BackgroundThe Government of Lao Peoples’ Democratic Republic (Lao PDR) has embarked on a path to achieve universal health coverage (UHC) through implementation of four risk-protection schemes. One of these schemes is community-based health insurance (CBHI) – a voluntary scheme that targets roughly half the population. However, after 12 years of implementation, coverage through CBHI remains very low. Increasing coverage of the scheme would require expansion to households in both villages where CBHI is currently operating, and new geographic areas. In this study we explore the prospects of both types of expansion by examining household and district level data.MethodsUsing a household survey based on a case-comparison design of 3000 households, we examine the determinants of enrolment at the household level in areas where the scheme is currently operating. We model the determinants of enrolment using a probit model and predicted probabilities. Findings from focus group discussions are used to explain the quantitative findings. To examine the prospects for geographic scale-up, we use secondary data to compare characteristics of districts with and without insurance, using a combination of univariate and multivariate analyses. The multivariate analysis is a probit model, which models the factors associated with roll-out of CBHI to the districts.ResultsThe household findings show that enrolment is concentrated among the better off and that adverse selection is present in the scheme. The district level findings show that to date, the scheme has been implemented in the most affluent areas, in closest proximity to the district hospitals, and in areas where quality of care is relatively good.ConclusionsThe household-level findings indicate that the scheme suffers from poor risk-pooling, which threatens financial sustainability. The district-level findings call into question whether or not the Government of Laos can successfully expand to more remote, less affluent districts, with lower population density. We discuss the policy implications of the findings and specifically address whether CBHI can serve as a foundation for a national scheme, while exploring alternative approaches to reaching the informal sector in Laos and other countries attempting to achieve UHC.

Community-based health insurance in Lao People's Democratic Republic targets the informal workforce. Estimates of the program's impact on utilization and out-of-pocket expenditures (OOPs) were obtained using a case-comparison study of 3000 households (14 804 individuals) in urban and semi-urban areas. We used propensity score matching to control for bias on observables and to account for heterogeneity. We check the sensitivity of the results using a weighted regression combined with propensity score matching, which leads to doubly robust treatment effect estimates. The results are robust across the two approaches and show that the insured have significantly higher utilization, lower OOPs and lower incidence of catastrophic expenditures, and are less likely to employ coping mechanisms. However, coverage of the scheme is extremely low, indicating negligible population level impact. Furthermore, the results show that the scheme provides greater protection to the better off than to the poor: the poor are less likely to enrol, and among the poor who are enrolled, there has been no significant impact on utilization of outpatient services, total OOPs or catastrophic expenditures. We discuss the policy implications in the context of the international debate regarding the prospects for the role of community-based health insurance in national financing strategies.

IntroductionDespite widespread gains toward the 5th Millennium Development Goal (MDG), pro-rich inequalities in reproductive health (RH) and maternal health (MH) are pervasive throughout the world. As countries enter the post-MDG era and strive toward UHC, it will be important to monitor the extent to which countries are achieving equity of RH and MH service coverage. This study explores how equity of service coverage differs across countries, and explores what policy factors are associated with a country’s progress, or lack thereof, toward more equitable RH and MH service coverage.MethodsWe used RH and MH service coverage data from Demographic and Health Surveys (DHS) for 74 countries to examine trends in equity between countries and over time from 1990 to 2014. We examined trends in both relative and absolute equity, and measured relative equity using a concentration index of coverage data grouped by wealth quintile. Through multivariate analysis we examined the relative importance of policy factors, such as political commitment to health, governance, and the level of prepayment, in determining countries’ progress toward greater equity in RH and MH service coverage.ResultsRelative equity for the coverage of RH and MH services has continually increased across all countries over the past quarter century; however, inequities in coverage persist, in some countries more than others. Multivariate analysis shows that higher education and greater political commitment (measured as the share of government spending allocated to health) were significantly associated with higher equity of service coverage. Neither country income, i.e., GDP per capita, nor better governance were significantly associated with equity.ConclusionEquity in RH and MH service coverage has improved but varies considerably across countries and over time. Even among the subset of countries that are close to achieving the MDGs, progress made on equity varies considerably across countries. Enduring disparities in access and outcomes underpin mounting support for targeted reforms within the broader context of universal health coverage (UHC).

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BackgroundIn the last decade, almost every low- or middle-income country in the world has expressed support for universal health coverage (UHC). While at the beginning of the UHC movement, country strategies focused on increasing access to the formal sector as the first step of UHC, there is now consensus that countries should cover the entire population, with particular attention to covering the poor. However, it is often assumed that mandatory schemes will automatically cover their target populations, and consequently little is known about why firms comply or do not comply with enrolment requirements.Using the experience of Lao PDR, where the enrolment rate in the mandatory social security scheme is low and the capacity for regulation is weak, we conducted this study to better understand the determinants of enrolment of private sector firms in mandatory social security.MethodsWe used a cross-sectional case-comparison design, surveying 130 firms. We applied a structured questionnaire to explore determinants of enrolment, specifically looking at firm characteristics (e.g., industry category, ownership); sociodemographic characteristics of company heads; firms’ risk perceptions; details of employment contracts; employee benefits; and exposure to social security. Closed ended questions were analysed quantitatively, while content analysis was applied to open-ended questions. Logistic regression was used to examine the determinants of enrolment.ResultsSmaller privately owned firms in the services industry were the least likely to enrol in social security, while firms in the trade industry were more likely to enrol than firms in manufacturing, construction, or services. The main reason for not enrolling was that firms offered a better package of benefits to their employees, although further investigation of company benefits showed that this was not the case in practice. Additional reasons for non-compliance were lack of knowledge and poor quality of care at government hospitals.ConclusionsThe study contributes to the dialogue on how best to increase coverage in the formal sector, which is an important element of achieving UHC. It also provides much needed information about the motivation of private sector firms to comply with mandatory schemes.