factors that affect uptake of community-based health insurance in low and middle-income countries

163 Pages·2014·1.81 MB·English

FACTORS THAT AFFECT UPTAKE OF COMMUNITY-BASED
HEALTH INSURANCE IN LOW AND MIDDLE-INCOME
COUNTRIES: A SYTEMATIC REVIEW

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A mini-dissertation submitted to the University of Cape Town in partial
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fulfillment of the requirements for the Caward of the degree of Master of

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Public Health (Health Systems)

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Student name: Esthevr Adebayo
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Student numberU: ADBEST001

Supervisors: Prof. Charles Wiysonge and Dr John Ataguba
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The copyright of this thesis vests in othe author. No
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quotation from it or information derived from it is to be

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published without full acknowledgement of the source.
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The thesis is to be used fora private study or non-
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commercial research purposes only.

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Published by the Universyity of Cape Town (UCT) in terms
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of the non-exclusive liciense granted to UCT by the author.
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Part 0: Preamble
Declaration
I, Esther Adebayo, hereby declare that the work on which this dissertation is based is my original
work (except where acknowledgements indicate otherwise) and that neither the whole work nor
any part of it has been, is being, or is to be submitted for another degree in this or any other
university.
I empower the university to reproduce for the purpose of research either the whole or any portion
of the contents in any manner whatsoever.
Signature Removed
SIGNATURE: ______ ________
DATE: __13TH of February 2014_______________
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Dedication
I dedicate this work to God Almighty for his faithfulness, love and mercy; and to my Dad who
passed on to glory during this research, for his constant encouragement and for being my hero.

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Thesis abstract
The systematic review undertaken for this MPH assesses the existing evidence for factors that
affect uptake of community-based health insurance in low and middle-income countries.

Part A is the review protocol which outlines the background, problem statement and process of
the review. Search strategies combined related terms for uptake, enrollment and health insurance.
Inclusion criteria were expanded enough to include a broad range of study designs, given the
heterogeneity of outcomes and the absence of randomized control trials (RCTs). Search records
were screened by two researchers, as were selected full articles. These were evaluated using the
STROBE checklist, a quantitative study assessment tool for observational studies.
Part B provides details on the background of the systematic review by exploring the existing
theoretical and empirical literature around the topic. It describes community financing and health
care financing in low and middle-income countries and the future of community-based health
insurance. It also explores community-based insurance and social capital, socio-demographic
factors and health related variables and how it affects enrollment, a generic conceptual
framework of analysis was also given. Community-based health insurance and equity was also
described, effectiveness and limitation of the scheme were studied and then an overview of a
selected number of community-based health insurance schemes in Asia and Africa was
presented.
Part C presents the full systematic review in a format appropriate for journal submission. The
background and method of the review is summarized and the results are presented and discussed
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Acknowledgement
Firstly, great thanks to God Almighty the giver and keeper of all good things. There is no single
man on earth who has the monopoly of knowledge and to the process of attaining a level of
success, certain ladder of human support need to be climbed. It is therefore appropriate to
express the word of “thanks” to all those who in one way or the other contributed to the
successful completion of this research.
To my Parents Prince and Mrs. Adeyemi Adebayo for their unwavering support in helping me
achieve my dream. An ocean full of thanks to the entire Shero’s and Hero’s of the Adebayo’s for
their support, spiritually, financially, emotionally and for being there for me. You all are the
sweetest siblings ever.
A mountain of thanks to my “bestest” gift from God Ben Olaoluwa Abikoye for his prayers,
encouragement and love during this research work
My unquantifiable appreciation goes to the best supervisors (Prof. Charles Wiysonge and Dr
John Ataguba); one could ever wish or pray for, for their guidance, patience, hard work,
dedication, support, capacity building and ever confident in me.
My appreciation goes to Mary Shelton for her guidance and assistance during this research;
VACFA team for your help throughout this research and to the University of Cape Town for
partially funding this research.
My profound gratitude goes to Rebecca Dwommoh for her prayers, counsel, and encouragement
and for being a true friend. To my friend, sister and confidant Ibukun Adepoju, thank you for
being there and for believing in me. Finally, to Mr. Francis Agbo thank you for being a true
mentor, boss, pastor and friend.

