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A Model to Estimate the Impact of Thresholds and Caps on Coverage Levels in Community-Based Health Insurance Schemes in Low-Income Countries

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DOI: 10.4236/health.2014.69104    4,727 Downloads   5,811 Views   Citations


Background: Community-based health insurance (CBHI) schemes are increasingly implemented in low-income settings. These schemes limit the coverage they offer both by the types of care considered, and by applying thresholds and/or caps to costs reimbursed. The consequences of these thresholds and/or caps on insurance coverage have hitherto been usually ignored, for lack of data on the distributions of healthcare costs or understanding of their impact on effective coverage levels. This article describes a theoretical model to obtain the distributions even without data collection in the field, and demonstrates the quantitative impact of thresholds and/or caps on claim reimbursements. Methods: This model applies to applications on healthcare expenditures in low-income settings, following research methods examined in the Western world. We looked at hospitalizations and tests; we compared the simulated distributions to empirical data obtained through 11 household surveys conducted between 2008 and 2010 in rural locations (9 in India and 2 in Nepal). Results: We found that the shape of the distributions was very similar in all locations for both benefits, and could be represented by a model based on a lognormal distribution. The agreement between theoretical and empirical results was satisfactory (mostly within 10% difference). Conclusions: The model makes it possible to simulate the expected performance of the CBHI (represented by the percentage of costs or bills covered). The aim is to match costs with local levels of willingness-to-pay for health insurance. This model makes it possible to determine at the stage of package-design the optimal levels of thresholds and/or caps for each benefit-type included.

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Binnendijk, E. , Koren, R. and Dror, D. (2014) A Model to Estimate the Impact of Thresholds and Caps on Coverage Levels in Community-Based Health Insurance Schemes in Low-Income Countries. Health, 6, 822-835. doi: 10.4236/health.2014.69104.


