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Sendekie AK, Gebremichael AH, Tadesse MW. Enrollment and clients' satisfaction with a community-based health insurance scheme: a community-based survey in Northwest Ethiopia. BMC Health Serv Res 2024; 24:70. [PMID: 38218770 PMCID: PMC10787395 DOI: 10.1186/s12913-024-10570-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 01/05/2024] [Indexed: 01/15/2024] Open
Abstract
BACKGROUND Although the Ethiopian government has implemented a community-based health insurance (CBHI) program, community enrollment and clients' satisfaction have not been well investigated in Gondar Zuria district, Northwest Ethiopia. This study assessed CBHI scheme enrollment, clients' satisfaction, and associated factors among households in the district. METHODS A community-based cross-sectional survey assessed CBHI scheme enrollment and clients' satisfaction among households in Gondar Zuria district, Northwest Ethiopia, from May to June 2022. A systematic random sampling method was used to select the study participants from eligible households. A home-to-home interview using a structured questionnaire was conducted. Data were analysed using the statistical packages for social sciences version 26. Logistic regression was used to identify variables associated with enrollment and clients' satisfaction. A p-value < 0.05 was considered statistically significant. RESULTS Out of 410 participants, around two-thirds (64.9%) of the participants were enrolled in the CBHI scheme. Residency status (AOR = 1.38, 95% CI: 1.02-5.32; p = 0.038), time taken to reach a health facility (AOR = 1.01, 95% CI: 1.00-1.02; p = 0.001), and household size (AOR = 0.77, 95% CI: 0.67-0.88; p < 0.001) were significantly associated with CBHI scheme enrollment. Two-thirds (66.5%) of enrolled households were dissatisfied with the overall services provided; in particular, higher proportions were dissatisfied with the availability of medication and laboratory tests (88.7%). Household size (AOR = 1.31, 95% CI: 1.01-2.24; p = 0.043) and waiting time to get healthcare services (AOR = 3.14, 95% CI: 1.01-9.97; p = 0.047) were predictors of clients' satisfaction with the CBHI scheme services. CONCLUSION Although a promisingly high proportion of households were enrolled in the CBHI scheme, most of them were dissatisfied with the service. Improving waiting times to get health services, improving the availability of medications and laboratory tests, and other factors should be encouraged.
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Affiliation(s)
- Ashenafi Kibret Sendekie
- Departement of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Ayenew Hailu Gebremichael
- Department of Sociology, School of Sociology and Social Work, College of Social Sciences and the Humanities, University of Gondar, Gondar, Ethiopia
| | - Melkamu Workie Tadesse
- School of Economics, College of Business and Economics, University of Gondar, Gondar, Ethiopia.
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Kagaigai A, Anaeli A, Grepperud S, Mori AT. Healthcare utilization and catastrophic health expenditure in rural Tanzania: does voluntary health insurance matter? BMC Public Health 2023; 23:1567. [PMID: 37592242 PMCID: PMC10436390 DOI: 10.1186/s12889-023-16509-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 08/10/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND Over 150 million people, mostly from low and middle-income countries (LMICs) suffer from catastrophic health expenditure (CHE) every year because of high out-of-pocket (OOP) payments. In Tanzania, OOP payments account for about a quarter of the total health expenditure. This paper compares healthcare utilization and the incidence of CHE among improved Community Health Fund (iCHF) members and non-members in central Tanzania. METHODS A survey was conducted in 722 households in Bahi and Chamwino districts in Dodoma region. CHE was defined as a household health expenditure exceeding 40% of total non-food expenditure (capacity to pay). Concentration index (CI) and logistic regression were used to assess the socioeconomic inequalities in the distribution of healthcare utilization and the association between CHE and iCHF enrollment status, respectively. RESULTS 50% of the members and 29% of the non-members utilized outpatient care in the previous month, while 19% (members) and 15% (non-members) utilized inpatient care in the previous twelve months. The degree of inequality for utilization of inpatient care was higher (insured, CI = 0.38; noninsured CI = 0.29) than for outpatient care (insured, CI = 0.09; noninsured CI = 0.16). Overall, 15% of the households experienced CHE, however, when disaggregated by enrollment status, the incidence of CHE was 13% and 15% among members and non-members, respectively. The odds of iCHF-members incurring CHE were 0.4 times less compared to non-members (OR = 0.41, 95%CI: 0.27-0.63). The key determinants of CHE were iCHF enrollment status, health status, socioeconomic status, chronic illness, and the utilization of inpatient and outpatient care. CONCLUSION The utilization of healthcare services was higher while the incidence of CHE was lower among households enrolled in the iCHF insurance scheme relative to those not enrolled. More studies are needed to establish the reasons for the relatively high incidence of CHE among iCHF members and the low degree of healthcare utilization among households with low socioeconomic status.
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Affiliation(s)
- Alphoncina Kagaigai
- Institute of Health and Society, University of Oslo, P.O. Box 0315, Oslo, Norway.
- School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, P.O. Box 65001, Dar Es Salaam, Tanzania.
| | - Amani Anaeli
- School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, P.O. Box 65001, Dar Es Salaam, Tanzania
| | - Sverre Grepperud
- Institute of Health and Society, University of Oslo, P.O. Box 0315, Oslo, Norway
| | - Amani Thomas Mori
- School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, P.O. Box 65001, Dar Es Salaam, Tanzania
- Department of Global Health and Primary Health Care, University of Bergen, P.O. Box 5007, Bergen, Norway
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Kangwagye P, Bright LW, Atukunda G, Basaza R, Bajunirwe F. Utilization of health insurance by patients with diabetes or hypertension in urban hospitals in Mbarara, Uganda. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0000501. [PMID: 37315042 DOI: 10.1371/journal.pgph.0000501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 05/18/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND Diabetes and hypertension are among the leading contributors to global mortality and require life-long medical care. However, many patients cannot access quality healthcare due to high out-of-pocket expenditures, thus health insurance would help provide relief. This paper examines factors associated with utilization of health insurance by patients with diabetes or hypertension at two urban hospitals in Mbarara, southwestern Uganda. METHODS We used a cross-sectional survey design to collect data from patients with diabetes or hypertension attending two hospitals located in Mbarara. Logistic regression models were used to examine associations between demographic factors, socio-economic factors and awareness of scheme existence and health insurance utilization. RESULTS We enrolled 370 participants, 235 (63.5%) females and 135 (36.5%) males, with diabetes or hypertension. Patients who were not members of a microfinance scheme were 76% less likely to enrol in a health insurance scheme (OR = 0.34, 95% CI: 0.15-0.78, p = 0.011). Patients diagnosed with diabetes/hypertension 5-9 years ago were more likely to enrol in a health insurance scheme (OR = 2.99, 95% CI: 1.14-7.87, p = 0.026) compared to those diagnosed 0-4 years ago. Patients who were not aware of the existing schemes in their areas were 99% less likely to take up health insurance (OR = 0.01, 95% CI: 0.0-0.02, p < 0.001) compared to those who knew about health insurance schemes operating in the study area. Majority of respondents expressed willingness to join the proposed national health insurance scheme although concerns were raised about high premiums and misuse of funds which may negatively impact decisions to enrol. CONCLUSION Belonging to a microfinance scheme positively influences enrolment by patients with diabetes or hypertension in a health insurance program. Although a small proportion is currently enrolled in health insurance, the vast majority expressed willingness to enrol in the proposed national health insurance scheme. Microfinance schemes could be used as an entry point for health insurance programs for patients in these settings.
