Achieving universal health coverage through voluntary insurance: what can we learn from the experience of Lao PDR?

BMC Health Services Research

Magnus Lindelow²  Bart Jacobs¹  Sarah Alkenbrack³ 

[1] Social Health Protection Programme (SHPP), Deutsche Gesellschaft für Internationale Zusammenarbeit, Phnom Penh, Cambodia;Human Development Department, The World Bank, Brasilia, Brazil;Futures Group, Washington, DC, USA

关键词: Enrolment;    Universal health coverage;    Voluntary health insurance;    South East Asia;    Lao PDR;    Health financing;    Risk-protection;    Community based health insurance;    Health insurance;   

Others  :  1137400
DOI  :  10.1186/1472-6963-13-521

 received in 2013-04-24, accepted in 2013-11-22,  发布年份 2013

【 摘 要 】

Background

The Government of Lao Peoples’ Democratic Republic (Lao PDR) has embarked on a path to achieve universal health coverage (UHC) through implementation of four risk-protection schemes. One of these schemes is community-based health insurance (CBHI) – a voluntary scheme that targets roughly half the population. However, after 12 years of implementation, coverage through CBHI remains very low. Increasing coverage of the scheme would require expansion to households in both villages where CBHI is currently operating, and new geographic areas. In this study we explore the prospects of both types of expansion by examining household and district level data.

Methods

Using a household survey based on a case-comparison design of 3000 households, we examine the determinants of enrolment at the household level in areas where the scheme is currently operating. We model the determinants of enrolment using a probit model and predicted probabilities. Findings from focus group discussions are used to explain the quantitative findings. To examine the prospects for geographic scale-up, we use secondary data to compare characteristics of districts with and without insurance, using a combination of univariate and multivariate analyses. The multivariate analysis is a probit model, which models the factors associated with roll-out of CBHI to the districts.

Results

The household findings show that enrolment is concentrated among the better off and that adverse selection is present in the scheme. The district level findings show that to date, the scheme has been implemented in the most affluent areas, in closest proximity to the district hospitals, and in areas where quality of care is relatively good.

Conclusions

The household-level findings indicate that the scheme suffers from poor risk-pooling, which threatens financial sustainability. The district-level findings call into question whether or not the Government of Laos can successfully expand to more remote, less affluent districts, with lower population density. We discuss the policy implications of the findings and specifically address whether CBHI can serve as a foundation for a national scheme, while exploring alternative approaches to reaching the informal sector in Laos and other countries attempting to achieve UHC.

【 授权许可】

   
2013 Alkenbrack et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

Figure 2.

