Community-Based Health Insurance (CBHI) in Rwanda was promulgated as the best alternative to address the financial barriers for accessibility to health care services for the poor population and the informal sector. The purpose of this study was to investigate whether CBHI reduce Out-of-pocket health expenses for their members as compared to non-members and to what extent CBHI provide financial protection for the poorest population. This research based itself on secondary source of data primarily collected for a prospective quasi-experimental design which evaluated the impact of Performance-Based Financing. The primary study had reported on the Out-Of-Pocket expenses for health by members and non-members of CBHI; residing in a sample of 1961 households; in addition to their demographics and socio-economic characteristics. The findings indicate that insured individuals were about 2.6 times more likely to utilize health care services than respondents without health insurance. It is also worth noting that households with health insurance coverage were less likely to experience a catastrophic health expenditure than households without health insurance (aOR: 0.744; 95% CI:[0.586 - 0.945]), and that the effect of health insurance coverage was higher in people living in poor households than in people living in middle or richer households / Health Studies / M.A. (Public Health)

La couverture universelle de santé est aujourd’hui au coeur du financement de la santé. Dans ce contexte, le développement des mécanismes d’assurance et l’amélioration de l’efficience constituent des enjeux majeurs pour garantir l’équité dans l’accès et le financement des services de santé. La transition vers la couverture universelle de santé s’appuie sur la combinaison des fonds d’équité de santé et de l’assurance santé communautaire au Cambodge et sur le développement de l’assurance santé communautaire en Chine avec le Nouveau Système de Coopératives Médicales Rurales. Alors que les modalités du financement de la santé changent, l’utilisation des ressources devient un enjeu central et on doit alors s’interroger sur leur efficience dans le contexte de la couverture universelle de santé. C’est l’objet de cette thèse qui s’articule autour de quatre chapitres. Le chapitre I analyse les enjeux du financement de la santé dans les pays en développement dans le contexte de la couverture universelle de santé, montrant pourquoi la problématique de l’efficience en constitue l’une des interrogations centrales. La thèse se concentre alors sur l’étude de l’efficience des établissements de santé au travers de trois chapitres. Le chapitre II porte sur la mesure de l’efficience technique via l’analyse d’enveloppement des données. Les chapitres III et IV présentent des études de cas portant respectivement sur l’activité et l’efficience des centres de santé de la province de Takéo au Cambodge et des hôpitaux municipaux de la préfecture de Weifang en Chine dans le contexte des réformes orientées vers la couverture universelle de santé. / Universal health coverage is at the heart of health financing. In such context, the development of insurance mechanisms and the improvement of efficiency are major stakes to insure equity in access and financing of health care services. In Cambodia, the transition to universal health coverage relies on a combination of health equity funds and community-based health insurance while in China it relies on the development of community-based health insurance with the New Rural Cooperative Medical Scheme. The composition of health financing evolves and thus, the utilization of resources becomes a central issue. So, as it proposed in this thesis, we have to examine the efficiency in the context of universal health coverage. The chapter I analyses the issues of health financing in developing countries in the context of universal health coverage and underlines why the efficiency is the central issue. The thesis then concentrates on the study of efficiency through three chapters. Chapter II details the data envelopment analysis to estimate technical efficiency. Chapters III and IV respectively study the activity and efficiency of health centers of Takeo province in Cambodia and townships hospitals of Weifang prefecture in China, in the context of reforms oriented to universal health coverage.

