Understanding the limitations of “quasi‐mandatory” approaches to enrolment in community‐based health insurance: Empirical evidence from Tanzania

In recent decades, a growing number of low‐income countries (LICs) have experimented with voluntary community‐based health insurance (CBHI), as an instrument to extend social health protection to the rural poor and the informal sector. While modest successes have been achieved, important challenges remain with regard to the recruitment and retention of members, and the regular collection of membership fees. In this context, there is a growing consensus among policymakers that there is a need to experiment with mandatory approaches towards CBHI. In some localities in Tanzania, local actors in charge of community health funds (CHFs) are now relying on what is best described as quasi‐mandatory enrolment strategies, such as increasing user fees for non‐members, automatically enrolling beneficiaries of cash transfer programmes and enrolling the exempted groups (people who are entitled to free healthcare). We find that, while these quasi‐mandatory enrolment strategies may temporarily increase enrolment rates, dropout and the non‐payment of contributions remain important problems. These problems are at least partly related to supply side issues, notably to inadequate benefit packages. Overall, these findings indicate the limitations of any strategy to increase enrolment into CBHI, which is not coupled to clear improvements in the supply and quality of healthcare.     

Implementation of Community Health Fund in Tanzania: why do some districts perform better than others?

In early 1990s, Tanzania, like other African countries, introduced user fees in public health systems. Although user fees were considered important in promoting health, they appear to reduce people's access to health services. To counteract the detrimental effects of the user fees, various types of health insurances were introduced, including the Community Health Fund (CHF). Drawing from the review of minutes, health facility visits and key informant interviews, this study explored why implementation of the CHF in Tanzania has been more successful in some districts than in others. The findings indicate that in Lindi district, the enrolment rate for the CHF was very low. This was attributed to high premium rates, frequent drug stock‐out, lack of trust by the community members to the health providers, low incentives and local politics. In contrast, in Iramba district, the performance was better. Availability of drugs in the health facilities, effective supervision, commitment of the top district‐level officials and incentives to the health facility committees were the main factors that facilitated good performance of the fund in Iramba district. The focus of the implementation needs to be placed on the active engagement of the local‐level leaders and politicians who are responsible for the implementation of the policy. Equally important is the availability of quality health services in the health facilities. Copyright © 2013 John Wiley & Sons, Ltd.     

Provision and remuneration of psychotherapeutic services in Switzerland

OBJECTIVES: To establish the number of psychotherapists with professional backgrounds; psychotherapeutic provision and its cost; change in cost in case of integration of non-medical psychotherapy into the mandatory minimum health care benefit. METHODS: A population-based survey using computer-assisted telephone interviews in a randomly selected sample of medical and non-medical psychotherapists (NMP), stratified by professional status and language regions. RESULTS: 1,633 psychiatrists, 2,332 general practitioners and 2,616 NMP provide psychotherapy in Switzerland. NMP by training: 1,674 (64%) hold a university degree in psychology; 539 (21%) hold a professional school degree in psychology; and 403 (15%) have various backgrounds. In 2000, 146,000 patients utilised 4.52 million hours of medical psychotherapy, which cost CHF 579 million, CHF 396 million of which were reimbursed by mandatory health insurance (MHI). Reimbursement of NMP by MHI would result in additional expenditures of CHF 102-252 million. CONCLUSIONS: NMP provide 46% of psychotherapy which is currently partly reimbursed by the MHI. An integration of NMP into the MHI benefit package would incur additional costs to MHI of CHF 102-252 million.     

