Implementation of Community-based Health Insurance in Post-war Settings: A Systematic Review

Implementation of Community-based Health Insurance in Post-war Settings: A Systematic Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Short Report Implementation of Community-based Health Insurance in Post-war Settings: A Systematic Review Brhane Gebremariam, Mussie Alemayehu, Letebrhan Weldemhret, Lemelem Legesse, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5224377/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Achieving universal health coverage is the biggest challenge in post-conflict situations. Community-based health insurance is an alternative mechanism to improve healthcare utilization and coverage through a prepayment mechanism and pooling health risks in the informal sector. However, there is limited data on the feasibility of community-based health insurance in countries emerging from conflict or war. Objective This systematic review aims to summarize the evidence on the feasibility of the implementation of community-based health insurance in post-conflict situations. Methods The search process included peer-reviewed literature and gray literature published between 1990 and 2023 in the electronic databases of Global Health, Pub Med, CINAHL, Science Direct, and Gray Publications. The search was conducted manually on December 10, 2023. We conducted a systematic review of articles published since 1990 using a search strategy. The Mixed Methods Assessment Tool (MMAT) was used for quality assessment to evaluate the methodological quality of various studies. Results In this review, a total of 30 articles were included and synthesized. Out of the eligible articles, cross-sectional studies, issue reports, and strategic documents were reviewed. In general, 66.7% of the studies were qualitative, and 33.3% were quantitative. We summarize and describe the feasibility of introducing community health insurance, its impact on universal health coverage, and the limitations of financial risk allocation and protection in the post-war period. Community-based health insurance (CBHI) schemes face several significant obstacles, such as poor financial risk protection, a limited risk pool, adverse selection, a lack of professional and standardized management, and a lack of availability and quality of services. Although they are less successful in reaching marginalized populations, CBHI programs with access to external or additional funding sources are more successful in extending access to healthcare services and offering financial security. Regardless of scheme type, CBHI schemes that involve the community in the design and implementation process are more effective at guaranteeing access to healthcare and financial protection. Furthermore, households with CBHI insurance have lower out-of-pocket medical costs, high odds of overall health care utilization, outpatient service use, health facility deliveries, and a lower frequency of catastrophic medical costs at various thresholds. Conclusions Community-based health insurance (CBHI) schemes have emerged as an alternative health financing mechanism in low- and middle-income countries. These schemes aim to improve access to healthcare and provide financial protection. However, their effectiveness is limited by several challenges. Studies have found that CBHI schemes often exclude the ultra-poor and suffer from adverse selection. While there is evidence that CBHI increases healthcare utilization, particularly for outpatient services, and reduces out-of-pocket spending, the overall impact remains small. Key challenges include limited risk pools, poor financial risk protection, and a lack of quality services. Factors influencing enrollment and sustainability include awareness, trust, perceived service quality, and community involvement. Despite some positive outcomes, CBHI schemes are considered complementary to more effective health financing systems rather than a standalone solution. Community Based Health Insurance Systematic Review Post-war Tigray Figures Figure 1 Introduction Health insurance has been endorsed in low- and medium-income countries to improve access to healthcare services because it avoids direct payments of fees by patients and spreads the financial risk among all the insured members [ 1 ]. Community-based health insurance (CBHI) is one of the health insurance schemes mainly proposed with the aim of reducing out-of-pocket payments, particularly in areas where many people engage in informal work and rural residence [ 2 ]. In a world of plenty, it becomes increasingly unacceptable that people die or suffer because they have no access to even the most basic medical care. Equally distressing is when poverty is the result of large catastrophic health expenditures [ 3 ]. In 2017, almost 1 billion people incurred catastrophic out-of-pocket payments (OPP); as such, the total number of people experiencing financial hardship ranged from 1.4 billion to 1.9 billion [ 4 ]. In sub-Saharan African countries, out-of-pocket expenditures accounted for 40% of total health expenditures. About 1.2 billion of the of the world's poorest people are estimated to live in fragile and post-conflict states; despite their increased health needs, their access to services is poor or nonexistent [ 5 ]. Hence, finding a way to finance and provide health care in post-conflict states is one of the major challenges for achieving universal health coverage [ 6 ]. Similarly, the World Health Organization (WHO) views medical fees as a significant obstacle to healthcare coverage and utilization [ 7 ]. Many post-conflict countries' health financing systems are characterized by high out-of-pocket expenditures, high donor dependence, and low levels of government contribution to provide and finance health services and reconstruct the health system. These countries have limited capacity for generating domestic revenues as the population has low economic income because of the devastating war effect. As donor aid decreases, alternative financing mechanisms are needed to increase the resilience of the health system in post-conflict countries [ 8 ]. WHO has stated and encouraged reducing reliance on direct payments through a risk-pooling prepayment approach [ 9 ]. From this point of view, community-based health insurance (CBHI) has emerged as an alternative to user fees. CBHI schemes are designed to ensure sufficient resources are available for members to access effective health care [ 10 , 11 ]. In the past 19 years, the ''health care crisis'' led to the emergence of many CBHI in different regions of developing countries, particularly in sub-Saharan Africa [ 12 ]. CBHI is characterized by a voluntary nonprofit character: a prepayment mechanism with pooling of health risks and funding taking place at the level of the community to cover the costs of health care services [ 12 , 13 ]. Additionally, the majority of CBHI schemes operate in rural areas, and their members are relatively poor. Most often, these people are unable to access adequate public, private, or employer-sponsored health insurance [ 14 ]. The government of Ethiopia endorsed and launched CBHI schemes in 13 pilot woredas in Tigray, Oromia, Amhara, and Southern Nations, Nationalities, and Peoples (SNNP) regions in 2010/11 to provide risk protection mechanisms for those employed in the rural and informal sectors. After a successful 3-year pilot implementation, the government has decided to scale up CBHI, with schemes in 161 woredas [ 15 ]. The introduction of the CBHI scheme has reduced catastrophic OOP expenditure, increased health care utilization, availability of drugs, and quality of services through retaining mobilized resources at health facilities [ 16 ]. However, the war in Tigray, North Ethiopia, which started in November 2020, has destroyed decades of the region's healthcare success [ 17 ]. Consequently, Tigray became an impoverished region with a largely destroyed health infrastructure dependent on international assistance for the provision of health services. Additionally, given the distinctive context of every nation and its starting point in terms of health financing arrangements, community health financing reforms and insurances in post-war or conflict settings cannot simply be imported from one nation to another. Instead, each country's underlying causes of performance issues are different, and it is these causes that the reforms suggested in a health financing strategy must address. Nonetheless, there are insights from global experience that enable the specification of several guiding principles for reforms that assist the advancement of UHC [ 18 ]. This paper therefore analyzes the experiences of post-conflict countries related to the implementation of CBHI and draws lessons from