Pradeep Panda Factors affecting uptake of Iddo H Dror voluntary and community-based Tracey Perez Koehlmoos S A Shahed Hossain health insurance schemes in low- Denny John and middle-income countries Jahangir A M Khan David M Dror A systematic review June 2016 Systematic Health Review 27 About 3ie The International Initiative for Impact Evaluation (3ie) is an international grant-making NGO promoting evidence-informed development policies and programmes. We are the global leader in funding, producing and synthesising high-quality evidence of what works, for whom, why and at what cost. We believe that better and policy-relevant evidence will make development more effective and improve people’s lives. 3ie systematic reviews 3ie systematic reviews appraise and synthesise the available high-quality evidence on the effectiveness of social and economic development interventions in low- and middle-income countries. These reviews follow scientifically recognised review methods, and are peer- reviewed and quality assured according to internationally accepted standards. 3ie is providing leadership in demonstrating rigorous and innovative review methodologies, such as using theory-based approaches suited to inform policy and programming in the dynamic contexts and challenges of low- and middle-income countries. About this review Factors affecting uptake of voluntary and community-based health insurance schemes in low- and middle-income countries: a systematic review, was submitted in partial fulfilment of the requirements of grant SR5.1253 issued under Systematic Review Window 5. This review is available on the 3ie website. 3ie is publishing this report as received from the authors; it has been formatted to 3ie style. This review has also been published by the EPPI-Centre and is available here. Major funding for this systematic review was provided by UK aid, the Bill & Melinda Gates Foundation and the Hewlett Foundation. A complete listing of all of 3ie’s donors can be found on the 3ie website. All content is the sole responsibility of the authors and does not represent the opinions of 3ie, its donors or its board of commissioners. Any errors are also the sole responsibility of the authors. Comments or queries should be directed to the corresponding author, Pradeep Panda, [email protected]. Suggested citation: Panda, P, Dror, IH, Koehlmoos, TP, Hossain, SAS, John, D, Khan, JAM and Dror, DM, 2016. Factors affecting uptake of voluntary and community-based health insurance schemes in low-and middle-income countries: a systematic review, 3ie Systematic Review 27. London: International Initiative for Impact Evaluation (3ie). 3ie systematic review executive editors: Edoardo Masset and Beryl Leach Managing editor: Deepthy Menon Technical editor: Birte Snilstveit Production manager: Pradeep Singh Cover design: John F McGill and Akarsh Gupta © International Initiative for Impact Evaluation (3ie), 2016 Factors affecting uptake of voluntary and community-based health insurance schemes in low- and middle-income countries: a systematic review Pradeep Panda Micro Insurance Academy and International Institute of Health Management Research Iddo H Dror Micro Insurance Academy Tracey Perez Koehlmoos Uniformed Services University of the Health Sciences S A Shahed Hossain icddr,b Denny John People's Open Access Education Initiative, India Jahangir A M Khan icddr,b and Liverpool School of Tropical Medicine David M Dror Micro Insurance Academy 3ie Systematic Review 27 June 2016 Acknowledgements The authors gratefully acknowledge funding provided by the International Initiative for Impact Evaluation (3ie). The authors would like to express their sincere appreciation to Kanika Garg, Anuj Pratap Singh, Tanuka Endow, Sunetra Ghatak, Isha Chaudhry, Sachin Hans and Shraddha Srivastava, researchers at the Micro Insurance Academy, Delhi, for their immense contributions to various drafts of this report. We also thank Atanu Majumdar (Senior Researcher, Micro Insurance Academy) for his excellent research assistance in meta- analysis. We would like to thank Hugh Waddington, Birte Snilstveit, John Eyers and Ami Bhavsar of International Initiative for Impact Evaluation (3ie) and Mukdarut Bangpan and Carol Vigurs of EPPI Centre, for guidance and technical assistance at every step during the completion of this report. We thank our Advisory Board members for having guided the formulation of this report. Last but not the least; we thank the external peer reviewers for their valuable comments that have enriched the report. MIA is involved in the implementation of CBHI schemes. In order to ensure that the review process, results and reporting are objective and unbiased, we followed the following steps: (a) we followed a protocol with explicit inclusion criteria and