Vertical Scaling up of Community Based Health Insurance in Armenia

Presenter: Dina Balabanova, London School of Hygiene & Tropical Medicine

Abstract

Armenia is a post-transition countries most affected by economic collapse and conflict, resulting in a severely underfunded health system dependent on out-of-pocket expenditure. Oxfam and a local NGO have supported community based health insurance schemes (CBHI) in rural areas to improve affordability and accessibility of basic primary care and public health initiatives, through mobilising community resources in 128 villages in two rural districts. These schemes have been shown to provide significant protection against catastrophic expenditure, and services are viewed as appropriate and accountable. Recent benefits-incidence analysis has shown that the schemes have achieved a high level of equity, according to socio-economic status, age, and gender, possibly due to an emphasis on accountability and community ownership. While the schemes have expanded geographically, membership remains limited (under 40% on average; 10% to 90% across villages) due to a lack of affordability and limited package of care (excluding ante-natal, reproductive and chronic diseases care). Improving quality of care was seen as a pragmatic strategy to implement a more attracting package and increase willingness to join, and overall cross-subsidisation within the schemes.

We explored the possibilities for vertical scaling up of CBHI to include a broader package of services. One of the key aspects was the lack of integration with other parts of the system, in terms of training of human resources, formal and informal incentives, of integration of financial flows, sharing information and procedure for good practice. Data were obtained from key informant interviews and focus group discussions with stakeholders at various positions within the health system. A quantitative checklist seeking to capture quality of care in rural areas was also applied.

The results suggest that there were significant synergies between CBHI and major health sector reforms in Armenia; as well as broad-based political support for scaling up as an intermediary step towards social insurance (which is not yet on the policy agenda). In terms of vertical integration with the rest of the system, the situation was more problematic despite the existing opportunities. There are structural factors obstructing orientation of the system towards primary care, including lack of support and supervision systems for front-line staff and a disrupted continuum of care from primary to secondary and tertiary levels allowing to follow-up patients (through stronger referral systems, information exchange. There were no channels to target budget subsidies directly to rural health post and instead the funds were managed by district secondary care facilities where the incentive was to retain a larger than necessary part of the funds.
There were also regulatory obstacles to shifting of tasks from doctors to nurses and other staff categories to enable them legally to perform basic ante-natal care, glucose testing etc. A weak professional self-regulation was a factor in the lack of standardised protocols and widely variable prescribing at health posts.

We conclude that measures to scale up CBHI schemes vertically and integrate them with the rest of the system, especially in terms of financial flows for primary care, have a potential to improve quality and access to care.