【 参考文献 】

• [1]WHO: Resolution of the World Health Assembly: Sustainable Health Financing, Universal Coverage and Social Health Insurance. Resolution WHA58.33. Geneva: World Health Assembly; 2005. Available at: http://www.who.int/providingforhealth/topics/WHA58_33-en.pdf webcite. Accessed on September 1, 2013.
• [2]Rodin J, de Ferranti D: Universal health coverage: the third global health transition? Lancet 2012, 380(9845):861-862.
• [3]Carrin G, Mathauer I, Xu K, Evans DB: Universal coverage of health services: tailoring its implementation. Bull World Health Organ 2008, 86(11):857-863.
• [4]Wagstaff A: Social health insurance reexamined. Health Econ 2010, 19(5):503-517.
• [5]Ekman B: Community-based health insurance in low-income countries: a systematic review of the evidence. Health Policy Plan 2004, 19(5):249-270.
• [6]De Allegri M, Sanon M, Bridges J, Sauerborn R: Understanding consumers’ preferences and decision to enrol in community-based health insurance in rural West Africa. Health Policy 2006, 76(1):58-71.
• [7]Schneider P, Hanson K: Horizontal equity in utilisation of care and fairness of health financing: a comparison of micro-health insurance and user fees in Rwanda. Health Econ 2006, 15(1):19-31.
• [8]Jowett M, Hsiao WC: The Philippines: extending coverage beyond the formal sector. In Social Health Insurance for Developing Nations. Edited by Hsiao W, Shaw RP. Washington, DC: The World Bank; 2007:81-104.
• [9]Lieberman SS, Wagstaff A: Health Financing and Delivery in Vietnam: Looking Forward. Washington, DC: The International Bank for Reconstruction and Development/ The World Bank; 2009.
• [10]Carrin G, Waelkens MP, Criel B: Community-based health insurance in developing countries: a study of its contribution to the performance of health financing systems. Trop Med Int Health 2005, 10(8):799-811.
• [11]Ogawa S, Hasegawa T, Carrin G, Kawabata K: Scaling up community health insurance: Japan’s experience with the 19th century Jyorei scheme. Health Policy Plan 2003, 18(3):270-278.
• [12]Department of Planning and International Cooperation MoH, Lao PDR: National Health Statistic Report FY 2010–2011: Contributing to Monitor Millennium Development Goals. Vientiane: Lao PDR; 2010–2011.
• [13]UNDP: Human Development Report 2011: Sustainability and Equity: A Better Future for All. New York: United Nations Development Programme; 2011.
• [14]Messerli P, Heinimann A, Epprecht M, Phonesaly S, Thiraka C: Minot Ne: Socio-Economic Atlas of the Lao PDR – an Analysis Based on the 2005 Population and Housing Census. In.: Swiss National Center of Competence in Research (NCCR) North–South. Geographica Bernensia: University of Bern, Bern and Vientiane; 2008.
• [15]MOH Lao PDR, UNESCAP, WHO, ILO: Review of Ongoing Health Financing Reform in Lao PDR and Challenges in Expanding the Current Social Protection Schemes: Promoting Sustainable Strategies to Improve Access to Health Care in the Greater Mekong Sub-Region. Bangkok: UNESCAP; 2008.
• [16]Tangcharoensathien V, Patcharanarumol W, Ir P, Aljunid SM, Mukti AG, Akkhavong K, Banzon E, Huong DB, Thabrany H, Mills A: Health-financing reforms in southeast Asia: challenges in achieving universal coverage. Lancet 2011, 377(9768):863-873.
• [17]Powell-Jackson T, Lindelow M: Out-of-Pocket Spending and Health Service Utilization in Lao P.D.R.: Evidence from the Lao Expenditure and Consumption Surveys (Policy Note). Vientiane: World Bank, Lao P.D.R. country office; 2010.
• [18]Paphassarang C, Philavong K, Boupha B, Blas E: Equity, privatization and cost recovery in urban health care: the case of Lao PDR. Health Policy Plan 2002, 17(1):72-84.
• [19]Patcharanarumol W: Health Care Financing for the Poor in Lao PDR, PhD Thesis. London: London School of Hygiene and Tropical Medicine; 2008:117-150.
• [20]Knowles J: Public Expenditure in the Lao PDR Health Sector: Background Paper for 2006 PER. Manila: Governance, Finance and Trade Division, Mekong Department, Asian Development Bank; 2006.
• [21]Thomé J-M, Pholsena S: Chapter III: Lao People’s Democratic Republic: Health Financing Reform and Challenges in Expanding the Current Social Protection Schemes. Bangkok: UNESCAP; 2009. [Promoting Sustainable Strategies to Improve Access to Health Care in the Asian and Pacific Region] Available at: http://www.unescap.org/publications/detail.asp?id=1307 webcite. Accessed: September 1, 2013
