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      Effectiveness of health voucher scheme and micro-health insurance scheme to support the poor and extreme poor in selected urban areas of Bangladesh: An assessment using a mixed-method approach

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          Abstract

          Background

          National healthcare financing strategy recommends tax-based equity funds and insurance schemes for the poor and extreme poor living in urban slums and pavements as the majority of these population utilise informal providers resulting in adverse health effects and financial hardship. We assessed the effect of a health voucher scheme (HVS) and micro-health insurance (MHI) scheme on healthcare utilisation and out-of-pocket (OOP) payments and the cost of implementing such schemes.

          Methods

          HVS and MHI schemes were implemented by Concern Worldwide through selected NGO health centres, referral hospitals, and private healthcare facilities in three City Corporations of Bangladesh from December 2016 to March 2020. A household survey with 1,294 enrolees, key-informant interviews, focus group discussions, consultative meetings, and document reviews were conducted for extracting data on healthcare utilisation, OOP payments, views of enrolees, and suggestions of implementers, and costs of services at the point of care.

          Results

          Healthcare utilisation including maternal, neonatal and child health (MNCH) services, particularly from medically trained providers, was higher and OOP payments were lower among the scheme enrolees compared to corresponding population groups in general. The beneficiaries were happy with their access to healthcare, especially for MNCH services, and their perceived quality of care was fair enough. They, however, suggested expanding the benefits package, supported by an additional workforce. The cost per beneficiary household for providing services per year was €32 in HVS and €15 in MHI scheme.

          Conclusion

          HVS and MHI schemes enabled higher healthcare utilisation at lower OOP payments among the enrolees, who were happy with their access to healthcare, particularly for MNCH services. However, they suggested a larger benefits package in future. The provider’s costs of the schemes were reasonable; however, there are potentials of cost containment by purchasing the health services for their beneficiaries in a competitive basis from the market. Scaling up such schemes addressing the drawback would contribute to achieving universal health coverage.

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          Most cited references36

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          A theory of justice

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            Community-based health insurance in low-income countries: a systematic review of the evidence.

            B Ekman (2004)
            Health policy makers are faced with competing alternatives, and for systems of health care financing. The choice of financing method should mobilize resources for health care and provide financial protection. This review systematically assesses the evidence of the extent to which community-based health insurance is a viable option for low-income countries in mobilizing resources and providing financial protection. The review contributes to the literature on health financing by extending and qualifying existing knowledge. Overall, the evidence base is limited in scope and questionable in quality. There is strong evidence that community-based health insurance provides some financial protection by reducing out-of-pocket spending. There is evidence of moderate strength that such schemes improve cost-recovery. There is weak or no evidence that schemes have an effect on the quality of care or the efficiency with which care is produced. In absolute terms, the effects are small and schemes serve only a limited section of the population. The main policy implication of the review is that these types of community financing arrangements are, at best, complementary to other more effective systems of health financing. To improve reliability and validity of the evidence base, analysts should agree on a more coherent set of outcome indicators and a more consistent assessment of these indicators. Policy makers need to be better informed as to both the costs and the benefits of implementing various financing options. The current evidence base on community-based health insurance is mute on this point.
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              Catastrophic payments for health care in Asia.

              Out-of-pocket (OOP) payments are the principal means of financing health care throughout much of Asia. We estimate the magnitude and distribution of OOP payments for health care in fourteen countries and territories accounting for 81% of the Asian population. We focus on payments that are catastrophic, in the sense of severely disrupting household living standards, and approximate such payments by those absorbing a large fraction of household resources. Bangladesh, China, India, Nepal and Vietnam rely most heavily on OOP financing and have the highest incidence of catastrophic payments. Sri Lanka, Thailand and Malaysia stand out as low to middle income countries that have constrained both the OOP share of health financing and the catastrophic impact of direct payments. In most low/middle-income countries, the better-off are more likely to spend a large fraction of total household resources on health care. This may reflect the inability of the poorest of the poor to divert resources from other basic needs and possibly the protection of the poor from user charges offered in some countries. But in China, Kyrgyz and Vietnam, where there are no exemptions of the poor from charges, they are as, or even more, likely to incur catastrophic payments. (c) 2007 John Wiley & Sons, Ltd.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Project administrationRole: SupervisionRole: Writing – original draftRole: Writing – review & editing
                Role: Formal analysisRole: Writing – original draftRole: Writing – review & editing
                Role: Data curationRole: Formal analysisRole: MethodologyRole: SupervisionRole: ValidationRole: Writing – original draftRole: Writing – review & editing
                Role: Data curationRole: Formal analysisRole: SupervisionRole: Writing – original draftRole: Writing – review & editing
                Role: ValidationRole: VisualizationRole: Writing – review & editing
                Role: SupervisionRole: VisualizationRole: Writing – review & editing
                Role: SupervisionRole: ValidationRole: VisualizationRole: Writing – review & editing
                Role: VisualizationRole: Writing – review & editing
                Role: ResourcesRole: VisualizationRole: Writing – review & editing
                Role: ConceptualizationRole: Formal analysisRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: SupervisionRole: VisualizationRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Formal analysisRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Project administrationRole: SupervisionRole: VisualizationRole: Writing – original draftRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS One
                plos
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                1 November 2021
                2021
                : 16
                : 11
                : e0256067
                Affiliations
                [1 ] Mathematical Modelling Group, Oxford University Clinical Research Unit (OUCRU), Ho Chi Minh City, Vietnam
                [2 ] Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
                [3 ] Liverpool School of Tropical Medicine (LSTM), Liverpool, United Kingdom
                [4 ] International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
                [5 ] Bangladesh Institute of Development Studies (BIDS), Agargaon, Dhaka, Bangladesh
                [6 ] Concern Worldwide, Dhaka, Bangladesh
                [7 ] BRAC, Dhaka, Bangladesh
                [8 ] Concern Worldwide, Dublin, Ireland
                [9 ] Health Economics and Policy Unit, School of Public Health and Community Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
                University of Georgia, UNITED STATES
                Author notes

                Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: Sayem Ahmed – none declared Md. Zahid Hasan – none declared Nausad Ali – none declared Mohammad Wahid Ahmed – none declared Emranul Haq – works at the Concern Worldwide Bangladesh Sadia Shabnam – works at the scheme implementing organization, BRAC Morseda Chowdhury – works at the scheme implementing organization, BRAC Breda Gahan – works at the funding organization, Concern Worldwide Christine Bousquet – works at the funding organization, Concern Worldwide Jahangir A. M. Khan – none declared Ziaul Islam – none declared This does not alter our adherence to PLOS ONE policies on sharing data and materials.

                Author information
                https://orcid.org/0000-0001-9499-1500
                https://orcid.org/0000-0002-3824-8947
                Article
                PONE-D-20-22715
                10.1371/journal.pone.0256067
                8559931
                34723992
                5ba33a27-65ae-49e2-9da4-668bafd1cee6
                © 2021 Ahmed et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 22 July 2020
                : 29 July 2021
                Page count
                Figures: 6, Tables: 9, Pages: 31
                Funding
                Funded by: Concern Worldwide Bangladesh
                Award ID: GR-01812
                Award Recipient :
                icddr,b received funding for this research study from the Concern Worldwide Bangladesh. The funding was awarded to Ziaul Islam under grant number GR-01812. icddr,b acknowledges with gratitude the commitment of Concern Worldwide Bangladesh to its research efforts. Concern Worldwide was funded by the European Union (EU) for the overall project.
                Categories
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