hiv-sensitive community based health insurance

8/23/2019 HIV-Sensitive Community Based Health Insurance

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HIV-Sensitive Community Based Health Insurance

Social Protection and HIV Series

Community Based Health Insurance

Social Protection and HIV series

HIV-Sensitive Community Based

Health InsuranceJ o Kaybryn

Plurpol Consulting

April 2013


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HIV-sensitive Community Based Health Insurance

A briefing paper on key issues related to ensuring community based health

insurance is relevant and sensitive to people living with HIV and households

affected by HIV.

ContentsDefining community based health insurance ...................................................................... 3

Why are HIV treatments often excluded from CBHI? ......................................................... 3

Ensuring community based health insurance schemes are HIV-sensitive ....................... 4

Automatically include people living with HIV as eligible ................................................ 4

Ensure confidentiality for people living with HIV who are categorically included .... 4

Eliminate HIV exclusions in coverage ................................................................................. 5

Case study: Rwanda................................................................................................................. 6

National policies .................................................................................................................... 6

Special adaptations for people living with HIV ................................................................ 6

Impact for people living with HIV ....................................................................................... 7

Specific outcomes for people living with HIV ................................................................... 7

Broader health impacts ........................................................................................................ 7

Towards Universal Healthcare Coverage in Uganda ..................................................... 8

Community based health insurance schemes in selected countries .............................. 9

Bibliography .............................................................................................................................. 11

J o Kaybryn

Plurpol Consulting

April 2013

www.plurpol.org


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Defining community based health

insuranceThe term community based health

insurance usually refers to a health financing

scheme that is not-for-profit and is aimed

primarily at the people working in the

informal sector and people living in poverty.

Community based health insurance schemes

are formed on the basis of providing mutual

assistance (among the members), the

collec tive pooling of health risks, and

members participation in their

management. Like many insurance

schemes, membership is voluntary and

enrolees pay a regular premium to

participate. In order to ensure that the most

vulnerable members of soc iety are included,

premiums are sometimes discounted or paid

in full by other sources (e.g. the government

or external international donors) for those that

cannot afford them.

Why are HIV treatments often

excluded from schemes?Community based health insurance often

covers a package of healthcare which

equates to a limited range of services rather

than comprehensive cover for all healthcare

needs. The coverage and non-coverage of

services varies between countries and

schemes, particularly where policy initiatives

to increase services to reach Universal

Healthcare C overage have not yet been

implemented. For example, the Kisiizi scheme

in Uganda covers outpatient care and

inpatient care in a general ward bed with no

annual limit on the number of visits a person

can make. However it excludes the provision

of eye glasses, ambulance call outs,cosmetic dental care, referrals to other

hospitals, self-inflicted injuries and normal

deliveries: these services need to be paid for

by the patient (Musau, 1999). Chogoria in

Kenya and Mburahati in Tanzania are

examples of schemes that have HIVexclusions (Musau, 1999). In Senegal, none

out of ten schemes surveyed included HIV

and AIDS related services, and 6 out of 8

schemes in Ghana included HIV but only

preventative care (Rijneveld, 2006).

The reason that HIV and other illnesses and

conditions are sometimes excluded from

schemes is the implementers are attempting

to avoid adverse selection. Adverseselection occurs when people with higher

risk (i.e. increased likelihood of utilising

services and increased likelihood of utilising

more expensive services) join a scheme and

the overall costs of providing services

increases. This impacts on premiums and

deters people with lower risk from joining.

However, community based health insurance

schemes can often be used as a referralpoint to help people access services which

specifically provide treatment and care for

HIV and other diseases. In the case of HIV

treatment, many countries have vertical

systems in place which ensure that HIV

treatment is provided free of charge

nationa lly. In these situations the exclusion of

HIV related services in community based

health insurance need not nec essarily have

adverse effec ts on people living with HIV if

there is effective management of and

referral to complementary services. As

countries move towards Universal Healthcare

Coverage, the vertical nature of services is

often gradually dismantled and re-

established in more horizontal programming

approaches. As HIV prevalence declines,

HIV related treatment and care pose a

reduced threat overall to adverse selectionas fewer people require expensive or long

term interventions.