[1] World Development Indicators (2012)
[2] Karan, A.K. and Selvaraj, S. (2012) Why Publicly-Financed Health Insurance Schemes Are Ineffective in Providing Financial Risk Protection. Economic and Political Weekly, 47.
[3] Binnendijk, E., Koren, R. and Dror, D.M. (2012) Hardship Financing of Healthcare among Rural Poor in Orissa, India. BMC Health Services Research, 12, 23.
[4] Kruk, M.E., Goldmann, E. and Galea, S. (2009) Borrowing and Selling to Pay for Health Care in Low- and Middle-Income Countries. Health Affairs (Millwood), 28, 1056-1066.
[5] James, C. and Savedoff, W. (2010) Risk Pooling and Redistribution in Health Care: An Empirical Analysis of Attitudes toward Solidarity. World Health Report 2010, World Health Organization, Geneva.
[6] World Health Organization (2010) Health Systems Financing: The Path to Universal Coverage. The World Health Report 2010, World Health Organization, Geneva.
[7] Staib, D. and Bevere, L. (2011) World Insurance in 2010: Premiums Back to Growth, Capital Increases. Swiss Re Sigma, 2011, 1-44.
[8] Ma, S. and Sood, N. (2008) A Comparison of the Health Systems in China and India. Rand Corporation, Center for Asia Pacific Policy, Santa Monica.
[9] Ahuja, R. (2005) Health Insurance for the Poor in India: An Analytical Study. Indian Council for Research on International Economic Relations (ICRIER), New Delhi.
[10] Bhat, R. and Jain, N. (2006) Factoring Affecting the Demand for Health Insurance in a Micro Insurance Scheme. Indian Institute of Management, Ahmedabad.
[11] Dror, D.M., Radermacher, R., Khadilkar, S.B., Schout, P., Hay, F.X., Singh, A. and Koren, R. (2009) Microinsurance: Innovations in Low-Cost Health Insurance. Health Affairs (Millwood), 28, 1788-1798.
[12] National Commission on Macroeconomics and Health (2005) Financing and Delivery of Healthcare Services in India. National Commission on Macroeconomics and Health Background Papers, Ministry of Health and Family Welfare, Government of India, New Delhi.
[13] Dror, D.M. and Jacquier, C. (1999) Micro-Insurance: Extending Health Insurance to the Excluded. International Social Security Review, 52, 71-97.
[14] Dror, D.M. (2007) Why “One-Size-Fits-All” Health Insurance Products Are Unsuitable for Low-Income Persons in the Informal Economy in India. Asian Economic Review, 49, 47-56.
[15] Dror, D.M., van Putten-Rademaker, O. and Koren, R. (2009) Incidence of Illness Among Resource-Poor Households: Evidence from Five Locations in India. Indian Journal of Medical Research, 130, 146-154.
[16] Dror, D.M., van Putten-Rademaker, O. and Koren, R. (2008) Cost of Illness: Evidence from a Study in Five Resource-Poor Locations in India. Indian Journal of Medical Research, 127, 347-361.
[17] Dror, D.M., Radermacher, R. and Koren, R. (2007) Willingness to Pay for Health Insurance among Rural and Poor Persons: Field Evidence from Seven Micro Health Insurance Units in India. Health Policy, 82, 12-27.
[18] Binnendijk, E., Dror, D.M., Gerelle, E. and Koren, R. (2013) Estimating Willingness-to-Pay for Health Insurance among Rural Poor in India by Reference to Engel’s Law. Social Science & Medicine, 76, 67-73.
[19] Dror, D.M. and Koren, R. (2012) The Elusive Quest for Estimates of Willingness to Pay for Micro Health Insurance among the Poor in Low-Income Countries. In: Churchill, C. and Matul, M., Eds., Protecting the Poor—A Micro Insurance Compendium Volume 2. Volume Chapter 7. International Labour Organization, Geneva, 156-173.
[20] Doyle, C., Panda, P., Van de Poel, E., Radermacher, R. and Dror, D.M. (2011) Reconciling Research and Implementation in Micro Health Insurance Experiments in India: Study Protocol for a Randomized Controlled Trial. Trials, 12, 224.
[21] Dong, H., Mugisha, F., Gbangou, A., Kouyate, B. and Sauer-born, R. (2004) The Feasibility of Community-Based Health Insurance in Burkina Faso. Health Policy, 69, 45-53.
[22] AC Nielsen ORG-MARG Pvt Ltd. (2001) Needs and Demands for Healthcare and Health Insurance among Landless Agriculture Laborers in Burdwan District, West Bengal. Final Report Submitted to GTZ Technical Assistance Team, Health Sector Support, AC Nielsen ORG-MARG Pvt Ltd., Kolkata.
[23] De Allegri, M., Pokhrel, S., Becher, H., Dong, H., Mansmann, U., Kouyate, B., Kynast-Wolf, G., Gbangou, A., Sanon, M., Bridges, J. and Sauerborn, R. (2008) Step-Wedge Cluster-Randomised Community-Based Trials: An Application to the Study of the Impact of Community Health Insurance. Health Research Policy and Systems, 6.
[24] Mwaura, J.W. and Pongpanich, S. (2012) Access to Health Care: The Role of a Community Based Health Insurance in Kenya. The Pan African Medical Journal, 12.
[25] Onwujekwe, O., Onoka, C.A., Uguru, N., Nnenna, T., Uzochukwu, B.S., Eze, S., Kirigia, J. and Petu, A. (2010) Preferences for Benefit Packages for Community-Based Health Insurance: An Exploratory Study in Nigeria. BMC Health Services Research, 10, 162.
[26] Binnendijk, E., Gautham, M., Koren, R. and Dror, D.M. (2012) Illness Mapping: A Time and Cost Effective Method to Estimate Healthcare Data Needed to Establish Community Based Health Insurance. BMC Medical Research Methodology, 12, 153.
[27] Som, R.K. (1996) Practical Sampling Techniques. 2nd Edition, Marcel Dekker, New York.
[28] National Sample Survey Organization (2008) Household Consumer Expenditure in India, 2006-07. Ministry of Statistics and Programme Implementation, Government of India, New Delhi.
[29] Flores, G., Krishnakumar, J., O’Donnell, O. and van Doorslaer, E. (2008) Coping with Health-Care Costs: Implications for the Measurement of Catastrophic Expenditures and Poverty. Health Economics, 17, 1393-1412.
[30] Wagstaff, A. (2008) Measuring Financial Protection in Health. World Bank, Washington DC.
[31] Newhouse, J.P. and The Insurance Experiment Group (1993) Free for All? Lessons from the RAND Health Insurance Experiment. Harvard University Press, Cambridge.
[32] Van der Laan, B.S. (1988) Modelling Total Costs of Claims of Non-Life Insurances: With Applications to Health Insurance and to Motor Insurance. Erasmus University, Rotterdam.
[33] Van Vliet, R.C. (2000) A Statistical Analysis of Mandatory Pooling across Health Insurers. Journal of Risk and Insurance, 67, 197-217.
[34] Van Vliet, R.C. (2004) Deductibles and Health Care Expenditures: Empirical Estimates of Price Sensitivity Based on Administrative Data. International Journal of Health Care Finance and Economics, 4, 283-305.
[35] World Economic Outlook Database (2012)
[36] Manning, G.W., Basu, A. and Mullahy, J. (2005) Generalized Modeling Approaches to Risk Adjustment of Skewed Outcomes Data. Journal of Health Economics, 24, 465-488.
[37] Gilleskie, D.B. and Mroz, T.A. (2004) A Flexible Approach for Estimating the Effects of Covariates on Health Expenditures. Journal of Health Economics, 23, 391-418.
[38] Harel, Y., Overpeck, M.D., Jones, D.H., Scheidt, P.C., Bijur, P.E., Trumble, A.C. and Anderson, J. (1994) The Effects of Recall on Estimating Annual Nonfatal Injury Rates for Children and Adolescents. American Journal of Public Health, 84, 599-605.

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