the success stories of these countries about the implementation of CBHIs and its effects on utilization and coverage of health care following the war. Methods Study Design A systematic review was conducted from December 5, 2023, through January 10, 2024, to synthesize evidence on implementation community-based health insurance in post conflict/war settings. A purposeful, non-systematic review of evidence was carried out with an iterative approach because of limited literature on community-based health insurance in post conflict settings. Searching strategy The review was included peer reviewed articles and grey literatures published in English between January 1, 1990, and Dec 2023 in electronic databases. Different databases were used during the search process, such as Global Health, Pub Med/Med line, Science Direct, and grey literatures. The following keywords were used during the search process; (“conflict” OR “post-conflict” OR “reconstruction” OR “fragile”) AND (Community based Health insurance) OR “CBHI” AND (“financing” OR “systems” OR “performance” OR “research” OR “user fees” OR “exemptions” OR “budgeting” OR “equity” OR “access” OR “performance-based” OR “output-based” OR “pay for performance” OR “incentives” OR “resource allocation” OR “public expenditure” OR “contracting” OR “public/private” OR “global health initiatives” OR “aid” OR “funding” OR “budgeting”) AND “health”. Inclusion criteria Studies published since 1990 regardless of study designs (qualitative, mixed, or quantitative), publication kinds, English language written, and at least one of the key terms in the title were taken Exclusion criteria Literatures that did not address the post conflict setting was excluded from the review. Screening process A group of authors double screen all articles in two stages. In the first stage, titles and abstracts were screened based on the inclusion criteria. Any disagreement arose during the search of literature was discussed in our weekly meeting. In the second screening stage, a similar group were conducting a full-text review and held weekly meetings to discuss disagreement and reach consensus. Research articles and reports whose full text dealt with information regarding the review of Evidence on Post-War/Conflict implementation of CBHI will be included (Fig. 1 ). Assessment of data quality For the quality appraisal, the Mixed Methods Appraisal Tool (MMAT) (Hong et al., 2018) was used to assess the methodological quality of the research studies (qualitative, quantitative, and mixed methods). This tool consists of two general screening questions as well as specific quality assessment questions for each type of study design. A study that did not fulfilled the general screening questions was considered in the next quality assessment process. Results Description of the reviewed articles A total of 30 articles were included and synthesized in this review. Regarding study design, 13(43%) of the eligible articles were reviews, seven (16.7%) were cross-sectional studies, five (16.7%) were issue reports and five (16.7%) of them were strategic documents. In general, 20(66.7%) of the studies were qualitative and whereas 10(33.3%) were quantitative (Fig. 1 ). Political commitments and governmental supports Showing strong political will and support are very essential to establish CBHI in post war settings [ 19 ]. Rwanda and Afghanistan government have shown the best experience in implementing health insurance compulsory for everyone [ 19 , 20 ]. The governments were working effectively on revenue generation, proper legal framework, multisectoral collaboration and effective coordination for the success of CBHI. Moreover, after Japan was defeated in the second world war, universal health coverage was a typical indicator of post war recovery hence politicians, local Governments particularly insurer were strongly supported for the success of community health insurance [ 21 ]. Viability of community-based health insurance in post-war Community-based health insurance piloted in five provinces of Afghanistan showed modest enrolment and cost-recovery though CBHI members had higher utilization of health services [ 22 ], But, CBHI was considered a potential resource for the health system, other than tax, social insurance, and donor funding in Afghanistan [ 19 ]. With an expected drop in donor funding, CBHI was considered as one of the alternative strategies of funding options in Afghanistan. Moreover, following the second world war, Japan was facing a persisting social problem, which was poverty among those who were not covered by any health insurance and unable to cover their medical expenses [ 21 ]. To alleviate this, Japan government was established equality through guaranteed health care access for all Japanese in post war [ 21 ]. As a result, the community health insurance system’s coverage has changed dramatically since 1961 with the insured paying 30 percent and insurers paying 70 percent of medical costs [ 23 ]. On the other hand, a study from Afghanistan suggests that community-based targeting of waivers is feasible in a fragile setting [ 12 , 24 ]. In addition to prepayment, Afghanistan government allowed waiver as a result waiver card holder household were more curative (85.5%) and preventive care (83.7%) compared to the user fee health care. There is a recognition of the potential use CBHI to enhance healthcare access for low-income and rural communities in India, but obstacles like mistrust, coverage restrictions, and the requirement for a larger risk pooling still exist [ 25 ]. Resolving important issues such as adverse selection, a small risk pool, and inadequate financial risk protection is necessary for these schemes to succeed [ 26 ]. Moreover, the sustainability of CBHI depends on incentive design, which must reduce moral hazard and adverse selection while providing scheme managers with suitable incentives [ 27 ]. Additionally, there are potential, and problems associated with implementing community-based health insurance in post-conflict environments. The potential use of such programs to generate income and offer financial security is emphasized [ 28 , 29 ]. But they also point out the necessity of a combination of funding sources as well as the significance of national laws and administrative frameworks emphasized how community health workers can provide effective and efficient healthcare in these contexts, especially when it comes to increasing access to care and detecting diseases [ 30 ]. Moreover, community engagement, the involvement of community health workers, the establishment of efficient administrative frameworks, and national policies are all necessary for the successful implementation of community-based health insurance in post-conflict settings. Coverage and utilization of CBHI in post-war settings In a country with a large population in the informal sector like Africa, CBHI is considered preferable a means of financing mechanism [ 19 ]. In addition, studies emphasized that the main potential remedy for the healthcare issues in impoverished populations in developing nations confront is community-based health insurance (CBHI) [ 26 , 31 ]. The Rwandan genocide of 1994 and civil war had a devastating effect on the health-care system, creating a shortage of health workers and destroying infrastructure. Since then, the country has faced an enormous challenge to reconstruct its health-care system and infrastructure and improving coverage and quality of health care [ 32 ]. Studies from Rwanda suggest that voluntary, community-based health insurance was improved the inequitable effects of user fees [ 33 ]. Due to this the life expectancy fell sharply during the civil war and genocide, but it has steady increased to 64 years which is higher than the life expectancy of 57 years in Sub Saharan Africa [ 20 ]. Under five mortality rate which was the highest in early 1990 and has declined to 42 per 1000. Additionally. The under-five mortality rate, which was among the highest in the world in the early 1990s, has declined to 42 per 1,000 maternal mortalities for 29 deaths per 10,000 live births and utilization of health care increased from 31 per cent in 2003 to 107 per cent in 2012 [ 19 , 20 , 34 ]. Today, about 90–95% of Rwandans in the informal sector are enrolled in CBHI. Rwanda and Ghana appear to have made significant progress toward providing universal health coverage through a national health insurance scheme for most of their citizens [ 19 , 20 ]. Ethiopian Government endorsed health insurance strategy with aim of equity in health service coverage both in the formal and informal health sector in 2008 [ 35 ]. Even though there are challenges related to the availability of essential medicines, diagnostic capacity of health facilities, accessibility of