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에티오피아의 지역사회기반 건강 보험: 보험가입, 자격갱신, 의료서비스 이용 효과
Get PDF학위논문 (박사)-- 서울대학교 대학원 : 보건대학원 보건학과, 2018. 2. Soonman Kwon.Community-Based Health Insurance in Ethiopia: Enrollment, Membership Renewal, and Effects on Health Service Utilization
Ayalneh Asmamaw Atnafu
Dept. of Health Care Management and Policy
The Graduate School of Public Health
Seoul National University
Background: Community-Based Health Insurance (CBHI) received a considerable attention as a mechanism of health care financing and a potential alternative for a user fee in many low and middle-income countries. The Ethiopian government has introduced different measures to implement pre-payment schemes including CBHI as of 2010. In this dissertation, three sub-studies were designed and implemented to explore 1) The determinants of CBHI enrollment, 2) the magnitude and factors associated with CBHI membership renewal, and 3) the association between CBHI enrollment and health service utilization in Northwest Ethiopia.
Methods: The main research design of the study was a case-comparison community based cross-sectional household survey linked to the health facility survey supplemented with a concurrent qualitative component. The study populations were all eligible households for CBHI in 15 selected clusters in five districts. A multi-stage cluster sampling was employed to obtain a representative sample for the three sub-studies. Applying a structured questionnaire, 2,008 households and 7 health centers were surveyed. Additionally, 8 focus group discussions (four with CBHI members and four with non-members) and 5 in-depth interviews were conducted to supplement the quantitative findings. A classical multivariate logistic regression, mixed-effect logistic regression, and bivariate-probit regression along with a thematic analysis of the qualitative data were used for the data analysis.
Results: The findings from the enrollment study showed that household-related factors such as age, education, self-rated health status, perceived quality of health services, household size, knowledge and information (awareness) about CBHI were the main influential factors affecting enrollment into CBHI in the study area. Additionally, participation in informal associations, such as local credit associations, and health facility factors in terms of availability of laboratory tests significantly influence probability of enrollment.
The findings from the membership renewal study showed that 36% of the participants were not willing to renew their membership for the next period. The results confirmed that once the households are enrolled in CBHI, factors related to institutional trusts, such as trust in public health facilities and trust in CBHI schemes, and inconvenience of the premium collection were the main influential factors to renew membership. Moreover, poor self-rated health status and perceived quality of healthcare services are correlated with membership renewal. Hence, there is a possibility of adverse selection with regard to CBHI enrollment and membership renewal in the study area.
The third study revealed that CBHI enrollment is positively associated with adult outpatient use, inpatient care, and sick children health services visits. CBHI membership shows 0.50 (50%), 0.22 (22%), and 0.44 (44%) points higher probability of health service visits for adult outpatient, inpatient, and sick childrens health problem in the study area, respectively.
Conclusion and recommendation: The study results in this thesis demonstrated important factors affecting CBHI enrollment and membership renewal. Moreover, it also revealed the link between CBHI enrollment and health service utilization.
Therefore, multifaceted policy interventions need to be considered before the nationwide rollout of CBHI and implementation of Social Health Insurance (SHI) in Ethiopia. Strategies such as compulsory enrollment, differential premiums, and group enrollment are essential to tackle adverse selection. Provision of continuous education and social marketing activities to increase enrollment and maintain the sustainability of the schemes are crucial. Policy interventions that enhance the capacity of health facilities and CBHI schemes to provide the promised services to the members and build trust are also necessary. Benefit package expansion and other supply-side interventions are required to strengthen the positive effect of CBHI on health care utilization.
