 participants. A structured interviewer-based administered questionnaire was used for data collection. EpI data is used for data entry, while SPSS 20 version is used for analysis. P-value <0.2 binary logistic regression was entered into multivariable logistic regression. Variables with a P-value of <0.05 and a 95% confidence level were considered to be significantly associated with the outcome variable.

          Results

          The CBHI dropout rate in the district is calculated to be 37.3% (95% CI: 34, 41%) in the district. Length of enrollment, ≥4 years in the CBHI program (AOR=0.39, 95% CI: 0.26, 0.59), households visit the health facilities 4–6 times a year (AOR=1.92, 95% CI: 1.10, 3.32), have no access to the hospital (AOR=1.68, 95% CI: 1.02, 2.77), knowledge of CBHI (AOR=1.93, 95% CI: 1.32, 2.82) and official position holder for decision-making in the households (AOR=2.07, 95% CI: 1.33, 3.23) were factors associated with CBHI dropout rate in the scheme.

          Conclusion

          This finding confirmed that the CBHI dropout rate in the district was high. Length of enrollment, health facility visit, hospital accessibility, knowledge of CBHI, and official position holders used for decision-making are significantly associated with the CBHI dropout rate. Therefore, emphasis should be given on improving members’ understanding of the CBHI package of benefits; increasing access to hospitals and empowering women will increase the utilization of CBHI. In addition, the quality of care for CBHI patients can be improved when they had access to health services.

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          Most cited references29

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          What Factors Affect Voluntary Uptake of Community-Based Health Insurance Schemes in Low- and Middle-Income Countries? A Systematic Review and Meta-Analysis

          Introduction This research article reports on factors influencing initial voluntary uptake of community-based health insurance (CBHI) schemes in low- and middle-income countries (LMIC), and renewal decisions. Methods Following PRISMA protocol, we conducted a comprehensive search of academic and gray literature, including academic databases in social science, economics and medical sciences (e.g., Econlit, Global health, Medline, Proquest) and other electronic resources (e.g., Eldis and Google scholar). Search strategies were developed using the thesaurus or index terms (e.g., MeSH) specific to the databases, combined with free text terms related to CBHI or health insurance. Searches were conducted from May 2013 to November 2013 in English, French, German, and Spanish. From the initial search yield of 15,770 hits, 54 relevant studies were retained for analysis of factors influencing enrolment and renewal decisions. The quantitative synthesis (informed by meta-analysis) and the qualitative analysis (informed by thematic synthesis) were compared to gain insight for an overall synthesis of findings/statements. Results Meta-analysis suggests that enrolments in CBHI were positively associated with household income, education and age of the household head (HHH), household size, female-headed household, married HHH and chronic illness episodes in the household. The thematic synthesis suggests the following factors as enablers for enrolment: (a) knowledge and understanding of insurance and CBHI, (b) quality of healthcare, (c) trust in scheme management. Factors found to be barriers to enrolment include: (a) inappropriate benefits package, (b) cultural beliefs, (c) affordability, (d) distance to healthcare facility, (e) lack of adequate legal and policy frameworks to support CBHI, and (f) stringent rules of some CBHI schemes. HHH education, household size and trust in the scheme management were positively associated with member renewal decisions. Other motivators were: (a) knowledge and understanding of insurance and CBHI, (b) healthcare quality, (c) trust in scheme management, and (d) receipt of an insurance payout the previous year. The barriers to renewal decisions were: (a) stringent rules of some CBHI schemes, (b) inadequate legal and policy frameworks to support CBHI and (c) inappropriate benefits package. Conclusion and Policy Implications The demand-side factors positively affecting enrolment in CBHI include education, age, female household heads, and the socioeconomic status of households. Moreover, when individuals understand how their CBHI functions they are more likely to enroll and when people have a positive claims experience, they are more likely to renew. A higher prevalence of chronic conditions or the perception that healthcare is of good quality and nearby act as factors enhancing enrolment. The perception that services are distant or deficient leads to lower enrolments. The second insight is that trust in the scheme enables enrolment. Thirdly, clarity about the legal or policy framework acts as a factor influencing enrolments. This is significant, as it points to hitherto unpublished evidence that governments can effectively broaden their outreach to grassroots groups that are excluded from social protection by formulating supportive regulatory and policy provisions even if they cannot fund such schemes in full, by leveraging people’s willingness to exercise voluntary and contributory enrolment in a community-based health insurance.
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            A systematic review of factors that affect uptake of community-based health insurance in low-income and middle-income countries

            Background Low-income and middle-income countries (LMICs) have difficulties achieving universal financial protection, which is primordial for universal health coverage. A promising avenue to provide universal financial protection for the informal sector and the rural populace is community-based health insurance (CBHI). We systematically assessed and synthesised factors associated with CBHI enrolment in LMICs. Methods We searched PubMed, Scopus, ERIC, PsychInfo, Africa-Wide Information, Academic Search Premier, Business Source Premier, WHOLIS, CINAHL, Cochrane Library, conference proceedings, and reference lists for eligible studies available by 31 October 2013; regardless of publication status. We included both quantitative and qualitative studies in the review. Results Both quantitative and qualitative studies demonstrated low levels of income and lack of financial resources as major factors affecting enrolment. Also, poor healthcare quality (including stock-outs of drugs and medical supplies, poor healthcare worker attitudes, and long waiting times) was found to be associated with low CBHI coverage. Trust in both the CBHI scheme and healthcare providers were also found to affect enrolment. Educational attainment (less educated are willing to pay less than highly educated), sex (men are willing to pay more than women), age (younger are willing to pay more than older individuals), and household size (larger households are willing to pay more than households with fewer members) also influenced CBHI enrolment. Conclusion In LMICs, while CBHI schemes may be helpful in the short term to address the issue of improving the rural population and informal workers’ access to health services, they still face challenges. Lack of funds, poor quality of care, and lack of trust are major reasons for low CBHI coverage in LMICs. If CBHI schemes are to serve as a means to providing access to health services, at least in the short term, then attention should be paid to the issues that militate against their success. Electronic supplementary material The online version of this article (doi:10.1186/s12913-015-1179-3) contains supplementary material, which is available to authorized users.
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              Drop-out analysis of community-based health insurance membership at Nouna, Burkina Faso.

              This study aims to identify the reasons why enrolled people decide not to renew their membership in following years. 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. 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. 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.
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                Author and article information

                Journal
                Risk Manag Healthc Policy
                Risk Manag Healthc Policy
                rmhp
                rmhp
                Risk Management and Healthcare Policy
                Dove
                1179-1594
                04 December 2020
                2020
                : 13
                : 2835-2844
                Affiliations
                [1 ]Department of Health System and Policy, Institute of Public Health, University of Gondar , Gondar, Ethiopia
                [2 ]Department of Human Nutrition, Institute of Public Health, University of Gondar , Gondar, Ethiopia
                Author notes
                Correspondence: Aysheshim Kassahun Belew Email aysheshim121@gmail.com
                Article
                277804
                10.2147/RMHP.S277804
                7723227
                33304111
                13373872-2a53-43bf-ac50-683e2871496e
                © 2020 Ashagrie et al.

                This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms ( https://www.dovepress.com/terms.php).

                History
                : 19 August 2020
                : 11 November 2020
                Page count
                Figures: 1, Tables: 5, References: 35, Pages: 10
                Funding
                Funded by: no fund;
                There was no fund for this study.
                Categories
                Original Research

                Social policy & Welfare
                community-based health insurance,dropout rate,dera district,northwest,ethiopia

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