health care to the poor, and quality of care, during the initial implementation, the CBHI have shown a remarkable progress with coverage of 45.5% target households in Ethiopia [ 2 , 35 , 36 ]. Despite a positive impact on health system coverage, there are practical challenges on ground for CBHI approach during implementation like service disparity, and low quality of health service need to be addressed critically [ 37 ]. Additionally, absence of formal insurance culture and poverty, which lead to low levels of revenues that can be mobilized from poor communities [ 38 ]. On the other hand, household factors including family size, distance to the health facility, health district of residency, education level of the head of the household, and radio ownership all affect a household's enrollment in CBHI [ 39 ]. Out of pocket expenditure (OPE) and financial protections There has been growing evidence for the necessity of payment to access health services, low capacity to pay, and the lack of prepayment or health insurance particularly in conflict affected settings [ 40 , 41 ]. Waivers and equity funds are ways of reducing the negative impact of user fees on specific groups on health service utilization and equity particularly countries emerging from crisis or conflict [ 42 , 43 ]. Community based health insurance schemes is supposed to reduce unforeseeable or unaffordable health care costs through calculable and regularly paid premiums. In Ethiopia donors contribute 40% of the health financing, while 37% is provided by householders’ payments. Furthermore, Rwanda’s community-based health insurance (CBHI) program has proved effective in lowering catastrophic health-related costs and raising the use of contemporary healthcare services [ 44 , 45 ]. Additionally, fifty per cent of the CBHI funding comes from Rwanda government annual premiums, and the rest of the cost of CBHI contributed from local and international organizations. Non-covered services (10%) are paid for by users at the point of service but are also free for the poorest [ 43 ]. The lowest out of pocket health expenditure were reported 10% in Rwanda followed by 20% in Angola [ 43 ]. Nonetheless, there has been growing evidence for the insured non-poor utilize the program at a higher rate than the insured poor which implied the program's advantages are biased towards the wealthy, even if it has a good effect on lowering out-of-pocket medical expenses and the frequency of catastrophic medical spending [ 1 , 45 , 46 ]. However, the impact of CBHI on financial protection is debatable [ 1 ]. Some studies indicated CBHI has a limited positive effect on financial protection despite an increased access to health care by the members [ 1 ]. Community-Based Health Insurance and Cost recovery The cost recovery ratio (CRR) indicates the proportion of monthly operating costs which was recovered through cost sharing (premiums and user fees). A study indicated that 16% of the clinics’ operating costs were recovered through community health insurance fund [ 22 ]. The estimated CRR based on non-salary costs ranged from 12–32%, with a median of 24% [ 22 ] whereas CRR of non-salary costs are double those of the CRR based on all costs since salaries were estimated to account for half the operating costs. Additionally, CBHI programme was able to recover a modest fraction (12%) of the clinic’s total operating costs though it recovered up to 24% of a clinic’s non-salary operating costs [ 22 ]. Another study from Tanzania reported that 8% of the district health budget was recovered; 2% from premiums, 6% from user fees (47). The CHF type scheme from Rwanda recovered between 6 and 9% of the district health. On the other hand, the system does not have enough money to cover for a new drugs and administration due to such as drop out of using health center. higher treatment costs and failing national drug supply [ 46 ]. Community-based health insurance (CBHI) schemes have been shown to be effective in reducing out-of-pocket payments and improving access to health services (38). However, their ability to recover costs is limited, with only a quarter to a half of health service costs being recovered (38). While they do provide some financial protection and improve cost-recovery, their effects are small, and they serve only a limited section of the population (1). The success of CBHI schemes is influenced by factors such as management, quality of government health services, and the resources available for health care financing (38). Affordability and altruism are key considerations in the design of effective CBHI schemes (49). The determination of premiums based on health costs and the willingness to pay is crucial in ensuring the sustainability and effectiveness of these schemes (50). Risk Pooling Risk pooling in the health system, as discussed by Smith (2004), is a crucial function that spreads the financial risk of health interventions across a pool of contributors. This not only promotes equity but also enhances efficiency by improving population health and reducing uncertainty. A study explores the application of risk pooling in hospitals, particularly in reducing demand and lead time uncertainty [51]. Additionally, a study suggests that risk pooling methods, such as inventory pooling and product substitution, can improve the economic situation of hospitals. A study in Afghanistan suggested that community health fund was designed to create a fund by catchments area of health facility which include many villages [ 22 ]. This study emphasized that community-based savings groups (microfinance programs) has shown that individuals and households are able and willing to save and pool funds within the community/village unit [ 22 ]. Furthermore, risk-pooling and risk-sharing arrangements are needed to address the challenges of providing healthcare to the poor in low and lower-middle-income countries [52].. These arrangements, such as health insurance and prepaid schemes, can help to achieve universal health coverage and promote health care. Risk pooling and prepayment, regardless of scale, improve financial protection for the populations it serves. Health financing policies through pre-payment schemes and public resources with higher risk of sharing have a progressive financing system and lower financial risk burden for people in high-income and middle-income countries. Individuals who purchase individual health insurance are generally in better health compared to those who remain uninsured. Recommendations Community Based Health Insurance (CBHI) has been found to be feasible and sustainable in rural areas. It has the potential to generate stable revenue for healthcare facilities and increase access to services. However, challenges such as trust issues, adverse selection, and administration costs need to be addressed for long-term sustainability. Both top-down and ground level planning approaches are crucial for the success of community health schemes. Community-based health insurance is particularly important in sub-Saharan Africa, where it can help address health inequality and the high burden of diseases. Community based health insurance framework and community participation are considered a key to effective functioning of the system. To sustain the health system financially, the government and partners provide subsidies to covering the costs of health care for community-based health insurance members particularly the poor communities. The government could make some arrangements for clear monitoring and evaluation mechanisms to avoid possible injustices resulting from inappropriate categorizations that might negatively affect the poorest households. Such steps might improve enrolment rates and could help to ensure the poorest households could benefit from the positive impacts of the community-based health insurance structure as much as those who can afford to pay their contributions. The implementation of community-based health insurance has had a positive impact on the demand for modern healthcare and the reduction of catastrophic health expenditure of the community. Mutual aid initiatives have emerged in the health sector as community responses to the re-introduction of user-fees in public, and mission health facilities. Aid coordination and introduction of cross-subsidization (the rich households pay a higher premium) facilitates the implementation of CBHI in conflict affected communities. Risk pooling shares a financial risk of health interventions across a pool of contributors Saving and pooling funds within the community level (large population/village) will be effective for CBHI Conclusions In post-conflict settings, financial access deteriorates because of a combination impact of conflict on livelihoods and incomes, the collapsed of financial