Effects of Community-Based Health Insurance on Child
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Zentrum f¨urEntwicklungsforschung Effects of Community-based Health Insurance on Child Health Outcomes and Utilisation of Preventive Health Services: Evidence from Rural South-Western Uganda Dissertation zur Erlangung des Grades Doktor der Agrarwissenschaften (Dr. Agr.) der Landwirtschaftlichen Fakult¨at der Rheinischen Friedrich-Wilhelms-Universit¨atBonn von Emmanuel Nshakira Rukundo aus Kabale, Uganda Bonn 2018 Referent: Prof. Dr. Joachim von Braun 1.Koreferent: Prof. Dr. Jan B¨orner 2.Koreferent: Prof. Dr. Ute N¨othlings Chair: Prof. Dr. Monika Hartmann Tag der m¨undlichen Pr¨ufung: –/–/2018 Erscheinungsjahr: 2018 ACKNOWLEDGMENTS I would like to thank the people and institutions, without whose assistance, inspira- tion, and guidance, this research would not have been possible. First, I would like to thank Prof Dr. Joachim von Braun, who guided me to think beyond my boundaries, open my mind to new ideas and challenge myself to aspire to be a better development economist. Your firm and gentle guidance and persistent advice to ”look again in to the goldmine of data” when I run out of ideas, made this thesis come to fruition. I would like to thank Prof Dr. Jan B¨orner,for accepting to become my second supervisor. Many thanks to Prof Dr. Ute N¨othlingsfor reviewing this thesis and Prof Dr. Monika Hartmann for accepting to chair the dissertation committee. Dr. Nicolas Gerber, my doctoral adviser, for always having your door open, giving me new thinking dimensions and calming me down when I was stressed. For that, you did more than your part and I will always be grateful.I am very grateful to Kisiizi Hospital, my local research partners in Uganda, who allowed me to use the Kisiizi Hospital Community-Based Health Insurance scheme as my case study. In particular, I would like to thank Dr. Ian Spillman, Dr. Francis Banya, Mr. Moses Mugume, Mr. Paul Majoli and the entire health insurance scheme staff. My work and stay in Kisiizi was made easy by your limitless support. My research assistants, Wyclif, Doreen, Patience, Rebecca and Monica, thank you so much for spending time with me in Kisiizi and making the household survey a success. I am indebted to the Deutscher Akademischer Austauschdienst (DAAD) for the Ph.D. scholarship. Most especially, I would like to thank Ms. Birgit Skailes through whose department my scholarship was administered. I also appreciate unendingly the fieldwork financial support from Dr. Hermann Eiselen Doctoral Program of the Foundation Fiat Panis. In the same spirit, my studies benefited so much from the ZEF Doctoral Studies team: Dr. G¨unther Manske, Ms. Maike Retat-Armin, Max, Anna and Anna, who provided all the administrative support that made my studies as conducive as possible. The IT support from Mr. Ludger Hammer and Anja K¨ohler,Library support from Mr. Volker Merx is highly appreciated. Most of my statistical analysis would not have been possible without the gracious assistance of Guido L¨uchters. From you, I learnt to always, ”play with the data” to learn new insights of what it says. Thank you so much. My ZEF colleagues, especially Batch 2014. You guys were amazing brothers and sis- ters in arms. Especially, I would like to thank Essa Chanie Mussa: your friendship has sustained me, your intellectual rigor has improved me and I look forward to many op- portunities for collaboration beyond our Ph.D. projects. Thank you so much. Marcos G, Pablo, Juliet, Bibiana, Minjung, Rabia, Alicia, Cesar, Getachew, Galia, Javier, Gerson, i Renzo, Marcos H, Gabriel, Holm, Hugo, and Johannes, I appreciate the social times we spent together. I hope we shall continue making our friend Maria (RIP) proud. My parents, the Nshakira family, I cannot thank you enough. For those with us and those who have departed from us, this thesis gives me an opportunity to express my unending gratefulness. Uncle Enoch Kwizera (RIP), the statement ”the sky is your limit” which you mentioned to me in 2004, still rings today. Uncle Nathan, thank you for bending lower to become a brother and a mentor to me in all dimensions. Auntie Blandina and Auntie Eleanor, you have really done more than you promised. Mukaikuru Lydia, for you, words are not enough, Thank You. To my siblings, Keren, Elisa, Deborah and Esther, and all the Nshakiras, thank you for being amazing people who I am proud to belong to. Magdalena, my beloved, and all the Mulhern family thank you for loving me. Finally, I would like to thank again Ms. Blandina Nshakira and Dr. Nathan Nshakira for proofreading assistance, and Ms Vicki Abrecht for graciously and professionally trans- lating the abstract in German. I gratefully benefited from the helpful comments of Dr. Chiara Kofol, Dr. Christoph Kronenberg (CINCH-Essen), and