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Shah A, Lemma S, Tao C, Wong J. The Role of Health Policy and Systems in the Uptake of Community-Based Health Insurance Schemes in Low- and Middle-Income Countries: A Narrative Review. Health Serv Insights 2023; 16:11786329231172675. [PMID: 37153878 PMCID: PMC10155025 DOI: 10.1177/11786329231172675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 03/15/2023] [Indexed: 05/10/2023] Open
Abstract
This study explores how health policies and systems can affect voluntary uptake of community-based health insurance (CBHI) schemes in low- and middle-income countries (LMICs). A narrative review was conducted involving searches of 10 databases (Medline, Global Index Medicus, Cumulative Index to Nursing, and Allied Health Literature, Health Systems Evidence, Worldwide Political Science Abstracts, PsycINFO, International Bibliography of the Social Sciences, EconLit, Bibliography of Asian Studies, and Africa Wide Information) across the social sciences, economics, and medical sciences. A total of 8107 articles were identified through the database searches, 12 of which were retained for analysis and narrative synthesis after 2 stages of screening. Our findings suggest that in the absence of directly subsidizing CBHI schemes by governments in LMICs, government policies can nonetheless promote voluntary uptake of CBHIs through intentional actions in 3 key areas: (a) improving quality of care, (b) providing a regulatory framework that integrates CBHIs into the national health system and its goals, and (c) leveraging administrative and managerial capacity to facilitate enrollment. The findings of this study highlight several considerations for CBHI planners and governments in LMICs to promote voluntary enrollment in CBHIs. Governments can effectively extend their outreach toward marginalized and vulnerable populations that are excluded from social protection by formulating supportive regulatory, policy, and administrative provisions that enhance voluntary uptake of CBHI schemes.
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Affiliation(s)
- Amika Shah
- The Reach Alliance, Munk School of
Global Affairs & Public Policy, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management,
and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Samrawit Lemma
- The Reach Alliance, Munk School of
Global Affairs & Public Policy, University of Toronto, Toronto, ON, Canada
| | - Chelsea Tao
- The Reach Alliance, Munk School of
Global Affairs & Public Policy, University of Toronto, Toronto, ON, Canada
- Munk School of Global Affairs &
Public Policy, University of Toronto, Toronto, ON, Canada
| | - Joseph Wong
- The Reach Alliance, Munk School of
Global Affairs & Public Policy, University of Toronto, Toronto, ON, Canada
- Munk School of Global Affairs &
Public Policy, University of Toronto, Toronto, ON, Canada
- Department of Political Science,
University of Toronto, Toronto, ON, Canada
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Parisi D, Srivastava S, Parmar D, Strupat C, Brenner S, Walsh C, Neogi R, Basu S, Ziegler S, Jain N, De Allegri M. Awareness of India's national health insurance scheme (PM-JAY): a cross-sectional study across six states. Health Policy Plan 2023; 38:289-300. [PMID: 36478057 PMCID: PMC10019566 DOI: 10.1093/heapol/czac106] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 10/19/2022] [Accepted: 12/06/2022] [Indexed: 12/12/2022] Open
Abstract
The literature suggests that a first barrier towards accessing benefits of health insurance in low- and middle-income countries is lack of awareness of one's benefits. Yet, across settings and emerging schemes, limited scientific evidence is available on levels of awareness and their determinants. To fill this gap, we assessed socio-demographic and economic determinants of beneficiaries' awareness of the Pradhan Mantri Jan Arogya Yojana (PM-JAY), the national health insurance scheme launched in India in 2018, and their awareness of own eligibility. We relied on cross-sectional household (HH) survey data collected in six Indian states between 2019 and 2020. Representative data of HHs eligible for PM-JAY from 11 618 respondents (an adult representative from each surveyed HH) were used. We used descriptive statistics and multivariable logistic regression models to explore the association between awareness of PM-JAY and of one's own eligibility and socio-economic and demographic characteristics. About 62% of respondents were aware of PM-JAY, and among the aware, 78% knew that they were eligible for the scheme. Regression analysis confirmed that older respondents with a higher educational level and salaried jobs were more likely to know about PM-JAY. Awareness was lower among respondents from Meghalaya and Tamil Nadu. Respondents from Other Backward Classes, of wealthier socio-economic status or from Meghalaya or Gujarat were more likely to be aware of their eligibility status. Respondents from Chhattisgarh were less likely to know about their eligibility. Our study confirms that while more than half of the eligible population was aware of PM-JAY, considerable efforts are needed to achieve universal awareness. Socio-economic gradients confirm that the more marginalized are still less aware. We recommend implementing tailored, state-specific information dissemination approaches focusing on knowledge of specific scheme features to empower beneficiaries to demand their entitled services.
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Affiliation(s)
| | - Swati Srivastava
- *Corresponding author. Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Im Neuenheimer Feld 130/3, Heidelberg 69120, Germany. E-mail:
| | - Divya Parmar
- King’s Centre for Global Health and Health Partnerships, King’s College London, Strand, London WC2R 2LS, UK
| | - Christoph Strupat
- German Institute of Development and Sustainability, Tulpenfeld, Bonn 6 53113, Germany
| | - Stephan Brenner
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Im Neuenheimer Feld 130.3, Heidelberg 69120, Germany
| | - Caitlin Walsh
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Im Neuenheimer Feld 130.3, Heidelberg 69120, Germany
| | - Rupak Neogi
- Nielsen India Private Limited, 7th floor Infotech Center 404-405 Near Country Inns and Suites, Phase III, Gurugram 122016, India
| | - Sharmishtha Basu
- Indo-German Social Security Programme (IGSSP), Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH, B – 5/1 & 5/2 Ground Floor, Safdurjung Enclave, New Delhi 110029, India
| | - Susanne Ziegler
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Im Neuenheimer Feld 130.3, Heidelberg 69120, Germany
- Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH, Friedrich-Ebert-Allee 32+36, Bonn 53113, Germany
| | - Nishant Jain
- Indo-German Social Security Programme (IGSSP), Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH, B – 5/1 & 5/2 Ground Floor, Safdurjung Enclave, New Delhi 110029, India
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Im Neuenheimer Feld 130.3, Heidelberg 69120, Germany
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Wood A. Patronage, partnership, voluntarism: Community-based health insurance and the improvisation of universal health coverage in Senegal. Soc Sci Med 2023; 319:115491. [PMID: 36404176 DOI: 10.1016/j.socscimed.2022.115491] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 07/16/2022] [Accepted: 10/26/2022] [Indexed: 11/06/2022]
Abstract
The turn towards Universal Health Coverage (UHC) in the past decade raises the question of the role of the state, following years of state withdrawal and a fragmented approach to public health. Senegal introduced its version of UHC, Couverture Maladie Universelle (CMU) in 2013 and this paper explores early efforts to fund it through the establishment of community-based health insurance (CBHI). The paper draws on ethnographic research at mutual health organisations, or mutuelles de santé as they are commonly referred to in francophone countries, which manage CBHI. The research was carried out as part of broader doctoral fieldwork on poverty and social protection in the capital, Dakar, in 2017-18. Responding to recent calls for the move away from the voluntary nature of CBHI with government subsidies and the professionalisation of management, this paper considers the financial strain that mutuelles were under. By drawing on the concept of 'improvisation' as it has come to be employed in recent ethnographies of health infrastructure in contexts of scarcity, the paper attends to the ways in which mutuelles and the voluntary workers that run them sought alternative forms of support, with a particular focus on patronage and partnership. I argue that what might appear to be very minimal gestures of support and material investment serve to maintain a sense of hope and potential in CMU, one however that is fragile and potentially unsustainable.
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Affiliation(s)
- Anna Wood
- Department of Social Anthropology at the University of Cambridge, Free School Lane, Cambridge, CB2 3RF, UK.
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Conde KK, Camara AM, Jallal M, Khalis M, Zbiri S, De Brouwere V. Factors determining membership in community-based health insurance in West Africa: a scoping review. Glob Health Res Policy 2022; 7:46. [PMID: 36443890 PMCID: PMC9703663 DOI: 10.1186/s41256-022-00278-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 10/28/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND In many low-income countries, households bear most of the health care costs. Community-based health insurance (CBHI) schemes have multiplied since the 1990s in West Africa. They have significantly improved their members' access to health care. However, a large proportion of users are reluctant to subscribe to a local CBHI. Identifying the major factors affecting membership will be useful for improving CBHI coverage. The objective of this research is to obtain a general overview of existing evidence on the determinants of CBHI membership in West Africa. METHODS A review of studies reporting on the factors determining membership in CBHI schemes in West Africa was conducted using guidelines developed by the Joanna Briggs Institute. Several databases were searched (PubMed, ScienceDirect, Global Health database, Embase, EconLit, Cairn.info, BDPS, Cochrane database and Google Scholar) for relevant articles available by August 15, 2022, with no methodological or linguistic restrictions in electronic databases and grey literature. RESULTS The initial literature search resulted in 1611 studies, and 10 studies were identified by other sources. After eliminating duplicates, we reviewed the titles of the remaining 1275 studies and excluded 1080 irrelevant studies based on title and 124 studies based on abstracts. Of the 71 full texts assessed for eligibility, 32 additional papers were excluded (not relevant, outside West Africa, poorly described results) and finally 39 studies were included in the synthesis. Factors that negatively affect CBHI membership include advanced age, low education, low household income, poor quality of care, lack of trust in providers and remoteness, rules considered too strict or inappropriate, low trust in administrators and inadequate information campaign. CONCLUSIONS This study shows many lessons to be learned from a variety of countries and initiatives that could make CBHI an effective tool for increasing access to quality health care in order to achieve universal health coverage. Coverage through CBHI schemes could be improved through communication, improved education and targeted financial support.
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Affiliation(s)
- Kaba Kanko Conde
- grid.501379.90000 0004 6022 6378International School of Public Health, Mohammed VI University of Health Sciences, Bld Mohammed Taïeb Naciri, Commune Hay Hassani, 82 403 Casablanca, Morocco
| | - Aboubacar Mariama Camara
- grid.501379.90000 0004 6022 6378International School of Public Health, Mohammed VI University of Health Sciences, Bld Mohammed Taïeb Naciri, Commune Hay Hassani, 82 403 Casablanca, Morocco
| | - Manar Jallal
- grid.501379.90000 0004 6022 6378International School of Public Health, Mohammed VI University of Health Sciences, Bld Mohammed Taïeb Naciri, Commune Hay Hassani, 82 403 Casablanca, Morocco ,grid.501379.90000 0004 6022 6378Laboratory of Public Health, Health Economics and Health Management, Mohammed VI University of Health Sciences, Casablanca, Morocco
| | - Mohamed Khalis
- grid.501379.90000 0004 6022 6378International School of Public Health, Mohammed VI University of Health Sciences, Bld Mohammed Taïeb Naciri, Commune Hay Hassani, 82 403 Casablanca, Morocco ,grid.501379.90000 0004 6022 6378Laboratory of Public Health, Health Economics and Health Management, Mohammed VI University of Health Sciences, Casablanca, Morocco ,Knowledge for Health Policies Centre, Casablanca, Morocco
| | - Saad Zbiri
- grid.501379.90000 0004 6022 6378International School of Public Health, Mohammed VI University of Health Sciences, Bld Mohammed Taïeb Naciri, Commune Hay Hassani, 82 403 Casablanca, Morocco ,grid.501379.90000 0004 6022 6378Laboratory of Public Health, Health Economics and Health Management, Mohammed VI University of Health Sciences, Casablanca, Morocco ,Knowledge for Health Policies Centre, Casablanca, Morocco
| | - Vincent De Brouwere
- grid.501379.90000 0004 6022 6378International School of Public Health, Mohammed VI University of Health Sciences, Bld Mohammed Taïeb Naciri, Commune Hay Hassani, 82 403 Casablanca, Morocco ,grid.11505.300000 0001 2153 5088Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium ,grid.444715.70000 0000 8673 4005School of Tropical Medicine and Global Health, University of Nagasaki, Nagasaki, Japan
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Sheikh N, Tagoe ET, Akram R, Ali N, Howick S, Morton A. Implementation barriers and remedial strategies for community-based health insurance in Bangladesh: insights from national stakeholders. BMC Health Serv Res 2022; 22:1200. [PMID: 36153512 PMCID: PMC9508716 DOI: 10.1186/s12913-022-08561-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 09/12/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Community-based health insurance (CBHI) is a part of the health system in Bangladesh, and overcoming the obstacles of CBHI is a significant policy concern that has received little attention. The purpose of this study is to analyze the implementation barriers of voluntary CBHI schemes in Bangladesh and the strategies to overcome these barriers from the perspective of national stakeholders.