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Affiliation(s)
- Peter Kangwagye
- Department of Public Health, Bishop Stuart University, Mbarara, Uganda
- Department of Internal Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Gershom Atukunda
- Department of Public Health, Bishop Stuart University, Mbarara, Uganda
| | - Robert Basaza
- Department of Public Health, Leadership Program, Uganda Christian University, Kampala, Uganda
| | - Francis Bajunirwe
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
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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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Quartey T, Peprah C, Morgan AK. Determinants of national health insurance enrolment among people at risk of statelessness in the Awutu Senya East Municipality and Gomoa East District of Ghana. BMC Health Serv Res 2023; 23:153. [PMID: 36788530 PMCID: PMC9927045 DOI: 10.1186/s12913-022-08738-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 10/25/2022] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND This paper investigates the factors influencing the decision to enrol in Ghana's National Health Insurance Scheme (NHIS) among people at risk of statelessness, with emphasis on the individual's demographic and socioeconomic factors. METHODS: The study used data from a cross-sectional household survey undertaken in the Awutu Senya East Municipality and Gomoa East District of Ghana's Central Region between March 9 and June 26, 2021, on healthcare utilization culture among people at risk of statelessness. Descriptive statistics and binary logistic regression were used in analysing data from a sample of 384 people at risk of statelessness. RESULTS: The results reveal that about 51% of the at-risk population have ever enrolled while 48% of the respondents were enrolled on the NHIS at the time of the survey (active members). The majority of the enrolled members acquired their membership through self-payment of the enrolment fee. Additionally, respondents aged 26-35 had higher odds of enrolling, whiles those within 56-65 years had lower odds of enrolling in health insurance. Also, persons who are married and have a high school education or an equivalent qualification were more likely to enrol, while persons with no employment were less likely to enrol. CONCLUSION According to the paper, while the gap in coverage between rich and poor, married and single appears to have narrowed, these factors continue to determine NHIS coverage among people at risk of statelessness. The same is true for education. Efforts must be increased to ensure equal access to healthcare financing interventions for better access to health services.
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Affiliation(s)
- Theophilus Quartey
- grid.9829.a0000000109466120Department of Planning, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Charles Peprah
- grid.9829.a0000000109466120Department of Planning, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Anthony Kwame Morgan
- Department of Planning, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
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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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A mixed methods study of community-based health insurance enrollment trends and underlying challenges in two districts of northeast Ethiopia: A proxy for its sustainability. PLoS One 2022; 17:e0266583. [PMID: 36037203 PMCID: PMC9423627 DOI: 10.1371/journal.pone.0266583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 08/10/2022] [Indexed: 11/20/2022] Open
Abstract
Background The term "community-based health insurance" refers to a broad range of nonprofit, prepaid health financing models designed to meet the health financing needs of disadvantaged populations, particularly those in the rural and informal sectors. Due to their voluntary nature, such initiatives suffer from persistently low coverage in low- and middle-income countries. In Ethiopia, the schemes’ membership growth has not been well investigated so far. This study sought to examine the scheme’s enrollment trend over a five-year period, and to explore the various challenges that underpin membership growth from the perspectives of various key stakeholders. Methods The study employed a mixed methods case study in two purposively selected districts of northeast Ethiopia: Tehulederie and Kallu. By reviewing the databases of health insurance schemes, quantitative data were collected retrospectively from 2017 to 2021 to examine enrollment trends. Trends for each performance indicator were analyzed descriptively for the period under study. Face-to-face interviews were conducted with nine community members and 19 key informants. Study participants were purposely selected using the maximum variation technique. Interviews were audio recorded, transcribed verbatim, and translated into English. Thematic analysis was employed with both deductive and inductive coding approaches. Results Over the course of the study period, enrollment in the scheme at both districts exhibited non-linear trends with both positive and negative growth rates being identified. Overall, the scheme in Tehulederie has a relatively higher population coverage and better membership retention, which could be due to the strong foundation laid by a rigorous public awareness campaign and technical support during the pilot phase. The challenges contributing to the observed level of performance have been summarized under four main themes that include quality of health care, claims reimbursement for insurance holders, governance practices, and community awareness and acceptability. Conclusions The scheme experienced negative growth ratios in both districts, indicating that it is not functionally viable. It will fail to meet its mission unless relevant stakeholders at all levels of government demonstrate political will and commitment to its implementation, as well as advocate for the community. Interventions should target on the highlighted challenges in order to boost membership growth and ensure the scheme’s viability.
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Hussien M, Azage M, Bayou NB. Financial viability of a community-based health insurance scheme in two districts of northeast Ethiopia: a mixed methods study. BMC Health Serv Res 2022; 22:1072. [PMID: 35996128 PMCID: PMC9396896 DOI: 10.1186/s12913-022-08439-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 08/10/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Community-based health insurance initiatives in low- and middle-income countries encountered a number of sustainability challenges due to their voluntary nature, small risk pools, and low revenue. In Ethiopia, the schemes' financial viability has not been well investigated so far. This study examined the scheme's financial viability and explored underlying challenges from the perspectives of various key stakeholders. METHODS This study employed a mixed methods case study in two purposively selected districts of northeast Ethiopia. By reviewing financial reports of health insurance schemes, quantitative data were collected over a seven years period from 2014 to 2020 to examine trends in financial status. Trends for each financial indicator were analyzed descriptively for the period under review. Interviews were conducted face-to-face with nine community members and 19 key informants. We used the maximum variation technique to select the study participants. Interviews were audio recorded, transcribed verbatim, and translated into English. Thematic analysis was applied with both inductive and deductive coding methods. RESULTS Both schemes experienced excess claims costs and negative net income in almost all the study period. Even after government subsidies, the scheme's net income remained negative for some reporting periods. The challenges contributing to the observed level of financial performance have been summarized under five main themes, which include adverse selection, moral hazard behaviors, stockout of medicines, delays in claims settlement for service providers, and low insurance premiums. CONCLUSIONS The health insurance scheme in both districts spent more than it received for claims settlement in almost all the period under the study, and experienced heavy losses in these periods, implying that it is not financially viable for the period in question. The scheme is also unable to fulfill its purpose of protecting members against out-of-pocket expenses at the point of health care. Interventions should target on the highlighted challenges to restore financial balance and enhance the scheme's viability.
