Community Based Health Insurance in the Context of Health Care Financing Reform in Azerbaijan

Presenter: Valerie Oliveira-Cruz, London School of Hygiene & Tropical Medicine

Abstract

Azerbaijan, like other transitional countries in the former Soviet Union, faces considerable problems in financing its health system. Despite the significant economic growth, the share of health expenditure from GDP fell by 10% in 1995-2006, resulting in a rapid decline in coverage and quality of essential primary health care. In this context, Oxfam supported community-based health insurance schemes (CBHI) covering 43 villages in four districts have been implemented aiming to improve access to drugs and first-line primary care in the rural areas. This study explored the possibility of scaling up these schemes, with a focus on integrating or aligning them with the current health financing reform seeking to introduce national health insurance. The case study involved a review of legal and administrative documents on CBHI; eight focus group discussions with community members (in villages with and without insurance scheme); in-depth key informant interviews with a range of providers and stakeholders at local, district and national levels.

Our findings suggest that the schemes benefit from a favourable environment in terms of social values and attitudes. There were reports of trust in non-governmental organisations; willingness to contribute financially to obtain services; a strong sense of solidarity within communities. The new government financing strategy offers an opportunity to strengthen primary health care which was greatly neglected in the past, with a focus on cost-effective and innovative interventions.

However a number of challenges were also identified. There was lack of clarity within government in defining the elements of the new health insurance scheme and the level of resources required. There was a lack of awareness among key stakeholders about the community insurance schemes and regulatory mechanisms allowing to build on the strengths of these schemes (e.g. a strong accountability system, high levels of community mobilisation, and a flexible management). Problems faced by the community insurance schemes generic to any insurance scheme (including social insurance), included for example general poverty as one of the determinants of low enrolment rates. Government will need to devise an exemption or subsidy system.
However targeting was said to be problematic – given context of poor government management capacity and lack of trust in its institutions as related to pervasive corruption. Another problem is the limited understanding of the complexity of ensuring a benefits package that responds to users needs; combining maternal and child care, infectious disease and chronic disease at primary care level. There are conflicting incentives among stakeholders, with many those who benefit from the existing financial prioritisation (e.g. specialists) of hospital based care being adverse to provision of primary care at village level, task shifting and loss in income (from formal sources and ‘patient’s gifts’).

Community based insurance schemes plays a role in improving access to care among the poor in rural Azerbaijan. This paper explores several scenarios to their future given the changing context of health sector reform. The schemes can be partially or fully incorporated in the national insurance scheme; they can coexist (e.g. geographically, or covering different groups); or they can be phased out.