Methods
This study is exploratory qualitative research, specifically case study design, using key informant interviews to investigate the barriers of CBHI that are faced during the implementation. Using a topic guide, we conducted thirteen semi-structured in-depth interviews with key stakeholders directly involved in the CBHI implementation process. The data were analyzed using the Framework analysis method.
Results
The implementation of CBHI schemes in Bangladesh is being constrained by several issues, including inadequate population coverage, adverse selection and moral hazard, lack of knowledge about health insurance principles, a lack of external assistance, and insufficient medical supplies. Door-to-door visits by local community-health workers, as well as regular promotional and educational campaigns involving community influencers, were suggested by stakeholders as ways to educate and encourage people to join the schemes. Stakeholders emphasized the necessity of external assistance and the design of a comprehensive benefits package to attract more people. They also recommended adopting a public–private partnership with a belief that collaboration among the government, microfinance institutions, and cooperative societies will enhance trust and population coverage in Bangladesh.
Conclusions
Our research concludes that systematically addressing implementation barriers by including key stakeholders would be a significant reform to the CBHI model, and could serve as a foundation for the planned national health protection scheme for Bangladesh leading to universal health coverage.
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Abu-Zaineh M, Chanel O, Makhloufi K. Estimating willingness to pay for public health insurance while accounting for protest responses: A further step towards universal health coverage in Tunisia? Int J Health Plann Manage 2022; 37:2809-2821. [PMID: 35607299 PMCID: PMC9542895 DOI: 10.1002/hpm.3505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 11/19/2021] [Accepted: 05/05/2022] [Indexed: 11/10/2022] Open
Abstract
Introduction Developing countries face major challenges in implementing universal health coverage (UHC): a widespread informal sector, general discontent with rising economic insecurity and inequality and the rollback of state and public welfare. Under such conditions, estimating the demand for a health insurance scheme (HIS) on voluntary basis can be of interest to accelerate the progress of UHC‐oriented reforms. However, a major challenge that needs to be addressed in such context is related to protest attitudes that may reflect, inter alia, a null valuation of the expected utility or unexpressed demand. Methods We propose to tackle this by applying a contingent valuation survey to a non‐healthcare‐covered Tunisian sample vis‐à‐vis joining and paying for a formal HIS. Our design pays particular attention to identifying the nature of the willingness‐to‐pay (WTP) values obtained, distinguishing genuine null values from protest values. To correct for potential selection issues arising from protest answers, we estimate an ordered‐Probit‐selection model and compare it with the standard Tobit and Heckman sample selection models. Results Our results support the presence of self‐selection and, by predicting protesters' WTP, allow the “true” sample mean WTP to be computed. This appears to be about 14% higher than the elicited mean WTP. Conclusion The WTP of the poorest non‐covered respondents represents about one and a half times the current contributions of the poorest formal sector enrolees, suggesting that voluntary participation in the formal HIS is feasible. We study how protest positions may impact affiliation to formal health insurance We apply a contingent valuation survey to a non‐healthcare‐covered population We account and correct for selection issues with appropriate econometric models Accounting for protest positions is found to impact the implementation of UHC
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Affiliation(s)
- Mohammad Abu-Zaineh
- Aix Marseille Univ, CNRS, AMSE, Marseille, France.,Faculty of Medical and Paramedical Sciences, Aix-Marseille Univ., Marseille, France.,Doha Institute for Graduate Studies, Doha, Qatar
| | | | - Khaled Makhloufi
- Aix-Marseille University, Faculty of Medicine - Timone, INSERM-IRD-UMR 912 (SESSTIM), Marseille, France
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Rouyard T, Mano Y, Daff BM, Diouf S, Fall Dia K, Duval L, Thuilliez J, Nakamura R. Operational and Structural Factors Influencing Enrolment in Community-Based Health Insurance Schemes: An Observational Study Using 12 Waves of Nationwide Panel Data from Senegal. Health Policy Plan 2022; 37:858-871. [PMID: 35413098 PMCID: PMC9347027 DOI: 10.1093/heapol/czac033] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 04/04/2022] [Accepted: 04/12/2022] [Indexed: 11/13/2022] Open
Abstract
Community-based health insurance (CBHI) has been implemented in many low and middle-income countries to increase financial risk protection in populations without access to formal health insurance. While the design of such social programs is fundamental to ensuring equitable access to care, little is known about the operational and structural factors influencing enrolment in CBHI schemes. In this study, we took advantage of newly established data monitoring requirements in Senegal to explore the association between the operational capacity and structure of CBHI schemes-also termed 'mutual health organisations' (MHO) in francophone countries-and their enrolment levels. The dataset comprised 12 waves of quarterly data over 2017-2019 and covered all 676 MHOs registered in the country. Primary analyses were conducted using dynamic panel data regression analysis. We found that higher operational capacity significantly predicted higher performance: enrolment was positively associated with the presence of a salaried manager at the MHO level (12% more total enrollees, 23% more poor members) and with stronger cooperation between MHOs and local health posts (for each additional contract signed, total enrollees and poor members increased by 7% and 5%, respectively). However, higher operational capacity was only modestly associated with higher sustainability proxied by the proportion of enrollees up to date with premium payment. We also found that structural factors were influential, with MHOs located within a health facility enrolling fewer poor members (-16%). Sensitivity analyses showed that these associations were robust. Our findings suggest that policies aimed at professionalising and reinforcing the operational capacity of MHOs could accelerate the expansion of CBHI coverage, including in the most impoverished populations. However, they also suggest that increasing operational capacity alone may be insufficient to make CBHI schemes sustainable over time.
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Affiliation(s)
- Thomas Rouyard
- Research Center for Health Policy and Economics, Hitotsubashi University, Tokyo, Japan
| | - Yukichi Mano
- Graduate School of Economics, Hitotsubashi University, Tokyo, Japan
| | - Bocar Mamadou Daff
- National Agency for Universal Health Financial Protection, Dakar, Senegal
| | - Serigne Diouf
- National Agency for Universal Health Financial Protection, Dakar, Senegal
| | | | - Laetitia Duval
- Centre d'Économie de la Sorbonne, UMR 8174, Centre National de la Recherche Scientifique-Université Paris 1 Panthéon-Sorbonne, Paris, France
| | - Josselin Thuilliez
- Centre d'Économie de la Sorbonne, UMR 8174, Centre National de la Recherche Scientifique-Université Paris 1 Panthéon-Sorbonne, Paris, France
| | - Ryota Nakamura
- Research Center for Health Policy and Economics, Hitotsubashi University, Tokyo, Japan
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Bousmah MAQ, Boyer S, Lalou R, Ventelou B. Reassessing the demand for community-based health insurance in rural Senegal: Geographic distance and awareness. SSM Popul Health 2021; 16:100974. [PMID: 34849390 PMCID: PMC8608590 DOI: 10.1016/j.ssmph.2021.100974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 10/26/2021] [Accepted: 11/16/2021] [Indexed: 11/19/2022] Open
Abstract
Limited access to information is one of the main health insurance market imperfections in developing countries. Differential access to information may determine individuals’ awareness of health insurance schemes, thereby influencing their probability of enrollment. Relying on primary data collected in 2019–2020 in rural Senegal, we estimate the uptake of community-based health insurance using a Heckman-type model to correct for awareness-based sample selection bias. Besides showing that health insurance awareness is a precondition for effective enrollment in community-based health insurance schemes, we also bring new evidence on the roles which geographic factors and individual risk preference play in health insurance uptake by rural dwellers. We show that geographic distance prevents individuals from accessing information on health insurance schemes, and discourage those who are informed from enrolling, because of the additional distance they must travel to benefit from covered healthcare services. Results also show that individual risk preference influences health insurance uptake, but only when information barriers are taken into account. Overall, our results could help decision-makers better shape the universal health coverage roadmap, as policies to improve health insurance awareness differ substantially from policies to improve the features of health insurance schemes.
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Affiliation(s)
| | - Sylvie Boyer
- INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de La Santé & Traitement de L'Information Médicale, Aix-Marseille University, Marseille, France
| | - Richard Lalou
- Université de Paris, MERIT, IRD, F-75006, Paris, France
| | - Bruno Ventelou
- Aix Marseille Univ, CNRS, AMSE, Marseille, 13001, France
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Nkutu Pululu JM, Vodiena Nsakala G, Van Loon H. [Factors associated with loyalty in the mutual health of Kisantu in Democratic Republic of the Congo]. SANTE PUBLIQUE (VANDOEUVRE-LES-NANCY, FRANCE) 2021; Vol. 33:569-577. [PMID: 35485113 DOI: 10.3917/spub.214.0569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Some African countries have initiated mutual health insurance to improve access to health care, However, most of these initiatives have not succeeded in covering the majority of the population, nor in securing long-term loyalty. Considering that very few studies, if not none, allude to the Democratic Republic of Congo (DRC), this study aims to determine the explanatory factors for both loyalty and non-loyalty within the Kisantu health mutual insurance in DRC and to identify any specific factors in the urban-rural Congolese context. PURPOSE OF RESEARCH We conducted a five-year prospective study, starting in 2013, among 320 households, selected among a cohort of 2202 households. Using the SPSS® 21.0 software, the association between loyalty and socio-demographic, socioeconomic variables and the degree of satisfaction with insurance products, as well as the motivations with respect to targeted loyalty, was sought. RESULTS Thus, we found that the sociodemographic characteristics were not associated with loyalty of payments. In contrast, statistically significant relations were found between loyalty and socioeconomic characteristics, including occupation, estimated income, as the motivations expressed with regard to loyalty (P ≤ 0.001). In a logistic regression model, occupation, estimated household income of $100 or above were twice more likely to be loyal than those with an income below $100. Protection by income has not been identified as a predictor in the studies included in our survey of the literature, but it proved to be significantly associated with loyalty in the present study. On the other hand, beyond the fidelity factors observed in this study, aspects relating to the management of mutual health insurance, which have appeared as predictors in other contexts, are not identified as such in our community. CONCLUSIONS In an urban - rural context in DR Congo where the majority of the population has a low and unstable income, and considering the low amount of contribution to the Kisantu health mutual, 4.2% of the median household income, it will be necessary therefore rethink the place of health spending in households and the extension of solidarity in the form of uniform or income-based contributions.
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Schleiff MJ, Aitken I, Alam MA, Damtew ZA, Perry HB. Community health workers at the dawn of a new era: 6. Recruitment, training, and continuing education. Health Res Policy Syst 2021; 19:113. [PMID: 34641898 PMCID: PMC8506097 DOI: 10.1186/s12961-021-00757-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This is the sixth of our 11-paper supplement entitled "Community Health Workers at the Dawn of New Era". Expectations of community health workers (CHWs) have expanded in recent years to encompass a wider array of services to numerous subpopulations, engage communities to collaborate with and to assist health systems in responding to complex and sometimes intensive threats. In this paper, we explore a set of key considerations for training of CHWs in response to their enhanced and changing roles and provide actionable recommendations based on current evidence and case examples for health systems leaders and other stakeholders to utilize. METHODS We carried out a focused review of relevant literature. This review included particular attention to a 2014 book chapter on training of CHWs for large-scale programmes, a systematic review of reviews about CHWs, the 2018 WHO guideline for CHWs, and a 2020 compendium of 29 national CHW programmes. We summarized the findings of this latter work as they pertain to training. We incorporated the approach to training used by two exemplary national CHW programmes: for health extension workers in Ethiopia and shasthya shebikas in Bangladesh. Finally, we incorporated the extensive personal experiences of all the authors regarding issues in the training of CHWs. RESULTS The paper explores three key themes: (1) professionalism, (2) quality and performance, and (3) scaling up. Professionalism: CHW tasks are expanding. As more CHWs become professionalized and highly skilled, there will still be a need for neighbourhood-level voluntary CHWs with a limited scope of work. Quality and performance: Training approaches covering relevant content and engaging CHWs with other related cadres are key to setting CHWs up to be well prepared. Strategies that have been recently integrated into training include technological tools and provision of additional knowledge; other strategies emphasize the ongoing value of long-standing approaches such as regular home visitation. Scale-up: Scaling up entails reaching more people and/or adding more complexity and quality to a programme serving a defined population. When CHW programmes expand, many aspects of health systems and the roles of other cadres of workers will need to adapt, due to task shifting and task sharing by CHWs. CONCLUSION Going forward, if CHW programmes are to reach their full potential, ongoing, up-to-date, professionalized training for CHWs that is integrated with training of other cadres and that is responsive to continued changes and emerging needs will be essential. Professionalized training will require ongoing monitoring and evaluation of the quality of training, continual updating of pre-service training, and ongoing in-service training-not only for the CHWs themselves but also for those with whom CHWs work, including communities, CHW supervisors, and other cadres of health professionals. Strong leadership, adequate funding, and attention to the needs of each cadre of CHWs can make this possible.