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Affiliation(s)
- Mohammed Hussien
- Department of Health Systems Management and Health Economics, School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia.
| | - Muluken Azage
- Department of Environmental Health, School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Negalign Berhanu Bayou
- Department of Health Policy and Management, Faculty of Public Health, Institute of Health, Jimma University, Jimma, Ethiopia
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Habte A, Tamene A, Ejajo T, Dessu S, Endale F, Gizachew A, Sulamo D. Towards universal health coverage: The level and determinants of enrollment in the Community-Based Health Insurance (CBHI) scheme in Ethiopia: A systematic review and meta-analysis. PLoS One 2022; 17:e0272959. [PMID: 35980888 PMCID: PMC9387799 DOI: 10.1371/journal.pone.0272959] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 07/31/2022] [Indexed: 11/18/2022] Open
Abstract
Background Community-based health insurance (CBHI) is a risk-pooling approach that tries to disperse health expenditures across families with varying health profiles to provide greater access to healthcare services by allowing cross-subsidies from wealthy to poor populations. It is crucial to assess the level of CBHI enrolment and its determinants in Ethiopia, where government health spending is limited to less than 5% of GDP, far below the Alma Ata Declaration’s benchmark of 15%. Although various epidemiological studies on CBHI enrolment status and its determinants have been undertaken in Ethiopia, the results have been inconsistent, with significant variability. However, no nationwide study assessing the pooled estimates exists today. Furthermore, the estimated strength of association at the country level varied and was inconsistent across studies. Hence, this systematic review and meta-analysis aimed at estimating the pooled prevalence of CBHI enrolment and its determinants in Ethiopia. Methods A comprehensive search of studies was done by using PubMed, EMBASE, Science Direct, HINARI, Scopus, Web of Science, and the Cochrane Library. The database search was complemented by google scholar and some repositories for grey literature. The search was carried out from February 11 to March 12, 2022. The relevant data were extracted using a Microsoft Excel 2013 spreadsheet and analyzed using STATATM Version 16. Studies reporting the level and determinants of CBHI enrolment in Ethiopia were considered. A weighted DerSimonian Laired random effect model was applied to estimate the pooled national prevalence of CBHI enrolment. The Cochrane Q test statistics and I2 tests were used to assess the heterogeneity of the included studies. A funnel plot, Begg’s and Egger’s tests, were used to check for the presence of publication bias. Results Fifteen studies were eligible for this systematic review and meta-analysis with a total of 8418 study participants. The overall pooled prevalence of CBHI enrolment in Ethiopia was 45.5% (95% CI: 32.19, 58.50). Affordability of premium for the scheme[OR = 2.58, 95% CI 1.68, 3.47], knowledge of respondents on the CBHI scheme[OR = 4.35, 95% CI 2.69, 6.01], perceived quality of service[OR = 3.21, 95% CI 2.04, 4.38], trust in the scheme[OR = 2.32, 95% CI 1.57, 3.07], and the presence of a person with a chronic disease in the household [OR = 3.58, 95% CI 2.37, 4.78] were all found to influence CBHI enrolment. Conclusion Community health workers (CHWs) need to make a high effort to improve knowledge of CBHI in rural communities by providing health education. To deal with the issue of affordability, due emphasis should be placed on building local solidarity groups and strengthening local initiatives to aid poor members. Stakeholders in the health service delivery points need to focus on the dimensions of high service quality. The financial gap created by the adverse selection of households with chronically ill members should be rectified by implementing targeted subsidies with robust plans.
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Affiliation(s)
- Aklilu Habte
- School of Public Health, College of Medicine and Health Sciences, Wachemo University, Hosanna, Ethiopia
- * E-mail:
| | - Aiggan Tamene
- School of Public Health, College of Medicine and Health Sciences, Wachemo University, Hosanna, Ethiopia
| | - Tekle Ejajo
- School of Public Health, College of Medicine and Health Sciences, Wachemo University, Hosanna, Ethiopia
| | - Samuel Dessu
- Department of Public Health, College of Medicine and Health Sciences, Wolkite University, Wolkite, Ethiopia
| | - Fitsum Endale
- School of Public Health, College of Medicine and Health Sciences, Wachemo University, Hosanna, Ethiopia
| | - Addisalem Gizachew
- School of Public Health, College of Medicine and Health Sciences, Wachemo University, Hosanna, Ethiopia
| | - Dawit Sulamo
- School of Public Health, College of Medicine and Health Sciences, Wachemo University, Hosanna, Ethiopia
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Morgan AK, Adei D, Agyemang-Duah W, Mensah AA. An integrative review on individual determinants of enrolment in National Health Insurance Scheme among older adults in Ghana. BMC PRIMARY CARE 2022; 23:190. [PMID: 35907799 PMCID: PMC9338578 DOI: 10.1186/s12875-022-01797-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 07/13/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND We conducted an integrative review in an attempt to methodically and systematically understand the individual (personal factors) that influence National Health Insurance Scheme [NHIS] enrolment among older adults aged 50 years and above. The study was premised on evidence pointing to a state of little or no change in the enrolment rates [especially among older adults], which contrasts with the initial euphoria that greeted the launch of the scheme - which culminated in high enrolment rates. METHODS The integrative literature review was conducted to synthesise the available evidence on individual determinants of NHIS among older adults. The methodological approach of the integrative literature review follows a five-stage interdependent and interconnected procedure of problem identification, literature search, data evaluation, data analysis and results presentation. Studies that met the inclusion criteria were peer-reviewed articles published in the English Language, from January 2010 to July 2020 and have Ghana as its setting or study area. The Andersen's Behavioural Model was used to categorize the predictor variables. RESULTS Predisposing factors [gender, age, level of education and marital status], enabling factors [income] and need factors [health conditions or health attributes of older adults] were identified as individual predictors of NHIS enrolment among older adults. The findings support argument of Andersen's Behavioural Model [where predisposing, enabling and need factors are considered as individual determinants of health behaviour]. CONCLUSIONS The findings call for policy reforms that take into account the aforementioned individual predictors of NHIS enrolment, especially among the aged.