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Ensuring community based health

insurance schemes are HIV-

sensitiveAutomatically include people living

with HIV as eligible

Many schemes are targeted at the very poor

who usually need to be assessed in some

measurable way to identify them as eligible.

For example, in India people who have BPL

(Below Poverty Line) status are automatically

included in the Rashtriya Swasthya Bima

Yojanaby (RSBY) health insurance scheme(UNDP, 2011), while in Cambodia household

poverty levels are categorised through the

IDPoor (Identification of Poor Households).

programme.

Soc io-economic impact studies regularly

show that households affected by HIV have

lower incomes and lower earning capacities

and other economic profile characteristics

that put them at a disadvantage such asbeing less likely to own their own home and

more likely to have liquidated their assets and

used up their savings, often for the purposes

of paying for healthcare but also for other

general expenditure as a result of loss of

income (Cercone, et al., 2011).

At the time of a periodic (3-yearly in

Cambodia and 5-yearly in India) soc io-

economic survey to determine eligibility for asoc ial protec tion scheme such as community

based health insurance, a number of

households affected by HIV may not qualify

for inclusion. However these households are

vulnerable to health and economic shocks;

and their circumstances could decline at any

time. In order to reduce their vulnerability,

policy makers can choose to make all

households affected by HIV automatically

eligible for community based health

insurance schemes regardless of their current

socio-economic status.

Ensure confidentiality for people livingwith HIV who are categorically

included

In some schemes qualifying individuals and

households are issued with an identification

card or certificate directly related to the

service they are eligible for. If the reason a

person qualifies for a service is not identified

on the card then a certain amount of the

cardholders confidentiality and privacy can

be upheld. A well-meaning scheme in Asia,

which provided subsidised transport to

people with chronic illnesses, printed the

nature of the patients illness on the transport

ID card. Regardless of the persons illness,

they should not be forced to disclose

personal information to everyone that they

are required to display the card to in order to

access the service.

In the case of illnesses and diseases that are

still accompanied by high levels of stigma

and discrimination, such as HIV, the disclosure

of a persons health status can have severely

negative consequences if the person they

are displaying it to reacts poorly, rejects them

or even behaves violently towards them.

Where a scheme issues an identification c ard

that is specific to the identification process,

such as a BPL card in India or IDPoor card in

Cambodia, the individual or household

needs to present this to the service such as a

health fac ility to gain access to the services

required. If this is the only mechanism that a

household can use, it makes it logistically

difficult to issue such the same card to a

categorical group, such as people living with

HIV, if they do not qualify as poor. In the

case of Cambodia, households can also beissued with a Health Equity Card which gives

them ac cess to hea lth services: such a card


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can be issued to anyone who qualifies and

not only poor households or households

affected by HIV. Such a card allows access

to services without disclosing the reason forthe cardholders eligibility.

Eliminate HIV exclusions in coverage

As discussed above, it is important that risk

and costs of schemes are spread and that

adverse selection is avoided. HIV exclusions

are likely to be included in schemes in

countries that have a generalised HIV

epidemic (above 1% prevalence among the

population aged 15-49) where the financialcosts to providing health care to people

living with HIV are perceived to be high

enough to pose a threat to the viability and

sustainability of a scheme. HIV exclusions are

also seen in schemes in countries where HIV

treatment is already provided free of charge

or at subsidised rates. For example,

antiretroviral therapy is often already

mandated by law and policy so community

based health insurance schemes may not

see a need to provide HIV treatment as well.

While potentially expensive to begin with, the

example below of Rwanda shows the

significant long term impacts of community

based health insurance on reducing HIV

prevalence. In reality many community

based health insurance schemes are

subsidised by the national government or

external international donors in their first

years, particularly if they are implemented aspilots. Such subsidies should be considered in

costing the schemes and in conjunction with

each national contexts current or potential

transition from vertical to horizontal HIV

programming and funding, with a few to

ensuring coverage for HIV related services in

future iterations of community based health

insurance schemes.