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Affiliation(s)
- Meike J. Schleiff
- Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Iain Aitken
- Management Sciences for Health, Ministry of Public Health, Kabul, Afghanistan
| | | | | | - Henry B. Perry
- Health Systems Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
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Demissie GD, Atnafu A. Barriers and Facilitators of Community-Based Health Insurance Membership in Rural Amhara Region, Northwest Ethiopia: A Qualitative Study. CLINICOECONOMICS AND OUTCOMES RESEARCH 2021; 13:343-348. [PMID: 33976557 PMCID: PMC8106446 DOI: 10.2147/ceor.s293847] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 04/09/2021] [Indexed: 11/23/2022] Open
Abstract
Background More than 150 million people encounter huge cost of health expenses every year, and most of these treatment seekers face poverty owing to out-of-pocket payments. Community-based health insurance (CBHI) won popularity as a makeshift health financing mechanism for out-of-pocket payments in poor communities. The aim of this study was therefore to explore the facilitators and impediments of enrollment to community-based health insurance in rural parts of the Amhara region, Ethiopia. Methods Focus Group Discussion (FGD) was the main data collection instrument supplemented by key informant interview (KII). The FGD participants were selected using a purposive sampling technique. The participants were therefore selected based on their membership status of CBHI (members or non-members). Six FGDs and four KIIs were conducted in November 2019 in three districts. Before analyzing the data, all FGDs and KIIs were transcribed and transferred into ATLAS.ti version 7.1 software. An inductive thematic analysis approach was done, that is, on the basis of major themes emerged from the data. Results Low level of awareness, perception of high amount of premium, poor perception of quality of services and lack of trust are the barriers to join community-based health insurance. Conclusion There has been low level of awareness and misconception about community-based health insurance. The major reason to decline to join CBHI was low capacity to pay the premium.
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Affiliation(s)
- Getu Debalkie Demissie
- Department of Health Education and Behavioral Sciences, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Asmamaw Atnafu
- Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Cheno RW, Tchabo W, Tchamy J. Willingness to join and pay for community-based health insurance and associated determinants among urban households of Cameroon: case of Douala and Yaounde. Heliyon 2021; 7:e06507. [PMID: 33817375 PMCID: PMC8010406 DOI: 10.1016/j.heliyon.2021.e06507] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/20/2021] [Accepted: 03/11/2021] [Indexed: 11/13/2022] Open
Abstract
Background The risks associated with direct health spending are high in Cameroon, where almost all household income is spent on health care. Moreover, there is no real social security in Cameroon because of the lack of a universal social protection system. Objectives This study aimed to assess the willingness of Cameroonian urban dwellers to subscribe and the amount to pay for voluntary (VCHI) or compulsory community-based health insurance (CCHI). Methods A cross-sectional study based on a three-stage stratified cluster random sampling design using a bidding game style based on the contingent valuation approach was performed to in the two largest urban areas of Cameroon (Douala and Yaoundé) evaluate the willingness to pay for the VCHI and CCHI. Results The results shown that 46% of respondent were willing to join the CCHI and 41% for VCHI. Furthermore, household income, working sector, chronic disease, health priority, and family size were factors mostly associated (p < 0.001) with the willingness to join CCHI or VCHI. Increase in household income has a positive effect on household's desire for both CCHI and VCHI. While for VCHI, increase of children number resulted in an increment of the premium, contrary to the occurrence of chronic ailment which led in the decrease of the bid. Conclusions From the results, it is clear that city dwellers in Cameroon are ready to join and pay for community health insurance. This willingness was related to their financial power which resulted in an average insurance premium of 9.03 USD and 8.17 USD, respectively for CCHI and VCHI. That bid was found to be enough for an implementation of these types of health insurance in Cameroon.
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Affiliation(s)
- Rosine Wafo Cheno
- Department of Health Policy and Management, Jiangsu University, 301 Xuefu Road, Zhenjiang 212013, China.,Ministry of Public Health of Cameroon, Road 3038, Quartier du Lac, Yaounde, Cameroon
| | - William Tchabo
- University of Ngaoundere, PO Box 455, Ngaoundere, Cameroon
| | - Jonathan Tchamy
- University of Ngaoundere, PO Box 455, Ngaoundere, Cameroon.,Jonathan Tchamy, School of Management and Economics, Kunming University of Science and Technology, Kunming 650093, China
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13
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Determinants of community-based health insurance implementation in west Gojjam zone, Northwest Ethiopia: a community based cross sectional study design. BMC Health Serv Res 2019; 19:544. [PMID: 31375108 PMCID: PMC6679527 DOI: 10.1186/s12913-019-4363-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 07/19/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In most developing countries, healthcare cost is mainly paid at the time of sickness and out-of-pocket at the point of service delivery which potentially could inhibit access. The total economic cost of illness for households is also estimated to be frequently above 10% of household income which is categorized as catastrophic. The purpose of this study was to assess factors that determine decisions to join the community based health insurance in West Gojjam zone. METHODS A community based cross sectional survey was conducted to collect data from 690 household heads using a multistage sampling technique. A binary logistic regression was used to identify the determinants of household decisions for CBHI enrollment. RESULTS Out of the participants, 58% were CBHI members. Besides, family size (AOR = 1.17; CI = 1.02-1.35), average health status (AOR = .380; CI = .179-.805), chronic disease (AOR = 3.42; CI = 1.89-6.19); scheme benefit package adequacy (AOR = 2.17; CI = 1.20-3.93), perceived health service quality (AOR = 3.69; CI = 1.77-7.69), CBHI awareness (AOR = 4.90; CI = 1.65-14.4); community solidarity (AOR = 3.77; CI = 2.05-6.92) and wealth (AOR = 3.62; CI = 1.67-7.83) were significant determinant factors for enrolment in the community based health insurance scheme. CONCLUSION CBHI awareness, family health status, community solidarity, quality of service of health institutions, and wealth were major factors that most determine the household decisions to enroll in the system. Therefore, in-depth and sustainable awareness creation programs on the scheme; stratified premium- based on economic status of households; incorporation of social capital factors, particularly building community solidarity in the scheme implementation are vital to enhance sustainable enrollment. As perceived family health status and the existence of chronic disease were also found significant determinants of enrollment, the Government might have to look for options to make the scheme mandatory.
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Diop M, Kanouté A, Diouf M, Ndiaye AD, Lo CMM, Faye D, Cissé D. The role of health insurance in the coverage of oral health care in Senegal. J Public Health Afr 2018; 9:772. [PMID: 30854174 PMCID: PMC6379686 DOI: 10.4081/jphia.2018.772] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Accepted: 02/19/2018] [Indexed: 12/03/2022] Open
Abstract
Oral diseases costs are among the most expensive health care benefits. In Senegal, households contribute up to 37.6% of the national health spending through direct payments. The aim of this work was to study the role of health insurance in the coverage of oral health care in Senegal. The study was based on health insurance agents and policyholders. The study reveals that oral health care coverage through health insurance still does not meet requirements for treatment of oral infections. In financial terms, oral health care costs health insurance too much. As a result, carriers cover them partially. On top of that, the majority of the population's lack of knowledge about mutual, because they have a little background on oral health care, the latter weighs heavily on health insurance leading to the use of self-medication, traditional medicine and handicraft prosthetists. The analysis reveals an unequal access to oral health care through the health insurance system. To bring under control the expenditure for oral health care, carriers and dental surgeons must work together to raise the populations' awareness on community solidarity.
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Affiliation(s)
| | - Aida Kanouté
- Department of Odontology, Faculty of Medicine, Pharmacy and Odonto-Stomatology, University Cheikh Anta Diop of Dakar, Senegal
| | | | | | | | - Daouda Faye
- Department of Public Health Faculty of Medicine
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15
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Bocoum F, Grimm M, Hartwig R, Zongo N. Can information increase the understanding and uptake of insurance? Lessons from a randomized experiment in rural Burkina Faso. Soc Sci Med 2018; 220:102-111. [PMID: 30415141 DOI: 10.1016/j.socscimed.2018.10.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 10/25/2018] [Accepted: 10/31/2018] [Indexed: 11/27/2022]
Abstract
Community Based Health Insurance Schemes are often confronted to very low uptake. We analyze the impact of a randomized information package on the understanding and adoption of Community Based Health Insurance in Burkina Faso. The sample consists of about 2000 households in the rural community of Ziniaré which we interviewed several times between 2013 and 2016. In contrast to previous studies in the literature, we assess the effects of an intensive information intervention combining tools and repeated interaction instead of only a single event of information provisioning. The information package combines three tools to present different types of information - a brochure presenting factual information, a video presenting a hypothetical health episode and a personalized phone call reminder. The brochure and video are delivered through home visits by specially trained agents. Despite the repeated interaction and the comprehensiveness of the information package, we find only modest improvements in the understanding of insurance principles following our intervention. Investigating treatment heterogeneity, we observe an increase in understanding in poorer households and in households with literate heads. Given the small improvements in insurance knowledge we do not see a significant effect on insurance uptake either. We conclude that information is not enough to increase insurance uptake and discuss the role of other factors that might matter including the political context in which our experiment was implemented.
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Affiliation(s)
- Fadima Bocoum
- Institute de Recherche en Sciences de Santé (IRSS), Ouagadougou, Burkina Faso
| | | | - Renate Hartwig
- University of Namur, Belgium; University of Passau, Germany
| | - Nathalie Zongo
- Association Songui Manégré- Aide au développement Endogène (ASMADE), Ouagadougou, Burkina Faso
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Yaya Bocoum F, Grimm M, Hartwig R. The health care burden in rural Burkina Faso: Consequences and implications for insurance design. SSM Popul Health 2018; 6:309-316. [PMID: 30533487 PMCID: PMC6262766 DOI: 10.1016/j.ssmph.2018.10.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 10/01/2018] [Accepted: 10/26/2018] [Indexed: 11/25/2022] Open
Abstract
This paper maps the health care burden of households in rural Burkina Faso. More specifically we investigate the financial burden of health shocks and the manner in which households respond. Our data allows us to differentiate the burden of chronic illness and handicap, more frequent and recurring illnesses and episodes of severe illness, accident and mortality. We find that the burden of health shocks and health spending is high, ranging from one third of monthly non-medical consumption for the treatment of common infectious illnesses to almost three times the monthly non-medical spending in case of death of a household member. To cope, households deplete savings, sell livestock or reduce consumption. In case of severe shocks they are also heavily reliant on transfers from outside. Looking at the economic consequences of health shocks we find that illness of whichever type – severe, chronic or more common – reduces household consumption. Furthermore, households which suffered from a severe illness show significantly lower livestock holdings. Many of the health insurance schemes implemented in developing countries are not yet taking note of the burden of severe and chronic illness. However, in light of the universal health insurance coverage objectives of the Sustainable Development Goals (SDGs) it should be considered an area for future expansion.