Le financement des soins de santé de qualité constitue un défi majeur pour les pays en développement. Malgré les efforts consentis pour améliorer l’offre des services de santé, une frange importante de la population n’a toujours pas accès aux soins de santé. La faible croissance économique, le manque des ressources, la corruption et les contraintes imposées au secteur public peuvent expliquer pourquoi la conception d’un système de financement des soins de santé est complexe. Au cours des deux dernières décennies, il y a eu une baisse de l'utilisation des services de santé après l'introduction du recouvrement des coûts dans les établissements de santé publics. Les personnes les plus touchées par cette politique sont les ménages à faibles revenus notamment dans les zones rurales qui sont le plus souvent vulnérables aux maladies. L'assurance communautaire a été proposée comme une alternative pour améliorer une meilleure accessibilité des ménages à faibles revenus aux soins de santé. L'assurance communautaire apparaît ainsi comme un outil de protection sociale pour un grand nombre de personnes qui, autrement, n'auraient pas une couverture face au risque maladie. Toutefois, un tel système d’assurance maladie ne peut avoir des effets à long terme que s’il existe une forte préférence des ménages pour une telle politique, et un capital social dans les zones rurales. Evaluer les préférences des ménages pour l'assurance communautaire est importante pour la formulation des recommandations de politique économique. Une connaissance adéquate des déterminants de la demande pour l'assurance communautaire est aussi essentielle pour l'élaboration de stratégies visant à accroître l’allocation des ressources, et à améliorer la qualité des services. La présente étude a pour objet d’évaluer les préférences des ménages pour l’assurance communautaire en milieu rural camerounais. L’usage de la méthode d’évaluation contingente suggère que les ménages à faibles revenus sont disposés à payer pour l’assurance communautaire. En outre, le capital social a un effet positif et significatif sur la demande. L’usage des doubles questions binaires pour évaluer des préférences des ménages est incompatible avec les incitations et sujets à un shift effect hétérogène expliqué par les caractéristiques intrinsèques des ménages. Les ménages très certains de leurs réponses ne sont pas sujets aux anomalies comportementales. Enfin, les préférences des ménages sont inter-indépendantes du fait des interactions spatiales expliquées par les normes sociales / The financing of quality healthcare is a major challenge for developing countries. Despite efforts to improve the provision of healthcare services, a significant proportion of the population does not always have access to healthcare services. Low economic growth, lack of economic resources, corruption and constraints on the public sector could explain why the design of a system of financing healthcare is complex. Over the past two decades, there has been a decline in the use of healthcare services after the introduction of cost recovery in public health facilities. Those most affected by this policy are low-income households particularly in rural areas that are most often vulnerable to diseases. The community-based health insurance has been proposed as an alternative to improve better access to low-income households to healthcare services. The community-based health insurance is thus a tool of social protection for many households who otherwise would not have formal insurance. However, such a health insurance scheme can have long-term effects if households have a strong preference for it, and there is social capital in rural areas. Assessing the preferences of households for the community-based health insurance is important for the formulation of policy recommendations. Adequate knowledge on the determinants of demand for the community-based health insurance is essential for developing strategies to increase resource allocation, and improve the quality of services. This study aims at assessing the preferences of households for community-based health insurance in rural areas of Cameroon. The use of contingent valuation method suggests that low-income households are willing to pay for the community-based health insurance. Furthermore, social capital has a positive and significant effect on the demand, and the use of double-bounded dichotomous choice to assess the preferences of households is incentive incompatible. We also found that there is heterogeneous shift effect in preferences anomalies and could be mostly explained by the salient characteristics of households. A striking result is that more certain households are not subjected to preference anomalies. Lastly, there is spatial dependence in the preferences of households explained by social norms

Community-Based Health Insurance (CBHI) in Rwanda was promulgated as the best alternative to address the financial barriers for accessibility to health care services for the poor population and the informal sector. The purpose of this study was to investigate whether CBHI reduce Out-of-pocket health expenses for their members as compared to non-members and to what extent CBHI provide financial protection for the poorest population. This research based itself on secondary source of data primarily collected for a prospective quasi-experimental design which evaluated the impact of Performance-Based Financing. The primary study had reported on the Out-Of-Pocket expenses for health by members and non-members of CBHI; residing in a sample of 1961 households; in addition to their demographics and socio-economic characteristics. The findings indicate that insured individuals were about 2.6 times more likely to utilize health care services than respondents without health insurance. It is also worth noting that households with health insurance coverage were less likely to experience a catastrophic health expenditure than households without health insurance (aOR: 0.744; 95% CI:[0.586 - 0.945]), and that the effect of health insurance coverage was higher in people living in poor households than in people living in middle or richer households / Health Studies / M.A. (Public Health)

Bibliography: leaves 268-317 / The challenge of accessing affordable healthcare services in the developing countries prompted the promotion of community-based health insurance (CBHI) as an effective alternative. CBHI has been implemented in many countries of the South over the last three decades for the purpose of improving access and attaining universal health coverage. However, the sudden stoppage of a CBHI programme in rural Nigeria raised a lot of concerns about the suitability of the health financing scheme. Thus, this thesis examines the stoppage of the CBHI programme in rural Kwara, Nigeria. Premised on the health policy triangle as a conceptual framework, mixed methods approach was adopted for data collection. This involved 12 focus group discussions, 22 in-depth interviews, 32 key informant interviews and 1,583 questionaires. The study participants were community members, community leaders, healthcare providers, policymakers, international partner, health maintenance organisation officials and a researcher. Findings revealed that transnational actors relied on various resources (e.g. fund and ‘expertise’) and formed alliances with local actors to drive the introduction of the programme. As such, the design and implementation of the policy were dominated by international actors. Despite the sustainability challenges faced by the programme, the study found that it benefitted some of the enrolled community members. Though, even at the subsidised amount, enrolment premium was still a challenge for many. The main reasons for the stoppage of the programme are a paucity of fund and poor management. The stoppage of the programme, however, signified a point of reversal in the relative achievements recorded by the CBHI scheme because community members have deserted the healthcare facilities due to high costs of care. In view of these, the thesis notes that short-term policies often lead to temporary outcomes and suggests the need to repurpose the role of the state by introducing a long-term comprehensive healthcare policy – based on the reality of the nation – to provide equitable healthcare services for the citizenry irrespective of their capacity to pay. / Sociology / D. Phil. (Sociology)