Haven Nahabwe, Dobson Andrew E, Yusuf Kuule, Kellermann Scott, Mutahunga Birungi, Stewart Alex G, Wilkinson Ewan
Church of Uganda Bwindi Community Hospital, Kinkizi Diocese, Kanungu, Uganda.
College of Life and Environmental Science, University of Exeter, Exeter, United Kingdom.
Front Public Health. 2018 Oct 9;6:281. doi: 10.3389/fpubh.2018.00281. eCollection 2018.
Out-of-pocket fees to pay for health care prevent poor people from accessing health care and drives millions into poverty every year. This obstructs progress toward the World Health Organization goal of universal health care. Community-based health insurance (CBHI) improves access to health care primarily by reducing the financial risk. The association of CBHI with reduced under-5 mortality was apparent in some voluntary schemes. This study evaluated the impact of eQuality Health Bwindi CBHI scheme on health care utilization and under-5 mortality in rural south-western Uganda. This was a retrospective cross-sectional study using routine electronic data on health insurance status, health care utilization, place of birth, and deaths for children aged under-5 in the catchment area of Bwindi Community Hospital, Uganda between January 2015 and June 2017. Data was extracted from four electronic databases and cross matched. To assess the association with health insurance, we measured the difference between those with and without insurance; in terms of being born in a health facility, outpatient attendance, inpatient admissions, length of stay and mortality. Associations were assessed by Chi-Square tests with -values < 0.05 and 95% confidence intervals. For variables found to be significant at this level, multivariable logistic regression was done to control for possible confounders. Of the 16,464 children aged under-5 evaluated between January 2015 and June 2017, 10% were insured all of the time 19% were insured for part of the period, and 71% were never insured. Ever having had health insurance reduced the risk of death by 36% [aOR; 0.64, = 0.009]. While children were insured, they visited outpatients ten times more, and were four times more likely to be admitted. If admitted, they had a significantly shorter length of stay. If mother was uninsured, children were less likely to be born in a health facility [adjusted odds ratio (aOR) 2.82, < 0.001]. This study demonstrated that voluntary CBHI increased health care utilization and reduced mortality for children under-5. But the scheme required appreciable outside subsidy, which limits its wider application and replicability. While CBHIs can contribute to progress toward Universal Health Care they cannot always be afforded.
自掏腰包支付医疗费用使贫困人口无法获得医疗服务，每年还致使数百万人陷入贫困。这阻碍了实现世界卫生组织全民医疗保健目标的进程。基于社区的医疗保险（CBHI）主要通过降低经济风险来改善医疗服务的可及性。在一些自愿参保计划中，CBHI与5岁以下儿童死亡率降低之间的关联很明显。本研究评估了布温迪eQuality健康社区医疗保险计划对乌干达西南部农村地区医疗服务利用情况和5岁以下儿童死亡率的影响。这是一项回顾性横断面研究，利用了2015年1月至2017年6月期间乌干达布温迪社区医院集水区内5岁以下儿童的医疗保险状况、医疗服务利用情况、出生地点和死亡情况的常规电子数据。数据从四个电子数据库中提取并进行交叉匹配。为评估与医疗保险的关联，我们测量了参保儿童和未参保儿童在以下方面的差异：在医疗机构出生、门诊就诊、住院、住院时长和死亡率。通过卡方检验评估关联，检验值<0.05且置信区间为95%。对于在此水平上发现具有显著意义的变量，进行多变量逻辑回归以控制可能的混杂因素。在2015年1月至2017年6月期间评估的16464名5岁以下儿童中，10%一直参保，19%部分时间段参保，71%从未参保。曾经参加过医疗保险使死亡风险降低了36%[调整后比值比（aOR）；0.64，P = 0.009]。参保儿童的门诊就诊次数增加了10倍，住院可能性增加了四倍。如果住院，他们的住院时长显著缩短。如果母亲未参保，孩子在医疗机构出生的可能性较小[调整后比值比（aOR）2.82，P < 0.001]。本研究表明，自愿参保的CBHI提高了医疗服务利用率，并降低了5岁以下儿童的死亡率。但该计划需要可观的外部补贴，这限制了其更广泛的应用和可复制性。虽然CBHI有助于推动全民医疗保健的进展，但并非总能负担得起。