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Affiliation(s)
| | - Michael Grimm
- University of Passau, Germany.,Erasmus University, Rotterdam, the Netherlands.,IZA, Bonn, Germany
| | - Renate Hartwig
- University of Passau, Germany.,University of Namur, Belgium
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17
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Gankpe GF, Gankpe EC, Baleba AN, Zinsou L, Mesenge C. [Does mutual health insurance reproduce health inequalities in Benin?]. SANTE PUBLIQUE (VANDOEUVRE-LES-NANCY, FRANCE) 2018; 30:389-396. [PMID: 30541268 DOI: 10.3917/spub.183.0389] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
INTRODUCTION The factors leading to exclusion of a part of the population from mutual health insurance were studied by examining the profile of members, the social dynamics and the mode of functioning of this type of health insurance. METHODS A cross-sectional survey was conducted in Parakou; Benin by selecting 50 patients from three healthcare centres selected at random from the ten "Réseau des Soins Coordonnés" centres. Individual interviews and focus groups were conducted with mutual health insurance beneficiaries and non-beneficiaries. RESULTS Thirty-seven of the 50 patients did not have any mutual health insurance and 35 of them were under the age of 35 years with a female predominance (23 out of 37) with a low monthly income (less than CFA30,000). Factors such as group dynamics, the feeling of belonging to a group and confidence in mutual insurance management committees were related to the presence or absence of mutual health insurance. CONCLUSION In the absence of universal health insurance coverage in Benin, mutual health insurance constitutes almost the only solution for populations, but few people take out this insurance. Consequently, the contribution of mutual health insurance in this region of Benin to access to healthcare remains marginal, as the most deprived populations cannot afford this insurance.
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18
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Coast J. A history that goes hand in hand: Reflections on the development of health economics and the role played by Social Science & Medicine, 1967-2017. Soc Sci Med 2017; 196:227-232. [PMID: 29132835 DOI: 10.1016/j.socscimed.2017.10.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 10/16/2017] [Accepted: 10/30/2017] [Indexed: 01/05/2023]
Affiliation(s)
- Joanna Coast
- Population Health Sciences, Bristol Medical School, University of Bristol, United Kingdom.
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19
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Oraro T, Ngube N, Atohmbom GY, Srivastava S, Wyss K. The influence of gender and household headship on voluntary health insurance: the case of North-West Cameroon. Health Policy Plan 2017; 33:163-170. [DOI: 10.1093/heapol/czx152] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2017] [Indexed: 11/12/2022] Open
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Boateng S, Amoako P, Poku AA, Baabereyir A, Gyasi RM. Migrant female head porters' enrolment in and utilisation and renewal of the National Health Insurance Scheme in Kumasi, Ghana. ZEITSCHRIFT FUR GESUNDHEITSWISSENSCHAFTEN = JOURNAL OF PUBLIC HEALTH 2017; 25:625-634. [PMID: 29177126 PMCID: PMC5681982 DOI: 10.1007/s10389-017-0832-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 08/20/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE As a social protection policy, Ghana's National Health Insurance Scheme (NHIS) aims to improve access to healthcare, especially for the vulnerable. Migrant female head porters (kayayoo), who are part of the informal economic workforce, are underscored as an ethnic minority and vulnerable group in Ghana. This study aimed to analyse the factors associated with enrolment in and renewal and utilisation of the NHIS among migrant female head porters in the Kumasi Metropolis. METHOD We purposively sampled 392 migrant female head porters in the Kejetia, Asafo and Bantama markets. We used a binary logit regression model to estimate associations among baseline characteristics, convenience and benefit factors and enrolment in and renewal and utilisation of the NHIS. RESULT Age and income significantly increased the probability of NHIS enrolment, renewal and utilisation. Long waiting times at NHIS offices significantly reduced the likelihood of renewal, while provision of drugs highly significantly increased the tendency for migrant female head porters to enrol in, renew and use the NHIS. Consulting and surgery also significantly increased renewal and utilisation of the NHIS. CONCLUSION Political commitment is imperative for effective implementation of the decentralisation policy of the NHIS through the National Health Insurance Authority in Kumasi. We argue that retail offices should be well equipped with logistic facilities to ensure convenience in NHIS initial enrolment and renewal processes by citizenry, and by vulnerable groups in particular.
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Affiliation(s)
- Simon Boateng
- Social Sciences Department, St. Monica’s College of Education, Mampong, Ghana
| | - Prince Amoako
- Department of Economics, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Adjoa Afriyie Poku
- Department of Geography Education, University of Education, Winneba, Ghana
| | - Anthony Baabereyir
- Department of Geography Education, University of Education, Winneba, Ghana
| | - Razak Mohammed Gyasi
- Department of Sociology and Social Policy, Faculty of Social Sciences, Lingnan University, Teun Mun, Hong Kong
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21
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Waelkens MP, Coppieters Y, Laokri S, Criel B. An in-depth investigation of the causes of persistent low membership of community-based health insurance: a case study of the mutual health organisation of Dar Naïm, Mauritania. BMC Health Serv Res 2017; 17:535. [PMID: 28784123 PMCID: PMC5545852 DOI: 10.1186/s12913-017-2419-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 06/28/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Persistent low membership is observed in many community-based health insurance (CBHI) schemes in Africa. Causes for low membership have been identified and solutions suggested, but this did not result in increased membership. In this case study of the mutual health organisation of Dar Naïm in Mauritania we explore the underlying drivers that may explain why membership continued to stagnate although several plans for change had been designed. METHODS We used a systems approach focussed on processes, underlying dynamics and complex interactions that produce the outcomes, to delve into 10 years of data collected between 2003 and 2012. We used qualitative research methods to analyse the data and interpret patterns. RESULTS Direct causes of stagnation and possible solutions had been identified in the early years of operations, but most of the possible solutions were not implemented. A combination of reasons explains why consecutive action plans were not put into practice, showing the complexity of implementation and the considerable management capacity required, as well as the challenges of integrating a novel organisational structure into exiting social structures. CONCLUSIONS For any CBHI project aiming at high membership, skilled professional management seems essential, with capacity to question and adapt routine procedures and interpret interactions within the wider society. Countries that include community-based health insurance in their strategic plan towards universal coverage will have to pay more attention to management capacity and the minutiae of implementation.
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Affiliation(s)
- Maria-Pia Waelkens
- Université libre de Bruxelles (ULB), School of Public Health, 808 Route de Lennik, 1070, Brussels, Belgium.
| | - Yves Coppieters
- Université libre de Bruxelles (ULB), School of Public Health, Health Policy and Systems - International Health, 808 Route de Lennik, 1070, Brussels, Belgium
| | - Samia Laokri
- Université libre de Bruxelles (ULB), School of Public Health, Health Policy and Systems - International Health, 808 Route de Lennik, 1070, Brussels, Belgium.,Tulane University, School of Public Health and Tropical Medicine, Global Community Health and Behavioral Sciences, 1440 Canal Street, New Orleans, LA, 70112, USA
| | - Bart Criel
- Department of Public Health - Equity & Health, Institute of Tropical Medicine, Nationalestraat 155, 2000, Antwerp, Belgium
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Umeh CA, Feeley FG. Inequitable Access to Health Care by the Poor in Community-Based Health Insurance Programs: A Review of Studies From Low- and Middle-Income Countries. GLOBAL HEALTH: SCIENCE AND PRACTICE 2017; 5:299-314. [PMID: 28655804 PMCID: PMC5487091 DOI: 10.9745/ghsp-d-16-00286] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 05/09/2017] [Indexed: 11/18/2022]
Abstract
The poor lack equitable access to health care in community-based health insurance schemes. Flexible installment payment plans, subsidized premiums, and elimination of co-pays can increase enrollment and use of health services by the poor. Background: Out-of-pocket payments for health care services lead to decreased use of health services and catastrophic health expenditures. To reduce out-of-pocket payments and improve access to health care services, some countries have introduced community-based health insurance (CBHI) schemes, especially for those in rural communities or who work in the informal sector. However, there has been little focus on equity in access to health care services in CBHI schemes. Methods: We searched PubMed, Web of Science, African Journals OnLine, and Africa-Wide Information for studies published in English between 2000 and August 2014 that examined the effect of socioeconomic status on willingness to join and pay for CBHI, actual enrollment, use of health care services, and drop-out from CBHI. Our search yielded 755 articles. After excluding duplicates and articles that did not meet our inclusion criteria (conducted in low- and middle-income countries and involved analysis based on socioeconomic status), 49 articles remained that were included in this review. Data were extracted by one author, and the second author reviewed the extracted data. Disagreements were mutually resolved between the 2 authors. The findings of the studies were analyzed to identify their similarities and differences and to identify any methodological differences that could account for contradictory findings. Results: Generally, the rich were more willing to pay for CBHI than the poor and actual enrollment in CBHI was directly associated with socioeconomic status. Enrollment in CBHI was price-elastic—as premiums decreased, enrollment increased. There were mixed results on the effect of socioeconomic status on use of health care services among those enrolled in CBHI. We found a high drop-out rate from CBHI schemes that was not related to socioeconomic status, although the most common reason for dropping out of CBHI was lack of money to pay the premium. Conclusion: The effectiveness of CBHI schemes in achieving universal health coverage in low- and middle-income countries is questionable. A flexible payment plan where the poor can pay in installments, subsidized premiums for the poor, and removal of co-pays are measures that can increase enrollment and use of CBHI by the poor.
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Affiliation(s)
- Chukwuemeka A Umeh
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA.
| | - Frank G Feeley
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
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Herberholz C, Fakihammed WA. Determinants of Voluntary National Health Insurance Drop-Out in Eastern Sudan. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2017; 15:215-226. [PMID: 27696328 DOI: 10.1007/s40258-016-0281-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Low enrolment and high drop-out rates are common problems in voluntary health insurance schemes. Yet, most studies in this research area focus on community-based health insurance and enrolment, rather than drop-out. OBJECTIVE This study examines what causes informal sector families not to renew their voluntary National Health Insurance Fund (NHIF) health insurance membership in Eastern Sudan. METHODS Primary data from about 600 informal sector households that dropped out or remained insured, collected through a household survey conducted in March 2014, were used. Logistic regressions were employed to examine what determines drop-out of the voluntary NHIF scheme. RESULTS The logistic regression results are consistent with the existing literature and confirm the importance of household head, household and community characteristics. Notably, worse family health status and higher health care utilization decrease the probability of drop-out, which requires further analysis as it may indicate the problem of adverse selection and insufficient risk management. Most importantly, the results consistently show that household heads who are satisfied with health services and those who understand the main features of the voluntary NHIF scheme are less likely to drop out. Also, 30 % of drop-out households hold a social support card and reported that the social support scheme is the main reason for not renewing their voluntary NHIF health insurance membership as they qualify for sponsored NHIF health insurance membership. CONCLUSIONS This study shows that satisfaction with health services and knowledge of the health insurance scheme are important factors explaining drop-out of a national health insurance programme. The results suggest that education and information campaigns should be developed further to raise understanding of the NHIF voluntary scheme. In addition, information systems and coordination between the main agencies should be strengthened to reduce administrative costs and ensure policy coherence.
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Affiliation(s)
- Chantal Herberholz
- Faculty of Economics, Centre for Health Economics, Chulalongkorn University, Bangkok, 10330, Thailand.
