Does community-based health insurance affect lifestyle and timing of treatment seeking behavior?Evidence from Ethiopia

Objectives This paper aims to investigate the effects of enrollment in the Ethiopian community-based health insurance(CBHI)scheme on household preventive care activities and the timing of treatment-seeking behavior for illness symptoms.There is growing concern about the financial sustainability of CBHI schemes in developing countries.However,few empirical studies have identified potential contributors,including ex-ante and ex-post moral hazards.Methods We implement a household fixed-effect panel data regression model,drawing on three rounds of household survey data collected face to face in districts where CBHI scheme is operational and in districts where it is not operational in Ethiopia.Results The findings show that enrolment in CBHI does not significantly influence household behaviour regarding preventive care activities such as water treatment before drinking and handwashing before meals.However,CBHI significantly increases delay in treatment-seeking behaviour for diseases symptoms.Particularly,on average,we estimate about 4-6 h delay for malaria symptoms,a little above 4 h for tetanus,and 10-11 h for tuberculosis among the insured households.Conclusions While there is evidence that CBHI improve the utilization of outpatient or primary care services,our study suggests that insured members may wait longer before visiting health facilities.This delay could be partly due to moral hazard problems,as insured households,particularly those from rural areas,may consider the opportunity costs associated with visiting health facilities for minor symptoms.Overall,it is essential to identify the primary causes of delays in seeking medical services and implement appropriate interventions to encourage insured individuals to seek early medical attention.

Community-Based Hepatitis B Campaign in Asian Americans

Chronic hepatitis B (CHB) disproportionately affects minority groups in the US, particularly Asian Americans, with numerous factors contributing to this disparity. Of the 2.4 million people living with chronic HBV in the US, 60% are Asian American. Many are unaware of their status and lack access to proper clinical care, with less than ten percent receiving necessary antiviral treatment. Barriers to screening and care include lack of disease awareness, language and cultural barriers, and financial constraints. Additionally, healthcare providers and systems in the US often overlook the importance of CHB, leading to inadequate care. In response, the Center for Viral Hepatitis (CVH) has implemented a community-based outreach program over the past sixteen years, employing a multifaceted approach involving all sectors of society and various organizations to combat health disparities in CHB. This grassroots campaign has proven highly effective, leveraging CVH’s leadership in spearheading numerous collaborative activities with community members, healthcare professionals, and policymakers. We have summarized the key points of CVH's efforts and their significance in combating CHB-related health disparities. The CHB Screening and Awareness Campaign, tailored to the Asian American community, serves as a successful model for increasing CHB screening, linkage-to-care, and addressing socio-cultural barriers and health literacy. Insights from these outreach programs have guided the development of culturally relevant resources and education initiatives. These findings suggest that such community-driven approaches are essential for addressing health disparities. The strategies and outcomes of CVH’s efforts can inform future health initiatives for other minority communities in the US and globally.

Impact of community-based rehabilitation on quality of life and self-esteem of persons with physical disabilities and their family members

Objective:Community-based rehabilitation(CBR)is a strategy by which persons living with disability(PWDs)access comprehensive rehabilitation services with limited evidence regarding its impact on the quality of life(QOL)and self-esteem(SE)of PWDs and their family members.This study compared the QOL and SE of Nigerian PWDs in communities with and without a CBR programme(CBR and non-CBR respectively),and the family quality of life(FQOL)of their family members.Methods:Cross-sectional study involving 2604 PWDs(1302 in CBR and 1302 in non-CBR);5208 family members of PWDs(2604 in CBR and 2604 non-CBR),recruited from four randomly selected geo-political zones in Nigeria,purposive/consecutive selection of eight CBR programmes,PWDs and their family members(CBR and non-CBR).Outcomes assessed using Rosenberg Self-Esteem Scale(RSES),World Health Organization Quality of Life Instrument-short form(WHOQOL-BREF)and Beach Centre Family Quality of Life Instrument(BCFQOL).Mann-Whitney U test and Spearman's rank order correlation were used to analyse data at P<0.05.Results:PWDs in CBR scored higher in all domains of WHOQOL-BREF(P<0.0001 in all cases)and RSES than non-CBR group(P<0.0001).The CBR families scored significantly higher than non-CBR families in all domains(P<0.05)except Emotional Well-Being of the BCFQOL.The CBR group scores on Psychological and Social Health domains of the WHOQOL-BREF showed significant positive correlation with CBR families'Family Interaction(P=0.06)and Parenting(P=0.07)domains and total FQOL(P=0.07).Conclusion:Community-based rehabilitation positively impacted on SE and QOL of PWDs and their family members.