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Case study: RwandaThe following example shows the evolution

and impacts of a concerted effort to

introduce c ommunity based health insurance

in Rwanda.

Rwanda, with a population of approximately

10 million, has a generalised HIV epidemic:

2011 prevalence is 2.90% [estimated low

2.60% - estimated high 3.50%] among the

population aged 15-49 (UNAIDS, 2013). Over

90% of people work in the informal sector and

45% of the population is living below thepoverty line (Nsanzimana, 2012). Rwanda

faced serious health challenges: in 1999 HIV

prevalence among the population aged 15-

49 was approximately 12% and utilisation of

health services was low (0.3 per pc /year);

there were significant financial barriers to

accessing health services; the health care

and services were of low quality with poorly

motivated staff; and the system was reliant

on vertical programmes (for HIV, TB etc.) andsuffered from a lack of integration

(Kagubare, 2010). The Government of

Rwanda introduced three major health

reforms, one of which was community based

health insurance. The other two were

performance based financing and quality

assurance.

National policies

A community based health insurance pilot

was introduced in 2000; policy debates and

adaptations followed and the pilot was

scaled up in 2004 (Nsanzimana, 2012). In

December 2004, the Government adopted a

national policy on the development of

mutual health organisations and a special

unit to deal with these mutuelleswas set up

within the Ministry of Health, the C TAMS

(Cellule technique dappui aux Mutuelles deSant). Standardisation of the structure and

organisation of the district-level mutual health

organisations (remuneration of personnel

etc.) have been consolidated through the

promulgation of Law No. 62/2007 of the

30/12/2007 on the Creation, Organisation,

Functioning and Management of Mutual

Health Organisations. In April 2010, new

Community Based Health Insurance policy

reforms were introduced to increase

solidarity, equity and sustainability

(Nsanzimana, 2012).

Special adaptations for people livingwith HIV

The premium for people living with HIV was

changed to the same rate as the premium

for indigents and orphans (USD 3.6) and not

at USD 13.5 as originally calculated.1 This

served as a strategy to treat people living

with HIV in the same way as other groups in

order to avoid stigmatisation, but was also

made possible because the costs of

treatment for HIV patients were ultimately not

considered higher than for other patients due

to the large number of existing vertical

programs providing additional funds for HIV-

related treatment (Kalavakonda, et al.,

2007).

The GFATM HSS Project2 paid the premium for

both the minimum and the complementary

package of ac tivities for indigents, orphans

and people living with HIV (RwF 1,000 for the

minimum package and RwF 1,000 for the

1 The membership fee for people living with HIVdecreased from USD 13.5 to USD 3.6, as it wasagreed that additional cost of treating HIV/AIDS

positive will be financed from other sources ratherthan using the insurance proceeds.2 Global Fund for AIDS TB & Malaria Health SystemsStrengthening Project


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complementary package as of 20073).

(Kalavakonda, et al., 2007)

Impact for people living with HIVAc cording to its evaluation, the GFATM HSS

Projec t contributed to increasing health

insurance coverage (i.e., number of people

insured) and exceeded expectations in the

coverage of indigents and people living with

HIV/AIDS. Against the cumulative target (i.e.,

year 1 and 2 combined) of 1,530,745

indigents/very poor the achievement was

1,574,306. Similarly, in the case of PLWHA

against a target of 76,074 for year 1 and 2

combined the achievement was 276,535

(Kalavakonda, et a l., 2007).

The project monitors HIV and TB to show that

through strengthening the health system as a

whole, HIV, TB and malaria can be effectively

addressed. Deaths at health centres related

to HIV decreased from 1.57% in 2005 to 0.2%

in June 2007 positively exceeding the target

set at 0.8% (Kalavakonda, et a l., 2007).

HIV has been mainstreamed (along with the

promotion of sexual and reproductive health

and gender and gender-based violence in

all areas) through initiatives such as Primary

Health Care and Combating HIV/AIDS,

commissioned by GIZ and led by the Rwanda

Ministry of Health (GIZ, 2013). Results so far

include the fact that 96 per cent of theRwandan population have health insurance,

and 91% are covered by community based

health insurance (Nsanzimana, 2012). Health

service utilisation has increased to 0.7 per

pc/year (Kagubare, 2010).