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Affiliation(s)
- Anthony Kwame Morgan
- Department of Planning, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Dina Adei
- Department of Planning, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | | | - Anthony Acquah Mensah
- Department of Planning, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
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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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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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Tefera BB, Kibret MA, Molla YB, Kassie G, Hailemichael A, Abate T, Zelelew H, Desta BF, Futrell E, Kebede Z, Abelti G, Routh S, Feyisetan B, Saad A. The interaction of healthcare service quality and community-based health insurance in Ethiopia. PLoS One 2021; 16:e0256132. [PMID: 34411148 PMCID: PMC8376052 DOI: 10.1371/journal.pone.0256132] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 07/29/2021] [Indexed: 11/19/2022] Open
Abstract
Community-based health insurance (CBHI) as a demand-side intervention is presumed to drive improvements in health services quality, and the quality of health services is an important supple-side factor in motivating CBHI enrollment and retention. There is, however, limited evidence on this interaction. This study examined the interaction between quality of health services and CBHI enrollment and renewal. A mixed-method comparative study was conducted in four agrarian regions of Ethiopia. The study followed the Donabedian model to compare quality of health services in health centers located in woredas/districts that implemented CBHI with those that did not. Data was collected through facility assessments, client-exit interviews, and key informant interviews. In addition to manual thematic analysis of qualitative data, quantitative descriptive and inferential analyses were done using SPSS vs 25. The process related (composite index including provider-client interpersonal communication) and outcome related (client satisfaction) measures of service quality in CBHI woreda/districts differed significantly from non-CBHI woredas/districts, but there were no significant differences in overall measures of structural quality between the two. The study found better diagnostic test capacity, availability of tracer drugs, provider interpersonal communication, and service quality standards in CBHI woredas. A higher proportion of clients at CBHI health centers gave high ratings of overall satisfaction with services. Individual and household factors including family size, age, household health care-related expenditures, and educational status, played a more significant role in CBHI enrollment and renewal decisions than health service quality. Key-informants reported in interviews that participation in the scheme increased accountability of health facilities in CBHI woredas/districts, because they promised to provide quality services using the CBHI premium collected at the beginning of the year from all enrolled households. This study indicates a need for follow-up research to understand the nuanced linkages between quality of care and CBHI enrollment.
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Affiliation(s)
- Bekele Belayihun Tefera
- USAID Transform: Primary Health Care Activity, Pathfinder International, Addis Ababa, Ethiopia
- * E-mail:
| | - Mengistu Asnake Kibret
- USAID Transform: Primary Health Care Activity, Pathfinder International, Addis Ababa, Ethiopia
| | - Yordanos B. Molla
- Pathfinder International, Boston, Massachusetts, United States of America
| | - Girma Kassie
- USAID Transform: Primary Health Care Activity, Pathfinder International, Addis Ababa, Ethiopia
| | - Aynalem Hailemichael
- USAID Transform: Primary Health Care Activity, Pathfinder International, Addis Ababa, Ethiopia
| | - Tarekegn Abate
- USAID Transform: Primary Health Care Activity, Abt associate, Addis Ababa, Ethiopia
| | - Hailu Zelelew
- Abt associate, Cambridge, Massachusetts, United States of America
| | - Binyam Fekadu Desta
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute, Inc., Addis Ababa, Ethiopia
| | - Elizabeth Futrell
- Pathfinder International, Boston, Massachusetts, United States of America
| | | | | | | | - Bamikale Feyisetan
- USAID Contractor, Global Health Bureau, Office of Population and Reproductive Health, USAID, Washington, DC, United States of America
| | - Abdulmumin Saad
- Global Health Bureau, USAID, Washington, DC, United States of America
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Nshakira-Rukundo E, Mussa EC, Cho MJ. Dropping out of voluntary community-based health insurance in rural Uganda: Evidence from a cross-sectional study in rural south-western Uganda. PLoS One 2021; 16:e0253368. [PMID: 34270556 PMCID: PMC8284644 DOI: 10.1371/journal.pone.0253368] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 06/04/2021] [Indexed: 11/30/2022] Open
Abstract
AIM Community Based Health Insurance (CBHI) schemes have become central to health systems financing as avenues of achieving universal health coverage in developing countries. Yet, while emphasis in research and policy has mainly concentrated on enrolment, very little has been apportioned to high rates of dropping out after initial enrolment. The main aim of this study is to understand the factors behind CBHI dropping out through a cross-sectional quantitative research design to gain insights into curtailing the drop out of CBHI in Uganda. METHODS The survey for the quantitative research component took place between August 2015 and March 2016 covering 464 households with under-5 children in south-western Uganda. To understand the factors associated with dropping out of CBHI, we employ a multivariate logistic regression on a subsample of 251 households who were either currently enrolled or had enrolled at one time and later dropped out. RESULTS Overall, we find that 25.1 percent of the households that had ever enrolled in insurance reported dropping out. Household socioeconomic status (wealth) was one of the key factors that associated with dropping out. Larger household sizes and distance from the hospital were significantly associated with dropping out. More socially connected households were less likely to drop out revealing the influence of community social capital in keeping households insured. CONCLUSION The findings have implications for addressing equity and inclusion concerns in community-based health insurance programmes such as one in south-western Uganda. Even when community based informal system aim for inclusion of the poorest, they are not enough and often the poorest of the poor slip into the cracks and remain uninsured or drop out. Moreover, policy interventions toward curtailing high dropout rates should be considered to ensure financial sustainability of CBHI schemes.
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Affiliation(s)
- Emmanuel Nshakira-Rukundo
- Institute for Food and Resource Economics, University of Bonn, Bonn, Germany
- Apata Insights, Kampala, Uganda
| | - Essa Chanie Mussa
- Department of Agriculture Economics, University of Gondar, Gondar, Ethiopia
| | - Min Jung Cho
- Faculty Governance and Global Affairs, Leiden University College, The Hague, Netherlands
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Hussien M, Azage M. Barriers and Facilitators of Community-Based Health Insurance Policy Renewal in Low- and Middle-Income Countries: A Systematic Review. CLINICOECONOMICS AND OUTCOMES RESEARCH 2021; 13:359-375. [PMID: 34007193 PMCID: PMC8123963 DOI: 10.2147/ceor.s306855] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 03/27/2021] [Indexed: 12/02/2022] Open
Abstract
PURPOSE A growing number of low- and middle-income countries are implementing small-scale community-based health insurance schemes to tackle the burdens posed by direct out-of-pocket payments. Apart from a few successful experiences, such schemes suffer from the problem of persistent low membership which could be attributed to either initial low enrollment or low renewal rate. However, there is a lack of comprehensive information on the factors that influence subscribers' policy renewal decisions. Hence, we systematically synthesize information to answer the review question "what are the barriers and facilitators of community-based health insurance policy renewal in low and middle-income countries?". METHODS We searched PubMed, Scopus, and Hinari electronic databases in line with the PRISMA guidelines. Our search was limited to studies published from January 2005 to February 2020 in the English language. Additional studies and grey literature were searched using Google Scholar. We included quantitative, qualitative, and mixed-method studies in the review. We assessed the methodological quality of the studies using standardized appraisal tools. The findings were synthesized inductively using a thematic analysis approach. RESULTS Our searches retrieved 2386 records among which 27 were included in the review. The thematic synthesis identified six major themes that influence the decision to renew scheme policy: socio-demographic factors; scheme-related awareness and understanding; participation in scheme and other voluntary groupings, need and benefit factors; health-care quality; and scheme operation and policy. CONCLUSION Lower socioeconomic status, poor quality of health care, lack of benefit from the scheme, lack of trust in scheme management, and dissatisfaction with scheme services are important barriers for community-based health insurance policy renewal. Better education, understanding the principles of the scheme, active participation in the scheme, and long-term illness experience of member households facilitate renewal decisions. These are important areas of intervention for governments and other relevant stakeholders to retain members and maintain the sustainability of the schemes. REGISTRATION The review protocol was registered in PROSPERO international prospective register of systematic reviews (ID = CRD42020168971).