Construction of Industrialization Development Model for"1+4+X"Community-Based Elderly Care in Gannan Old Revolutionary Base Area in the Context of Population Aging

In the context of controlling population development in a planned way,China entered an aging society in the early 21 st century.In this context,how to meet the needs of the elderly care and form an effective elderly care model has become a key problem to be solved urgently by local government departments.With the continuous advancement of the elderly care policy,the community-based elderly care has gradually become the mainstream and is in the stage of vigorous promotion.Taking the Gannan old revolutionary base area in Jiangxi Province as an example,this study puts forward"1+4+X"community-based elderly care model based on the policy system of community-based elderly care,the physical and mental health of the elderly,the material space and the construction of evaluation system,and explores how to promote the application of this community model efficiently in the form of industrialization,so as to drive the economic growth of the Gannan old revolutionary base area,promote the employment development and improve the community-based elderly care service.

A community-based epidemiological study of elevated serum alanine aminotransferase levels in Kinmen, Taiwan

AIM: To explore any gender-related differences in prevalence of and condition-associated factors related to an elevated serum alanine aminotransferase (ALT) level amongst residents of Kinmen, Taiwan. METHODS: A total of 11 898 of a potential 20 112 regional residents aged 30 years or more completed a related questionnaire that was carried out by the Yang-Ming Crusade between 1991 and 1994 inclusively, with blood samples being collected by public nurses. The overall questionnaire response rate was 59.3% (52.4% for males and 66.0% for females). RESULTS: The prevalence of an elevated serum ALT level for this sub-population was found to be 7.2%, the prevalence revealing a statistically significant decrease with increasing population age (P<0.0001). Males exhibited a greater prevalence of elevated serum ALT level than did females (9.4% vs 5.3%, P<0.0001). Using multiple logistic regression analysis, in addition to male gender, a younger age, greater waist circumference, presence of type-2 diabetes and hyperuricemia were the significant factors associated with an elevated serum ALT level for both males and females. Gender-related differences as regards associated factors were also revealed. For males, obesity was significantly related to an elevated serum ALT level (OR = 1.28, 95%CI: 1.00-1.66) but this was not so for females (OR = 1.09, 95%CI: 0.84-1.42). Hypertriglyceridemia (OR = 1.80, 95%CI: 1.36-2.39) and hyperuricemia (OR = 1.61, 95%CI: 1.03-2.52) were significantly related to elevated serum ALT levels only for females. CONCLUSION: Several gender-related differences were noted pertaining to the prevalence of and relationship between obesity, hypertriglyceridemia and hyperuricemia and elevated serum ALT level in the present study.

Effectiveness of cognitive behavior therapy for sleep disturbance and glycemic control in persons with type 2 diabetes mellitus:A community-based randomized controlled trial in China

BACKGROUND Poor sleep quality is a common clinical feature in patients with type 2 diabetes mellitus(T2DM),and often negatively related with glycemic control.Cognitive behavioral therapy(CBT)may improve sleep quality and reduce blood sugar levels in patients with T2DM.However,it is not entirely clear whether CBT delivered by general practitioners is effective for poor sleep quality in T2DM patients in community settings.AIM To test the effect of CBT delivered by general practitioners in improving sleep quality and reducing glycemic levels in patients with T2DM in community.METHODS A cluster randomized controlled trial was conducted from September 2018 to October 2019 in communities of China.Overall 1033 persons with T2DM and poor sleep quality received CBT plus usual care or usual care.Glycosylated hemoglobin A1c(HbAlc)and sleep quality[Pittsburgh Sleep Quality Index(PSQI)]were assessed.Repeated measures analysis of variance and generalized linear mixed effects models were used to estimate the intervention effects on hemoglobin A1c and sleep quality.RESULTS The CBT group had 0.64,0.50,and 0.9 lower PSQI scores than the control group at 2 mo,6 mo,and 12 mo,respectively.The CBT group showed 0.17 and 0.43 lower HbAlc values than the control group at 6 mo and 12 mo.The intervention on meanΔHbAlc values was significant at 12 mo(t=3.68,P<0.01)and that meanΔPSQI scores were closely related toΔHbAlc values(t=7.02,P<0.01).Intentionto-treat analysis for primary and secondary outcomes showed identical results with completed samples.No adverse events were reported.CONCLUSION CBT delivered by general practitioners,as an effective and practical method,could reduce glycemic levels and improve sleep quality for patients with T2DM in community.