Keywords: Adverse selection, Bivariate probit model, CBHI enrollment, Ethiopia, Health care use, Institutional trust, Membership renewal, Mixed-effect model, Mixed method
Student number: 2014-31499CHAPTER 1: INTRODUCTION 1
1.1. Backgrounds 1
1.2. Problem Statement 4
1.3. Purpose of the Study 6
CHAPTER 2: LITERATURE REVIEW 8
2.1. Health Sector Policy and Health Care Financing in Ethiopia 8
2.2. Health Insurance and CBHI Scheme in Ethiopia 10
2.2.1. Management, Participation, and Premium of CBHI 11
2.2.2. Benefit Coverage 13
2.3. Determinants of CBHI Enrollment 14
2.4. Effects of CBHI on the utilization of health services 17
2.5. Determinants of CBHI Membership Renewal Intention (Drop-Out) 18
CHAPTER 3: THEORETICAL FOUNDATIONS, OBJECTIVES, AND CONCEPTUAL FRAMEWORK OF THE STUDY 20
3.1. Theoretical Foundations 20
3.1.1. The Demand for Healthcare 20
3.1.2. The Demand for Health Insurance 21
3.1.3. Healthcare Utilization Model 22
3.2. Research Objectives 24
3.2.1 General Objective of the Study 24
3.2.2. Specific Objectives of the Study 24
3.3. Conceptual Framework of the Study 24
CHAPTER 4: DATA AND RESEARCH METHODS 28
4.1. Study Area 28
4.2. Research Methods and Design 30
4.2.1 Research Methods and Design for Objective One and Two 31
4.2.2. Research Methods and Design for Objective Three 32
4.3. Source and Study Population 32
4.3.1. Source/Target Population 32
4.3.2. Study Population 33
4.4. Sampling 34
4.4.1. Sampling and Sample Collection Procedure for Quantitative Data 34
4.4.2. Sample Size Calculation for the Quantitative Data 35
4.5. Data Collection Tools and Procedures 37
4.5.1. Quantitative Data Collection Tool 37
4.5.2. Qualitative Data Collection Tool 40
4.6. Variables of the Study 42
4.7. Independent Variables 44
4.8. Operational Definition 48
4.9. Ethical Clearance 50
CHAPTER 5-7. STUDY RESULTS 51
CHAPTER 5: ADVERSE SELECTION AND ENROLLMENT IN COMMUNITY-BASED-HEALTH INSURANCE IN NORTHWEST ETHIOPIA, A MIXED METHODOLOGY 52
ABSTRACT 53
5.1. Introduction 55
5.2. Methods 58
5.2.1. Overview of the methods and Design 58
5.2.2. Quantitative Data Analysis and Modeling 59
5.2.3. Qualitative Data Analysis 63
5.3. Results 63
5.3.1. Descriptive Findings on Enrollment in CommunityBased Health Insurance 63
5.3.2. Determinants of Enrollment in Community-Based Health Insurance 69
5.4. Discussion 77
5.5. Contributions and Limitation of the Study 81
5.6. Conclusions and Policy Recommendations 81
CHAPTER 6: FACTORS ASSOCIATED WITH WILLINGNESS TO RENEW COMMUNITY-BASED HEALTH INSURANCE MEMBERSHIP IN NORTHWEST ETHIOPIA, A MULTILEVEL ANALYSIS 83
ABSTRACT 84
6.1. Introduction 85
6.2. Methods 87
6.2.1. Overview of the Methods and design 87
6.2.2. Quantitative Data Analysis and Modeling 88
6.2.3. Qualitative Data Analysis 92
6.3. Results 92
6.3.1. Descriptive Findings on the CBHI Membership Renewal 92
6.3.2. Factors Associated with Willingness to Renew CBHI Membership 99
6.4. Discussion 107
6.5. Contributions and Limitation of the Study 110
6.6. Conclusions and Policy Recommendations 111
CHAPTER 7: THE ASSOCIATION BETWEEN COMMUNITY-BASED HEALTH INSURANCE ENROLLMENT AND HEALTH SERVICES UTILIZATION IN NORTHWEST ETHIOPIA 113
ABSTRACT 114
7.1. Introduction 115
7.2. Methods 116
7.2.1. Data Analysis and Modeling 117
7.3. Results 120
7.3.1. Descriptive Results (Annex table 16) 120
7.3.2. The Association between CBHI Enrollment and Adult Outpatient Healthcare Visit 121
7.3.3. The Association between CBHI Enrollment and Adult Inpatient Health Service Utilization 128
7.3.4. The Association between CBHI Enrollment and Sick Childrens Healthcare Visit 133
7.3.5. Summary results of the effect of CBHI enrollment on outpatient, inpatient, and sick childrens health care visits 139
7.4. Discussion 140
7.5. Contributions and Limitations of the Study 143
7.6. Conclusion and Policy Recommendations 144
CHAPTER 8: CONCLUSION AND POLICY IMPLICATIONS 145
8.1. Summary of Key Findings 145
8.1.1. The Determinants of CBHI Enrollment in Northwest Ethiopia (Sub-study 1, chapter 5) 145
8.1.2. Factors Associated With the Willingness to Renew Community-Based Health Insurance Membership in Northwest Ethiopia (sub-study 2, chapter 6) 146
8.1.3. Association Between Community-Based Health Insurance Enrollment and Health Services Utilizations in Northwest Ethiopia (sub-study 3, chapter 7) 147
8.2. Summary of Methodological Limitations and Strengths 147
8.3. Summary Contribution to the Literature 149
8.4. Policy Implications of the Study 150
9. REFERENCES 153
국문초록 161
ANNEX 165Docto
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