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Affiliation(s)
- Mohammed Hussien
- Department of Health Systems Management and Health Economics, School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Muluken Azage
- Department of Environmental Health, School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
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Hussein MR, Dongarwar D, Yusuf RA, Yusuf Z, Aliyu GG, Elmessan GR, Salihu HM. Health Insurance Status of Pregnant Women and the Likelihood of Receipt of Antenatal Screening for HIV in Sub-Saharan Africa. Curr HIV Res 2021; 19:248-259. [PMID: 33622225 DOI: 10.2174/1570162x19666210223124835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 01/08/2021] [Accepted: 01/21/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND We investigated if initiating preventive care against HIV vertical transmission by antenatal HIV screening is independent of the patients' source of financial reimbursement for the care received in sub-Saharan Africa (SSA). METHODS Using information from the WHO's Global Health Expenditure Database and the Demographic Health Surveys Database for 27 sub-Saharan countries, we used Spearman's correlation and adjusted survey logistic regression to determine the potential relationship between enrollment in health insurance and the likelihood that expectant mothers would be offered antenatal HIV screening. RESULTS We found that expectant mothers covered by health insurance were more than twice as likely to be offered antenatal screening for HIV compared to the uninsured. The likelihood differed by the type of insurance plan the expectant mother carried. DISCUSSION Health insurance is more of a financial tool that this study finds to be necessary to boost the uptake of preventive and therapeutic HIV care in SSA. CONCLUSION The ensuing disparity in receiving proper care could hinder the goals of 90-90-90 and the forthcoming 95-95-95 plan in SSA.
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Affiliation(s)
- Muhammad Ragaa Hussein
- Department of Management, Policy, and Community Health (MPACH), University of Texas Health Science Center at Houston (UTHealth), School of Public Health, Houston, TX, United States
| | - Deepa Dongarwar
- Center of Excellence in Health Equity, Training & Research, Baylor College of Medicine, Houston, TX, United States
| | - Rafeek A Yusuf
- Department of Management, Policy, and Community Health (MPACH), University of Texas Health Science Center at Houston (UTHealth), School of Public Health, Houston, TX, United States
| | - Zenab Yusuf
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA; Houston VA Health Services Research and Development Service Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston TX, USA and VA South Central Mental Illness Research, Education and Clinical Center, Houston, TX, United States
| | | | - George Ryan Elmessan
- Center of Excellence in Health Equity, Training & Research, Baylor College of Medicine, Houston, TX, United States
| | - Hamisu M Salihu
- Center of Excellence in Health Equity, Training & Research, Baylor College of Medicine, Houston, TX, United States
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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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Abdilwohab MG, Abebo ZH, Godana W, Ajema D, Yihune M, Hassen H. Factors affecting enrollment status of households for community based health insurance in a resource-limited peripheral area in Southern Ethiopia. Mixed method. PLoS One 2021; 16:e0245952. [PMID: 33493240 PMCID: PMC7833211 DOI: 10.1371/journal.pone.0245952] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 01/11/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Despite the efforts made by the government of Ethiopia, the community-based health insurance (CBHI) enrollment rate failed to reach the potential beneficiaries. Therefore, this study aimed to assess the enrollment status of households for community-based health insurance and associated factors in peripheral areas of Southern Ethiopia. METHODS We conducted a community based cross-sectional study design with both quantitative and qualitative methods. Systematic random sampling was employed to select 820 households from 27, April to 12 June 2018. A pretested structured questionnaire, in-depth interview, and focus group discussion guiding tool were used to obtain information. A binary logistic regression model was used to assess the association between independent and outcome variables. A P-Value of less than 0.05 was taken as a cutoff to declare association in multivariable analysis. Qualitative data were analyzed manually using the thematic analysis method. RESULTS Out of 820 households, 273[33.30%; 95% CI: 29.9-36.20] were enrolled in the community based health insurance scheme. Having good knowledge [AOR = 13.97, 95%CI: 8.64, 22.60], having family size of greater than five [AOR = 1.88, 95% CI: 1.15, 3.06], presence of frequently ill individual [AOR = 3.90, 95% CI: 2.03, 7.51] and presence of chronic illness [AOR = 3.64, 95% CI: 1.67, 7.79] were positively associated with CBHI enrollment. In addition, poor quality of care, lack of managerial commitment, lack of trust and transparency, unavailability of basic logistics and supplies were also barriers for CBHI enrollment. CONCLUSION AND RECOMMENDATION The study found that lower community based health insurance enrollment status. A higher probability of CBHI enrollment among higher health care demanding population groups was observed. Poor perceived quality of health care, poor managerial support and lack of trust were found to be barriers for non-enrollment. Therefore, wide-range awareness creation strategies should be used to address adverse selection and poor knowledge. In addition, trust should be built among communities through transparent management. Furthermore, the quality of care being given in public health facilities should be improved to encourage the community to be enrolled in CBHI.