Serum insulin, insulin resistance, p-cell dysfunction, and gallstone disease among type 2 diabetics in Chinese population: A community-based study in Kinmen, Taiwan

AIM: To explore the association of serum insulin, insulin resistance, and β-cell dysfunction with gallstone disease (GSD) in type 2 diabetics. METHODS: We used a community-based study conducted between 1991 and 1993 in Kinmen, Taiwan to identify type 2 diabetics. A screening program for GSD was performed in 2001 by a panel of specialists who employed real-time ultrasound sonography to examine the abdominal region after the patient had fasted for at least 8 h. Screening was conducted in 2001 on 848 patients diagnosed with type 2 diabetes. The HOMA method was used to compare the profile differences for insulin resistance (HOMA IR) and β-cell dysfunction (HOMA β-cell). RESULTS: We studied 440 type 2 diabetics who attended sonography check-ups. After excluding eight insulin-treated diabetics, the prevalence of GSD among the remaining 432 was 13.9% (26/187) among males and 14.7% (36/245) among females. After adjustment for other GSD-associated risk factors in addition to age and obesity, GSD risk increased among females with levels of serum insulin [4th vs 1st quartile odds ratios (OR) = 4.46 (95%CI: 1.71-11.66)] and HOMA IR [4th vs 1st quartile OR = 4.46 (95%CI: 1.71-11.66)]. Better HOMA β-cell function was significantly related to decreased risk of GSD [4th vs 1st quartile OR = 0.16 (95%CI: 0.03-1.70)]. Among males, age and central obesity were the most significant risk factors for GSD. No association of GSD with serum insulin, HOMA IR, and HOMA β-cell was observed among males. CONCLUSION: Serum insulin, insulin resistance, and β-cell dysfunction are risk factors for GSD in females, but not males with type 2 diabetes.

COMMUNITY-BASED ECOTOURISM IN NATURE RESERVE OF CHINA

This paper introduces a new concept of community-based ecotourism (CBET) that originated in foreign countries. Then it analyzes the significance of CBET development in nature reserve (NR). The authors think that community participation is the evitable choice of nature reserve′s conservation and development. CBET, as the self-improved model of ecotourism, can promote tourism community sustainable development. Based on the stakeholder analysis of CBET in NRs, this paper addresses the reality, especially the problem of CBET development in NRs of China. In order to develop CBET in NRs of China, this paper takes some suggestions to promote the community participation: 1)gradual political empowerment, 2) deep level economic incentive, 3) widespread educational support, 4) impartial distribution of community benefits, and 5) stakeholders cooperation.

A community-based friendly health clinic:An initiative adolescent reproductive health project in the rural and urban areas of Indonesia

Objective:This study aims to examine the effects of a community-based friendly health clinic(CFHC)program that adopts manual participatory learning(MPL)intervention on the adolescents living in the rural and urban areas of Indonesia to gain further insights into their knowledge,attitudes,and skills related to adolescent reproductive health(ARH).Methods:A quasi-experimental design was used to obtain information on the ARH knowledge,attitudes,and skills of adolescents.Two intervention studies that used similar protocols and measures were conducted.A total of 192 adolescents(96 adolescents from urban and rural areas)participated in the project,and the participants from each area were divided into eight groups.A questionairre was adopted to measure the ARH knowledge,attitudes,and skills of these participants.A content analysis of the logbook entries of these respondents was conducted to identify their ARH-related problems.The questionnairre and self-reported ARH data were collected before and after the eight-week program.Results:The CFHC program significantly increased the ARH attitudes(p=0.045)and skills(p=0.009)of adolescents in the rural area,but only improved the ARH knowledge(p<0.001)of adolescents in both rural and urban areas.Fourteen themes were identified in three dominant categories,namely,schools,families,and communities.Conclusions:The CFHC with MPL intervention can improve the ARH knowledge,attitudes,and skills of adolescents in the rural area,but can only improve the ARH knowledge of adolescents in the urban area.The ARH program must be designed based on the characterictics of these adolescents to improve their life skills during puberty.