A community-based approach to non-communicable chronic disease management within a context of advancing universal health coverage in China: progress and challenges

Paralleled with the rapid socio-economic development and demographic transition, an epidemic of non-communicable chronic diseases (NCDs) has emerged in China over the past three decades, resulting in increased disease and economic burdens. Over the past decade, with a political commitment of implementing universal health coverage, China has strengthened its primary healthcare system and increased investment in public health interventions. A community-based approach to address NCDs has been acknowledged and recognized as one of the most cost-effective solutions. Community-based strategies include: financial and health administrative support; social mobilization; community health education and promotion; and the use of community health centers in NCD detection, diagnosis, treatment, and patient management. Although China has made good progress in developing and implementing these strategies and policies for NCD prevention and control, many challenges remain. There are a lack of appropriately qualified health professionals at grass-roots health facilities; it is difficult to retain professionals at that level; there is insufficient public funding for NCD care and management; and NCD patients are economically burdened due to limited benefit packages covering NCD treatment offered by health insurance schemes. To tackle these challenges we propose developing appropriate human resource policies to attract greater numbers of qualified health professionals at the primary healthcare level; adjusting the service benefit packages to encourage the use of community-based health services; and increase government investment in public health interventions, as well as investing more on health insurance schemes.     

Impact of packaged interventions on neonatal health: a review of the evidence

A disproportionate burden of infant and under-five childhood mortality occurs during the neonatal period, usually within a few days of birth and against a backdrop of socio-economic deprivation in developing countries. To guide programmes aimed at averting these 4 million annual deaths, recent reviews have evaluated the efficacy and cost-effectiveness of individual interventions during the antenatal, intrapartum and postnatal periods in reducing neonatal mortality, and packages of interventions have been proposed for wide-scale implementation. However, no systematic review of the empirical data on packages of interventions, including consideration of community-based intervention packages, has yet been performed. To address this gap, we reviewed peer-reviewed journals and grey literature to evaluate the content, impact, efficacy (implementation under ideal circumstances), effectiveness (implementation within health systems), type of provider, and cost of packages of interventions reporting neonatal health outcomes. Studies employing more than one biologically plausible neonatal health intervention (i.e. package) and reporting neonatal morbidity or mortality outcomes were included. Studies were ordered by study design and mortality stratum, and their component interventions classified by time period of delivery and service delivery mode. We found 41 studies that implemented packages of interventions and reported neonatal health outcomes, including 19 randomized controlled trials. True effectiveness trials conducted at scale in health systems were completely lacking. No study targeted women prior to conception, antenatal interventions were largely micronutrient supplementation studies, and intrapartum interventions were limited principally to clean delivery. Few studies approximated complete packages recommended in The Lancet's Neonatal Survival Series. Interventions appeared largely bundled out of convenience or funding requirements, rather than based on anticipated synergistic effects, like service delivery mode or cost-effectiveness. Only two studies reported cost-effectiveness data. The evidence base for the impact of neonatal health intervention packages is a weak foundation for guiding effective implementation of public health programmes addressing neonatal health. Significant investment in effectiveness trials carefully tailored to local health needs and conducted at scale in developing countries is required.     

Twelve months of implementation of health care performance‐based financing in Burkina Faso: A qualitative multiple case study

To improve health services' quantity and quality, African countries are increasingly engaging in performance‐based financing (PBF) interventions. Studies to understand their implementation in francophone West Africa are rare. This study analysed PBF implementation in Burkina Faso 12 months post‐launch in late 2014. The design was a multiple and contrasted case study involving 18 cases (health centres). Empirical data were collected from observations, informal (n = 224) and formal (n = 459) interviews, and documents. Outside the circle of persons trained in PBF, few in the community had knowledge of it. In some health centres, the fact that staff were receiving bonuses was intentionally not announced to populations and community leaders. Most local actors thought PBF was just another project, but the majority appreciated it. There were significant delays in setting up agencies for performance monitoring, auditing, and contracting, as well as in the payment. The first audits led rapidly to coping strategies among health workers and occasionally to some staging beforehand. No community‐based audits had yet been done. Distribution of bonuses varied from one centre to another. This study shows the importance of understanding the implementation of public health interventions in Africa and of uncovering coping strategies.     