protection of the health system, and an increasing reliance on user fees. Evidence on the potential role and feasibility of CBHI in post-conflict settings is limited. However, our review findings emphasized community-based health insurance can be an alternative resource for the health system, other than tax, social insurance, and donor funding with full or partial waver provides financial protection particularly to vulnerable population for equitable and quality of health service delivery. Additionally, in post conflict settings, low out of pocket expenditure or partial or full waiver to the vulnerable or poor population is strongly emphasized which was lesson from Rwanda and Afghanistan. Government sponsor public health financing system has a mandate and plays a significant role for protecting citizens from catastrophic effect of out-of-pocket expenditure in post war or conflict. In conflict settings, there has been also an increasing need to reduce payment barriers to ensure equitable physical access which is a key to equity in post-conflict settings. Community engagement, the involvement of community health workers, the establishment of efficient and effective CBHI frameworks, and national CBHI policies or approaches are vital for the successful implementation of community-based health insurance in post-conflict settings. Risk pooling is crucial function that spreads the financial risk of health interventions across a pool of contributors. Community based health fund will be effective if the saving groups are willing to save and pool funds within the community level. Additionally, CBHI programmed was able to recover a modest fraction (12%) of the health facilities total operating costs and up to 24% of a health facilities’ non-salary operating costs. However, CBHI scheme has limited ability to recover the operating costs of health expenditure, only a quarter health service costs being recovered through this scheme. Abbreviations CBHI Community Based Health Insurance CRR Cost Recovery Ratio MMAT Mixed Methods Assessment Tool OPE Out of pocket expenditure OPP out-of-pocket payments Declarations Ethical approval NA Data availability statements All data are available within the manuscript Acknowledgments First, we are grateful to Tigray Health Research Institute for taking initiative for this review process in collaboration with Mekelle University College of Health Science (MUCHS), and Tigray Institute of Policy Studies (TIPS) to realize this review document. We would like also to acknowledge Dr. Mussie Alemayehu Mekelle University College of Health Science, for his valuable and constructive comments throughout the review of evidence. Authors Contribution The study was conceptualized by HK, BA, MA and LL, LW and BG drafted the manuscript. BA, LL and HK critically reviewed the initial draft and MA, BG and LW reviewed and approved the final manuscript. 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Steinhardt, L. & Peters, D. 2010, "Targeting accuracy and impact of a community identified waiver card scheme for primary care user fees in Afghanistan", International Journal for Equity in Health, vol. 9, no. 28. 24 Chol Chol, Joel Negin, Alberto Garcia-Basteiro, Tesfay Gebregzabher Gebrehiwot, Berhane Debru, Maria Chimpolo, Kingsley Agho, Robert G Cumming & Seye Abimbola (2018) Health system reforms in five sub-Saharan African countries that experienced major armed conflicts (wars) during 1990–2015: a literature review, Global Health Action, 11:1, 1517931, DOI: 10.1080/16549716.2018.1517931 J. Aly, H. Rajhi, Taoufik Vencatachellum, D. Salami, A. Moummi, 2010. Community Based Health Insurance Schemes in Africa: The Case of Rwanda. A. Shimeles, 2010. Community based health insurance schemes in Africa: The case of Rwanda. A. Woldemichael, Daniel Gurara, A. Shimeles, 2019. The Impact of Community Based Health Insurance Schemes on Out-of-Pocket Healthcare Spending: Evidence from Rwanda. IMF Working Papers. Chee G, Smith k, Kapinga A. Assessment of the community health fund in Hanang District, Tanzania, 2002. Partner for health reformplus project, Abt Associates Inc., Bethesda Tabor SR. Community based health insurance and social protection.2005 Onwujekwe O, Hanson K, Uzochukwu B. Are poor differentially benefiting from provision of priority public health services? A benefit incidence analysis in Nigeria. International Journal for Equity in Health. 2012: 11(7) Gusliana. Determination of Community based health microfinance. International Journal of Research in Community Services, 20023; 4(3). Additional Declarations No competing interests reported. Supplementary Files CBHISummary.docx PRISMAChecklistCBHI.doc Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Institute","correspondingAuthor":false,"prefix":"","firstName":"Brhane","middleName":"","lastName":"Ayele","suffix":""},{"id":364374324,"identity":"1dd31621-ccf4-4f25-ac54-9f5900cb32c0","order_by":5,"name":"Hayelom Kahsay","email":"","orcid":"","institution":"Tigray Health Research Institute","correspondingAuthor":false,"prefix":"","firstName":"Hayelom","middleName":"","lastName":"Kahsay","suffix":""}],"badges":[],"createdAt":"2024-10-08 10:23:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5224377/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5224377/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":80192068,"identity":"07c625c7-177e-4506-a02e-1c43ec35eafa","added_by":"auto","created_at":"2025-04-09 04:33:26","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":77332,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic presentation of systematic review processes on the Community Based Health Insurance in post-war settings.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5224377/v1/97e79a5383366259668dcd19.png"},{"id":80192605,"identity":"34b8dbda-f7f0-44be-a632-b8def3f29e80","added_by":"auto","created_at":"2025-04-09 04:41:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":701618,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5224377/v1/77b2bf3e-c406-4eda-9abb-16d8111b7ec1.pdf"},{"id":80192069,"identity":"6acf4d29-cae5-45c6-96fd-7b56d225f01e","added_by":"auto","created_at":"2025-04-09 04:33:26","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":25055,"visible":true,"origin":"","legend":"","description":"","filename":"CBHISummary.docx","url":"https://assets-eu.researchsquare.com/files/rs-5224377/v1/8af37765e6fc98b091ea41c2.docx"},{"id":80192070,"identity":"af462d84-707b-49a0-a930-84d6af4dbbda","added_by":"auto","created_at":"2025-04-09 04:33:26","extension":"doc","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":65536,"visible":true,"origin":"","legend":"","description":"","filename":"PRISMAChecklistCBHI.doc","url":"https://assets-eu.researchsquare.com/files/rs-5224377/v1/f46999f3eb94686b93facd1f.doc"}],"financialInterests":"No competing interests reported.","formattedTitle":"Implementation of Community-based Health Insurance in Post-war Settings: A Systematic Review","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHealth insurance has been endorsed in low- and medium-income countries to improve access to healthcare services because it avoids direct payments of fees by patients and spreads the financial risk among all the insured members [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Community-based health insurance (CBHI) is one of the health insurance schemes mainly proposed with the aim of reducing out-of-pocket payments, particularly in areas where many people engage in informal work and rural residence [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In a world of plenty, it becomes increasingly unacceptable that people die or suffer because they have no access to even the most basic medical care. Equally distressing is when poverty is the result of large catastrophic health expenditures [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In 2017, almost 1\u0026nbsp;billion people incurred catastrophic out-of-pocket payments (OPP); as such, the total number of people experiencing financial hardship ranged from 1.4\u0026nbsp;billion to 1.9\u0026nbsp;billion [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn sub-Saharan African countries, out-of-pocket expenditures accounted for 40% of total health expenditures. About 1.2\u0026nbsp;billion of the of the world's poorest people are estimated to live in fragile and post-conflict states; despite their increased health needs, their access to services is poor or nonexistent [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Hence, finding a way to finance and provide health care in post-conflict states is one of the major challenges for achieving universal health coverage [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Similarly, the World Health Organization (WHO) views medical fees as a