How to Effectively Detect and Manage People Living with HIV/AIDS in China:Establishment of a Community-based Model

This study explored a novel systemic community-based model for detecting and manag-ing people living with HIV/AIDS (PLWHA). Both quantitative and qualitative research methods were used in this study. A quantitative questionnaire investigation was conducted in a sample of 1192 subjects which were randomly selected from two areas with high HIV prevalence, Xiangfan City and Shiyan City of Hubei Province, China. Twenty-two medical and health service staffs were inter-viewed by semi-structured questionnaire focusing on awareness, status, problems, and suggestions about community-based Voluntary Counseling and Testing and Provider Initiated Testing and Coun-seling (VCT/PITC). And they were organized to discuss about the aforementioned issues in Xiangfan City and Shiyan City, respectively. Our results showed that the accessibility and availability of the general VCT/PITC were bad. About 28.3% had known and only 4.9% had made use of VCT/PITC. Developing community-based VCT/PITC had some special advantages that can overcome some ex-isting problems to remedy the aforementioned defects. We are led to conclude that, to maximize the availability and uptake rate of the VCT/PITC, we plan to detect PLWHA by developing the commu-nity-based VCT/PITC through 4 paths. Then we establish the community HIV health care center con-stituted of 8 sectors to provide an overall management. Thus, we can effectively detect and manage the PLWHA with a new systemic community-based model.

Community-Based Approach in the Prevention and Management of Flood Disasters in Babessi Sub-Division (Ndop Plain, North West Cameroon)

Flood is a recurrent natural disaster that has caused enormous human and material damage in many places and continues to hit local committees at an alarming rate. The need to setup permanent committees to prevent and manage flood disasters by local communities is therefore indispensable. In rural areas, the creation of such a structure is always a welcome relief to flood victims but it is often marred by numerous management problems. This study aimed to analyze the community-based approach in the prevention and management of flood disasters in Babessi Subdivision (North West Cameroon), to identify the causes of flood disasters and the preventive strategies used by this local community. A total number of 300 questionnaires as well as structured interviews were used to collect data in the field and the data were analyzed by simple descriptive statistics. The main results revealed that the main cause of flood disasters is heavy and consistent rainfall. Also, poor refuse disposal and drainage system management contribute to floods. The identification of areas likely to be affected by floods and preventing the riparian population from constructing houses along these areas especially beside the main rivers are the flood preventive measures adopted by the local flood management committee. The flood victims are reluctant to relocate to the settlement site earmarked by the Government, meanwhile, the local flood committee do not have the legal tools to forcefully relocate them. The population of Babessi needs to be sensitized on the impending dangers of flood hazard and be encouraged to participate in implementing the adopted strategies to prevent and manage subsequent flood disasters.

Community-Based Integrated Watershed Management

Community-based watershed management is different from the traditional natural resources management. Traditional natural resources management is a way from up to bottom, but the community-based watershed management is from bottom to up. This approach focused on the joining of different stakeholders in integrated watershed management, especially the participation of the community who has been ignored in the past. The purpose of this paper is to outline some of the important basic definitions, concepts and operational framework for initiating community-based watershed management projects and programs as well as some successes and practical challenges associated with the approach.

Predicting South Korea adolescents vulnerable to depressive disorder using Bayesian nomogram:A community-based crosssectional study

BACKGROUND Although South Korea has developed and carried out evidence-based interventions and prevention programs to prevent depressive disorder in adolescents,the number of adolescents with depressive disorder has increased every year for the past 10 years.AIM To develop a nomogram based on a naïve Bayesian algorithm by using epidemiological data on adolescents in South Korea and present baseline data for screening depressive disorder in adolescents.METHODS Epidemiological data from 2438 subjects who completed a brief symptom inventory questionnaire were used to develop a model based on a Bayesian nomogram for predicting depressive disorder in adolescents.RESULTS Physical symptoms,aggression,social withdrawal,attention,satisfaction with school life,mean sleeping hours,and conversation time with parents were influential factors on depressive disorder in adolescents.Among them,physical symptoms were the most influential.CONCLUSION Active intervention by periodically checking the emotional state of adolescents and offering individual counseling and in-depth psychological examinations when necessary are required to mitigate depressive disorder in adolescents.

