2014年-世界发展银行全球_Effects_of_Interventions_to_Raise_Voluntary_Enrollment_in_a_Social_Health_Insurance_Scheme___A_Cluster_Randomized_Trial_27页_839kb

Summary of "Effects of Interventions to Raise Voluntary Enrollment in a Social Health Insurance Scheme: A Cluster Randomized Trial"

Core Content

This paper presents the findings of a cluster randomized trial conducted in the Philippines to evaluate the effectiveness of interventions aimed at increasing voluntary enrollment in the Individual Payer Program (IPP), a social health insurance (SHI) scheme for informal-sector workers and their families. The study tested two interventions: one combining information and a premium subsidy, and another that further reduced the enrollment burden through additional support measures.

Main Objectives

• To assess how voluntary enrollment in SHI responds to information and subsidy interventions.
• To evaluate the impact of reducing enrollment effort on participation rates.
• To understand the cost-effectiveness of different strategies to encourage enrollment in the IPP.

Key Findings

• Overall Enrollment Increase: The combined intervention of information and a 50% premium subsidy increased IPP enrollment by 5 percentage points, from 10% in the control group to 15% in the intervention group.
• Sub-experiment Results: The sub-experiment, which included additional support such as home visits and form delivery, led to a 39.7% enrollment rate among non-compliers, compared to 3.4% without such support.
• Relative Odds Ratio: The relative odds ratio for the combined intervention was 1.59, indicating a 50% increase in enrollment.
• Impact of Intervention III: The intervention that included home visits and form delivery had a much larger effect, with a relative odds ratio of 18.47, suggesting that reducing the enrollment burden is more effective than just financial incentives.
• Still Low Enrollment: Despite the interventions, enrollment rates remained below 50%, with 60% of families still choosing not to enroll even after receiving the information kit, subsidy, and support.

Intervention Details

Intervention I

• Components: Insurance voucher (covering 50% of the premium, up to 25% if family income exceeds 25,000 pesos), information kit, and SMS reminders.
• Timing: Valid from 1 February to 31 December 2011.
• Impact: Increased enrollment by 5 percentage points.

Intervention II

• Components: Re-sending membership forms, extending voucher validity to February 2012, and SMS reminders.
• Impact: Combined with Intervention I, it led to a 5 percentage point increase in enrollment.

Intervention III

• Components: Enumerator assistance in completing and delivering the enrollment form, and receiving the IPP ID card by mail.
• Impact: When combined with Intervention II, it led to a 39.7% enrollment rate among non-compliers, a dramatic increase compared to 3.4%.

Study Design and Methodology

• Sample Size: 2,950 families were interviewed in the baseline survey.
• Randomization: 179 out of 243 municipalities were randomly assigned to the intervention group, while 64 were controls.
• Cluster Assignment: Randomization was done at the municipality level, with a multi-stage cluster design.
• Statistical Methods: Logistic regression was used to estimate the effect of interventions, with adjustments for clustering and baseline covariates.

Key Observations

• Baseline Balance: The control and intervention groups were balanced at baseline.
• Eligibility: Households were considered eligible if the head of the household was not covered or had not paid a premium in the preceding six months.
• Non-Compliance: Among the eligible non-compliers, the sub-experiment showed a much higher enrollment rate when additional support was provided.
• Education and Health Events: Families with a household head having at most some secondary education and those reporting adverse health events showed a higher response to the interventions.

Limitations and Implications

• Low Enrollment Despite Interventions: Even with a 50% premium subsidy and information, only 15% of eligible families enrolled.
• Cost-Effectiveness: The study highlights that while subsidies and information can help, they are not sufficient on their own to achieve high enrollment.
• Policy Implications: The results suggest that reducing the effort required to enroll is more effective than reducing costs alone. However, significant barriers remain, especially for less educated and poorer families.

Conclusion

The study demonstrates that a combination of information and premium subsidy can increase voluntary enrollment in SHI schemes, but it is not enough to achieve universal coverage. Additional support measures, such as home visits and form delivery, significantly enhance the effectiveness of interventions. These findings underscore the importance of addressing both financial and non-financial barriers to enrollment in SHI programs.