significant obstacle to healthcare coverage and utilization [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMany post-conflict countries' health financing systems are characterized by high out-of-pocket expenditures, high donor dependence, and low levels of government contribution to provide and finance health services and reconstruct the health system. These countries have limited capacity for generating domestic revenues as the population has low economic income because of the devastating war effect. As donor aid decreases, alternative financing mechanisms are needed to increase the resilience of the health system in post-conflict countries [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. WHO has stated and encouraged reducing reliance on direct payments through a risk-pooling prepayment approach [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. From this point of view, community-based health insurance (CBHI) has emerged as an alternative to user fees. CBHI schemes are designed to ensure sufficient resources are available for members to access effective health care [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the past 19 years, the ''health care crisis'' led to the emergence of many CBHI in different regions of developing countries, particularly in sub-Saharan Africa [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. CBHI is characterized by a voluntary nonprofit character: a prepayment mechanism with pooling of health risks and funding taking place at the level of the community to cover the costs of health care services [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Additionally, the majority of CBHI schemes operate in rural areas, and their members are relatively poor. Most often, these people are unable to access adequate public, private, or employer-sponsored health insurance [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The government of Ethiopia endorsed and launched CBHI schemes in 13 pilot woredas in Tigray, Oromia, Amhara, and Southern Nations, Nationalities, and Peoples (SNNP) regions in 2010/11 to provide risk protection mechanisms for those employed in the rural and informal sectors. After a successful 3-year pilot implementation, the government has decided to scale up CBHI, with schemes in 161 woredas [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The introduction of the CBHI scheme has reduced catastrophic OOP expenditure, increased health care utilization, availability of drugs, and quality of services through retaining mobilized resources at health facilities [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, the war in Tigray, North Ethiopia, which started in November 2020, has destroyed decades of the region's healthcare success [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Consequently, Tigray became an impoverished region with a largely destroyed health infrastructure dependent on international assistance for the provision of health services. Additionally, given the distinctive context of every nation and its starting point in terms of health financing arrangements, community health financing reforms and insurances in post-war or conflict settings cannot simply be imported from one nation to another. Instead, each country's underlying causes of performance issues are different, and it is these causes that the reforms suggested in a health financing strategy must address. Nonetheless, there are insights from global experience that enable the specification of several guiding principles for reforms that assist the advancement of UHC [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. This paper therefore analyzes the experiences of post-conflict countries related to the implementation of CBHI and draws lessons from the success stories of these countries about the implementation of CBHIs and its effects on utilization and coverage of health care following the war.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy Design\u003c/p\u003e \u003cp\u003eA systematic review was conducted from December 5, 2023, through January 10, 2024, to synthesize evidence on implementation community-based health insurance in post conflict/war settings. A purposeful, non-systematic review of evidence was carried out with an iterative approach because of limited literature on community-based health insurance in post conflict settings.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSearching strategy\u003c/h2\u003e \u003cp\u003eThe review was included peer reviewed articles and grey literatures published in English between January 1, 1990, and Dec 2023 in electronic databases. Different databases were used during the search process, such as Global Health, Pub Med/Med line, Science Direct, and grey literatures. The following keywords were used during the search process; (\u0026ldquo;conflict\u0026rdquo; OR \u0026ldquo;post-conflict\u0026rdquo; OR \u0026ldquo;reconstruction\u0026rdquo; OR \u0026ldquo;fragile\u0026rdquo;) AND (Community based Health insurance) OR \u0026ldquo;CBHI\u0026rdquo; AND (\u0026ldquo;financing\u0026rdquo; OR \u0026ldquo;systems\u0026rdquo; OR \u0026ldquo;performance\u0026rdquo; OR \u0026ldquo;research\u0026rdquo; OR \u0026ldquo;user fees\u0026rdquo; OR \u0026ldquo;exemptions\u0026rdquo; OR \u0026ldquo;budgeting\u0026rdquo; OR \u0026ldquo;equity\u0026rdquo; OR \u0026ldquo;access\u0026rdquo; OR \u0026ldquo;performance-based\u0026rdquo; OR \u0026ldquo;output-based\u0026rdquo; OR \u0026ldquo;pay for performance\u0026rdquo; OR \u0026ldquo;incentives\u0026rdquo; OR \u0026ldquo;resource allocation\u0026rdquo; OR \u0026ldquo;public expenditure\u0026rdquo; OR \u0026ldquo;contracting\u0026rdquo; OR \u0026ldquo;public/private\u0026rdquo; OR \u0026ldquo;global health initiatives\u0026rdquo; OR \u0026ldquo;aid\u0026rdquo; OR \u0026ldquo;funding\u0026rdquo; OR \u0026ldquo;budgeting\u0026rdquo;) AND \u0026ldquo;health\u0026rdquo;.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInclusion criteria\u003c/h3\u003e\n\u003cp\u003eStudies published since 1990 regardless of study designs (qualitative, mixed, or quantitative), publication kinds, English language written, and at least one of the key terms in the title were taken\u003c/p\u003e\n\u003ch3\u003eExclusion criteria\u003c/h3\u003e\n\u003cp\u003eLiteratures that did not address the post conflict setting was excluded from the review.\u003c/p\u003e\n\u003ch3\u003eScreening process\u003c/h3\u003e\n\u003cp\u003eA group of authors double screen all articles in two stages. In the first stage, titles and abstracts were screened based on the inclusion criteria. Any disagreement arose during the search of literature was discussed in our weekly meeting. In the second screening stage, a similar group were conducting a full-text review and held weekly meetings to discuss disagreement and reach consensus. Research articles and reports whose full text dealt with information regarding the review of Evidence on Post-War/Conflict implementation of CBHI will be included (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAssessment of data quality\u003c/p\u003e \u003cp\u003eFor the quality appraisal, the Mixed Methods Appraisal Tool (MMAT) (Hong et al., 2018) was used to assess the methodological quality of the research studies (qualitative, quantitative, and mixed methods). This tool consists of two general screening questions as well as specific quality assessment questions for each type of study design. A study that did not fulfilled the general screening questions was considered in the next quality assessment process.