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Fenny AP, Kusi A, Arhinful DK, Asante FA. Factors contributing to low uptake and renewal of health insurance: a qualitative study in Ghana. Glob Health Res Policy 2016; 1:18. [PMID: 29202066 PMCID: PMC5693548 DOI: 10.1186/s41256-016-0018-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 11/04/2016] [Indexed: 11/15/2022] Open
Abstract
Background The effort to expand access to healthcare and reduce health inequalities in many low income countries have meant that many have adopted different levels of social health protection mechanisms. Ghana introduced a National Health Insurance Scheme (NHIS) in 2005 with the aim of removing previous barriers created by the user fees financing system. Although the NHIS has made health accessible to some category of people, the majority of Ghanaians (60 %) are not enroled on the scheme. Earlier studies have looked at various factors that account for this low uptake. However, we recognise that this qualitative study will nuance the depth of these barriers to enrolment. Methods Minimally structured, qualitative interviews were conducted with key stakeholders at the district, regional and national levels. Focus group discussions were also undertaken at the community level. Using an inductive and content analytic approach, the transcripts were analyzed to identify and define categories that explain low uptake of health insurance. Results The results are presented under two broad themes: sociocultural and systemic factors. Sociocultural factors identified were 1) vulnerability within certain groups such as the aged and the disabled groups which impeded access to the NHIS 2) cultural and religious norms which discouraged enrolment into the scheme. System-wide factors were 1) inadequate distribution of social infrastructure such as healthcare facilities, 2) weak administrative processes within the NHIS, and 3) poor quality of care. Conclusions Mapping the interplay of these dynamic relations between the NHIS, its clients and service providers, the study identifies critical factors at the policy-making level, service provider level, and client level (reflective in household and community level institutional arrangements) that affect enrolment in the scheme. Our findings inform a number of potential reforms in the area of distribution of health resources and cost containment to expand coverage, increase choices and meeting the needs of the end user.
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Affiliation(s)
- Ama Pokuaa Fenny
- Economics Division, Institute of Statistical, Social and Economic Research (ISSER), University of Ghana, PO Box LG 74, Legon, LG74 Accra, Ghana
| | - Anthony Kusi
- Department of Epidemiology, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
| | - Daniel K Arhinful
- Department of Epidemiology, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
| | - Felix Ankoma Asante
- Economics Division, Institute of Statistical, Social and Economic Research (ISSER), University of Ghana, PO Box LG 74, Legon, LG74 Accra, Ghana
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Agyepong IA, Abankwah DNY, Abroso A, Chun C, Dodoo JNO, Lee S, Mensah SA, Musah M, Twum A, Oh J, Park J, Yang D, Yoon K, Otoo N, Asenso-Boadi F. The "Universal" in UHC and Ghana's National Health Insurance Scheme: policy and implementation challenges and dilemmas of a lower middle income country. BMC Health Serv Res 2016; 16:504. [PMID: 27655007 PMCID: PMC5031274 DOI: 10.1186/s12913-016-1758-y] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 09/14/2016] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Despite universal population coverage and equity being a stated policy goal of its NHIS, over a decade since passage of the first law in 2003, Ghana continues to struggle with how to attain it. The predominantly (about 70 %) tax funded NHIS currently has active enrolment hovering around 40 % of the population. This study explored in-depth enablers and barriers to enrolment in the NHIS to provide lessons and insights for Ghana and other low and middle income countries (LMIC) into attaining the goal of universality in Universal Health Coverage (UHC). METHODS We conducted a cross sectional mixed methods study of an urban and a rural district in one region of Southern Ghana. Data came from document review, analysis of routine data on enrolment, key informant in-depth interviews with local government, regional and district insurance scheme and provider staff and community member in-depth interviews and focus group discussions. RESULTS Population coverage in the NHIS in the study districts was not growing towards near universal because of failure of many of those who had ever enrolled to regularly renew annually as required by the NHIS policy. Factors facilitating and enabling enrolment were driven by the design details of the scheme that emanate from national level policy and program formulation, frontline purchaser and provider staff implementation arrangements and contextual factors. The factors inter-related and worked together to affect client experience of the scheme, which were not always the same as the declared policy intent. This then also affected the decision to enrol and stay enrolled. CONCLUSIONS UHC policy and program design needs to be such that enrolment is effectively compulsory in practice. It also requires careful attention and responsiveness to actual and potential subscriber, purchaser and provider (stakeholder) incentives and related behaviour generated at implementation levels.
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Affiliation(s)
- Irene Akua Agyepong
- Ghana Health Service, Research and Development Division, P.O. Box 1, Dodowa, Greater Accra Region Ghana
| | - Daniel Nana Yaw Abankwah
- Department of Social and Behavioral Sciences, University of Ghana, School of Public Health, Accra, Ghana
| | - Angela Abroso
- Department of Epidemiology, University of Ghana, School of Public Health, Accra, Ghana
| | - ChangBae Chun
- Korea Foundation for International Healthcare (KOFIH), Seoul, Republic of Korea
| | - Joseph Nii Otoe Dodoo
- Policy Analysis Unit, Policy Planning Monitoring and Evaluation Division, Ministry of Health, Accra, Ghana
| | - Shinye Lee
- Korea Foundation for International Healthcare (KOFIH), Seoul, Republic of Korea
| | | | - Mariam Musah
- National Health Insurance Authority, Accra, Ghana
| | - Adwoa Twum
- National Health Insurance Authority, Accra, Ghana
| | - Juwhan Oh
- JW LEE Center for Global Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jinha Park
- Korea Foundation for International Healthcare (KOFIH), Seoul, Republic of Korea
| | - DoogHoon Yang
- Korea Foundation for International Healthcare (KOFIH), Seoul, Republic of Korea
| | - Kijong Yoon
- National Health Insurance Service, Seoul, Republic of Korea
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Dror DM, Hossain SAS, Majumdar A, Pérez Koehlmoos TL, John D, Panda PK. What Factors Affect Voluntary Uptake of Community-Based Health Insurance Schemes in Low- and Middle-Income Countries? A Systematic Review and Meta-Analysis. PLoS One 2016; 11:e0160479. [PMID: 27579731 PMCID: PMC5006971 DOI: 10.1371/journal.pone.0160479] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2016] [Accepted: 07/20/2016] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION This research article reports on factors influencing initial voluntary uptake of community-based health insurance (CBHI) schemes in low- and middle-income countries (LMIC), and renewal decisions. METHODS Following PRISMA protocol, we conducted a comprehensive search of academic and gray literature, including academic databases in social science, economics and medical sciences (e.g., Econlit, Global health, Medline, Proquest) and other electronic resources (e.g., Eldis and Google scholar). Search strategies were developed using the thesaurus or index terms (e.g., MeSH) specific to the databases, combined with free text terms related to CBHI or health insurance. Searches were conducted from May 2013 to November 2013 in English, French, German, and Spanish. From the initial search yield of 15,770 hits, 54 relevant studies were retained for analysis of factors influencing enrolment and renewal decisions. The quantitative synthesis (informed by meta-analysis) and the qualitative analysis (informed by thematic synthesis) were compared to gain insight for an overall synthesis of findings/statements. RESULTS Meta-analysis suggests that enrolments in CBHI were positively associated with household income, education and age of the household head (HHH), household size, female-headed household, married HHH and chronic illness episodes in the household. The thematic synthesis suggests the following factors as enablers for enrolment: (a) knowledge and understanding of insurance and CBHI, (b) quality of healthcare, (c) trust in scheme management. Factors found to be barriers to enrolment include: (a) inappropriate benefits package, (b) cultural beliefs, (c) affordability, (d) distance to healthcare facility, (e) lack of adequate legal and policy frameworks to support CBHI, and (f) stringent rules of some CBHI schemes. HHH education, household size and trust in the scheme management were positively associated with member renewal decisions. Other motivators were: (a) knowledge and understanding of insurance and CBHI, (b) healthcare quality, (c) trust in scheme management, and (d) receipt of an insurance payout the previous year. The barriers to renewal decisions were: (a) stringent rules of some CBHI schemes, (b) inadequate legal and policy frameworks to support CBHI and (c) inappropriate benefits package. CONCLUSION AND POLICY IMPLICATIONS The demand-side factors positively affecting enrolment in CBHI include education, age, female household heads, and the socioeconomic status of households. Moreover, when individuals understand how their CBHI functions they are more likely to enroll and when people have a positive claims experience, they are more likely to renew. A higher prevalence of chronic conditions or the perception that healthcare is of good quality and nearby act as factors enhancing enrolment. The perception that services are distant or deficient leads to lower enrolments. The second insight is that trust in the scheme enables enrolment. Thirdly, clarity about the legal or policy framework acts as a factor influencing enrolments. This is significant, as it points to hitherto unpublished evidence that governments can effectively broaden their outreach to grassroots groups that are excluded from social protection by formulating supportive regulatory and policy provisions even if they cannot fund such schemes in full, by leveraging people's willingness to exercise voluntary and contributory enrolment in a community-based health insurance.
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Affiliation(s)
- David Mark Dror
- Micro Insurance Academy, New Delhi, India
- Erasmus University Rotterdam, Rotterdam, Netherlands
| | | | | | | | - Denny John
- Peoples Open Access Education Initiative (Peoples-Uni), Delhi, India
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Amo-Adjei J, Anku PJ, Amo HF, Effah MO. Perception of quality of health delivery and health insurance subscription in Ghana. BMC Health Serv Res 2016; 16:317. [PMID: 27472916 PMCID: PMC4966716 DOI: 10.1186/s12913-016-1602-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 07/28/2016] [Indexed: 11/25/2022] Open
Abstract
Background National health insurance schemes (NHIS) in developing countries and perhaps in developed countries as well is a considered a pro-poor intervention by helping to bridge the financial burden of access to quality health care. Perceptions of quality of health service could have immense impacts on enrolment. This paper shows how perception of service quality under Ghana’s insurance programme contributes to health insurance subscription. Methods The study used the 2014 Ghana Demographic and Health Survey (GDHS) dataset. Both descriptive proportions and binary logistic regression techniques were applied to generate results that informed the discussion. Results Our results show that a high proportion of females (33 %) and males (35 %) felt that the quality of health provided to holders of the NHIS card was worse. As a result, approximately 30 % of females and 22%who perceived health care as worse by holding an insurance card did not own an insurance policy. While perceptions of differences in quality among females were significantly different (AOR = 0.453 [95 % CI = 0.375, 0.555], among males, the differences in perceptions of quality of health services under the NHIS were independent in the multivariable analysis. Beyond perceptions of quality, being resident in the Upper West region was an important predictor of health insurance ownership for both males and females. Conclusion For such a social and pro-poor intervention, investing in quality of services to subscribers, especially women who experience enormous health risks in the reproductive period can offer important gains to sustaining the scheme as well as offering affordable health services.
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Affiliation(s)
- Joshua Amo-Adjei
- African Population and Health Research Centre, Nairobi, Kenya. .,Department of Population and Health, University of Cape Coast, Cape Coast, Ghana.
| | - Prince Justin Anku
- Department of Population and Health, University of Cape Coast, Cape Coast, Ghana
| | - Hannah Fosuah Amo
- Department of Business Administration, Valley View University, Oyibi, Ghana
| | - Mavis Osei Effah
- Department of Accounting and Finance, University of Cape Coast, Cape Coast, Ghana
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Abiiro GA, Torbica A, Kwalamasa K, De Allegri M. What factors drive heterogeneity of preferences for micro-health insurance in rural Malawi? Health Policy Plan 2016; 31:1172-83. [DOI: 10.1093/heapol/czw049] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2016] [Indexed: 11/12/2022] Open
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Agier I, Ly A, Kadio K, Kouanda S, Ridde V. Endorsement of universal health coverage financial principles in Burkina Faso. Soc Sci Med 2016; 151:157-66. [DOI: 10.1016/j.socscimed.2016.01.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 01/06/2016] [Accepted: 01/09/2016] [Indexed: 10/22/2022]
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Adebayo EF, Uthman OA, Wiysonge CS, Stern EA, Lamont KT, Ataguba JE. A systematic review of factors that affect uptake of community-based health insurance in low-income and middle-income countries. BMC Health Serv Res 2015; 15:543. [PMID: 26645355 PMCID: PMC4673712 DOI: 10.1186/s12913-015-1179-3] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Accepted: 11/18/2015] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Low-income and middle-income countries (LMICs) have difficulties achieving universal financial protection, which is primordial for universal health coverage. A promising avenue to provide universal financial protection for the informal sector and the rural populace is community-based health insurance (CBHI). We systematically assessed and synthesised factors associated with CBHI enrolment in LMICs. METHODS We searched PubMed, Scopus, ERIC, PsychInfo, Africa-Wide Information, Academic Search Premier, Business Source Premier, WHOLIS, CINAHL, Cochrane Library, conference proceedings, and reference lists for eligible studies available by 31 October 2013; regardless of publication status. We included both quantitative and qualitative studies in the review. RESULTS Both quantitative and qualitative studies demonstrated low levels of income and lack of financial resources as major factors affecting enrolment. Also, poor healthcare quality (including stock-outs of drugs and medical supplies, poor healthcare worker attitudes, and long waiting times) was found to be associated with low CBHI coverage. Trust in both the CBHI scheme and healthcare providers were also found to affect enrolment. Educational attainment (less educated are willing to pay less than highly educated), sex (men are willing to pay more than women), age (younger are willing to pay more than older individuals), and household size (larger households are willing to pay more than households with fewer members) also influenced CBHI enrolment. CONCLUSION In LMICs, while CBHI schemes may be helpful in the short term to address the issue of improving the rural population and informal workers' access to health services, they still face challenges. Lack of funds, poor quality of care, and lack of trust are major reasons for low CBHI coverage in LMICs. If CBHI schemes are to serve as a means to providing access to health services, at least in the short term, then attention should be paid to the issues that militate against their success.