Community wellness: a group empowerment model for rural America

Because answers to rural health problems no longer reside solely at the federal or state level, county Extension agents in Georgia are playing a pivotal role in helping communities empower themselves with the Community Wellness program. Community Wellness is a process-oriented program that encompasses community-based program planning; facilitates interventions based on an assessment of community-specific health needs; encourages empowerment of the community; and develops a community-wide support system. County Extension agents and other leaders serve as catalysts to bring together members of the community to identify health needs, develop strategies to solve problems, and implement solutions. Four case histories describe how this model has strengthened community infrastructure, developed human capital, and created rural leadership. A discussion of barriers to implementation and lessons learned follows.     

Satisfaction with the level and type of resource use of a health insurance scheme in Nigeria: health management organizations' perspectives

Some developing countries have incorporated managed care elements into their national health insurance schemes. In practice, hybrid health management organizations (Hmos) are insurers who, bearing some resemblance to managed care in the USA, are vertically integrated in the scheme's revenue collection and pool and purchase healthcare services within a competitive framework. To date, few studies have focused on these organizations and their level of satisfaction with the scheme's optimal‐resource‐use (ORU) implementation. In Nigeria, the study site, Hmos were categorized on the basis of their satisfaction with ORU activities. One hundred forty‐seven Hmo staff were randomly interviewed. The types of ORU domain categories were provider payment mechanism, administrative efficiency, benefit package inclusions and active monitoring mechanism. Bivariate analysis was used to determine differences among the Hmos' satisfaction with the various ORU domains. The Hmos' satisfaction with the health insurance scheme's ORU activities was 59.2% generally, and the associated factors were identified. According to the Hmos' perspectives related to the type of ORU, the fee‐for‐service payment method and regular inspection performed weakly. Hmos' limited satisfaction with the scheme's ORU raises concerns regarding ineffectiveness that may hinder implementation. To offset high risks in the scheme, it appears necessary for the regulatory agency to adapt and reform strategies of provider payment and active monitoring mechanisms according to stakeholder needs. Our findings further reveal that having Hmos evaluate ORU is useful for providing evidence‐based information for policy making and regulatory utilization related to implementation of the health insurance scheme. Copyright © 2013 John Wiley & Sons, Ltd.     

The globalization of emergency medicine and its importance for public health

Emergency medicine (EM) is a global discipline that provides secondary disease prevention and is also a tool for primary prevention. It is a horizontally integrated system of emergency care consisting of access to EM care; provision of EM care in the community and during transportation of patients; and provision of care at the receiving facility or hospital emergency department. EM can offer many tools to improve public health. These tools include primary disease prevention; interventions for addressing substance abuse and interpersonal violence; education about safety practices; epidemiological surveillance; enrolment of patients in clinical research trials focusing on acute interventions; education and clinical training of health-care providers; and participation in local and regional responses to natural and man-made disasters. Public health advocates and health policy-makers can benefit from the opportunities of EM and can help overcome its challenges. Advocating the establishment and recognition of the specialty of EM worldwide can result in benefits for health-care education, help in incorporating the full scope of EM care into the system of public health, and expand the capabilities of EM for primary and secondary prevention for the benefit of the health of the public.     

Peer Reviewed: A Midpoint Process Evaluation of the Los Angeles Basin Racial and Ethnic Approaches to Community Health Across the US (REACH US) Disparities Center, 2007-2009

Background

Racial/ethnic minority groups have higher risks for disease resulting from obesity.

Community Context

The University of California, Los Angeles, and the Los Angeles County Department of Public Health partnered with community organizations to disseminate culturally targeted physical activity and nutrition-based interventions in worksites.

Methods

We conducted community dialogues with people from 59 government and nonprofit health and social service agencies to develop wellness strategies for implementation in worksites. Strategies included structured group exercise breaks and serving healthy refreshments at organizational functions. During the first 2 years, we subcontracted with 6 community-based organizations (primary partners) who disseminated these wellness strategies to 29 organizations within their own professional networks (secondary worksites) through peer modeling and social support. We analyzed data from the first 2 years of the project to evaluate our dissemination approach.

Outcome

Primary partners had difficulty recruiting organizations in their professional network as secondary partners to adopt wellness strategies. Within their own organizations, primary partners reported significant increases in implementation in 2 of the 6 core organizational strategies for promoting physical activity and healthy eating. Twelve secondary worksites that completed organizational assessments on 2 occasions reported significant increases in implementation in 4 of the 6 core organizational strategies.

