While there are many strategies for improving financial access to care (including those that will be addressed in the Health Financing Improvement Strategies module), here we focus on four local-level strategies that have been commonly used in LMICs with varying success:
- Community-based health insurance
- Removal or reduction of user fees
- Conditional cash transfers
- Voucher programs.
Community-based health insurance
There are many methods for ensuring health insurance coverage within a population. Governments may choose to develop various schemes for different segments of the population based on employment, income, or age, provide national health insurance to all populations, or decentralize health insurance to communities. Many of these options will be addressed in the Health Financing module. However, like all methods of financial coverage, it is important to note that the availability of insurance does not ensure financial access in practice. Here we focus exclusively on community-based health insurance (CBHI) because it is a local-level intervention, and therefore most pertinent to financial access, as experienced by the patient.
Community-based health insurance is a decentralized health insurance scheme that is has been used in a number of LMICs. While CBHI schemes are established by communities and are therefore quite diverse, some common qualities include: pooling of risks and funds at the community level, not-for-profit payment plans most often at a flat rate and not dependent upon health risk, community control in setup and management, and voluntary membership.11 12 CBHI has often been implemented in areas where there is a significant poor and/or informal worker population, and revenue collection for health insurance administered at the national level would be challenging. As such, CBHI is generally considered a means for improving financial access among these populations that are often overlooked by other insurance schemes.
Given that community control is a defining characteristic of CBHI, these schemes are likely to include benefit packages that are closely aligned to community values and needs, and leadership decisions may be more transparent and accountable than other forms of health insurance.12 13 Additionally, CBHI schemes can be inclusive of informally employed people, a population excluded from common employment-based insurance.
However, there are many notable challenges associated with CBHI, specifically regarding equitable access. A recent review of 49 papers from Africa, Asia, and South America found that wealthier individuals were more likely to pay for CBHI, and price was a significant determinant of membership in these schemes. The review suggested five strategies that may mitigate these inequalities in CBHI. Many of these suggestions also apply to other types of insurance as well:
- Offer flexible payment plans
- Provide premium subsidies or eliminate premiums for the poor
- Eliminate copayments for the poor
- Remove or reduce any waiting periods between premium payment and utilization of services
- Avoid delayed reimbursements to both the patient and the facility that make patients pay out of pocket at the time of care.11
However, it is important to note that because pools are relatively small, when premiums are lowered to accommodate poorer individuals, it is often accompanied with a reduction in financial protection and benefits. Thus, these strategies must be designed with financial sustainability in mind.
The WHO has developed a Health Financing Policy Brief on CBHI that addresses many of the challenges associated with these schemes. Most fundamentally, although CBHI is often used as a strategy to increase financial access among traditionally overlooked populations, premiums still prevent access for the poorest populations. Both Ghana and Rwanda have experienced success in their CBHI schemes, and Rwanda is discussed in greater detail in Evidence of Implementation. However, in both cases, the CBHI was linked in a national system and included government tax revenues, and in Rwanda participation was required.12 Therefore, both of the more successful implementations of CBHI have incorporated elements that are not community-based. The WHO suggests drawing from these successes and retaining decentralized, community-based arms but connecting them into a larger pool that can support greater sustainability and financial protection.
Removal of user fees
Beginning in the 1980s, user fees became a popular health financing mechanism in LMIC because they were considered to increase revenue, improve efficient use of services, and improve access by subsidizing fees for the poor using these newly generated funds.14 However, numerous reviews across multiple settings have found that when user fees are implemented, there is a consistent accompanying decrease in access – particularly among the poor.15 Despite this, it is important to note that many studies evaluating the effects of the removal of user fees are not designed such that they measure both changes in utilization and changes in service delivery quality. Both of these considerations are crucial, as an increase in utilization may have a negative effect on quality and subsequently health outcomes if facilities are inadequately equipped to respond to growing demand.