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Affiliation(s)
- Esther F Adebayo
- Centre for Evidence-based Health Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
- School of Public Health and Family Medicine, University of Cape Town, Observatory, South Africa.
| | - Olalekan A Uthman
- Centre for Evidence-based Health Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
- Warwick-Centre for Applied Health Research and Delivery (WCAHRD), Division of Health Sciences, Warwick Medical School, The university of Warwick, Coventry, CV4 7AL, UK.
- Liverpool School of Tropical Medicine, International Health Group, Liverpool, Merseyside, UK.
| | - Charles S Wiysonge
- Centre for Evidence-based Health Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa.
| | - Erin A Stern
- Women's Health Research Unit, School of Public Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | - Kim T Lamont
- Soweto Cardiovascular Research Unit, University of the Witwatersrand, Johannesburg, South Africa.
| | - John E Ataguba
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Observatory, South Africa.
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Obse A, Hailemariam D, Normand C. Knowledge of and preferences for health insurance among formal sector employees in Addis Ababa: a qualitative study. BMC Health Serv Res 2015; 15:318. [PMID: 26260445 PMCID: PMC4532245 DOI: 10.1186/s12913-015-0988-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 08/05/2015] [Indexed: 11/28/2022] Open
Abstract
Background The Ethiopian health system has been undergoing through reforms. One of the reforms stipulated in policy documents is the introduction of health insurance at national level. Having the majority of the population without any experience of health insurance, investigating preferences and knowledge of the essence of health insurance among potential enrolees will provide vital information for policy makers. This formative study seeks to explore the knowledge and the preference for health insurance among formal sector employees in Addis Ababa. Methods Six focus group discussions with formal sector employees and five key informant interviews were conducted in Addis Ababa. A thematic analysis is used to analyse the results. Results The findings suggest that there is little knowledge about the concept and elements of health insurance. Some concepts such as, risk pooling and sharing are not well understood. The participants of the study considered health insurance as only a prepayment mechanism without risk sharing among members of the scheme. Regarding preference for health insurance, they have revealed quality of care as the most important factor. Comprehensiveness of benefit packages and the amount of premium level are also found to be concerns related to health insurance. However, a trade-off is also observed among premium level, comprehensive benefit packages, and healthcare facilities. Conclusions Improvements on availability and quality of services need to precede the introduction of social health insurance. There is also a need to work on awareness creation regarding concepts of health insurance. Further studies may explore if the knowledge gap is real or appeared due to reservations of the participants on the introduction of health insurance.
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Affiliation(s)
- Amarech Obse
- School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethopia.
| | - Damen Hailemariam
- School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethopia.
| | - Charles Normand
- Centre for Global Health, Trinity College Dublin, 3-4 Foster Place, Dublin 2, Ireland.
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Agago TA, Woldie M, Ololo S. Willingness to join and pay for the newly proposed social health insurance among teachers in Wolaita Sodo Town, South Ethiopia. Ethiop J Health Sci 2015; 24:195-202. [PMID: 25183925 PMCID: PMC4141222 DOI: 10.4314/ejhs.v24i3.2] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background Cost-sharing between beneficiaries and governments is critical to achieve universal health care coverage. To address this, Ethiopia is currently introducing Social Health Insurance. However, there has been limited evidence on willingness to join the newly proposed insurance scheme in the country. The purpose of this study is to assess willingness to join and pay for the scheme among teachers in Wolaita Sodo Town government educational institutions, South Ethiopia. Methods A cross-sectional study was conducted from February 5 to March 10, 2012 on 335 teachers. Stratified simple random sampling technique was used and data were collected using structured interviewer administered questionnaire. Binary and multiple logistic regressions were used to estimate the crude and adjusted odds ratios for willingness to pay. Results Three hundred twenty-eight teachers participated in the study with response rate of 98%. About 55% of the teachers had never heard of any type of health insurance scheme. However, 74.4% of them were willing to pay for the suggested insurance scheme. About 47% of those who were willing to pay agreed to contribute greater than or equal to 4% of their monthly salaries. Willingness to pay was more likely among those who had heard about health insurance, had previous history of inability to pay for medical bills and achieved higher educational status. Conclusion The majority of the teachers were willing to join social health insurance; however, adequate awareness creation and discussion should be made with all employees at various levels for the successful implementation of the scheme.
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Affiliation(s)
| | - Mirkuzie Woldie
- Department of Health Services Management, Jimma University, Ethiopia
| | - Shimeles Ololo
- Department of Health Services Management, Jimma University, Ethiopia
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Panda P, Chakraborty A, Dror DM. Building awareness to health insurance among the target population of community-based health insurance schemes in rural India. Trop Med Int Health 2015; 20:1093-107. [DOI: 10.1111/tmi.12524] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
| | | | - David M. Dror
- Micro Insurance Academy; New Delhi India
- Erasmus University Rotterdam; Rotterdam The Netherlands
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Makhloufi K, Ventelou B, Abu-Zaineh M. Have health insurance reforms in Tunisia attained their intended objectives? INTERNATIONAL JOURNAL OF HEALTH ECONOMICS AND MANAGEMENT 2015; 15:29-51. [PMID: 27878666 DOI: 10.1007/s10754-014-9157-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2013] [Accepted: 11/24/2014] [Indexed: 06/06/2023]
Abstract
A growing number of developing countries are currently promoting health system reforms with the aim of attaining ' universal health coverage' (UHC). In Tunisia, several reforms have been undertaken over the last two decades to attain UHC with the goals of ensuring financial protection in health and enhancing access to healthcare. The first of these goals has recently been addressed in a companion paper by Abu-Zaineh et al. (Int J Health Care Financ Econ 13(1):73-93, 2013). The present paper seeks to assess whether these reforms have in fact enhanced access to healthcare. The average treatment effects of two insurance schemes, formal-mandatory (MHI) and state-subsidized (MAS) insurance, on the utilization of outpatient and inpatient healthcare are estimated using propensity score matching. Results support the hypothesis that both schemes (MHI and MAS) increase the utilization of healthcare. However, significant variations in the average effect of these schemes are observed across services and areas. For all the matching methods used and compared with those the excluded from cover, the increase in outpatient and inpatient services for the MHI enrollees was at least 19 and 26 %, respectively, in urban areas, while for MAS beneficiaries this increase was even more pronounced (28 and 75 % in the urban areas compared with 27 and 46 % in the rural areas for outpatient and inpatient services, respectively). One important conclusion that emerges is that the current health insurance schemes, despite improving accessibility to healthcare services, are nevertheless incapable of achieving effective coverage of the whole population for all services. Attaining the latter goal requires a strategy that targets the "trees" not the "forest".
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Affiliation(s)
- Khaled Makhloufi
- INSERM-IRD-UMR 912 (SESSTIM), Aix-Marseille University, 13006, Marseille, France
| | - Bruno Ventelou
- French National Center for Scientific Research, Research Group in Quantitative Economics of Aix-Marseille (CNRS-GREQAM-IDEP), INSERM-IRD-UMR 912 (SESSTIM), Aix-Marseille School of Economics (AMSE), 13006, Marseille, France
| | - Mohammad Abu-Zaineh
- INSERM-IRD-UMR 912 (SESSTIM), Faculty of Medicine and Aix-Marseille School of Economics (AMSE), Aix-Marseille University, 13006, Marseille, France.
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Savadogo G, Souarès A, Sié A, Parmar D, Bibeau G, Sauerborn R. Using a community-based definition of poverty for targeting poor households for premium subsidies in the context of a community health insurance in Burkina Faso. BMC Public Health 2015; 15:84. [PMID: 25884874 PMCID: PMC4337311 DOI: 10.1186/s12889-014-1335-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 12/22/2014] [Indexed: 11/23/2022] Open
Abstract
Background One of the biggest challenges in subsidizing premiums of poor households for community health insurance is the identification and selection of these households. Generally, poverty assessments in developing countries are based on monetary terms. The household is regarded as poor if its income or consumption is lower than a predefined poverty cut-off. These measures fail to recognize the multi-dimensional character of poverty, ignoring community members’ perception and understanding of poverty, leaving them voiceless and powerless in the identification process. Realizing this, the steering committee of Nouna’s health insurance devised a method to involve community members to better define ‘perceived’ poverty, using this as a key element for the poor selection. The community-identified poor were then used to effectively target premium subsidies for the insurance scheme. Methods The study was conducted in the Nouna’s Health District located in northwest Burkina Faso. Participants in each village were selected to take part in focus-group discussions (FGD) organized in 41 villages and 7 sectors of Nouna’s town to discuss criteria and perceptions of poverty. The discussions were audio recorded, transcribed and analyzed in French using the software NVivo 9. Results From the FGD on poverty and the subjective definitions and perceptions of the community members, we found that poverty was mainly seen as scarcity of basic needs, vulnerability, deprivation of capacities, powerlessness, voicelessness, indecent living conditions, and absence of social capital and community networks for support in times of need. Criteria and poverty groups as described by community members can be used to identify poor who can then be targeted for subsidies. Conclusion Policies targeting the poorest require the establishment of effective selection strategies. These policies are well-conditioned by proper identification of the poor people. Community perceptions and criteria of poverty are grounded in reality, to better appreciate the issue. It is crucial to take these perceptions into account in undertaking community development actions which target the poor. For most community-based health insurance schemes with limited financial resources, using a community-based definition of poverty in the targeting of the poorest might be a less costly alternative. Electronic supplementary material The online version of this article (doi:10.1186/s12889-014-1335-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Germain Savadogo
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso. .,Institute of Public Health, University of Heidelberg, INF 324 69120, Heidelberg, Germany.
| | - Aurelia Souarès
- Institute of Public Health, University of Heidelberg, INF 324 69120, Heidelberg, Germany.
| | - Ali Sié
- Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso.
| | - Divya Parmar
- School of Health Sciences, City University, London, UK.
| | - Gilles Bibeau
- Department of Anthropology, University of Montreal, Montreal, Canada.
| | - Rainer Sauerborn
- Institute of Public Health, University of Heidelberg, INF 324 69120, Heidelberg, Germany.
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Boidin B. [Extension of health coverage and community based health insurance schemes in Africa: Myths and realities]. BULLETIN DE LA SOCIETE DE PATHOLOGIE EXOTIQUE (1990) 2015; 108:63-9. [PMID: 24827877 DOI: 10.1007/s13149-014-0364-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Accepted: 03/25/2014] [Indexed: 11/30/2022]
Abstract
This article tackles the perspectives and limits of the extension of health coverage based on community based health insurance schemes in Africa. Despite their strong potential contribution to the extension of health coverage, their weaknesses challenge their ability to play an important role in this extension. Three limits are distinguished: financial fragility; insufficient adaptation to characteristics and needs of poor people; organizational and institutional failures. Therefore lessons can be learnt from the limits of the institutionalization of community based health insurance schemes. At first, community based health insurance schemes are to be considered as a transitional but insufficient solution. There is also a stronger role to be played by public actors in improving financial support, strengthening health services and coordinating coverage programs.
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Affiliation(s)
- B Boidin
- Centre lillois d'études et de recherches sociologiques et économiques, UMR, 8019, Faculté des sciences économiques et sociales, Université Lille 1, GISPE (groupe d'intervention en santé publique et épidémiologie), Lille, France.
