Health Policy and Planning Advance Access originally published online on February 22, 2009
Health Policy and Planning 2009 24(3):209-216; doi:10.1093/heapol/czp001
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Equity in community health insurance schemes: evidence and lessons from Armenia
1 London School of Hygiene and Tropical Medicine, Keppel St., London WC1E 7HT, UK.
2 Institute for International Health and Development, Queen Margaret University College, Musselburgh, Edinburgh, EH21 6UU, UK.
3 Australian Permanent Mission, 2 Chemin des Fins, 1211 Geneva, Switzerland.
4 Oxfam GB, Oxfam House, John Smith Drive, Oxford, OX4 2JY, UK.
* Corresponding author. Lecturer, Health Policy/Systems, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom. Tel: +44 (0) 20 7927 2104. Fax: +44 (0) 20 7637 5391. E-mail: dina.balabanova{at}lshtm.ac.uk
Introduction Community health insurance (CHI) schemes are growing in importance in low-income settings, where health systems based on user fees have resulted in significant barriers to care for the poorest members of communities. They increase revenue, access and financial protection, but concerns have been expressed about the equity of such schemes and their ability to reach the poorest. Few programmes routinely evaluate equity impacts, even though this is usually a key objective. This lack of evidence is related to the difficulties in collecting reliable data on utilization and socio-economic status. This paper describes the findings of an evaluation of the equity of Oxfam's CHI schemes in rural Armenia.
Methods Members of a random sample of 506 households in villages operating insurance schemes in rural Armenia were interviewed using a structured questionnaire. Household wealth scores based on ownership of assets were generated using principal components analysis. Logistic and Poisson regression analyses were performed to identify the determinants of health facility utilization, and equity of access across socio-economic strata.
Results The schemes have achieved a high level of equity, according to socio-economic status, age and gender. However, although levels of participation compare favourably with international experience, they remain relatively low due to a lack of affordability and a package of primary care that does not include coverage for chronic disease.
Conclusion This paper demonstrates that the distribution of benefits among members of this community-financing scheme is equitable, and that such a degree of equity in community insurance can be achieved in such settings, possibly through an emphasis on accountability and local management. Such a scheme presents a workable model for investing in primary health care in resource-poor settings.
Key Words: Community-based health insurance, equity, health care utilization, Former Soviet Union, Armenia
Accepted for publication 26 November 2008.