A system dynamics model of community-based health insurance system in Bangladesh

In Bangladesh, the rising cost of out-of-pocket health expenditures is a significant obstacle to healthcare access, particularly for the lowincome population. Although the government has developed a healthcare financing strategy (HCFS) in an endeavor to achieve universal PRESENTER: Shehrin Shaila Mahmood, International Centre for Diarrhoeal Disease Research, Bangladesh AUTHORS: Tania Wahed, Mohammad Nahid Mia, Abbas Bhuiya Can Micro Health Insurance Reduce out-of-Pocket Expense for Accessing Formal Healthcare? Results from a Cross Sectional Study. PRESENTER: Nurnabi Sheikh, University of Strathclyde AUTHORS: Susan Howick, Shehrin Shaila Mahmood, Syed Manjoor Ahmed Hanifi, Alec Morton A System Dynamics Model of Community-Based Health Insurance System in Bangladeshhealthcare coverage (UHC), providing healthcare protection for the large informal sector and their families remains a persistent concern. To reach a greater portion of the informal sector in Bangladesh, community-based health insurance (CBHI) initiatives managed by nongovernment organizations (NGOs) and microfinance institutions are aimed at the HCFS. However, there are barriers to implementing sustainable CBHI and overcoming these obstacles is a policy priority for Bangladesh. Therefore, the goal of this study is to identify appropriate policies which support a sustainable CBHI. To achieve this goal, a simulation model is constructed to identify where policies should be targeted and to then observe the impact of these policies over time.

In this analysis, we use data from a case CBHI scheme in Bangladesh from 2015 to 2020, and projections for the scheme for 2030. A System Dynamics approach is used to build the model, simulate, and evaluate policy scenario alternatives. The approach includes (1) understanding the problem behavior, (2) undertaking a literature review and conducting interviews to develop the model structure, (3) data collection and processing to populate the model (4) performing tests such as Theil’s inequality statistic for assessing model fit to data to enhance confidence in the model (5) simulation and policy analysis. Four policies were evaluated: door-to-door visits by community health workers, the inclusion of non-health grocery benefits to the benefit package, financial assistance for low-income families, and increasing service availability by offering telehealth and online consultation, ensuring the availability of higher-quality medicines, and providing healthcare services by paramedics to reduce physicians' workload to alleviate the problem and increase performance.

We developed a base model to simulate the historical behavior of the CBHI scheme and projected the long-term behavior to assess which policy interventions would be more effective. Our base model demonstrated that even after a decade of implementation, only one-third of the target population would be covered due to persistently low enrollment and significant drop-out rates. In addition, we discovered a widening gap between premium collection and overall expenses, which poses a threat to the scheme's self-sustainability in the long run. Therefore, we intend to test strategies through simulation that are affirmed to increase population coverage by accelerating the enrollment and renewal processes. Initial simulation results demonstrated a significant improvement in population coverage (i.e., an increase in enrollment and renewal rates) and a higher likelihood of self-sufficiency with the successful implementation of four policies; however, the execution of these policies is contingent upon the availability of sufficient funding. This study will add to the literature by advocating for appropriate policies for the scheme operators to overcome CBHI implementation barriers and by proposing recommendations for policymakers to allow CBHI to contribute to the health sector in line with the healthcare financing strategy in Bangladesh to accomplish the target of UHC.