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Kusi A, Enemark U, Hansen KS, Asante FA. Refusal to enrol in Ghana's National Health Insurance Scheme: is affordability the problem? Int J Equity Health 2015; 14:2. [PMID: 25595036 PMCID: PMC4300159 DOI: 10.1186/s12939-014-0130-2] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2014] [Accepted: 12/10/2014] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Access to health insurance is expected to have positive effect in improving access to healthcare and offer financial risk protection to households. Ghana began the implementation of a National Health Insurance Scheme (NHIS) in 2004 as a way to ensure equitable access to basic healthcare for all residents. After a decade of its implementation, national coverage is just about 34% of the national population. Affordability of the NHIS contribution is often cited by households as a major barrier to enrolment in the NHIS without any rigorous analysis of this claim. In light of the global interest in achieving universal health insurance coverage, this study seeks to examine the extent to which affordability of the NHIS contribution is a barrier to full insurance for households and a burden on their resources. METHODS The study uses data from a cross-sectional household survey involving 2,430 households from three districts in Ghana conducted between January-April, 2011. Affordability of the NHIS contribution is analysed using the household budget-based approach based on the normative definition of affordability. The burden of the NHIS contributions to households is assessed by relating the expected annual NHIS contribution to household non-food expenditure and total consumption expenditure. Households which cannot afford full insurance were identified. RESULTS Results show that 66% of uninsured households and 70% of partially insured households could afford full insurance for their members. Enroling all household members in the NHIS would account for 5.9% of household non-food expenditure or 2.0% of total expenditure but higher for households in the first (11.4%) and second (7.0%) socio-economic quintiles. All the households (29%) identified as unable to afford full insurance were in the two lower socio-economic quintiles and had large household sizes. Non-financial factors relating to attributes of the insurer and health system problems also affect enrolment in the NHIS. CONCLUSION Affordability of full insurance would be a burden on households with low socio-economic status and large household size. Innovative measures are needed to encourage abled households to enrol. Policy should aim at abolishing the registration fee for children, pricing insurance according to socio-economic status of households and addressing the inimical non-financial factors to increase NHIS coverage.
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Affiliation(s)
- Anthony Kusi
- Section for Health Promotion and Health Services Research, Department of Public Health, Faculty of Health, Aarhus University, Vennelyst Boulevard 6, 8000, Arhus C, Denmark.
- Institute of Statistical, Social and Economic Research (ISSER), University of Ghana, P.O. Box LG 74, Legon, Accra, Ghana.
| | - Ulrika Enemark
- Section for Health Promotion and Health Services Research, Department of Public Health, Faculty of Health, Aarhus University, Vennelyst Boulevard 6, 8000, Arhus C, Denmark.
| | - Kristian S Hansen
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, WC1H 9SH, London, UK.
| | - Felix A Asante
- Institute of Statistical, Social and Economic Research (ISSER), University of Ghana, P.O. Box LG 74, Legon, Accra, Ghana.
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Atinga RA, Abiiro GA, Kuganab-Lem RB. Factors influencing the decision to drop out of health insurance enrolment among urban slum dwellers in Ghana. Trop Med Int Health 2014; 20:312-21. [DOI: 10.1111/tmi.12433] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Roger A. Atinga
- Department of Public Administration and Health Services Management; University of Ghana Business School; Legon, Accra Ghana
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Macha J, Kuwawenaruwa A, Makawia S, Mtei G, Borghi J. Determinants of community health fund membership in Tanzania: a mixed methods analysis. BMC Health Serv Res 2014; 14:538. [PMID: 25411021 PMCID: PMC4246628 DOI: 10.1186/s12913-014-0538-9] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Accepted: 10/20/2014] [Indexed: 11/29/2022] Open
Abstract
Background In many developing countries, initiatives are underway to strengthen voluntary community based health insurance as a means of expanding access to affordable care among the informal sector. However, increasing coverage with voluntary health insurance in low income settings can prove challenging. There are limited studies on determinants of enrolling in these schemes using mixed methods. This study aims to shed light on the characteristics of those joining a community health fund, a type of community based health insurance, in Tanzania and the reasons for their membership and subsequent drop out using mixed methods. Methods A cross sectional survey of households in four rural districts was conducted in 2008, covering a total of 1,225 (524 members of CHF and 701 non-insured) households and 7,959 individuals. In addition, 12 focus group discussions were carried out with CHF members, non-scheme members and members of health facility governing committees in two rural districts. Logistic regression was used to assess the determinants of CHF membership while thematic analysis was done to analyse qualitative data. Results The quantitative analysis revealed that the three middle income quintiles were more likely to enrol in the CHF than the poorest and the richest. CHF member households were more likely to be large, and headed by a male than uninsured households from the same areas. The qualitative data supported the finding that the poor rather than the poorest were more likely to join as were large families and of greater risk of illness, with disabilities or persons with chronic diseases. Households with elderly members or children under-five years were also more likely to enrol. Poor understanding of risk pooling deterred people from joining the scheme and was the main reason for not renewing membership. On the supply side, poor quality of public care services, the limited benefit package and a lack of provider choice were the main factors for low enrolment. Conclusions Determinants of CHF membership are diverse and improving the quality of health services and expanding the benefit package should be prioritised to expand voluntary health insurance coverage.
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Affiliation(s)
- Jane Macha
- Ifakara Health Institute, P.O BOX 78373, Plot 463, Kiko Ave., Mikocheni, Dar es Salaam, Tanzania.
| | - August Kuwawenaruwa
- Ifakara Health Institute, P.O BOX 78373, Plot 463, Kiko Ave., Mikocheni, Dar es Salaam, Tanzania.
| | - Suzan Makawia
- Ifakara Health Institute, P.O BOX 78373, Plot 463, Kiko Ave., Mikocheni, Dar es Salaam, Tanzania.
| | - Gemini Mtei
- Ifakara Health Institute, P.O BOX 78373, Plot 463, Kiko Ave., Mikocheni, Dar es Salaam, Tanzania.
| | - Josephine Borghi
- Ifakara Health Institute, P.O BOX 78373, Plot 463, Kiko Ave., Mikocheni, Dar es Salaam, Tanzania. .,London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.
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Abiiro GA, Torbica A, Kwalamasa K, De Allegri M. Eliciting community preferences for complementary micro health insurance: a discrete choice experiment in rural Malawi. Soc Sci Med 2014; 120:160-8. [PMID: 25243642 DOI: 10.1016/j.socscimed.2014.09.021] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 08/23/2014] [Accepted: 09/09/2014] [Indexed: 10/24/2022]
Abstract
There is a limited understanding of preferences for micro health insurance (MHI) as a strategy for moving towards universal health coverage. Using a discrete choice experiment (DCE), we explored community preferences for the attributes and attribute-levels of a prospective MHI scheme, aimed at filling health coverage gaps in Malawi. Through a qualitative study informed by a literature review, we identified six MHI attributes (and attribute-levels): unit of enrollment, management structure, health service benefit package, copayment levels, transportation coverage, and monthly premium per person. Qualitative data was collected from 12 focus group discussions and 8 interviews in August-September, 2012. We constructed a D-efficient design of eighteen choice-sets, each comprising two MHI choice alternatives and an opt-out. Using pictorial images, trained interviewers administered the DCE in March-May, 2013, to 814 household heads and/or their spouse(s) in two rural districts. We estimated preferences for attribute-levels and relative importance of attributes using conditional and nested logit models. The results showed that all attribute-levels except management by external NGO significantly influenced respondents' choice behavior (P<0.05). These included: enrollment as core nuclear family (odds ratio (OR)=1.1574), extended family (OR=1.1132), compared to individual; management by community committee (OR=0.9494) compared to local micro finance institution; comprehensive health service package (OR=1.4621), medium service package (OR=1.2761), compared to basic service package; no copayment (OR=1.1347), 25% copayment (OR=1.1090), compared to 50% copayment; coverage of all transport (OR=1.5841), referral and emergency transport (OR=1.2610), compared to no transport; and premium (OR=0.9994). The relative importance of attributes is ordered as: transport, health services benefits, enrollment unit, premium, copayment, and management. To maximize consumer utility and encourage community acceptance of MHI, potential MHI schemes should cover transport costs, offer a comprehensive benefit package, define the core family as the unit of enrollment, avoid high copayments, and be managed by a competent financial institution.
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Affiliation(s)
- Gilbert Abotisem Abiiro
- Institute of Public Health, Medical Faculty, University of Heidelberg, Heidelberg, Germany; Department of Planning and Management, University for Development Studies, Wa, Ghana.
| | - Aleksandra Torbica
- Centre for Research on Health and Social Care Management - CERGAS, Department of Policy Analysis and Public Management, Bocconi University, Italy
| | - Kassim Kwalamasa
- Research for Equity and Community Health Trust (REACH Trust), Malawi
| | - Manuela De Allegri
- Institute of Public Health, Medical Faculty, University of Heidelberg, Heidelberg, Germany
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Fenny AP, Enemark U, Asante FA, Hansen KS. Patient satisfaction with primary health care - a comparison between the insured and non-insured under the National Health Insurance Policy in Ghana. Glob J Health Sci 2014; 6:9-21. [PMID: 24999137 PMCID: PMC4825362 DOI: 10.5539/gjhs.v6n4p9] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Accepted: 02/17/2014] [Indexed: 11/25/2022] Open
Abstract
Ghana has initiated various health sector reforms over the past decades aimed at strengthening institutions, improving the overall health system and increasing access to healthcare services by all groups of people. The National Health Insurance Scheme (NHIS) instituted in 2005, is an innovative system aimed at making health care more accessible to people who need it. Currently, there is a growing amount of concern about the capacity of the NHIS to make quality health care accessible to its clients. A number of studies have concentrated on the effect of health insurance status on demand for health services, but have been quiet on supply side issues. The main aim of this study is to examine the overall satisfaction with health care among the insured and uninsured under the NHIS. The second aim is to explore the relations between overall satisfaction and socio-demographic characteristics, health insurance and the various dimensions of quality of care. This study employs logistic regression using household survey data in three districts in Ghana covering the 3 ecological zones (coastal, forest and savannah). It identifies the service quality factors that are important to patients' satisfaction and examines their links to their health insurance status. The results indicate that a higher proportion of insured patients are satisfied with the overall quality of care compared to the uninsured. The key predictors of overall satisfaction are waiting time, friendliness of staff and satisfaction of the consultation process. These results highlight the importance of interpersonal care in health care facilities. Feedback from patients' perception of health services and satisfaction surveys improve the quality of care provided and therefore effort must be made to include these findings in future health policies.
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Affiliation(s)
- Ama Pokuaa Fenny
- Institut for Folkesundhed, Aarhus University, Århus C, Denmark; Economics Division, ISSER, University of Ghana, Accra, Ghana.
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Mladovsky P. Why do people drop out of community-based health insurance? Findings from an exploratory household survey in Senegal. Soc Sci Med 2014; 107:78-88. [DOI: 10.1016/j.socscimed.2014.02.008] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Revised: 01/31/2014] [Accepted: 02/11/2014] [Indexed: 10/25/2022]
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Kimani JK, Ettarh R, Warren C, Bellows B. Determinants of health insurance ownership among women in Kenya: evidence from the 2008-09 Kenya demographic and health survey. Int J Equity Health 2014; 13:27. [PMID: 24678655 PMCID: PMC3973618 DOI: 10.1186/1475-9276-13-27] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 03/25/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Government of Kenya is making plans to implement a social health insurance program by transforming the National Hospital Insurance Fund (NHIF) into a universal health coverage program. The objective of this study was to examine the determinants associated with health insurance ownership among women in Kenya. METHODS Data came from the 2008-09 Kenya Demographic and Health Survey, a nationally representative survey. The sample comprised 8,435 women aged 15-49 years. Descriptive statistics and multivariable logistic regression analysis were used to describe the characteristics of the sample and to identify factors associated with health insurance ownership. RESULTS Being employed in the formal sector, being married, exposure to the mass media, having secondary education or higher, residing in households in the middle or rich wealth index categories and residing in a female-headed household were associated with having health insurance. However, region of residence was associated with a lower likelihood of having insurance coverage. Women residing in Central (OR = 0.4; p < 0.01) and North Eastern (OR = 0.1; p < 0.5) provinces were less likely to be insured compared to their counterparts in Nairobi province. CONCLUSIONS As the Kenyan government transforms the NHIF into a universal health program, it is important to implement a program that will increase equity and access to health care services among the poor and vulnerable groups.