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Affiliation(s)
- Mustefa Glagn Abdilwohab
- Department of Public Health, College of Medicine and Health Sciences, Arba Minch University, Arba Minch Town, Ethiopia
| | - Zeleke Hailemariam Abebo
- Department of Public Health, College of Medicine and Health Sciences, Arba Minch University, Arba Minch Town, Ethiopia
| | - Wanzahun Godana
- Department of Public Health, College of Medicine and Health Sciences, Arba Minch University, Arba Minch Town, Ethiopia
| | - Dessalegn Ajema
- Department of Public Health, College of Medicine and Health Sciences, Arba Minch University, Arba Minch Town, Ethiopia
| | - Manaye Yihune
- Department of Public Health, College of Medicine and Health Sciences, Arba Minch University, Arba Minch Town, Ethiopia
| | - Hadiya Hassen
- Department of Public Health, College of Medicine and Health Sciences, Arba Minch University, Arba Minch Town, Ethiopia
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Atnafu A, Tariku A. Perceived Quality of Healthcare and Availability of Supplies Determine Household-Level Willingness to Join a Community-Based Health Insurance Scheme in Amhara Region, Ethiopia. CLINICOECONOMICS AND OUTCOMES RESEARCH 2020; 12:683-691. [PMID: 33235474 PMCID: PMC7678707 DOI: 10.2147/ceor.s279529] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 11/05/2020] [Indexed: 11/25/2022] Open
Abstract
Purpose The Ethiopian health system has been challenged by a shortage of funds and is heavily reliant on foreign donation. However, voluntary community-based health insurance (CBHI) has been implemented to reach and cover the very large agricultural sector since 2010. Thus, the level of acceptability of the scheme needs to be regularly assessed through households’ willingness to join before the nationwide rollout of the scheme. This study was intended to assess the level of willingness to join in community-based health insurance and associated factors in northwest Ethiopia. Patients and Methods Using a pretested structured questionnaire, a cross-sectional community-based study was conducted in 2017 in Amhara Region, northwest Ethiopia. Using a multi-stage sampling method, from 15 clusters in which CBHI was implemented, 1,179 households without CBHI membership were included as a sample for the study. Bivariable and multivariable logistic regression was fitted to assess the association between predictor variables and the outcome of interest. Results Out of the total (1,179) participants, 60.5% (713) were willing to join the scheme. Households’ occupation (AOR=2.26; 95% CI:=1.12–5.07), perceived good (AOR=2.21; 95% CI:=1.53−3.21), and medium (AOR=1.44; 95% CI=1.22–2.0) healthcare quality and richer wealth status (AOR=1.72; 95% CI=1.08–2.73) were associated with higher odds of willingness to join the scheme. Conclusion As The study revealed that level of willingness to join is lower compared to other studies. Therefore, social protection activities for the low-income population and enhancement of the capacity of health facilities are crucial.
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Affiliation(s)
- Asmamaw Atnafu
- Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Amare Tariku
- Department of Human Nutrition, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Dao A. What it means to say "I Don't have any money to buy health insurance" in rural Vietnam: How anticipatory activities shape health insurance enrollment. Soc Sci Med 2020; 266:113335. [PMID: 32932002 DOI: 10.1016/j.socscimed.2020.113335] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 06/29/2020] [Accepted: 08/25/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Amy Dao
- Department of Geography and Anthropology, Cal Poly Pomona. 3801 W. Temple Ave, Pomona, CA, 91768, United States.
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Donfouet HPP, Mohamed SF, Otieno P, Wambiya E, Mutua MK, Danaei G. Economic valuation of setting up a social health enterprise in urban poor-resource setting in Kenya. Soc Sci Med 2020; 266:113294. [PMID: 32927381 DOI: 10.1016/j.socscimed.2020.113294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 08/07/2020] [Accepted: 08/11/2020] [Indexed: 10/23/2022]
Abstract
The failure of the market and government to provide quality healthcare services have been the motivation to set up social health enterprise. However, the value for money associated with setting up a social health enterprise in sub-Sahara African countries has been relatively unexplored in the literature. The study presents the first empirical estimates of the mean willingness-to-pay (WTP) for setting up a social health enterprise that will simultaneously run a health center and provide health insurance scheme in an urban resource-poor setting and explores whether the benefits outweigh the costs. The contingent valuation method is used to estimate the mean WTP for the health insurance scheme proposed by the social health enterprise in Viwandani slum (Nairobi, Kenya). The survey was conducted between June and July 2018 on 300 households. We find that the feasibility of setting up a social health enterprise could be promising with 97 percent of respondents willing to pay about US$ 2 per person per month for a scheme that would provide quality healthcare services. More importantly, setting up the social health enterprise will yield a positive net profit, and investors could expect US$ 1.11 in benefits for each US$ 1 of costs of investment in setting up the social health enterprise. We, therefore, conclude that this health policy in this urban resource-poor setting could be a viable solution to reach the neglected urban households in the Kenyan slums.
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Affiliation(s)
- Hermann Pythagore Pierre Donfouet
- African Population and Health Research Center, APHRC Campus, 2nd Floor, Manga Close, Off Kirawa Road, P.O. Box: 10787-00100, Nairobi, Kenya; University of Rennes 1, CREM UMR-CNRS 6211, 7 Place Hoche, 35065, RENNES Cedex, France.
| | - Shukri F Mohamed
- African Population and Health Research Center, APHRC Campus, 2nd Floor, Manga Close, Off Kirawa Road, P.O. Box: 10787-00100, Nairobi, Kenya.
| | - Peter Otieno
- African Population and Health Research Center, APHRC Campus, 2nd Floor, Manga Close, Off Kirawa Road, P.O. Box: 10787-00100, Nairobi, Kenya.
| | - Elvis Wambiya
- African Population and Health Research Center, APHRC Campus, 2nd Floor, Manga Close, Off Kirawa Road, P.O. Box: 10787-00100, Nairobi, Kenya.
| | - Martin Kavao Mutua
- African Population and Health Research Center, APHRC Campus, 2nd Floor, Manga Close, Off Kirawa Road, P.O. Box: 10787-00100, Nairobi, Kenya.
| | - Goodarz Danaei
- Harvard T.H. Chan School of Public Health, United States.
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Criel B, Waelkens MP, Kwilu Nappa F, Coppieters Y, Laokri S. Can mutual health organisations influence the quality and the affordability of healthcare provision? The case of the Democratic Republic of Congo. PLoS One 2020; 15:e0231660. [PMID: 32298341 PMCID: PMC7162613 DOI: 10.1371/journal.pone.0231660] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 03/29/2020] [Indexed: 02/01/2023] Open
Abstract
Background In their mission to achieve better access to quality healthcare services, mutual health organisations (MHOs) are not limited to providing health insurance. As democratically controlled member organisations, MHOs aim to make people’s voices heard. At national level, they seek involvement in the design of social protection policies; at local level, they seek to improve responsiveness of healthcare services to members’ needs and expectations. Methods In this qualitative study, we investigated whether MHOs in the Democratic Republic of Congo (DRC) succeed in defending members’ rights by improving healthcare quality while minimising expenses. The data originate from an earlier in-depth investigation conducted in the DRC in 2016 of the performance of 13 MHOs. We re-analysed this existing dataset and more specifically investigated actions that the MHOs undertook to improve quality and affordability of healthcare provision for their members, using a framework for analysis based on Hirschman’s exit-voice theory. This framework distinguishes four mechanisms for MHO members to use in influencing providers: (1) ‘exit’ or ‘voting with the feet’; (2) ‘co-producing a long voice route’ or imposing rules through strategic purchasing; (3) ‘guarding over the long voice route of accountability’ or pressuring authorities to regulate and enforce regulations; and (4) ‘strengthening the short voice route’ by transforming the power imbalance at the provider–patient interface. Results All studied MHOs used these four mechanisms to improve healthcare provision. Most healthcare providers, however, did not recognise their authority to do so. In the DRC, controlling quality and affordability of healthcare is firmly seen as a role for the health authorities, but the authorities only marginally take up this role. Under current circumstances, the power of MHOs in the DRC to enhance quality and affordability of healthcare is weak. Conclusion On their own, mutual health organisations in the DRC do not have sufficient power to influence the practices of healthcare providers. Greater responsiveness of the health services to MHO members requires cooperation of all actors involved in healthcare delivery to create an enabling environment where voices defending people’s rights are heard.