Dr. Andrew Mirelman (University of York, UK), Prof Frank Windmeijer (University of Bristol, UK), Prof Arjun Bedi (Erasmus University Rotterdam), participants in the African Economic Conference 2017, NORDIC Development Economics 2017, CINCH Health Economics Summer School 2017, Ruhr Graduate School Economics Conference 2018, Royal Economics Conference 2018 and the ZEF Research Colloquiums. I thank you all. Above all, Thank You, Lord, for the blessings I don’t deserve and your amazing love. ii DEDICATION To my late parents, Eriya Nsengiyunva Byarugaba Nshakira and Robinah Byarugaba And Prof Enoch Kwizera Nshakira May you continue resting in eternal peace. iii CONTENTS 1 Introduction1 1.1 Introduction..................................2 1.1.1 What is community-based health insurance?............2 1.1.2 The evolution of community-based health insurance........3 1.2 The problem statement............................6 1.3 Research objectives..............................7 1.4 Conceptual framework: pathways from health insurance to improved health outcomes....................................7 1.5 Study area in the broader context......................9 1.5.1 Health and development in Uganda.................9 1.5.2 Health sector governance under decentralisation.......... 10 1.5.3 Health financing in Uganda..................... 12 1.5.3.1 The landscape of health insurance in Uganda...... 14 1.5.3.2 Coverage of private health insurance........... 14 1.5.3.3 Community-based health insurance in Uganda...... 15 1.5.3.4 The study area: A brief history of Kigezi......... 16 1.5.3.5 Kisiizi Hospital Community Health Insurance Scheme.. 19 1.6 Sampling strategy and data collection.................... 23 1.7 Ethical considerations............................ 25 1.8 Some assumptions and caveats of this research............... 25 1.9 Further organisation of the dissertation................... 29 2 What Determines Enrolment in and Renewing of Community-based Health Insurance in Rural Uganda? 30 2.1 Introduction.................................. 31 2.2 Enrolment in health insurance in developing countries........... 32 2.3 Empirical approach.............................. 34 2.4 Results..................................... 36 2.4.1 Descriptive results.......................... 36 2.4.2 Empirical results........................... 37 2.4.2.1 Determinants of enrolment in CBHI............ 37 2.4.2.2 Determinants of staying in CBHI............. 39 2.4.2.3 Effect of perceptions on enrolment and staying insured.. 42 2.5 Discussion and conclusions.......................... 43 iv 3 Impact of Community-Based Health Insurance on Child Health Out- comes: Evidence on Stunting. 46 3.1 Introduction.................................. 47 3.1.1 The stunting problem......................... 49 3.2 Health Insurance and Health Outcomes in Developing Countries: State of the Art..................................... 50 3.3 The empirical strategy............................ 51 3.3.1 Treatment and control variables................... 51 3.3.2 Identification strategy: Two Stage Residual Inclusion estimator. 52 3.3.3 The empirical model specification.................. 53 3.3.3.1 A review of the instruments used in health insurance studies 54 3.3.3.2 Our instruments...................... 55 3.4 Results..................................... 59 3.4.1 Descriptive results.......................... 59 3.4.1.1 Health facilities’ data.................... 59 3.4.1.2 Household survey data................... 60 3.4.2 Empirical results........................... 61 3.4.2.1 Main model results..................... 61 3.4.2.2 Some heterogeneous treatment effects........... 65 3.4.2.3 A comment on breastfeeding results........... 66 3.4.3 Robustness checks.......................... 68 3.5 Discussion and conclusion.......................... 69 4 Effect of Community-Based Health Insurance on Preventive Health: An Analysis of Self-reported Use of Preventive Health Interventions. 73 4.1 Introduction: Community-based health insurance and preventive health. 74 4.1.1 Preventive health in Uganda..................... 75 4.2 Preventive health and strategies for uptake in developing countries.... 76 4.2.1 What is preventive health and why is it important?........ 76 4.2.2 Disease burden from preventable illnesses in developing countries 77 4.2.3 Low uptake of preventive health strategies............. 78 4.2.4 Improving uptake of preventive health interventions........ 79 4.2.5 Effect of health insurance on preventive health outcomes..... 81 4.2.6 Our contribution to the literature.................. 82 4.3 Theoretical and empirical strategy...................... 83 4.3.1 A model of preventive health.................... 83 4.3.2 Empirical strategy:Inverse probability weighting (IPW)....... 85 4.3.2.1 Selection on the observables and balancing diagnostics.