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Table of Content
Part 0: Preamble ............................................................................................................................ i
Declaration ..................................................................................................................................................... i
Dedication ..................................................................................................................................................... ii
Thesis abstract .............................................................................................................................................. iii
Acknowledgement ....................................................................................................................................... iv
Table of contents ………………………………………………………………………………….v
List of Tables ............................................................................................................................................. viii
List of Figures …………………………………………………………………………………...ix

Part A: Study Protocol ................................................................................................................. 1
Protocol Abstract .......................................................................................................................................... 2
1.0 Background ............................................................................................................................................. 4
1.1 Problem statement ................................................................................................................................... 6
1.2 Description of the condition .................................................................................................................... 8
1.3 How the intervention might work ........................................................................................................... 9
1.4 The importance of conducting this review ............................................................................................ 10
1.6 Methods................................................................................................................................................. 12
1.7 Selection of studies ............................................................................................................................... 16
1.8 Data extraction and management .......................................................................................................... 16
1.9 Assessment of studies ........................................................................................................................... 17
2.0 Expected significance of the review ..................................................................................................... 19
2.1 Ethics .................................................................................................................................................... 19
References ................................................................................................................................................... 20
Appendix 1: PUBMED .............................................................................................................................. 25
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Appendix 2: Other electronic databases ...................................................................................................... 27

Part B: Literature Review .......................................................................................................... 32
2.0 Introduction ........................................................................................................................................... 33
2.1 Overview of community financing ....................................................................................................... 33
2.2 Health care financing in low and middle-income countries .................................................................. 36
2.3 The emergence of community-based health insurance ......................................................................... 38
2.4 Community based health insurance and social capital .......................................................................... 40
2.5 Community-based health insurance scheme and social protection programmes .................................. 42
2.6 The future of community based health insurance ................................................................................. 44
2.7 Community-based health insurance and factors that influence its uptake ............................................ 45
2.8 Framework for analysis ......................................................................................................................... 47
Figure 1: Generic conceptual framework for analyzing uptake of CBHIs ................................................. 50
2.9 Community-based health insurance and equity .................................................................................... 51
3.0 Effectiveness of community-based health insurance ............................................................................ 55
3.1 Drawbacks of community-based health insurance ................................................................................ 59
3.2 Community-based health insurance in Asia and Africa ........................................................................ 61
3.3 Discussion ............................................................................................................................................. 66
3.4 Conclusion ............................................................................................................................................ 68

Part C: Journal Manuscript ...................................................................................................... 82
Abstract ....................................................................................................................................................... 83
3.0 Introduction ........................................................................................................................................... 85
3.2 Methods................................................................................................................................................. 92
3.3 Selection of studies ............................................................................................................................... 96
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3.4 Data extraction and management .......................................................................................................... 96
3.5 Assessing the risk of bias ...................................................................................................................... 97
3.6 Dealing with missing data ..................................................................................................................... 97
3.7 Presenting and reporting of results ........................................................................................................ 97
3.8 Results ................................................................................................................................................... 98
3.9 Discussion ........................................................................................................................................... 115
4.0 Limitations .......................................................................................................................................... 117
4.1 Conclusion .......................................................................................................................................... 117
Appendix 1: PUBMED ............................................................................................................................. 124
Appendix 2: Other electronic databases .................................................................................................... 126
Appendix 3: Excluded studies and reason for exclusion .......................................................................... 130
Appendix 4: Data Extraction Form ........................................................................................................... 131
Appendix 5: STROBE Statement ............................................................................................................. 140
Appendix 6: Authors Guideline ................................................................................................................ 142
Appendix 7: Plagiarism Declaration ......................................................................................................... 152

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List of Tables
Part B: Literature Review
Table 1: Social capital and network links ..................................................................................... 41
Table 2: Characteristics and the key areas of consideration of CBHI .......................................... 53
Table 3: Overview of factors influencing the effectiveness of community based health insurance
within the health financing sub functions ..................................................................................... 58
Table 4: Limitations of community based health insurance scheme within the sub functions of
health financing. ............................................................................................................................ 60
Table 5: An overview of a selected community-based health insurance in Asia and Africa ....... 62
Part C: Journal Manuscript
Table 1: Summary results for socio-demographic factors .......................................................... 102
Table 2: Summary results for health-related and other factors ................................................... 106
Table 3: Characteristics of quantitative studies that met inclusion criteria ................................ 107
Table 4: Characteristics of qualitative studies that met inclusion criteria .................................. 109
Table 5: Findings of quantitative studies .................................................................................... 110
Table 6: Findings of qualitative studies……..…………………………………...…..................113

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