High out of pocket payments are correlated with catastrophic and impoverishing health care costs,16 17 and these payments are often regressive, representing a larger proportion of a poor individual’s income compared to wealthy individual’s income. Consequentially, a model developed in 2005 estimated that abolition of user fees coupled with adequate efforts to ensure financing through other mechanisms could avert 233,000 annual deaths of children under five in 20 African countries.18 Thus, removal of user fees is a common and tangible solution for LMIC seeking to increase financial access to services and subsequently improve health outcomes, including child mortality. However, it is important to note that despite the observed benefits of removing user fees, countries must have plans to supplement the lost revenue and keep quality consistent.
There are three ways that countries can address the removal or reduction of user fees. First, countries may choose to abolish or reduce user fees for all individuals. This is of course dependent upon available financial resources and has serious financial implications including loss of discretionary revenues at facilities. Some strategies that may facilitate removal or reduction of user fees will be addressed in the Health Financing module.19 Second, certain populations may be specifically selected for exemption through the use of waivers. These populations might be determined by socioeconomic status or demographics. For instance, the poorest members of society, pregnant women, or children under five are common recipients of free or reduced fee services. Finally, removal of user fees may apply only to specific services such as antenatal care. These methods are not mutually exclusive, as exemptions may apply for both specific groups and selected services. It is important to note that removal of user fees is likely to increase utilization of services which may overwhelm health systems that are not prepared to provide the volume and quality of services being demanded. This was the case in 2013 in Kenya where user fees were removed for maternal health services without adequate preparation for increased demand. This case is discussed in “how others have done it”.20
When removing or reducing user fees for only a segment of the population, it is important to consider the effects on access to services for the rest of the population. Access may change for other populations through a number of different mechanisms.21 For instance, user fee reduction or exemption for children under five may encourage parents to bring all children – even those older than five – to access health services. Alternatively, if user fee reduction or exemption increases utilization among the target population and results in over-crowding of facilities, non-targeted groups may choose not to seek care, seek care at non-public and potentially more expensive facilities or from informal providers, or may bypass to higher-level facilities. Therefore, it is important for implementers to be attuned to these potential impacts during evaluation and build robust monitoring systems to identify any unintended effects.
In order to facilitate a smooth transition, the World Health Organization provides four important preconditions and considerations for health systems removing user fees:
- “Sufficient financial resources need to be provided and effectively transferred to the facility level to compensate for both the loss of revenue at the provider level…and for the desired increase in use of services.
- Provider payment and financial transfer methods must be in place – prior to the policy coming into being – through which the promised free services are effectively purchased and through which health workers are incentivized.
- Efforts are needed to improve and make health services available, bringing them closer to the most distant and vulnerable population groups [this is addressed in the geographic accessibility module]…
- Policy makers need to look for synergies in implementation and ensure that reform initiatives lead towards a coherent health financing architecture.”22
The first two considerations are the most relevant to financial access but also may be the most challenging to effectively implement. While many studies evaluate the effects of user fee changes on utilization, as reported above, few have compared and evaluated how countries have achieved user fee reduction or removal from a financial sustainability perspective. Examples of strategies that various countries have undertaken are discussed in greater detail in “How others have done it”.
Conditional cash transfers
Conditional cash transfers (CCTs) are a demand-side financing mechanism that can be used to improve financial access to care. In CCT programs, individuals or families receive payments contingent upon a certain behavior – in the case of health, it is often utilization of specific services. CCTs have been implemented extensively in LMIC.23 Even if the conditions tied to CCTs are not health-related, the payments can also be used to help individuals overcome financial barriers related to accessing health services, such as out of pocket payments, travel costs, or childcare.24 A systematic review of such programs found that they can, but do not always, improve access to health services and ultimately health outcomes.23 Important considerations for the success of a CCT program include:
- Efficient targeting of poorer groups – specific individuals or leaders within a community may be made responsible for identification of eligible households. Alternatively, there may be existing social security programs that have similar eligibility criteria as the intended program, and implementers can use their existing lists.