Interpretation

Dissemination of organizational wellness strategies by trained community organizations through their existing networks (train-the-trainer) was only marginally successful. Therefore, we discontinued this dissemination approach and focused on recruiting leaders of organizational networks.     

Effectiveness of a community-directed 'healthy lifestyle' program in a remote Australian aboriginal community

OBJECTIVE: To assess the sustainability and effectiveness of a community-directed program for primary and secondary prevention of obesity, diabetes and cardiovascular disease in an Aboriginal community in north-west Western Australia. METHOD: Evaluation of health outcomes (body mass index, glucose tolerance, and plasma insulin and triglyceride concentrations) in a cohort of high-risk individuals (n = 49, followed over two years) and cross-sectional community samples (n = 200 at baseline, 185 at two-year and 132 at four-year follow-ups), process (interventions and their implementation) and impact (diet and exercise behaviour). RESULTS: For the high-risk cohort, involvement in diet and/or exercise strategies was associated with protection from increases in plasma glucose and triglycerides seen in a comparison group; however, sustained weight loss was not achieved. At the community level, significant reductions were observed in fasting insulin concentration but no change in prevalence of diabetes, overweight or obesity. Weight gain remained a problem among younger people. Sustainable improvements were observed for dietary intake and level of physical activity. These changes were related to supportive policies implemented by the community council and store management. CONCLUSIONS: Community control and ownership enabled embedding and sustainability of program, in association with social environmental policy changes and long-term improvements in important risk factors for chronic disease. IMPLICATIONS: Developmental initiatives facilitating planning, implementation and ownership of interventions by community members and organisations can be a feasible and effective way to achieve sustainable improvements in health behaviours and selected health outcomes among Aboriginal people.     

Substance misuse intervention research in remote Indigenous Australian communities since the NHMRC ‘Roadmap’

Objective : Describe program theories of substance misuse interventions with Aboriginal and Torres Strait Islander (Indigenous) Australians funded by the National Health and Medical Research Council (NHMRC) since the ‘Roadmap’ for Indigenous health. Methods : Projects funded 2003–2013 were categorised by intervention strategies. Realist concepts informed the program theory: intended resources and responses; influence of context on outcomes; explicit and implicit program assumptions. Results : Seven interventions were included. Three randomised controlled trials targeted tobacco using psychosocial interventions in primary health centres using the program theory: “Local Indigenous health workers extend and sustain the effects of conventional clinical brief intervention by engendering social and cultural resources”. Four pragmatic trials of multiple‐component, community‐based interventions using controlled, semi‐controlled or before‐and‐after designs used the program theory: “Discrete intervention components targeting locally defined substance misuse issues will activate latent capacities to create an environment that favours cessation.” Publications did not report clear effect, implementation fidelity or explicit mechanisms affecting participant thinking. Conclusions : Rigorous intervention designs built on ‘Roadmap’ principles neither reduced substance use in the populations studied nor identified transferable mechanisms for behaviour change. Implications for public health : Substance misuse impacts among Indigenous Australians remain severe. Theoretical mechanisms of behaviour change may improve intervention design.     

Seeing Community Benefit broadly. Everybody wins when hospitals collaborate with others to serve their communities

Community benefit is an opportunity for hospitals and health systems to affirm their community-focused missions and to ensure implementation of those missions in their organizations. There are four key themes of community benefit: community health improvement, underserved populations and unmet needs, collaboration outside the hospital, and coordination and strategic management inside the hospital. Together, these constitute a broader perspective, one in which community benefit is of strategic value to both the community and the hospital, and serves as a departure point for some of the hospital's most fruitful contributions to health and well-being. The community benefit function can be organized and managed to achieve specific priorities with measurable objectives, just like any other hospital activity. There are innumerable examples of creative and successful models for community benefit programs that incorporate the principles of community health improvement, unmet needs, collaboration externally, and strategic management internally. These are models that hospital leaders should create and pursue, because they demonstrate the value of a broad view of community benefit that fully realizes the potential of hospitals' charitable purpose.     