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Affiliation(s)
- James K Kimani
- Population Council, General Accident Insurance House, Ralph Bunche Road, P,O, Box 17643-00500, Nairobi, Kenya.
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Odeyemi IAO. Community-based health insurance programmes and the National Health Insurance Scheme of Nigeria: challenges to uptake and integration. Int J Equity Health 2014; 13:20. [PMID: 24559409 PMCID: PMC3941795 DOI: 10.1186/1475-9276-13-20] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Accepted: 02/07/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Nigeria has included a regulated community-based health insurance (CBHI) model within its National Health Insurance Scheme (NHIS). Uptake to date has been disappointing, however. The aim of this study is to review the present status of CBHI in SSA in general to highlight the issues that affect its successful integration within the NHIS of Nigeria and more widely in developing countries. METHODS A literature survey using PubMed and EconLit was carried out to identify and review studies that report factors affecting implementation of CBHI in SSA with a focus on Nigeria. RESULTS CBHI schemes with a variety of designs have been introduced across SSA but with generally disappointing results so far. Two exceptions are Ghana and Rwanda, both of which have introduced schemes with effective government control and support coupled with intensive implementation programmes. Poor support for CBHI is repeatedly linked elsewhere with failure to engage and account for the 'real world' needs of beneficiaries, lack of clear legislative and regulatory frameworks, inadequate financial support, and unrealistic enrolment requirements. Nigeria's CBHI-type schemes for the informal sectors of its NHIS have been set up under an appropriate legislative framework, but work is needed to eliminate regressive financing, to involve scheme members in the setting up and management of programmes, to inform and educate more effectively, to eliminate lack of confidence in the schemes, and to address inequity in provision. Targeted subsidies should also be considered. CONCLUSIONS Disappointing uptake of CBHI-type NHIS elements in Nigeria can be addressed through closer integration of informal and formal programmes under the NHIS umbrella, with increasing involvement of beneficiaries in scheme design and management, improved communication and education, and targeted financial assistance.
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Affiliation(s)
- Isaac A O Odeyemi
- Health Economics & Outcomes Research, Astellas Pharma Europe Ltd, 2000 Hillswood Drive, Chertsey KT16 0RS, UK.
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Robyn PJ, Bärnighausen T, Souares A, Traoré A, Bicaba B, Sié A, Sauerborn R. Provider payment methods and health worker motivation in community-based health insurance: a mixed-methods study. Soc Sci Med 2014; 108:223-36. [PMID: 24681326 DOI: 10.1016/j.socscimed.2014.01.034] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Revised: 01/16/2014] [Accepted: 01/22/2014] [Indexed: 10/25/2022]
Abstract
In a community-based health insurance (CBHI) introduced in 2004 in Nouna health district, Burkina Faso, poor perceived quality of care by CBHI enrollees has been a key factor in observed high drop-out rates. The poor quality perceptions have been previously attributed to health worker dissatisfaction with the provider payment method used by the scheme and the resulting financial risk of health centers. This study applied a mixed-methods approach to investigate how health workers working in facilities contracted by the CBHI view the methods of provider payment used by the CBHI. In order to analyze these relationships, we conducted 23 in-depth interviews and a quantitative survey with 98 health workers working in the CBHI intervention zone. The qualitative in-depth interviews identified that insufficient levels of capitation payments, the infrequent schedule of capitation payment, and lack of a payment mechanism for reimbursing service fees were perceived as significant sources of health worker dissatisfaction and loss of work-related motivation. Combining qualitative interview and quantitative survey data in a mixed-methods analysis, this study identified that the declining quality of care due to the CBHI provider payment method was a source of significant professional stress and role strain for health workers. Health workers felt that the following five changes due to the provider payment methods introduced by the CBHI impeded their ability to fulfill professional roles and responsibilities: (i) increased financial volatility of health facilities, (ii) dissatisfaction with eligible costs to be covered by capitation; (iii) increased pharmacy stock-outs; (iv) limited financial and material support from the CBHI; and (v) the lack of mechanisms to increase provider motivation to support the CBHI. To address these challenges and improve CBHI uptake and health outcomes in the targeted populations, the health care financing and delivery model in the study zone should be reformed. We discuss concrete options for reform based on the study findings.
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Affiliation(s)
- Paul Jacob Robyn
- University of Heidelberg, Institute of Public Health, Germany; The World Bank, Washington, DC, USA.
| | - Till Bärnighausen
- Harvard School of Public Health, Department of Global Health and Population, USA; Africa Centre for Health and Population Studies, University of KwaZulu-Natal, South Africa
| | - Aurélia Souares
- University of Heidelberg, Institute of Public Health, Germany
| | - Adama Traoré
- Nouna Health Research Centre, Ministry of Health, Burkina Faso
| | - Brice Bicaba
- Nouna Health Research Centre, Ministry of Health, Burkina Faso; Nouna Health District, Ministry of Health, Burkina Faso
| | - Ali Sié
- Nouna Health Research Centre, Ministry of Health, Burkina Faso
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Zöllner C, De Allegri M, Louis VR, Yé M, Sié A, Tiendrebéogo J, Jahn A, Müller O. Insecticide-treated mosquito nets in rural Burkina Faso: assessment of coverage and equity in the wake of a universal distribution campaign. Health Policy Plan 2014; 30:171-80. [PMID: 24463333 DOI: 10.1093/heapol/czt108] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Insecticide-treated mosquito nets (ITNs) are an essential tool of the Roll Back Malaria strategy. An increasing number of African countries have embarked on mass distribution campaigns of long-lasting insecticide-treated nets (LLINs) with the ultimate goal of universal coverage. Such a national campaign with the goal of one ITN for every two people has been conducted in Burkina Faso in 2010. Our aim was to assess the coverage and equity effect of the universal distribution campaign of LLINs in Burkina Faso and to identify determinants of ITN ownership across households after the campaign. We evaluated its effects through comparison of data from two household surveys conducted in early 2010 (before the campaign) and early 2011 (after the campaign) on a representative rural district in north-western Burkina Faso. Data were collected on household characteristics (including socio-economic status) and ITN ownership. We used concentration curves and indices to compare ITN coverage indicators before and after the campaign and multilevel multivariate logistic regression to estimate factors associated with achievement of the universal coverage target in 2011. The survey included 1106 households in 2010 and 1094 in 2011. We found that the proportion of households with at least one ITN increased from 59% before the campaign to 99% afterwards, whereas the concentration index dropped from 0.087 (standard error (SE): 0.014) to 0.002 (SE: 0.002). Fifty-two per cent of households reached the target of one ITN for every two people per household, with the relevant concentration index at -0.031 (SE: 0.016). Eighty-six per cent of households owned at least one ITN for every three people. The main characteristics significantly associated with the targeted intra-household coverage were family size and distance to the health centre but not socio-economic status. In conclusion, despite not having fully met its target, the national LLIN campaign achieved a high level of coverage and fostered equity.
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Affiliation(s)
- Caroline Zöllner
- Institute of Public Health, University of Heidelberg, INF 324, 69120 Heidelberg, Germany and Centre de Recherche en Santé de Nouna, BP 02, Nouna, Burkina Faso
| | - Manuela De Allegri
- Institute of Public Health, University of Heidelberg, INF 324, 69120 Heidelberg, Germany and Centre de Recherche en Santé de Nouna, BP 02, Nouna, Burkina Faso
| | - Valérie R Louis
- Institute of Public Health, University of Heidelberg, INF 324, 69120 Heidelberg, Germany and Centre de Recherche en Santé de Nouna, BP 02, Nouna, Burkina Faso
| | - Maurice Yé
- Institute of Public Health, University of Heidelberg, INF 324, 69120 Heidelberg, Germany and Centre de Recherche en Santé de Nouna, BP 02, Nouna, Burkina Faso
| | - Ali Sié
- Institute of Public Health, University of Heidelberg, INF 324, 69120 Heidelberg, Germany and Centre de Recherche en Santé de Nouna, BP 02, Nouna, Burkina Faso
| | - Justin Tiendrebéogo
- Institute of Public Health, University of Heidelberg, INF 324, 69120 Heidelberg, Germany and Centre de Recherche en Santé de Nouna, BP 02, Nouna, Burkina Faso
| | - Albrecht Jahn
- Institute of Public Health, University of Heidelberg, INF 324, 69120 Heidelberg, Germany and Centre de Recherche en Santé de Nouna, BP 02, Nouna, Burkina Faso
| | - Olaf Müller
- Institute of Public Health, University of Heidelberg, INF 324, 69120 Heidelberg, Germany and Centre de Recherche en Santé de Nouna, BP 02, Nouna, Burkina Faso
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Ridde V, Belaid L, Mallé Samb O, Faye A. Les modalités de collecte du financement de la santé au Burkina Faso de 1980 à 2012. SANTÉ PUBLIQUE 2014. [DOI: 10.3917/spub.145.0715] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Cofie P, De Allegri M, Kouyaté B, Sauerborn R. Effects of information, education, and communication campaign on a community-based health insurance scheme in Burkina Faso. Glob Health Action 2013; 6:20791. [PMID: 24314344 PMCID: PMC3856340 DOI: 10.3402/gha.v6i0.20791] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Revised: 10/31/2013] [Accepted: 11/05/2013] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE The study analysed the effect of Information, Education, and Communication (IEC) campaign activities on the adoption of a community-based health insurance (CHI) scheme in Nouna, Burkina Faso. It also identified the factors that enhanced or limited the campaign's effectiveness. DESIGN Complementary data collection approaches were used. A survey was conducted with 250 randomly selected household heads, followed by in-depth interviews with 22 purposively selected community leaders, group discussions with the project management team, and field observations. Bivariate analysis and multivariate logistic regression models were used to assess the association between household exposure to campaign and acquisition of knowledge as well as household exposure to campaign and enrolment. RESULTS The IEC campaign had a positive effect on households' knowledge about the CHI and to a lesser extent on household enrolment in the scheme. The effectiveness of the IEC strategy was mainly influenced by: (1) frequent and consistent IEC messages from multiple media channels (mass and interpersonal channels), including the radio, a mobile information van, and CHI team, and (2) community heads' participation in the CHI scheme promotion. Education was the only significantly influential socio-demographic determinant of knowledge and enrolment among household heads. The relatively low effects of the IEC campaign on CHI enrolment are indicative of other important IEC mediating factors, which should be taken into account in future CHI campaign evaluation. CONCLUSION The study concludes that an IEC campaign is crucial to improving the understanding of the CHI scheme concept, which is an enabler to enrolment, and should be integrated into scheme designs and evaluations.
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Fink G, Robyn PJ, Sié A, Sauerborn R. Does health insurance improve health?: Evidence from a randomized community-based insurance rollout in rural Burkina Faso. JOURNAL OF HEALTH ECONOMICS 2013; 32:1043-56. [PMID: 24103498 DOI: 10.1016/j.jhealeco.2013.08.003] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Revised: 07/23/2013] [Accepted: 08/14/2013] [Indexed: 05/17/2023]
Abstract
From 2004 to 2006, a community-based health insurance (CBI) scheme was rolled out in Nouna District, Burkina Faso, with the objective of improving access to health services and population health. We explore the random timing of the insurance rollout generated by the stepped wedge cluster-randomized design to evaluate the welfare and health impact of the insurance program. Our results suggest that the insurance had limited effects on average out-of-pocket expenditures in the target areas, but substantially reduced the likelihood of catastrophic health expenditure. The introduction of the insurance scheme did not have any effect on health outcomes for children and young adults, but appears to have increased mortality among individuals aged 65 and older. The negative health effects of the program appear to be primarily driven by the adverse provider incentives generated by the scheme and the resulting decline in the quality of care received by patients.
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