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eDescription of the reviewed articles\u003c/h2\u003e \u003cp\u003eA total of 30 articles were included and synthesized in this review. Regarding study design, 13(43%) of the eligible articles were reviews, seven (16.7%) were cross-sectional studies, five (16.7%) were issue reports and five (16.7%) of them were strategic documents. In general, 20(66.7%) of the studies were qualitative and whereas 10(33.3%) were quantitative (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePolitical commitments and governmental supports\u003c/h3\u003e\n\u003cp\u003eShowing strong political will and support are very essential to establish CBHI in post war settings [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Rwanda and Afghanistan government have shown the best experience in implementing health insurance compulsory for everyone [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The governments were working effectively on revenue generation, proper legal framework, multisectoral collaboration and effective coordination for the success of CBHI. Moreover, after Japan was defeated in the second world war, universal health coverage was a typical indicator of post war recovery hence politicians, local Governments particularly insurer were strongly supported for the success of community health insurance [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eViability of community-based health insurance in post-war\u003c/h3\u003e\n\u003cp\u003eCommunity-based health insurance piloted in five provinces of Afghanistan showed modest enrolment and cost-recovery though CBHI members had higher utilization of health services [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], But, CBHI was considered a potential resource for the health system, other than tax, social insurance, and donor funding in Afghanistan [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. With an expected drop in donor funding, CBHI was considered as one of the alternative strategies of funding options in Afghanistan. Moreover, following the second world war, Japan was facing a persisting social problem, which was poverty among those who were not covered by any health insurance and unable to cover their medical expenses [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. To alleviate this, Japan government was established equality through guaranteed health care access for all Japanese in post war [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. As a result, the community health insurance system\u0026rsquo;s coverage has changed dramatically since 1961 with the insured paying 30 percent and insurers paying 70 percent of medical costs [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. On the other hand, a study from Afghanistan suggests that community-based targeting of waivers is feasible in a fragile setting [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In addition to prepayment, Afghanistan government allowed waiver as a result waiver card holder household were more curative (85.5%) and preventive care (83.7%) compared to the user fee health care.\u003c/p\u003e \u003cp\u003eThere is a recognition of the potential use CBHI to enhance healthcare access for low-income and rural communities in India, but obstacles like mistrust, coverage restrictions, and the requirement for a larger risk pooling still exist [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Resolving important issues such as adverse selection, a small risk pool, and inadequate financial risk protection is necessary for these schemes to succeed [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Moreover, the sustainability of CBHI depends on incentive design, which must reduce moral hazard and adverse selection while providing scheme managers with suitable incentives [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Additionally, there are potential, and problems associated with implementing community-based health insurance in post-conflict environments. The potential use of such programs to generate income and offer financial security is emphasized [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. But they also point out the necessity of a combination of funding sources as well as the significance of national laws and administrative frameworks emphasized how community health workers can provide effective and efficient healthcare in these contexts, especially when it comes to increasing access to care and detecting diseases [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Moreover, community engagement, the involvement of community health workers, the establishment of efficient administrative frameworks, and national policies are all necessary for the successful implementation of community-based health insurance in post-conflict settings.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eCoverage and utilization of CBHI in post-war settings\u003c/h2\u003e \u003cp\u003eIn a country with a large population in the informal sector like Africa, CBHI is considered preferable a means of financing mechanism [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In addition, studies emphasized that the main potential remedy for the healthcare issues in impoverished populations in developing nations confront is community-based health insurance (CBHI) [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. The Rwandan genocide of 1994 and civil war had a devastating effect on the health-care system, creating a shortage of health workers and destroying infrastructure. Since then, the country has faced an enormous challenge to reconstruct its health-care system and infrastructure and improving coverage and quality of health care [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStudies from Rwanda suggest that voluntary, community-based health insurance was improved the inequitable effects of user fees [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Due to this the life expectancy fell sharply during the civil war and genocide, but it has steady increased to 64 years which is higher than the life expectancy of 57 years in Sub Saharan Africa [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Under five mortality rate which was the highest in early 1990 and has declined to 42 per 1000. Additionally. The under-five mortality rate, which was among the highest in the world in the early 1990s, has declined to 42 per 1,000 maternal mortalities for 29 deaths per 10,000 live births and utilization of health care increased from 31 per cent in 2003 to 107 per cent in 2012 [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Today, about 90\u0026ndash;95% of Rwandans in the informal sector are enrolled in CBHI. Rwanda and Ghana appear to have made significant progress toward providing universal health coverage through a national health insurance scheme for most of their citizens [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eEthiopian Government endorsed health insurance strategy with aim of equity in health service coverage both in the formal and informal health sector in 2008 [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Even though there are challenges related to the availability of essential medicines, diagnostic capacity of health facilities, accessibility of health care to the poor, and quality of care, during the initial implementation, the CBHI have shown a remarkable progress with coverage of 45.5% target households in Ethiopia [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Despite a positive impact on health system coverage, there are practical challenges on ground for CBHI approach during implementation like service disparity, and low quality of health service need to be addressed critically [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Additionally, absence of formal insurance culture and poverty, which lead to low levels of revenues that can be mobilized from poor communities [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. On the other hand, household factors including family size, distance to the health facility, health district of residency, education level of the head of the household, and radio ownership all affect a household's enrollment in CBHI [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eOut of pocket expenditure (OPE) and financial protections\u003c/h2\u003e \u003cp\u003eThere has been growing evidence for the necessity of payment to access health services, low capacity to pay, and the lack of prepayment or health insurance particularly in conflict affected settings [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Waivers and equity funds are ways of reducing the negative impact of user fees on specific groups on health service utilization and equity particularly countries emerging from crisis or conflict [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Community based health insurance schemes is supposed to reduce unforeseeable or unaffordable health care costs through calculable and regularly paid premiums. In Ethiopia donors contribute 40% of the health financing, while 37% is provided by householders\u0026rsquo; payments.