3 US Dollar USD 1 = Rwandan Francs RwF 555 at2007 exchange rates

Specific outcomes for people living

with HIV

Outcomes related to health insurance andHIV management include:

1. Morbidity and mortality among peopleliving with HIV are significantly reduced

(Nsanzimana, 2012)

2. The incidence of HIV has reduced from12% in 1998 to 2.8% in 2011 among the

population aged 15-49 (Kagubare, 2010).

3. 81% of all hea lth facilities offer voluntarycounseling and testing for HIV (Kagubare,2010).

4. 74% of pregnant women receiveantiretroviral therapy prophylaxis as part

of prevention of mother to child

transmission (PMTCT) programmes

(Kagubare, 2010).

5. 47% of hea lth facilities offer antiretroviraltherapy services (217/464) (Kagubare,

2010).

6. 85% of adults and children (of those inneed) are accessing antiretroviral

therapy (Kagubare, 2010).

Broader health impacts

Broader health impacts were noted in

comparisons between the 2005 and 2007 DHS

data: a reduction in the total fertility rate

(from 6.1 to 5.5); modern contraceptive

prevalence among married women

increased from 10% to 27%; increase births

attended by a skilled attendant from 39% to

52%; under-five mortality reduced from

152/1,000 to 103/1,000; infant mortality

declined from 82/1,000 to 62/1,000; and

vaccination coverage (against measles for

children aged 12-13 months) increased from

75% to 90% (Kagubare, 2010). Out-of-pocket

spending for health has been reduced from

28% to 12% of total health expenditure(Makara, et al., 2012).


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Towards Universal Healthcare

Coverage in Uganda

A number of factors facilitated the movetowards Universal Coverage in Rwanda

(Nsanzimana, 2012).

1. A conducive legislative and policyenvironment included a legal

framework for health insurance

implementation and mandatory

coverage under an insurance scheme

for all Rwandans (Law N 62/2007 of

30/12/2007). Health insurance wasestablished as a government priority in

Vision 20/20, the Economic

Development and Poverty Reduction

Strategy (EDPRS) and the Health

Sector Strategic Plan (HSSP). These

legal and policy frameworks were

accompanied by strong political

commitment and leadership to attain

universal coverage, for example

through the implementation of thesubsidy to cover all indigents under

community based health insurance

schemes.

2. The management of the nationalhealth insurance system had been

decentralised since 2006 which

balanced the proximity of the

community based health insurance

scheme and risk-pooling. Two parts of

the system have distinct functions in

relation to the scheme. The CBHI

Sec tion facilitates member

rec ruitment and increases

subscriptions by enhancing the

capacities of mobilisation committees

in villages, cells and sectors. The C BHI

District (union of CBHIs) enlarges the

risk pool for high risk events (i.e. those

that require district hospital care) and

enhances the capacities of sections

through training/ supervision and

adequate resources.

3. Strong local support for insurancecoverage saw the introduction of

performance contrac ts between the

President and District Mayors which

include insurance coverage as one of

the performance indicators;

Communities had an active role in themanagement of the schemes through

representation and membership

mobilisation in villages. The existing

national ID system and wealth

categorisation was used as a basis for

calculating premium contributions.

District Accountability Days provided

the opportunity for public dialogue,

annual audits and regular reporting.

Challenges remain and there is still work to be

done to increase the technical capac ity of

community based health insurance scheme

managers, in the establishment of a

regulatory body, and in improving the

ac curacy and frequency with which the

socio-economic impact database is

updated. The equitable distribution of

resources between poor and rich districts

needs improving as do solutions for patientroaming and the participation of the private

sec tor. However, overall three important

outcomes can be seen in improved ac cess

to health for all, increased early consultation

and reduced morbidity and mortality

(Nsanzimana, 2012).