did not make inclusion based on study findings, (b) drafts of protocol and review were externally peer reviewed and approved, and (c) drafts of review were also peer reviewed by an eminent advisory group. i Summary Background Most healthcare expenditures in developing countries are borne through out-of-pocket (OOP) spending payable by healthcare-seekers at the time and place of treatment. In India, 70 percent of total health spending is borne by private sources, 86 percent of which is through OOP spending (World Bank, 2009; Selvaraj et al., 2012). This inequitable and inefficient health financing situation persists in other low-income countries as well. The solution proposed by WHO and other international bodies has been to strive towards universal health coverage (UHC), notably through prepayment and risk pooling mechanisms. Very few low-income countries (e.g. Armenia, Moldova, and Mongolia) have so far been able to mandate the entire population to pay premiums for UHC (Stuckler and Feigl, 2010). Attempts to subsidize large segments of the (below poverty line) population have also been rare, and fell short of UHC as coverage has been partial (Dror and Vellakkal, 2012). One way to enhance coverage, it was suggested, would be through community-based health insurance (CBHI) schemes; we refer here to the earliest suggestion (Dror and Jacquier, 1999) which flagged the mutual operational model. In this model, the community plays an important role in mobilizing, pooling, allocating, managing and/or supervising health-care resources. CBHI schemes have been shown to be effective in reducing out-of-pocket payments of their members, and in improving access to health services (Tabor, 2005). However, many schemes also reported low enrollment rates. If CBHI should move from niche to scale as a social protection mechanism, they need to attract more members and retain them. Hence, we focus on analyzing the factors that affect joining on a voluntary basis and retaining members. Stated differently, we seek to understand the demand and supply- side factors that affect uptake and renewal of community-based voluntary health insurance schemes in low- and middle-income countries. Objective The objective of this systematic review is to review and analyze the literature reporting empirical evidence on voluntary uptake in CBHI schemes in low- and middle- income countries, and identify factors influencing such uptake and renewal. Methodology This systematic review is delineated by the databases included and the specific search terms applied. The following important datasets were used: EconLit and similar: MEDLINE and similar; Google and similar; Global Health and similar; ProQuest and similar; Scopus and similar; and Cochrane and similar. In addition, grey literature was also consulted. Five basic exclusion criteria were followed: a study was excluded if published before 1990; if it was a policy analysis or an opinion piece; if it was conducted in a country that is not a low or middle-income (following World Bank classification); if the health insurance mechanisms discussed was other than CBHI (private, social, and mandatory); or if the study was only on impact of CBHI. The inclusion criteria were determined by “PICOS”: Participants (that were offered to join CBHI voluntarily, whether they decided to enroll or not) were included provided they resided ii in low- and middle-income countries (World Bank definitions 2012); voluntary, contributory and community-based Interventions were included (when in low- and middle- income countries); Comparisons between individuals were included (joining CBHI schemes and those who do not, those that renew or dropout); Outcomes were included when related to determinants of demand (e.g. socio-economic characteristics, or social capital in the community) or of supply (e.g. scheme-related factors affecting access to CBHI, or the role of institutional factors or other health-related factors that enhances CBHI uptake). The review also included factors affecting renewal (or dropout) in CBHI schemes. Study design also influenced the choice for inclusion (through a process of data extraction and quality appraisal). The main search language was English, but we also included relevant studies in Spanish, French, and German. Moreover, decisions regarding data extraction were guided by the review question. In addition, we conducted preliminary quality assessment following Waddington et al., (2012) and detail appraisal of quality and adequacy of different types of studies (reporting, data collection, presentation, analysis and conclusions drawn) following relevant checklists (Waddington et al. (2012) for quantitative studies, CASP (2006) checklist for qualitative studies, CASP (2013) checklist for cohort studies (2006),