Equity in community health insurance schemes: evidence and lessons from Armenia.
BACKGROUND
Community health insurance (CHI) schemes are growing in importance in low-income settings, where health systems based on user fees have resulted in significant barriers to care for the poorest members of communities. They increase revenue, access and financial protection, but concerns have been expressed about the equity of such schemes and their ability to reach the poorest. Few programmes routinely evaluate equity impacts, even though this is usually a key objective. This lack of evidence is related to the difficulties in collecting reliable data on utilization and socio-economic status. This paper describes the findings of an evaluation of the equity of Oxfam's CHI schemes in rural Armenia.


METHODS
Members of a random sample of 506 households in villages operating insurance schemes in rural Armenia were interviewed using a structured questionnaire. Household wealth scores based on ownership of assets were generated using principal components analysis. Logistic and Poisson regression analyses were performed to identify the determinants of health facility utilization, and equity of access across socio-economic strata.


RESULTS
The schemes have achieved a high level of equity, according to socio-economic status, age and gender. However, although levels of participation compare favourably with international experience, they remain relatively low due to a lack of affordability and a package of primary care that does not include coverage for chronic disease.


CONCLUSIONS
This paper demonstrates that the distribution of benefits among members of this community-financing scheme is equitable, and that such a degree of equity in community insurance can be achieved in such settings, possibly through an emphasis on accountability and local management. Such a scheme presents a workable model for investing in primary health care in resource-poor settings.
Polonsky
Jonny
J
London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom.
Balabanova
Dina
D
McPake
Barbara
B
Poletti
Timothy
T
Vyas
Seema
S
Ghazaryan
Olga
O
Yanni
Mohga Kamal
MK
D000328:Adult; D001136:Armenia; D003153:Community Health Services / Q000191:economics; D005260:Female; D019538:Health Care Surveys; D006297:Health Services Accessibility / Q000191:economics / Q000592:standards*; D006801:Humans; D007348:Insurance, Health / Q000191:economics; D007407:Interviews as Topic; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016012:Poisson Distribution; D012424:Rural Population / Q000706:statistics & numerical data*; D012923:Social Class; D011795:Surveys and Questionnaires