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Community based health insurance schemes in selected countries

Community based health insurance schemes and coverage

Bolivia Universal Mother and Child Insurance Scheme (Seguro Universal Materno Infantil,SUMI): Technically, SUMI is not an insurance scheme, but rather a health financingmechanism that offers a package of free services provided universally, which thepopulation can access through all public health service providers. As of 2008.(Switlick, 2010)

Cambodia 13 CBHIs run by a variety of local and international NGOs, under guidelinesdeveloped by Ministry of Health, as of 2012. CBHIs operate largely in areas that

are not covered by Health Equity Funds: a scheme which costs very poor peoplenothing to ac cess a minimum package of healthcare and providesreimbursements and subsidies for related costs such as transport and food.Health Equity Funds are currently operational in 50 health districts, as of 2012.(Kaybryn, 2013)

Colombia Health Promotion Enterprises (EPS), covers those with the ability to contribute andis financed through employer and employee contributions through a tax of 12%of income (formal and informal workers may opt in). One-twelfth of these fundsare used to finance the subsidized scheme, called the Subsidized SystemAdministrator (ARS). Members of the ARS also contribute resources on a sliding

scale based on income and some beneficiaries contribute nothing. As of 2010.(Switlick, 2010)

Ghana 42% of population covered by community based health insurance as of 2007.(Switlick, 2010)

India Rashtriya Swasthya Bima Yojana (RSBY) is for workers engaged in the informalsector and belonging to BPL category and their family members (head ofhousehold, spouse and up to three dependents) are eligible to becomemembers with no age limit. Five Indian states have started delivering the RSBYservices to their enrolees while nine others have started the enrolment; 8 have

initiated the tendering process. By the end of May 2009, about six million peoplewere enrolled and 4.60 million smart cards were issued. (Durairaj, et a l., 2010)

Kenya Small jamiibora sacco scheme, as of 2009. (Kimani, 2009)

Mali In Phase 1 roll-out of the standardised nationa l CBHI strategy in 3 out of 8 of Malisregions (Sikasso, Sgou and Mopti). The targeted number of beneficiaries in thisfirst phase is approximately 1.2 million people, or about 40% of the targetpopulation in the three regions. First phase is 3 years from 2011, aims to produce150 mutuelles in 21 health districts. As of 2012. (Mbengue, et al., 2012)

Myanmar Myanmar has begun piloting a community-based health insurance in onetownship and will expand its Social Security Scheme to cover the mostdisadvantaged, as of 2013. (Quick, 2013)


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Nigeria CBHI: Owned and run by the community.

Shongai community and market women in Lagos paid by the Dutch government

through Hygeia HMO, as of 2009 (Namadi, 2009).15,000 beneficiaries in Katsina State, as of 2012. (This Day Live, 2012)

Ikosi-Isheri Mutual Health Plan (MHP) was established in 2008 in Lagos Stage by theState Ministry of Health (MOH), one loc al government area (LGA), and threecommunities (Health Finance Nigeria, 2011). Members pay a monthly fee of 400Naira (US$2.49) for single people and 800 Naira (US$4.97) for a family of six. Thisfee covers consultation, antenatal care, and basic healthcare services. Enroleespay directly for referrals and higher-level care. The MHP is heavily subsidised bythe State MOH and the local government agency.

The Hygeia Community Health Plan (CHP) in Kwara State is based on a managed

care system similar to a health maintenance organisation (Health FinanceNigeria, 2011). It uses a network of public and private health facilities to providecomprehensive health services. The benefit package covers inpatient andoutpatient visits, hospital care, consultation with spec ialists, provision ofprescribed drugs, laboratory and diagnostic tests, radiology, and treatment ofHIV/AIDS, malaria, and tuberculosis. The plan introduced one scheme in 2007 anda second one in 2009. Both schemes focus on rural farmers.

Rwanda 91% coverage among population, as of 2011. (Nsanzimana, 2012)

Tanzania Covers rural informal sector and is managed by local government agenc ies (5-6%

of population), as of 2009. (Mikongoti, 2009)

Uganda 33 schemes, 120 000 beneficiaries over 9 districts out of 80 districts, as of 2009.Benefit package: OPD, IPD. Exclusions: referrals, chronic diseases, self-inflictedinjuries, eye care. (Nyanzi, 2009)


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hiv-sensitive community based health insurance

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