Factors Affecting Community-Based Tourism Development and Environmental Protection: Practical Study in Vietnam

Community-based tourism (CBT) is considered as one of the typical types of tourism towards sustainable development with three important goals such as bringing back economic benefits, protecting natural environment and preserving indigenous cultural values. Therefore, this paper analyzes the factors that affect community ecotourism development associated with environmental protection in emerging economies, including Vietnam, by the method of key and community tourism potential value assessment with 721 sample surveys. In this paper, we have applied to assess the key factors of tourism in Vietnam and other key points to have more comprehensive solutions to promote the development of community-based tourism with environmental protection. The article has used guest-based approach and method of assessing the key success factors. The results of researching factors to develop community tourist (impacting tourist community needs of tourists) by running Logit function have shown the great influence of factors such as: environmental protection (influence factor +3.585780, with a statistical significance of 99%), security and safety (+3.024816—statistical significance 99%) followed by infrastructure conditions & facilities for the community based tourism, the level of information etc… for your community based tourism needs. From the research results, we propose the following policy groups: 1) Developing guidelines for CBT, the first step as a basis for the development of community based tourism laws later;2) Policies related to the implementation of planning, development of key community tourist areas and destinations;3) Policies related to the development of community-based tourism associated with the protection of natural and cultural environments;4) Policies related to tourism management;coordinating monitoring of community tourism resource points;policies related to the local community in community tourism development;5) Policies related to human resource development;promotion work;developing community based tourism products.

Research on Design and Management of Community-Based Ecotourism Model in Aksu-Zhabagly Nature Reserve of Kazakhstan

This study investigates the community-based ecotourism (CBE) model using a sample of the Aksu-Zhabagly nature reserve (NR). The aim is to propose a suitable CBE model for Aksu-Zhabgly nature-based tourism destinations by employing a combination of field observation, examination, evaluation, and SWOT analysis. The study determines the strategic suggestions for CBE model designing by the results of SWOT analysis. It concludes that convenient transportation and superior location, diversified wild animals and plants, rich in ethnocultural resources, traditional and tranquil life in a typical rural setting, hospitality and positive attitude of locals to tourism and great potential of the region for sustainable development of ecotourism are the strengths. At the same time, the far residential location from the provincial cities, low-quality service, outdated facilities and shortage of skilled employees in tourism management are the main weakness. Another group of constraints to tourism development is lack of tourism marketing and promotion agencies, lack of transparency, poor institution arrangement and corruption, and lack of preferential policies for CBE development. Finally, the paper recommends that economic development, environmental protection, culture and heritage, marketing and image, favorable political environment, and local residents’ empowerment are the main essential to effectively implement the sustainable development of CBE in the Aksu-Zhabagly tourist destination.

Congestive Heart Failure Clinics:How to Make Them Work in a Community-Based Hospital System

Introduction:Congestive heart failure(CHF)accounts for over$32 billion in health care costs per year and is at the epicenter of health care reform.CHF remains a major cause of hospitalizations.It is known and has been reported that missed diagnosis of and missed opportunities to treat heart failure are associated with higher mortality and morbidity.CHF disease management programs have emerged as a potential solution to the CHF epidemic.The paradox remains that CHF disease management programs still cluster in tertiary hospital systems.The impact of heart failure specialists and specialty teams in community health systems is less well understood.Currently there are not enough CHF-trained teams in the community setting to address this unmet health need.Methods:We explored the impact of CHF clinics in a community-based hospital system on readmission rates,mortality,and symptomatic relief.A total of 384 patients were enrolled in the clinic between 2012 and 2015.Data collected included age,sex,type of heart failure,New York Heart Association class,ejection fraction,serum creatinine and brain natriuretic peptide values,and readmission and mortality rates within 30 days,3 months,6 months,and 1 year.We also compared readmission rates between patients who were followed up in the CHF clinic versus those who were not seen in the CHF clinic.Results:A statistically signifi cant difference was demonstrated in readmission rates between patients who were followed up in the CHF clinic versus those who did not visit the CHF clinic for up to 1 year of follow-up.Conclusion:CHF community hospital clinics that use a rapid and frequent follow-up format with CHF-trained teams effectively reduce rehospitalization rates up to 1 year.