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Affiliation(s)
- Bart Criel
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- * E-mail:
| | - Maria-Pia Waelkens
- School of Public Health, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Fulbert Kwilu Nappa
- Department of Health System Management, Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Yves Coppieters
- School of Public Health, Health Policy and Systems–International Health, Université Libre de Bruxelles, Brussels, Belgium
| | - Samia Laokri
- School of Public Health and Tropical Medicine, Global Community Health and Behavioral Sciences, Tulane University, New Orleans, LA, United States of America
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Examining purchasing reforms towards universal health coverage by the National Hospital Insurance Fund in Kenya. Int J Equity Health 2020. [PMID: 32013955 DOI: 10.1186/s12939‐019‐1116‐x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Kenya has prioritized the attainment of universal health coverage (UHC) through the expansion of health insurance coverage by the National Hospital Insurance Fund (NHIF). In 2015, the NHIF introduced reforms in premium contribution rates, benefit packages, and provider payment methods. We examined the influence of these reforms on NHIF's purchasing practices and their implications for strategic purchasing and health system goals of equity, efficiency and quality. METHODS We conducted an embedded case study with the NHIF as the case and the reforms as embedded units of analysis. We collected data at the national level and in two purposively selected counties through 41 in-depth interviews with health financing stakeholders, facility managers and frontline providers; 4 focus group discussions with 51 NHIF members; and, document reviews. We analysed the data using a Framework approach. RESULTS The new NHIF reforms were characterized by weak purchasing actions. Firstly, the new premium contribution rates were inadequately communicated and unaffordable for certain citizen groups. Secondly, while the new benefit packages were reported to be based on service needs, preferences and values of the population, they were inadequately communicated and unequally distributed across different citizen groups. In addition, the presence of service delivery infrastructure gaps in public healthcare facilities and the pro-urban and pro-private distribution of contracted health facilities compromised delivery of, and access to, these new services. Lastly, the new provider payment methods and rates were considered inadequate, with delayed payments and weak links to financial accountability mechanisms which compromised their ability to incentivize equity, efficiency and quality of healthcare delivery. CONCLUSION While NHIF sought to expand population and service coverage and reduce out-of-pocket payments with the new reforms, weaknesses in the reforms' design and implementation limited NHIF's purchasing actions with negative implications for the health system goals of equity, efficiency and quality. For the reforms to accelerate the country's progress towards UHC, policy makers at the NHIF and, national and county government should make deliberate efforts to align the design and implementation of such reforms with strategic purchasing actions that are aimed at improving health system goals.
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Mbau R, Kabia E, Honda A, Hanson K, Barasa E. Examining purchasing reforms towards universal health coverage by the National Hospital Insurance Fund in Kenya. Int J Equity Health 2020; 19:19. [PMID: 32013955 PMCID: PMC6998279 DOI: 10.1186/s12939-019-1116-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 12/23/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Kenya has prioritized the attainment of universal health coverage (UHC) through the expansion of health insurance coverage by the National Hospital Insurance Fund (NHIF). In 2015, the NHIF introduced reforms in premium contribution rates, benefit packages, and provider payment methods. We examined the influence of these reforms on NHIF's purchasing practices and their implications for strategic purchasing and health system goals of equity, efficiency and quality. METHODS We conducted an embedded case study with the NHIF as the case and the reforms as embedded units of analysis. We collected data at the national level and in two purposively selected counties through 41 in-depth interviews with health financing stakeholders, facility managers and frontline providers; 4 focus group discussions with 51 NHIF members; and, document reviews. We analysed the data using a Framework approach. RESULTS The new NHIF reforms were characterized by weak purchasing actions. Firstly, the new premium contribution rates were inadequately communicated and unaffordable for certain citizen groups. Secondly, while the new benefit packages were reported to be based on service needs, preferences and values of the population, they were inadequately communicated and unequally distributed across different citizen groups. In addition, the presence of service delivery infrastructure gaps in public healthcare facilities and the pro-urban and pro-private distribution of contracted health facilities compromised delivery of, and access to, these new services. Lastly, the new provider payment methods and rates were considered inadequate, with delayed payments and weak links to financial accountability mechanisms which compromised their ability to incentivize equity, efficiency and quality of healthcare delivery. CONCLUSION While NHIF sought to expand population and service coverage and reduce out-of-pocket payments with the new reforms, weaknesses in the reforms' design and implementation limited NHIF's purchasing actions with negative implications for the health system goals of equity, efficiency and quality. For the reforms to accelerate the country's progress towards UHC, policy makers at the NHIF and, national and county government should make deliberate efforts to align the design and implementation of such reforms with strategic purchasing actions that are aimed at improving health system goals.
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Affiliation(s)
- Rahab Mbau
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, P.O. BOX 43640-00100, Nairobi, Kenya
| | - Evelyn Kabia
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, P.O. BOX 43640-00100, Nairobi, Kenya
| | | | - Kara Hanson
- London School of Hygiene and Tropical Medicine, London, UK
| | - Edwine Barasa
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, P.O. BOX 43640-00100, Nairobi, Kenya
- Nuffield department of medicine, Oxford University, Oxford, UK
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Kwarteng A, Akazili J, Welaga P, Dalinjong PA, Asante KP, Sarpong D, Arthur S, Bangha M, Goudge J, Sankoh O. The state of enrollment on the National Health Insurance Scheme in rural Ghana after eight years of implementation. Int J Equity Health 2019; 19:4. [PMID: 31892331 PMCID: PMC6938612 DOI: 10.1186/s12939-019-1113-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Accepted: 12/13/2019] [Indexed: 11/10/2022] Open
Abstract
Background In 2004, Ghana implemented a national health insurance scheme (NHIS) as a step towards achieving universal health coverage. In this paper, we assessed the level of enrollment and factors associated with NHIS membership in two predominantly rural districts of northern Ghana after eight years of implementation, with focus on the poor and vulnerable populations. Methods A cross-sectional survey was conducted from July 2012 to December 2012 among 11,175 randomly sampled households with their heads as respondents. Information on NHIS status, category of membership and socio-demographic characteristics of household members was obtained using a structured questionnaire. Principal component analysis was used to compute wealth index from household assets as estimates of socio-economic status (SES). The factors associated with NHIS enrollment were assessed using logistic regression models. The reasons behind enrollment decisions of each household member were further investigated against their SES. Results Approximately half of the sampled population of 39,262 were registered with a valid NHIS card; 53.2% of these were through voluntary subscriptions by payment of premium whilst the remaining (46.8%) comprising of children below the ages of 18 years, elderly 70 years and above, pregnant women and formal sector workers were exempt from premium payment. Despite an exemption policy to ameliorate the poor and vulnerable households against catastrophic health care expenditures, only 0.5% of NHIS membership representing 1.2% of total exemptions granted on accounts of poverty and other social vulnerabilities was applied for the poor. Yet, cost of premium was the main barrier to NHIS registration (92.6%) and non-renewal (78.8%), with members of the lowest SES being worst affected. Children below the ages of 18 years, females, urban residents and those with higher education and SES were significantly more likely to be enrolled with the scheme. Conclusions Despite the introduction of policy exemptions as an equity measure, the poorest of the poor were rarely identified for exemption. The government must urgently resource the Department of Social Welfare to identify the poor for NHIS enrollment.
