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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
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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HIV-Sensitive Community Based Health Insurance
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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HIV-Sensitive Community Based Health Insurance
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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HIV-Sensitive Community Based Health Insurance
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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HIV-Sensitive Community Based Health Insurance
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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HIV-Sensitive Community Based Health Insurance
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
April 2013
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