August, 2008 - SUPPORT Summary of a systematic review | print this article |

Do risk sharing mechanisms improve access to health services in low and middle-income countries?

The introduction of user charges in many low and middle-income countries has been proposed as a strategy to increase revenues. But delayed treatment, catastrophic health expenditures and impoverishment are among the detrimental effects attributed to them. To reduce these risks, mechanisms allowing payment of care in advance or risk pooling have been increasingly advocated.

Key messages

  • Only one study was found that describes the impact of community-based health insurance schemes in Rwanda. Based on routine data collected at facility level, it seems that the introduction of these mechanisms may have increased utilization of care. But weaknesses in the design of the study limit the scope and validity of its findings.

Who is this summary for?

This summary includes:

  • Key findings from research based on a systematic review
  • Considerations about the relevance of this research for low income countries

Not included:

  • Recommendations
  • Additional evidence not included in the systematic review
  • Detailed descriptions of interventions or their implementation

This summary is based on the following systematic review:

What is a systematic review?

A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.

SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.

Glossary of terms used in this report

Background references on this topic

Background

“Risk protection mechanisms” include community-based insurance, social or private health insurance and pre-payment schemes. They all share the particularity of involving prospective payments for health care – as opposed to payment at the point of delivery. In all of the schemes funds are collected in advance. Pre-payment schemes are individual forms of health financing and offer no opportunity for risk pooling, in contrast to community-based insurance that allows pooling across all beneficiaries of the scheme. Unlike community-based insurance, social health insurance is a compulsory scheme, whose coverage may vary from a specific large group (e.g. formal employees) to the whole population of a country. Social insurance schemes are usually mainly based on payroll contribution, from employers and employees. Increasingly support for such risk protection mechanisms has been voiced on grounds of their theoretical capacity to protect vulnerable people and alleviate financial constraints to accessing health services.

How this summary was prepared

After searching widely for systematic reviews that can help inform decisions about health systems, we have selected ones that provide information that is relevant to low-income countries. The methods used to assess the reliability of the review and to make judgements about its relevance are described here

Knowing what’s not known is important

A reliable review might not find any studies from low-income countries or might not find any well-designed studies. Although that is disappointing, it is important to know what is not known as well as what is known.

A lack of evidence does not mean a lack of effects. It means the effects are uncertain. When there is a lack of evidence, consideration should be given to monitoring and evaluating the effects of intervention, if it is used.



About the systematic review underlying this summary

About the certainty of the 
evidence (GRADE)


High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.


Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.


Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.


Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.

* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.

† Substantially different = a large enough difference that it might affect a decision.

See last page for more information.

Summary of findings

The review included one controlled before-after study that evaluated a communitybased health insurance scheme in Rwanda. Enrolment in the scheme was voluntary and allowed access to a benefit package which included all preventive and curative services provided in the health centre, including essential drugs (as listed by the Ministry of Health). The only relevant outcomes collected before and after the beginning of the programme were monthly routine data from facilities located in the intervention and control districts. Health utilization outcomes measured by utilization of all available services in health centres (curative outpatient visits, prenatal care visits, deliveries, family planning, vaccinations, laboratory, hospitalization admissions and days) and in hospitals (curative outpatient visits, curative inpatient visits, deliveries, laboratory and radological tests, hospitalisation by ward, hospitalisation days). The volume of essential drugs prescribed in health centres and hospitals was also monitored.

  • There is low quality evidence that community-based health insurance can increase utilization of health care.

Relevance of the review for low-income countries

Additional information

Related literature

This systematic review is currently in press: Lagarde M, Palmer N. The impact of risk sharing mechanisms on access to health services in low and middle-income countries. Cochrane Database of Systematic Reviews.

 

The protocol for the systematic review above: The impact of health financing strategies on access to health services in low and middle-income countries (Protocol). Cochrane Database of Systematic Reviews 2006, Issue 3.

 

This chapter summarizes the financing mechanisms of health systems: The world health report 2000 -Health systems: improving performance. Chapter 5: Who pays health systems?. Geneva: WHO, 2000. http://www.who.int/whr/2000/en/whr00_ch5_en.pdf

 

Systematic review addressing the impact of community-based health insurance: Ekman B. Communitybased health insurance in low-income countries: a systematic review of the evidence. Health Policy Plan 2004; 19:249-70.

 

Review: Creese A, Bennett S. Rural risk-sharing strategies. In: Schieber G (ed.). Innovations in Health Care Financing. Proceedings of a World Bank Conference. Washington, D.C: World Bank, 1997, pages 163-93. http://books.google.com/books?id=bDIl8bDJXe0C&printsec=frontcover

 

This summary was prepared by

García Marti Sebastían and Ciapponi Agustín. Institute for Clinical Effectiveness and Health Policy. Argentina

 

Conflict of interest

None declared. For details, see: http://www.support-collaboration.org/summaries/coi.htm

 

Acknowledgements

This summary has been peer reviewed by: Tracey Perez Koehlmoos, Bangladesh; Gabriel Rada, Chile.

 

This summary should be cited as

García Martí S, Ciapponi A. Does risk sharing mechanisms improve access to health services in low and middle income countries? A SUPPORT Summary of a systematic review. August 2008. http://www.supportcollaboration.org/summaries.htm



About certainty of evidence (GRADE)

The “certainty of the evidence” is an assessment of how good an indication the research provides of the likely effect, i.e. the likelihood that the effect will be substantially different from what the research found. By “substantially different” we mean a large enough difference that it might affect a decision. These judgements are made using the GRADE system, and are provided for each outcome. The judgements are based on the study design (randomised trials versus observational studies), factors that reduce the certainty (risk of bias, inconsistency, indirectness, imprecision, and publication bias) and factors that increase the certainty (a large effect, a dose response relationship, and plausible confounding). For each outcome, the certainty of the evidence is rated as high, moderate, low or very low using the definitions on page 3.

For more information about GRADE

SUPPORT collaborators:

The Cochrane Effective Practice and Organisation of Care Group (EPOC) is part of the Cochrane Collaboration. The Norwegian EPOC satellite supports the production of Cochrane reviews relevant to health systems in low- and middle-income countries . www.epocoslo.cochrane.org

The Evidence-Informed Policy Network (EVIPNet) is an initiative to promote the use of health research in policymaking in low- and middle-income countries. www.evipnet.org

The Alliance for Health Policy and Systems Research (HPSR) is an international collaboration that promotes the generation and use of health policy and systems research in low- and middle-income countries. www.who.int/alliance-hpsr

Norad, the Norwegian Agency for Development Cooperation, supports the Norwegian EPOC satellite and the production of SUPPORT Summaries. www.norad.no

The Effective Health Care Research Consortium is an international partnership that prepares Cochrane reviews relevant to low-income countries. www.evidence4health.org

To receive e-mail notices of new SUPPORT summaries or provide feedback on this summary, go to: www.supportsummaries.org/contact

Comments