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Laos Sachiko Ozawa 10.9.08


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From Health and Social Protection: Meeting the needs of the poor, 9-10 October 2008,

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Laos Sachiko Ozawa 10.9.08

  1. 1. Investigation of Trust in the Context of a Community-Based Health Insurance Scheme in Cambodia Sachiko Ozawa, MHS, PhD Candidate Johns Hopkins Bloomberg School of Public Health October 9, 2008
  2. 2. <ul><ul><ul><li>Managed by Cambodian NGO </li></ul></ul></ul><ul><ul><ul><li>Enrollment: 20-25% out of 22,000 families </li></ul></ul></ul><ul><ul><ul><li>20,000 insureds – largest scheme in Cambodia </li></ul></ul></ul><ul><ul><ul><li>Insured families can access 10 Health Centers, Thmar Pouk & Mongkol Borei Hospitals for free </li></ul></ul></ul><ul><ul><ul><li>Enrollment by family; Premium is $2.00 per person per year, up to maximum of $12.00 per family </li></ul></ul></ul>Community-Based Health Insurance *CAAFW: Cambodian Association for Assistance to Families and Widows <ul><li>Scheme operated by CAAFW* in Thmar Pouk, Banteay Meanchey Province since Feb ‘05 </li></ul>
  3. 3. Trust in CBHI <ul><li>Trust is hypothesized to be one of the factors affecting enrollment in CBHI schemes </li></ul><ul><li>Trust may be critical in CBHI where: </li></ul><ul><ul><ul><li>Enrollment is voluntary </li></ul></ul></ul><ul><ul><ul><li>Health care spending entails an element of risk </li></ul></ul></ul><ul><ul><ul><li>Health care arrangements are relational </li></ul></ul></ul><ul><li>Research Question: </li></ul><ul><li>Is CBHI enrollment associated with trust? </li></ul><ul><li>Trust CBHI Enrollment </li></ul>
  4. 4. Research Design: Mixed Methods <ul><li>Qualitative Research </li></ul><ul><ul><li>Focus Groups </li></ul></ul><ul><ul><ul><li>Explore the meaning and role of trust </li></ul></ul></ul><ul><ul><ul><li>Culturally-adapt existing survey instruments </li></ul></ul></ul><ul><li>Quantitative Research </li></ul><ul><ul><li>Cluster-Randomized Household Survey </li></ul></ul><ul><ul><ul><li>Develop scales to measure trust levels </li></ul></ul></ul><ul><ul><ul><li>Examine the relationship of trust with other variables </li></ul></ul></ul><ul><ul><ul><li>Is CBHI enrollment associated with trust? </li></ul></ul></ul>
  5. 5. Analytical methods <ul><li>Qualitative Research </li></ul><ul><ul><li>Grounded Theory </li></ul></ul><ul><ul><ul><li>Develop theory grounded in field data </li></ul></ul></ul><ul><ul><ul><li>Inductive & Deductive approach </li></ul></ul></ul><ul><ul><ul><li>Systematic Coding, Reflexivity </li></ul></ul></ul><ul><ul><ul><li>Adaptation of existing survey instruments </li></ul></ul></ul><ul><li>Quantitative Research </li></ul><ul><ul><li>Factor Analysis </li></ul></ul><ul><ul><ul><li>Development of Trust scales </li></ul></ul></ul><ul><ul><li>Multiple Regression Analysis </li></ul></ul><ul><ul><ul><li>Examine associations: trust & enrollment </li></ul></ul></ul>
  6. 6. Strengths of the Research Design <ul><li>Scientific rigor in methodology </li></ul><ul><li>Follows established method to study trust </li></ul><ul><li>Uses complementary qualitative & quantitative approaches </li></ul><ul><li>Comparable with other trust measures </li></ul><ul><li>Lessons are transferable </li></ul><ul><ul><li>Meanings of trust in CBHI </li></ul></ul><ul><ul><li>Scales to measure trust in CBHI </li></ul></ul>Goudge J, Gilson L. How can trust be investigated? Drawing lessons from past experience. Social Science and Medicine 2005;61(7):1439-51. Hall MA, Camacho F, Dugan E, Balkrishnan R. Trust in the medical profession: conceptual and measurement issues. Health Services Research 2002;37(5):1419-39.
  7. 7. Limitations of the Research Design <ul><li>Only CAAFW’s scheme in Banteay Meanchey </li></ul><ul><li>Only community member’s trust </li></ul><ul><li>Cross-sectional data </li></ul><ul><li>Differences in quality of care </li></ul><ul><li>Endogeneity between trust and enrollment </li></ul><ul><li>Difficult to earn interviewees’ trust </li></ul><ul><li>Illiteracy compounds difficulty of questions </li></ul><ul><li>Difficult to integrate qualitative & quantitative results </li></ul>
  8. 8. Other Research Design Options <ul><li>Qualitative Only </li></ul><ul><ul><li>Key Informant Interviews </li></ul></ul><ul><ul><li>Observational Research </li></ul></ul><ul><ul><li>Ethnographic Research </li></ul></ul><ul><li>Quantitative Only </li></ul><ul><ul><li>Randomized Control Trial </li></ul></ul><ul><ul><li>Cohort study </li></ul></ul><ul><ul><li>Panel study </li></ul></ul><ul><ul><li>Game Theory </li></ul></ul>With Comparator
  9. 9. Needs of researchers vs. policy makers <ul><li>Researchers </li></ul><ul><ul><li>Scientific rigor first </li></ul></ul><ul><ul><li>Definitions, Hypothesis </li></ul></ul><ul><ul><li>Conceptual framework </li></ul></ul><ul><ul><li>Literature review </li></ul></ul><ul><ul><li>Objectivity </li></ul></ul><ul><ul><li>Generalizability </li></ul></ul><ul><ul><li>Uncertainty </li></ul></ul><ul><ul><li>Minimize bias </li></ul></ul><ul><ul><li>Research ethics </li></ul></ul><ul><ul><li>Dissemination </li></ul></ul><ul><li>Policy makers </li></ul><ul><ul><li>Need insight to guide policy </li></ul></ul><ul><ul><li>Balance political interests </li></ul></ul><ul><ul><li>Applied research with actionable results </li></ul></ul><ul><ul><li>Timely results </li></ul></ul><ul><ul><li>Relevance to policy agenda </li></ul></ul><ul><ul><li>Results put in context e.g. comparisons, costs etc. </li></ul></ul><ul><ul><li>Awareness of results </li></ul></ul>
  10. 10. Questions for Reflection <ul><li>How can researchers better design studies with policy implementation in mind? </li></ul><ul><li>How can policy makers objectively give feedback to researchers’ study designs? </li></ul>