• [22]Murakami H, Phommasack B, Oula R, Sinxomphou S: Revolving drug funds at front-line health facilities in Vientiane, Lao PDR. Health Policy Plan 2001, 16(1):98-106.
• [23]MOH: Instruction of Prime Ministerial Decree 52. Edited by Ministry of Health. Vientiane: Lao PDR; 1995.
• [24]Patcharanarumol W, Mills A, Tangcharoensathien V: Dealing with the cost of illness: The experience of four villages in Lao PDR. J Int Dev 2009, 21(2):212-230.
• [25]World development indicators [http://data.worldbank.org/data-catalog/world-development-indicators webcite]
• [26]WHO: Western Pacific country health information profiles, health system of Lao PDR. Manila: Western Pacific Regional Office; 2010. Available at: http://www.wpro.who.int/countries/lao/2010/national_health_priorities.htm webcite
• [27]Ron A, Phonvisay B, Manivong K, Jacobs B: Medicine prescribing and the provider payment method in community-based health insurance in Lao People’s Democratic Republic. WHO Essential Medicines Monitor 2010, (3):pp. 1-5.
• [28]MOH Lao PDR: Draft Health Financing Strategy, Lao PDR, 2011–2015, Department of Planning and Finance, MOH. Vientiane: Lao PDR; 2010.
• [29]Ron A: CBHI in Vientiane Capital: support to the health sector project. Edited by Agence Française de Développement (AFD). Vientiane: Swiss Red Cross; 2010.
• [30]Alkenbrack S: Health Insurance in Lao PDR: Examining Enrolment, Impacts, and the Prospects for Expansion. London: London School of Hygiene and Tropical Medicine; 2011. [PhD Thesis]
• [31]Long S, Freese J: Regression Models for Categorical Dependent Variables Using Stata. 2nd edition. College Station, Texas: Stata Press; 2006.
• [32]Filmer D, Pritchett LH: Estimating wealth effects without expenditure data–or tears: an application to educational enrollments in states of India. Demography 2001, 38(1):115-132.
• [33]Miles MB, Huberman AM: Qualitative Data Analysis: An Expanded Sourcebook. 2nd edition. Thousand Oaks, California: Sage Publications; 1994.
• [34]Binswanger HP: Attitudes toward risk: experimental measurement in rural India. Am J Agric Econ 1980, 62(3):395-407.
• [35]Krishnan P, Krutikova S: Skill Formation in Bombay’s Slums. Cambridge: Cambridge University; 2010. [Cambridge Working Papers in Economics, No 1010] Available at: http://www.econ.cam.ac.uk/research/repec/cam/pdf/cwpe1010.pdf webcite. Accessed: September 1, 2013
• [36]Jakab M, Preker A, Krishnan C, Schneider P, Diop F, Jutting J, Gumber A, Ranson K, Supakankunti S: Social Inclusion and Financial Protection Through Community Financing: Initial Results from Five Household Surveys. Washington, DC: The World Bank; 2001. [HNP Discussion Paper]
• [37]Wang H, Yip W, Zhang L, Wang L, Hsiao W: Community-based health insurance in poor rural China: the distribution of net benefits. Health Policy Plan 2005, 20(6):366-374.
• [38]Zhang L, Wang H: Dynamic process of adverse selection: evidence from a subsidized community-based health insurance in rural China. Soc Sci Med 2008, 67(7):1173-1182.
• [39]Wang H, Zhang L, Yip W, Hsiao W: Adverse selection in a voluntary Rural Mutual Health Care health insurance scheme in China. Soc Sci Med 2006, 63(5):1236-1245.
• [40]Chankova S, Sulzbach S, Diop F: Impact of mutual health organizations: evidence from West Africa. Health Policy Plan 2008, 23(4):264-276.
• [41]Jütting JP: Health Insurance for the Poor? Determinants of Participation in Community-Based Health Insurance Schemes in Rural Senegal. OECD Development Center Working Papers; 2003. [Technical Paper No 204] Available at: http://ideas.repec.org/p/oec/devaaa/204-en.html webcite. Accessed September 1, 2013.
• [42]Schneider P, Diop F: Ch. 7. Community-Based Health Insurance in Rwanda. In Health Financing for Poor People: Resource Mobilization and Risk Sharing. Edited by Preker A, Carrin G. Washington, DC: The World Bank; 2004:251-274.
• [43]De Allegri M, Kouyate B, Becher H, Gbangou A, Pokhrel S, Sanon M, Sauerborn R: Understanding enrolment in community health insurance in sub-Saharan Africa: a population-based case–control study in rural Burkina Faso. Bull World Health Organ 2006, 84(11):852-858.
• [44]Nguyen H, Knowles J: Demand for voluntary health insurance in developing countries: the case of Vietnam’s school-age children and adolescent student health insurance program. Soc Sci Med 2010, 71(12):2074-2082.
• [45]Acharya A, Lor F, Masset E, Satija A, Burke M, Ebrahim S: The impact of health insurance schemes for the informal sector in low- and middle-income countries: a systematic review. The World Bank Research Observer Advance Access; 2012.