Impact of community-based exercise program participation on aerobic capacity in women with and without breast cancer

BACKGROUND Evidence for exercise as an efficacious strategy to improve aerobic capacity of breast cancer survivors(BCS)has come largely from intervention studies conducted in laboratory settings.There is an increasing need to translate to community-type settings,but the efficacy of those interventions using gold standard evaluation is not well-established.AIM To investigate whether similar improvement in aerobic capacity(maximal oxygen consumption[VO2])measured with gold standard testing can be achieved through a community-based setting in BCS.METHODS A peak cardiopulmonary exercise test(VO2peak),6-min walk test(6MWT),and timed up and go test(TUG)were assessed pre-and post-16 wk of progressive intensity aerobic and strength training exercise at a community center.RESULTS The sample consisted of 31 early BCS(<1 year since treatment completion)and 15 controls(CTLs).Both groups significantly improved VO2peak(+1.2 mL/kg/min;P=0.030),6MWT(+35 meters;P<0.001),and TUG(-0.44 s;P<0.01)following training.Both groups improved peak cycling power during the cardiopulmonary exercise test with BCS improving by+10 watts more than the CTLs(P=0.020).Average exercise attendance was 71%(34 of 48 possible days),but compliant days averaged only 60%of total days for aerobic,and<40%for strength in both groups.CONCLUSION Community-based exercise programs can be an effective strategy to improve aerobic capacity and physical function for early-stage BCS but potentially not to the same extent observed in laboratory-based randomized controlled trials.Further research is needed to explore barriers and facilitators of exercise engagement in community-based centers to maximize training benefits for adults with cancer.

Economic Cost of Community-Based Management of Severe Acute Malnutrition in a Rural District in Ghana

Background: The community based management of severe acute malnutrition (CMAM) was introduced in Ghana in 2008 to manage cases of severe acute malnutrition (SAM) recorded at the community level. This study estimated the economic cost of the CMAM programme for children under-five in the Agona west municipality of Ghana. Methods: A retrospective cross sectional study that used a cost analysis design was employed to estimate the economic cost of the programme from the societal perspective. Household cost data from caregivers were obtained using a semi-structured questionnaire. That of programme cost data was obtained from document reviews as well as the use of semi-structured questionnaires and subsequent discussions with key personnel of the Ghana Health Service, Food and Nutrition Technical Assistance and UNICEF. One and multi-way sensitivity analyses were conducted to test how sensitive the cost estimates are to certain variations in the cost profiles. Results: The economic household cost of CMAM was estimated as $1905.32 ($47.63 per household) of which 79% was attributed to direct cost while the remaining 21% made up indirect cost. Programme economic cost of CMAM was estimated as $27633.5 (96% recurrent and 4% capital), with refresher training constituting majority of the cost (34%). The constituents of the total economic cost of the programme, estimated as $32214.56 are programme cost (86%), household costs (6%) and community volunteer cost (8%). Therefore, the economic cost of treating one SAM case using the CMAM protocol was estimated as $805.36. Conclusion: Although CMAM has proven to be an effective tool for the management of SAM, its associated costs are quite enormous when coverage levels (geographic) are high yet small number of cases are detected and treated. Therefore, it is prudent to implement several cost saving strategies such as a reduction in the number of days spent on trainings in order to reduce these costs.

Community-based obesity prevention initiatives in aboriginal communities: The experience of the eat well be active community programs in South Australia

Childhood obesity is a growing concern world-wide, and obesity rates are higher in certain groups in the developed world, including Australian Aboriginal people. Community-based obesity prevention interventions (CBOPI) can help to address obesity, however the approach of such programs to reach diverse groups, including Aboriginal people, must be considered. This paper considers one mainstream1 CBOPI, the eat well be active (ewba) Community Programs in South Australia, which was delivered in two communities and sought to reach Aboriginal people as part of the overall program. This paper considers how well this approach was received by the Aboriginal people living and working in those communities. Semi-structured interviews were conducted with nine Aboriginal workers who had some connection to the ewba program, and seven ewba project staff. Qualitative data analysis was performed and factors found to affect how well the program was received by Aboriginal people include relationships, approach and project target group, including geographical area. A different response was observed in the two communities, with a more positive response being observed in the community where more relationships were developed between ewba and Aboriginal staff. For any CBOPI seeking to work with Aboriginal (or other Indigenous) communities, it is vital to consider and plan how the program will meet the needs and preferences of Aboriginal people in all stages of the project, in order to reach this group.

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

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.