Case study of a decolonising Aboriginal community controlled comprehensive primary health care response to alcohol‐related harm

Objective: This paper provides a case study of the responses to alcohol of an Aboriginal Community Controlled Health Service (The Service), and investigates the implementation of comprehensive primary health care and how it challenges the logic of colonial approaches. Methods: Data were drawn from a larger comprehensive primary health care study. Data on actions on alcohol were collected from: a) six‐monthly service reports of activities; b) 29 interviews with staff and board members; c) six interviews with advocacy partners; and d) community assessment workshops with 13 service users. Results: The Service engaged in rehabilitative, curative, preventive and promotive work targeting alcohol, including advocacy and collaborative action on social determinants of health. It challenged other government approaches by increasing Aboriginal people’s control, providing culturally safe services, addressing racism, and advocating to government and industry. Conclusions: This case study provides an example of implementation of the full continuum of comprehensive primary health care activities. It shows how community control can challenge colonialism and ongoing power imbalances to promote evidence‐based policy and practice that support self‐determination as a positive determinant for health. Implications for public health: Aboriginal Community Controlled Health Services are a good model for comprehensive primary health care approaches to alcohol control.     

A methodology for building culture and gender norms into intervention: an example from Mumbai, India

This paper responds to the call for culturally-relevant intervention research by introducing a methodology for identifying community norms and resources in order to more effectively implement sustainable interventions strategies. Results of an analysis of community norms, specifically attitudes toward gender equity, are presented from an HIV/STI research and intervention project in a low-income community in Mumbai, India (2008-2012). Community gender norms were explored because of their relevance to sexual risk in settings characterized by high levels of gender inequity. This paper recommends approaches that interventionists and social scientists can take to incorporate cultural insights into formative assessments and project implementation These approaches include how to (1) examine modal beliefs and norms and any patterned variation within the community; (2) identify and assess variation in cultural beliefs and norms among community members (including leaders, social workers, members of civil society and the religious sector); and (3) identify differential needs among sectors of the community and key types of individuals best suited to help formulate and disseminate culturally-relevant intervention messages. Using a multi-method approach that includes the progressive translation of qualitative interviews into a quantitative survey of cultural norms, along with an analysis of community consensus, we outline a means for measuring variation in cultural expectations and beliefs about gender relations in an urban community in Mumbai. Results illustrate how intervention strategies and implementation can benefit from an organic (versus a priori and/or stereotypical) approach to cultural characteristics and analysis of community resources and vulnerabilities.     

Using community wealth ranking to identify the poor for subsidies: a case study of community‐based health insurance in Nouna,Burkina Faso

Access to health‐care is low in developing countries. Poor people are less likely to seek care than those who are better off. Community‐based health insurance (CBI) aims to improve healthcare utilisation by removing financial barriers, unfortunately CBI has been less effective in securing equity than expected. Poor people, who probably require greater protection from catastrophic health expenses, are less likely to enrol in such schemes. Therefore, it is important to implement targeted interventions so that the most in need are not left out. CBI has been offered to a district in Burkina Faso, comprising 7762 households in 41 villages and the district capital of Nouna since 2004. Community wealth ranking (CWR) was used in 2007 to identify the poorest quintile of households who were subsequently offered insurance at half the usual premium rate. The CWR is easy to implement and requires minimal resources such as interviews with local informants. As used in this study, the agreement between the key informants was more (37.5%) in the villages than in Nouna town (27.3%). CBI management unit only received nine complaints from villagers who considered that some households had been wrongly identified. Among the poorest, the annual enrolment increased from 18 households (1.1%) in 2006 to 186 (11.1%) in 2007 after subsidies. CWR is an alternative methodology to identify poor households and was found to be more cost and time efficient compared to other methods. It could be successfully replicated in low‐income countries with similar contexts. Moreover, targeted subsidies had a positive impact on enrolment.