\u003c/p\u003e \u003cp\u003eFurthermore, Rwanda\u0026rsquo;s community-based health insurance (CBHI) program has proved effective in lowering catastrophic health-related costs and raising the use of contemporary healthcare services [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Additionally, fifty per cent of the CBHI funding comes from Rwanda government annual premiums, and the rest of the cost of CBHI contributed from local and international organizations. Non-covered services (10%) are paid for by users at the point of service but are also free for the poorest [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. The lowest out of pocket health expenditure were reported 10% in Rwanda followed by 20% in Angola [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Nonetheless, there has been growing evidence for the insured non-poor utilize the program at a higher rate than the insured poor which implied the program's advantages are biased towards the wealthy, even if it has a good effect on lowering out-of-pocket medical expenses and the frequency of catastrophic medical spending [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. However, the impact of CBHI on financial protection is debatable [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Some studies indicated CBHI has a limited positive effect on financial protection despite an increased access to health care by the members [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCommunity-Based Health Insurance and Cost recovery\u003c/p\u003e \u003cp\u003eThe cost recovery ratio (CRR) indicates the proportion of monthly operating costs which was recovered through cost sharing (premiums and user fees). A study indicated that 16% of the clinics\u0026rsquo; operating costs were recovered through community health insurance fund [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The estimated CRR based on non-salary costs ranged from 12\u0026ndash;32%, with a median of 24% [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] whereas CRR of non-salary costs are double those of the CRR based on all costs since salaries were estimated to account for half the operating costs. Additionally, CBHI programme was able to recover a modest fraction (12%) of the clinic\u0026rsquo;s total operating costs though it recovered up to 24% of a clinic\u0026rsquo;s non-salary operating costs [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Another study from Tanzania reported that 8% of the district health budget was recovered; 2% from premiums, 6% from user fees (47). The CHF type scheme from Rwanda recovered between 6 and 9% of the district health. On the other hand, the system does not have enough money to cover for a new drugs and administration due to such as drop out of using health center. higher treatment costs and failing national drug supply [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCommunity-based health insurance (CBHI) schemes have been shown to be effective in reducing out-of-pocket payments and improving access to health services (38). However, their ability to recover costs is limited, with only a quarter to a half of health service costs being recovered (38). While they do provide some financial protection and improve cost-recovery, their effects are small, and they serve only a limited section of the population (1). The success of CBHI schemes is influenced by factors such as management, quality of government health services, and the resources available for health care financing (38). Affordability and altruism are key considerations in the design of effective CBHI schemes (49). The determination of premiums based on health costs and the willingness to pay is crucial in ensuring the sustainability and effectiveness of these schemes (50).\u003c/p\u003e \u003cp\u003eRisk Pooling\u003c/p\u003e \u003cp\u003eRisk pooling in the health system, as discussed by Smith (2004), is a crucial function that spreads the financial risk of health interventions across a pool of contributors. This not only promotes equity but also enhances efficiency by improving population health and reducing uncertainty. A study explores the application of risk pooling in hospitals, particularly in reducing demand and lead time uncertainty [51]. Additionally, a study suggests that risk pooling methods, such as inventory pooling and product substitution, can improve the economic situation of hospitals. \u003cb\u003eA\u003c/b\u003e study in Afghanistan suggested that community health fund was designed to create a fund by catchments area of health facility which include many villages [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. This study emphasized that community-based savings groups (microfinance programs) has shown that individuals and households are able and willing to save and pool funds within the community/village unit [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFurthermore, risk-pooling and risk-sharing arrangements are needed to address the challenges of providing healthcare to the poor in low and lower-middle-income countries [52].. These arrangements, such as health insurance and prepaid schemes, can help to achieve universal health coverage and promote health care. Risk pooling and prepayment, regardless of scale, improve financial protection for the populations it serves. Health financing policies through pre-payment schemes and public resources with higher risk of sharing have a progressive financing system and lower financial risk burden for people in high-income and middle-income countries. Individuals who purchase individual health insurance are generally in better health compared to those who remain uninsured.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eRecommendations\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eCommunity Based Health Insurance (CBHI) has been found to be feasible and sustainable in rural areas. It has the potential to generate stable revenue for healthcare facilities and increase access to services. However, challenges such as trust issues, adverse selection, and administration costs need to be addressed for long-term sustainability.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eBoth top-down and ground level planning approaches are crucial for the success of community health schemes. Community-based health insurance is particularly important in sub-Saharan Africa, where it can help address health inequality and the high burden of diseases.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eCommunity based health insurance framework and community participation are considered a key to effective functioning of the system.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTo sustain the health system financially, the government and partners provide subsidies to covering the costs of health care for community-based health insurance members particularly the poor communities.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThe government could make some arrangements for clear monitoring and evaluation mechanisms to avoid possible injustices resulting from inappropriate categorizations that might negatively affect the poorest households. Such steps might improve enrolment rates and could help to ensure the poorest households could benefit from the positive impacts of the community-based health insurance structure as much as those who can afford to pay their contributions.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eThe implementation of community-based health insurance has had a positive impact on the demand for modern healthcare and the reduction of catastrophic health expenditure of the community.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eMutual aid initiatives have emerged in the health sector as community responses to the re-introduction of user-fees in public, and mission health facilities.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAid coordination and introduction of cross-subsidization (the rich households pay a higher premium) facilitates the implementation of CBHI in conflict affected communities.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eRisk pooling shares a financial risk of health interventions across a pool of contributors\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eSaving and pooling funds within the community level (large population/village) will be effective for CBHI\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn post-conflict settings, financial access deteriorates because of a combination impact of conflict on livelihoods and incomes, the collapsed of financial protection of the health system, and an increasing reliance on user fees. Evidence on the potential role and feasibility of CBHI in post-conflict settings is limited. However, our review findings emphasized community-based health insurance can be an alternative resource for the health system, other than tax, social insurance, and donor funding with full or partial waver provides financial protection particularly to vulnerable population for equitable and quality of health service delivery. Additionally, in post conflict settings, low out of pocket expenditure or partial or full waiver to the vulnerable or poor population is strongly emphasized which was lesson from Rwanda and Afghanistan. Government sponsor public health financing system has a mandate and plays a significant role for protecting citizens from catastrophic effect of out-of-pocket expenditure in post war or conflict. In conflict settings, there has been also an increasing need to reduce payment barriers to ensure equitable physical access which is a key to equity in post-conflict settings. Community engagement, the involvement of community health workers, the establishment of efficient and effective CBHI frameworks, and national CBHI policies or approaches are vital for the successful implementation of community-based health insurance in post-conflict settings. Risk pooling is crucial function that spreads the financial risk of health interventions across a pool of contributors. Community based health fund will be effective if the saving groups are willing to save and pool funds within the community level. Additionally, CBHI programmed was able to recover a modest fraction (12%) of the health facilities total operating costs and up to 24% of a health facilities\u0026rsquo; non-salary operating costs. However, CBHI scheme has limited ability to recover the operating costs of health expenditure, only a quarter health service costs being recovered through this scheme.