Community Based Health Insurance scale-up as a path to Universal Health Coverage: Lessons from pilot schemes.

By Dr. Getnet Alemu

Different studies on the impact of pilot Community Based Health Insurance (CBHI) showed that CBHI members are using health services more than the non-members. Impoverishing effect of out of pocket payments on CBHI members is also much less than that of non-members. The insurance scheme has also improved the financial status of the contracted health facilities by allowing them to mobilize additional resources for the health sector. It should be noted, however, that there are different lessons that can inform the scale-up strategy of CBHI scheme from different perspectives such as health care service provision, governance and management of CBHI schemes, risk pooling, monitoring and follow up, managing complaints, collection of premium contribution and health service provision (especially the referral system), …This article articulates some of the key issues that should be considered when scaling up CBHI. 

Quality of health service provision: Health care quality, as measured by availability of medical equipment/drugs/diagnostic facilities, quality and availability of staffs, waiting time to get medical services in the contracted health facilities affects the decision to subscribe to the scheme. CBHI members complain about availability and quality of existing staffs, inadequate pharmacy services (absence of even essential drugs), lack of some diagnostic facilities even at referral hospital level as well as inadequate and non-functioning diagnostic facilities. This eventually forces CBHI members to use private health facilities and those who cannot afford private healthcare are forced to pay through dubious means that make reimbursement difficult. Evidences from household survey, key informant interview and focus group discussion showed that this has a discouraging effect on new enrolment and renewal. The government need to consider standardization of health centres in terms of health professionals, make drugs and diagnostic facilities available to make CBHI as a path to universal health coverage (UHC).

The referral system has also some problems. In some areas members can only be referred to the closest hospital and in another areas member can be referred to regional referral and federal hospitals. This needs some revisit and to make the referral system satisfactory to all members.

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Governance and management of CBHI schemes: The governance structure of CBHI includes regional steering committees and district steering committees. The CBHI scheme is housed within the district administration office. In some cases, it is also housed in district health office and also in premises rented from private landlords. The district administration pays the salary of all CBHI employees.

At scheme level there is General Assembly and the Board of Governance of the scheme elected by the general assembly. The General Assembly of the pilot district consists of kebele leaders (lowest structure of the government), two member representatives from the community of each kebele and 10 district sector offices. The main task of the assembly is to approve bylaws and annual plan of the CBHI scheme and to elect a board of the CBHI scheme management. The General Assembly elects nine members and in addition to this, there are three individuals from district government (district chief administrator, head of district health office, and district finance and development office). This board is expected to meet every quarter to review the scheme activities, review complaints of members and quality of services. This meeting used to be financed by HSFR/HFG but since 2013/14 this support was no more in place. Because of this the board in all pilot woredas is no more functional. Due to this, members from the community are reduced from 9 to 4 and in some cases there is no community representation. This is a serious concern and needs further exploration on how to bring the community on board for the management of the scheme.

The kebele structure has remained at design but non-functional at kebele level. Kebele officials are asked to collect premiums and sensitize community and make sure enrolment is always active. But they have many regular workloads and because of this they are not serious about CBHI. In addition, there is no any kinds of incentives. In fact, kebele officials are forced to incur financial costs from their pocket when they travel to district capital to deposit CBHI funds or to carry out other CBHI activities. What makes even worse is that when kebele officials participated in collecting annual land use fee and fertilizer loan, they are provided with financial incentives. This has seriously hampered CBHI activities. There is a need to establish CBHI structure at kebele level and assign at least one person whose full time activity CBHI.

Despite all these, some districts are trying to improve the uptake of CBHI by regularly engaging major stakeholders. The experience in Tehuledere district is a good example to learn from in the scale up of CBHI. In Tehulende district, employees and woreda administrators monitor each kebele performance every quarter and communicate their feedback to each kebele leaders. In addition to this, all woreda sector heads and deputies are organized in different command posts to follow up kebele activities. Each member of this command post is assigned to a specific kebele to follow up on a weekly basis. Every Friday, members of the command post meet and evaluate each other. In some cases, kebele leaders and managers are also invited in this regular evaluation meetings. This has helped the CBHI leadership to understand challenges around CBHI and to collectively come up with strategies for sensitization and mobilization of communities during renewal of subscriptions. In Tehulende district, success of the scheme can also be attributed to the fact each Kebele has a CBHI plan related to renewal and new enrolment

Each district will have between 20 and 30 kebeles and each kebele is around 800-1000 households.

The project that provide technical assistance in establishing and managing CBHI.

and kebele leaders and managers have to be evaluated against the plan. The other important lesson is that the district administration linked CBHI activities with the kebele based women development force structure. Every woman in each kebele is a member of this development structure and regularly meets to discuss health issues including CBHI. This structure is instrumental for enhancing awareness of health insurance and increasing the uptake of the scheme.

The other issues that emerges during the district visits and discussion with stakeholders is that there is no clear structural linkage between Ethiopian Health Insurance Agency (EHIA) which has branch offices all over the country and CBHI schemes. EHIA is a federal agency with a federal budget and its own employees and CBHI, as explained above, is managed by woreda administration. This is a clear gap in structurally linking the two insurance institutions.

Enhance financial sustainability of schemes: The financial sustainability of schemes seems a source of concern for significant number of schemes. Some schemes are already having negative balances, some are struggling, and some are making positive savings. Currently risk is pooled at district level and this makes districts vulnerable to financial deficits. There is a need to establish larger risk pools to have reinsurance and risk pooling among schemes. To do this, zonal and regional CBHI risk pools with clear resource contribution and expenditure assignment criteria should be established. This could gradually evolve into a national CBHI risk pool. Given that a significant number of schemes are running deficits or at least borders deficits, there is a need to revise the premium and also think of co-payment as one mechanism to improve financial sustainability both by mobilising additional money and by discouraging unnecessary visits to health facilities by members.

Monitoring and follow up system: Currently, there is no system at all levels to monitor the activity and progress of CBHI in a structured and regular fashion.. There is a need to review and strengthen the CBHI monitoring and evaluation (M&E) and management information system by taking actions that include defining the types of information required, at what level, at what time and by defining responsibilities at the federal, regional, zonal, and district levels.

Selecting indigents: In each pilot scheme the district administration is supposed to provide a fee waiver for the poorest of the poor (10% of the population). The regional state and woreda administration cover the full cost of medical expenses. Selection of indigents involves the community and this is carried out once every three years. It has been observed that some schemes do not use a transparent and participatory process to select indigents and the lists are not revised regularly yet many times people may be improved their economic status.

Managing complaints: In order to retain the existing members and to enrol new members, improving the health service provision is critical. One way of improving the service is by managing members’ complaints. Most schemes visited have no systematic mechanism for collecting and properly addressing complaints. Neither CBHI offices nor district health offices  have a systematic mechanism by which to measure CBHI member satisfaction and collect and properly address complaints about the services provided by the schemes or the contracted health facilities. Managing complaints is critical to move forward and hence there is a need to institutionalise and practice complaints management.