• [46]Jehu-Appiah C, Aryeetey G, Spaan E, de Hoop T, Agyepong I, Baltussen R: Equity aspects of the National Health Insurance Scheme in Ghana: who is enrolling, who is not and why? Soc Sci Med 2011, 72(2):157-165.
• [47]Gnawali DP, Pokhrel S, Sié A, Sanon M, De Allegri M, Souares A, Dong H, Sauerborn R: The effect of community-based health insurance on the utilization of modern health care services: Evidence from Burkina Faso. Health Policy 2009, 90(2):214-222.
• [48]Annear PL, Bigdeli M, Jacobs B: A functional model for monitoring equity and effectiveness in purchasing health insurance premiums for the poor: evidence from Cambodia and the Lao PDR. Health Policy 2011, 102(2–3):295-303.
• [49]Wagstaff A, van Doorslaer E: Catastrophe and impoverishment in paying for health care: with applications to Vietnam 1993–1998. Health Econ 2003, 12(11):921-934.
• [50]Pannarunothai S, Mills A: The poor pay more: health-related inequality in Thailand. Soc Sci Med 1997, 44(12):1781-1790.
• [51]Arrow KJ: Uncertainty and the welfare of medical care. Am Econ Rev 1963, 53(5):941-973.
• [52]Basaza R, Criel B, Van der Stuyft P: Low enrollment in Ugandan Community Health Insurance schemes: underlying causes and policy implications. BMC Health Serv Res 2007, 7:105. BioMed Central Full Text
• [53]Basaza R, Criel B, Van der Stuyft P: Community health insurance in Uganda: Why does enrolment remain low? A view from beneath. Health Policy 2008, 87(2):172-184.
• [54]Bendig M, Arun T: Enrolment in Micro Life and Health Insurance: Evidences from Sri Lanka: IZA Discussion Paper No. 5427. Bonn, Germany: Institute for the Study of Labor (IZA); 2011.
• [55]Dercon S: Designing Insurance for the Poor. Washington, DC: International Food Policy Research Institute; 2007. [2020 Focus Brief on the World’s Poor and Hungry People]
• [56]Dercon S: Income risk, coping strategies, and safety nets. The World Bank Research Observer 2002, 17(2):141-166.
• [57]Gine X, Townsend R, Vickery J: Patterns of rainfall insurance participation in rural India. The World Bank Economic Review 2008, 22(3):539-566.
• [58]Syhakhang L, Soukaloun D, Tomson G, Petzold M, Rehnberg C, Wahlstrom R: Provider performance in treating poor patients–factors influencing prescribing practices in Lao PDR: a cross-sectional study. BMC Health Serv Res 2011, 11:3. BioMed Central Full Text
• [59]Wiesman D, Jütting J: The emerging movement of community based health insurance in sub-Saharan Africa: experiences and lessons learned. Africa Spectrum, Institute of African Affairs, GIGA German Institute of Global and Area Studies, Hamburg 2000, 35(2):193-210.
• [60]Hu S, Tang S, Liu Y, Zhao Y, Escobar M-L, de Ferranti D: Reform of how health care is paid for in China: challenges and opportunities. Lancet 2008, 372(9652):1846-1853.
• [61]Bennett S, Creese A, Monash R: Health insurance schemes for people outside formal sector employment. In Current Concerns: ARA Paper No 16. Geneva: World Health Organization; 1998.
• [62]De Allegri M, Sauerborn R, Kouyate B, Flessa S: Community Health Insurance in sub-Saharan Africa: what operational difficulties hamper its successful development? Trop Med Int Health 2009, 14(5):586-596.
• [63]Prakongsai P, Limwattananon S, Tangcharoensathien V: The equity impact of the universal coverage policy: lessons from Thailand. In Innovations in Health System Finance in Developing and Transitional Economies: Advances in Health Economics and Health Services Research Volume 21. Bingley: Emerald; 2009:57-81.
• [64]Tangcharoensathien V, Prakongsai P, Limwattananon S, Patcharanarumol W, Jongudomsuk P: Achieving Universal Coverage in Thailand: What Lessons Do We Learn?: Social Science Research Network Working Paper. 2007. Available at SSRN: http://ssrn.com/abstract=1111870 webcite or http://dx.doi.org/10.2139/ssrn.1111870 webcite. Accessed September 1, 2013.
• [65]Frenk J, González-Pier E, Gómez-Dantés O, Lezana MA, Knaul FM: Comprehensive reform to improve health system performance in Mexico. Lancet 2006, 368(9546):1524-1534.
• [66]Savedoff WD, de Ferranti D, Smith AL, Fan V: Political and economic aspects of the transition to universal health coverage. Lancet 2012, 380(9845):924-932.
• [67]Lagomarsino G, Garabrant A, Adyas A, Muga R, Otoo N: Moving towards universal health coverage: health insurance reforms in nine developing countries in Africa and Asia. Lancet 2012, 380(9845):933-943.