Title of the seminar
Healthcare Financing Challenges in Bangladesh and Impact of a Community-Based
Health Insurance Scheme on Affordable Access to Qualified Healthcare
Topic 1: Catastrophic Healthcare Expenditure and Economic Impoverishment Related to Out-of-
Pocket Payments for Healthcare in Bangladesh - an Analysis of Household Income and
Expenditure Survey, 2010
Background
Out-of-pocket (OOP) spending is the major payment strategy for healthcare in most low-andmiddle-income countries, like Bangladesh. Large and unpredictable health payments can expose households to substantial financial risk and, at their most extreme, can result in economic and social impoverishment. Total health expenditure in Bangladesh is primarily characterized by
OOP spending, leading to an increased risk of catastrophic health expenditure (CHE) and consequently household impoverishment.
Objectives
The aim of this study was to estimate the incidence and intensity of catastrophic healthcare expenditure and the impact of OOP payments on economic impoverishment in Bangladesh.
Methods
The nationally representative Household Income and Expenditure Survey 2010 was used to determine household consumption expenditure and health related spending in the last 30 days.
Mean CHE headcount and overshoot were estimated as measurements of incidence and intensity of CHE respectively. Concentration indices (CI) were calculated to present the disparity among socioeconomic quintiles. The poverty headcount was estimated using ‘total household consumption expenditure and such expenditure without OOP payments for health. The gap between these two poverty headcount measurements captured the impact of OOP payments on poverty.
Results
A pro-rich distribution of OOP payment for healthcare was found in urban and rural Bangladesh.
The poorest households spent a higher proportion of their total expenditure (7·3%) than the richest (6·1%). At the 10%-threshold level, 14·2% of households faced CHE with 1·9% overshoot. An overall pro-poor distribution was found for CHE incidence (CI=-0·064) and for intensity (CI=-0·053). The poverty head count increased by 3·5 percent point (5·1 million individuals) due to OOP payments. OOP payments for healthcare resulted in CHE and economic impoverishment for many households in Bangladesh.
Conclusions
Households in poorer socioeconomic groups and in rural areas faced the highest burden.
Reliance on OOP payments for healthcare in Bangladesh should be reduced for poverty alleviation in urban and rural Bangladesh.

Topic 2: Title.
Impact of a Community-Based Health Insurance Scheme on Affordable Access to
Qualified Healthcare
Background
Reliance on out-of-pocket payment for healthcare leads to catastrophic burden in low- and middle income countries (LMIC). Risk-pooling mechanism is recommended for financing healthcare to achieve universal coverage (UHC). Inclusion of informal sector workers for achieving UHC appears to be a challenge in
LMICs. Cooperative can be a strong entity for reaching a large number of informal sector workers for developing self-financed community-based health scheme. Such a scheme, based on a cooperative, named
Labor Association for Social Protection (LASP), has been tested in Chandpur sub-district, in Bangladesh.
Objectives
To assess the impact of community-based health insurance on utilization of healthcare from qualified providers and associated out-of-pocket payments of informal workers and their dependents
Methods
A quasi-experimental case-control study design was employed to examine the impact of Community-
Based Health Insurance (CBHI). This implies that informal workers who joined the cooperative organization (treatment group) have been compared with those who did not (comparison group). Survey data which included 1,292 observations (case and control households) show that the utilization of qualified healthcare (corresponding to the benefit package) is higher among LASP beneficiaries than their corresponding matched control in last three months. In total 6,859 individuals (case=3,645; control=3,214) from these households were included in the survey. Multiple regression analyses were applied for explaining the utilization of formal healthcare providers and out-of-pocket payments for receiving such care. The main explanatory variable was the participation in CBHI scheme where 0 and 1 indicated ‘comparison’ and ‘treatment’ group respectively. A number of control variables like, income, education, household composition, geographic location and health condition (presence of chronic illness) were incorporated in the regression models.
Results
Informal providers (village doctors and non-prescribed medicines from drugstores) were utilized less by
LASP beneficiaries. It was observed that LASP beneficiaries utilized village doctors and non-prescribed drug sellers by 12% and 3% less respectively than their corresponding comparison. On the other hand, of total service utilization among LASP beneficiaries, 32% was done to qualified MBBS/specialist doctors, while 20% of such services were utilized by individuals in control households. Utilizations of ‘private clinic’ and ‘Medical College hospitals and district hospitals’ were made by LASP beneficiaries at a higher proportion (14% and 5% respectively) than individuals in control households (11% and 4% respectively).
Regression analysis demonstrated that the LASP beneficiaries were 1.75 times more likely to utilize qualified healthcare. Further analysis, while considering non-utilization and utilization from informal providers as unexpected (same), it was found that utilization from qualified care providers was 14% higher among LASP beneficiaries (not presented in appendix). It was also observed that OOP payments were 38% lower among LASP beneficiaries for healthcare utilization from qualified providers. Further

analysis using Double-hurdle regression model showed that out-of-pocket payments among LASP beneficiaries was 13.8% lower in comparison with their corresponding control.
Conclusion
The outcomes showed that the pilot health scheme for informal workers, based on the cooperative, was likely to increase healthcare utilization from qualified providers at lower out-of-pocket payments.