- Monitoring systems to ensure requirements are being met – implementers must plan programs with consideration of how they will ensure that individuals or households are fulfilling the required behaviors. Examples of monitoring strategies include check-ins with patients and providers during facility visits or home visits. Regardless of the method, however, monitoring will necessarily incur costs and require human resources to implement but is important to ensure that the program is being implemented with fidelity.
- Presence of high quality services and resilient staff and system to withstand increased demand – as with interventions that remove or reduce user fees, health systems must be capable of providing high quality care both at baseline and when demand increases as result of the program.23
The size of the transfer needed to result in positive effects on health has not been extensively studied and differs based on context. Therefore, it is important for implementers to consider the cost-effectiveness of a CCT intervention.24 Additionally, it is important to consider perverse incentives that may arise as a result of eligibility criteria. For instance, a review of CCT programs found that eligibility related to pregnancy was correlated with an increase in fertility.24 One potential challenge with CCTs may be stigma associated with the receipt of reduced or free services, although this phenomenon is not well studied in the literature. More details regarding CCTs can be found in a WHO technical brief on CCTs for health, which reviews how CCTs are used, the impact of such programs, and additional implementation considerations.25
A second, demand-side method for improving financial access to health services is vouchers. During voucher programs, vouchers are distributed to a specific subset of the population and these are used to obtain free or reduced fee services at the point of care. The facility is subsequently reimbursed. These programs are especially common for antenatal care or delivery. Some of the benefits of voucher programs include:
- Voucher programs enable targeting of low-income or high-risk individuals through distribution.
- By making vouchers only redeemable at facilities that meet specific quality standards, vouchers may encourage quality improvement processes at non-qualifying facilities.
- Voucher programs require the use of an information system to track distribution and collection of vouchers. These data can be used to monitor providers.26
There are several important considerations for stakeholders when planning a voucher program:
- Coverage of voucher – Implementers must consider the services and individuals eligible for a transportation voucher. Vouchers may be provided for specific services such as antenatal care/delivery or emergency services or to certain portions of the population, most often poor individuals or other high-risk groups. Sometimes, vouchers are used specifically for transportations, in which case specifics related to the cost of vouchers and whether they are flat-rate or flexible often must be negotiated with local transportation organizations.
- Method for identifying recipients and distributing vouchers – after identification of the target population, systems must be put in place to distribute vouchers. This may occur in communities as part of proactive population outreach or in facilities. For instance, transportation vouchers for delivery may be distributed when women attend antenatal care visits. However, in these cases, it is important to identify the target individuals who may qualify but are unable to seek care in these settings and reach them through alternative means.
- System for detecting fraud and tracking vouchers – Implementers should ensure that there are ways to detect fraudulent vouchers and track the distribution and use of vouchers. As always, any data management tool should be easy to use and compatible with the available infrastructure.
- Buy-in – In order to ensure use of vouchers, community members must be aware of the conditions for use. This may be achieved through community meetings, discussion at clinics, radio shows, or other accessible means of communication.27
- Facility capacity – As with other interventions to improve access, patients must be met by competent providers and effectively run facilities in order to ensure that patients receive high quality and timely care. These facilities must be sufficiently resilient to respond to increased demand.
In addition to the removal of financial barriers at the point of care, ensuring financial access also requires that patients do not face prohibitive costs related to seeking care which are external to the health system, for example transportation costs. Transportation vouchers are a common strategy used in LMIC to improve both financial and geographic barriers related to transportation. This requires partnership with a local taxi or other transportation group. Transportation vouchers and interventions intended to ease geographic or transportation-related barriers to care are discussed in greater detail within geographic access. As with other interventions that increase access to care, it is important to ensure that the health system can support increased demand without compromising quality. Additionally, because many voucher programs are donor-funded and/or specific to vertical programs, they should be planned with long-term sustainability and comprehensiveness in mind.28