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eCBHI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 462px;\"\u003e\n \u003cp\u003eCommunity Based Health Insurance\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eCRR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 462px;\"\u003e\n \u003cp\u003eCost Recovery Ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eMMAT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 462px;\"\u003e\n \u003cp\u003eMixed Methods Assessment Tool\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eOPE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 462px;\"\u003e\n \u003cp\u003eOut of pocket expenditure\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003eOPP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 462px;\"\u003e\n \u003cp\u003eout-of-pocket payments\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;NA\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data are available within the manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFirst, we are grateful to Tigray Health Research Institute for taking initiative for this review process in collaboration with Mekelle University College of Health Science (MUCHS), and Tigray Institute of Policy Studies (TIPS) to realize this review document. We would like also to acknowledge Dr. Mussie Alemayehu Mekelle University College of Health Science, for his valuable and constructive comments throughout the review of evidence.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eAuthors Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conceptualized by HK, BA, MA and LL, LW and BG drafted the manuscript. BA, LL and HK critically reviewed the initial draft and MA, BG and LW reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNA\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors\u0026rsquo; declared no competing interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eEkman, Bj\u0026ouml;rn. 2004. Community-Based Health Insurance in low-income countries: a systematic review of the evidence. 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Aly, H. Rajhi, Taoufik Vencatachellum, D. Salami, A. Moummi, 2010. Community Based Health Insurance Schemes in Africa: The Case of Rwanda. \u003c/li\u003e\n\u003cli\u003eA. Shimeles, 2010. Community based health insurance schemes in Africa: The case of Rwanda. \u003c/li\u003e\n\u003cli\u003eA. Woldemichael, Daniel Gurara, A. Shimeles, 2019. The Impact of Community Based Health Insurance Schemes on Out-of-Pocket Healthcare Spending: Evidence from Rwanda. IMF Working Papers. \u003c/li\u003e\n\u003cli\u003eChee G, Smith k, Kapinga A. Assessment of the community health fund in Hanang District, Tanzania, 2002. Partner for health reformplus project, Abt Associates Inc., Bethesda\u003c/li\u003e\n\u003cli\u003eTabor SR. Community based health insurance and social protection.2005\u003c/li\u003e\n\u003cli\u003eOnwujekwe O, Hanson K, Uzochukwu B. Are poor differentially benefiting from provision of priority public health services? A benefit incidence analysis in Nigeria. International Journal for Equity in Health. 2012: 11(7)\u003c/li\u003e\n\u003cli\u003eGusliana. Determination of Community based health microfinance. International Journal of Research in Community Services, 20023; 4(3).\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Community Based Health Insurance, Systematic Review, Post-war, Tigray","lastPublishedDoi":"10.21203/rs.3.rs-5224377/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5224377/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAchieving universal health coverage is the biggest challenge in post-conflict situations. Community-based health insurance is an alternative mechanism to improve healthcare utilization and coverage through a prepayment mechanism and pooling health risks in the informal sector. However, there is limited data on the feasibility of community-based health insurance in countries emerging from conflict or war.\u003c/p\u003e\u003cp\u003e\u003cb\u003eObjective\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis systematic review aims to summarize the evidence on the feasibility of the implementation of community-based health insurance in post-conflict situations.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe search process included peer-reviewed literature and gray literature published between 1990 and 2023 in the electronic databases of Global Health, Pub Med, CINAHL, Science Direct, and Gray Publications. The search was conducted manually on December 10, 2023. We conducted a systematic review of articles published since 1990 using a search strategy. The Mixed Methods Assessment Tool (MMAT) was used for quality assessment to evaluate the methodological quality of various studies.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eIn this review, a total of 30 articles were included and synthesized. Out of the eligible articles, cross-sectional studies, issue reports, and strategic documents were reviewed. In general, 66.7% of the studies were qualitative, and 33.3% were quantitative. We summarize and describe the feasibility of introducing community health insurance, its impact on universal health coverage, and the limitations of financial risk allocation and protection in the post-war period. Community-based health insurance (CBHI) schemes face several significant obstacles, such as poor financial risk protection, a limited risk pool, adverse selection, a lack of professional and standardized management, and a lack of availability and quality of services. Although they are less successful in reaching marginalized populations, CBHI programs with access to external or additional funding sources are more successful in extending access to healthcare services and offering financial security. Regardless of scheme type, CBHI schemes that involve the community in the design and implementation process are more effective at guaranteeing access to healthcare and financial protection. Furthermore, households with CBHI insurance have lower out-of-pocket medical costs, high odds of overall health care utilization, outpatient service use, health facility deliveries, and a lower frequency of catastrophic medical costs at various thresholds.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e \u003cp\u003eCommunity-based health insurance (CBHI) schemes have emerged as an alternative health financing mechanism in low- and middle-income countries. These schemes aim to improve access to healthcare and provide financial protection. However, their effectiveness is limited by several challenges. Studies have found that CBHI schemes often exclude the ultra-poor and suffer from adverse selection. While there is evidence that CBHI increases healthcare utilization, particularly for outpatient services, and reduces out-of-pocket spending, the overall impact remains small. Key challenges include limited risk pools, poor financial risk protection, and a lack of quality services. Factors influencing enrollment and sustainability include awareness, trust, perceived service quality, and community involvement. Despite some positive outcomes, CBHI schemes are considered complementary to more effective health financing systems rather than a standalone solution.\u003c/p\u003e","manuscriptTitle":"Implementation of Community-based Health Insurance in Post-war Settings: A Systematic Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-09 04:33:21","doi":"10.21203/rs.3.rs-5224377/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3a62c7c2-714c-4f81-8e61-ae8c68567063","owner":[],"postedDate":"April 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-04-09T04:33:21+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-09 04:33:21","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5224377","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5224377","identity":"rs-5224377","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}