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Affiliation(s)
- Anthony Kwarteng
- Kintampo Health Research Center, Ghana Health Service, P. O. Box 200, Kintampo, Ghana.
| | - James Akazili
- Navrongo Health Research Center, Ghana Health Service, Navrongo, Ghana
| | - Paul Welaga
- Navrongo Health Research Center, Ghana Health Service, Navrongo, Ghana
| | | | - Kwaku Poku Asante
- Kintampo Health Research Center, Ghana Health Service, P. O. Box 200, Kintampo, Ghana
| | - Doris Sarpong
- Dodowa Health Research Center, Ghana Health Service, Dodowa, Ghana
| | | | | | - Jane Goudge
- Center for Health Policy/MRC Health Policy Research Group, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Abstract
In the global South, low-income populations are faced with frequent health shocks. Formal mechanisms to protect them against these shocks are absent or limited. Thus, what are the mechanisms used by low-income rural populations to finance healthcare? This paper draws on a qualitative study to examine the healthcare financing mechanisms of low-income rural populations in Cameroon. The findings suggest that low-income populations use 13 mechanisms to finance healthcare. Depending on several factors, people may use more than one of these mechanisms. In addition, social factors shape people’s patterns of usage of these mechanisms. Patterns of usage of these mechanisms are embedded in the principle of reciprocity. The notion of reciprocity does seem to discourage people from enrolling in the limited voluntary health insurance programmes which exist in various communities. Newly insured people were more likely to drop out if they did not receive a payout.
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Kiendrébéogo JA, Meessen B. Ownership of health financing policies in low-income countries: a journey with more than one pathway. BMJ Glob Health 2019; 4:e001762. [PMID: 31646009 PMCID: PMC6782032 DOI: 10.1136/bmjgh-2019-001762] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 09/03/2019] [Accepted: 09/11/2019] [Indexed: 11/28/2022] Open
Affiliation(s)
- Joël Arthur Kiendrébéogo
- Department of Public Health, University Joseph Ki-Zerbo, Health Sciences Training and Research Unit, Ouagadougou, Kadiogo, Burkina Faso.,Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Heidelberg, Germany
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Nshakira-Rukundo E, Mussa EC, Nshakira N, Gerber N, von Braun J. Determinants of Enrolment and Renewing of Community-Based Health Insurance in Households With Under-5 Children in Rural South-Western Uganda. Int J Health Policy Manag 2019; 8:593-606. [PMID: 31657186 PMCID: PMC6819630 DOI: 10.15171/ijhpm.2019.49] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 06/09/2019] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The desire for universal health coverage in developing countries has brought attention to communitybased health insurance (CBHI) schemes in developing countries. The government of Uganda is currently debating policy for the national health insurance programme, targeting the integration of existing CBHI schemes into a larger national risk pool. However, while enrolment has been largely studied in other countries, it remains a generally under-covered issue from a Ugandan perspective. Using a large CBHI scheme, this study, therefore, aims at shedding more light on the determinants of households' decisions to enrol and renew membership in these schemes. METHODS We collected household data from 464 households in 14 villages served by a large CBHI scheme in southwestern Uganda. We then estimated logistic and zero-inflated negative binomial (ZINB) regressions to understand the determinants of enrolment and renewing membership in CBHI, respectively. RESULTS Results revealed that household's socioeconomic status, husband's employment in rural casual work (odds ratio [OR]: 2.581, CI: 1.104-6.032) and knowledge of health insurance premiums (OR: 17.072, CI: 7.027-41.477) were significant predictors of enrolment. Social capital and connectivity, assessed by the number of voluntary groups a household belonged to, was also positively associated with CBHI participation (OR: 5.664, CI: 2.927-10.963). More positive perceptions on insurance (OR: 2.991, CI: 1.273-7.029), access to information were also associated with enrolment and renewing among others. Burial group size and number of burial groups in a village, were all significantly associated with increased the likelihood of renewing CBHI. CONCLUSION While socioeconomic factors remain important predictors of participation in insurance, mechanisms to promote inclusion should be devised. Improving the participation of communities can enhance trust in insurance and eventual coverage. Moreover, for households already insured, access to correct information and strengthening their social network information pathways enhances their chances of renewing.
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Affiliation(s)
| | - Essa Chanie Mussa
- Department of Economics and Technological Change, Center for Development Research (ZEF), University of Bonn, Bonn, Germany
| | - Nathan Nshakira
- Department of Environmental and Public Health, Kabale University, Kabale, Uganda
| | - Nicolas Gerber
- Department of Economics and Technological Change, Center for Development Research (ZEF), University of Bonn, Bonn, Germany
| | - Joachim von Braun
- Department of Economics and Technological Change, Center for Development Research (ZEF), University of Bonn, Bonn, Germany
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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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Mahmood SS, Hanifi SMA, Mia MN, Chowdhury AH, Rahman M, Iqbal M, Bhuiya A. Who enrols in voluntary micro health insurance schemes in low-resource settings? Experience from a rural area in Bangladesh. Glob Health Action 2019; 11:1525039. [PMID: 30289056 PMCID: PMC6179054 DOI: 10.1080/16549716.2018.1525039] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Micro health insurance (MHI) has proved to be a potential health-financing tool for many developing countries. Bangladesh also included MHI in its current health-financing strategy which aims to achieve universal health coverage. However, low uptake, low renewal and high dropouts have historically challenged financial sustainability of these schemes. OBJECTIVE This study aims to identify factors influencing people from low-resource settings, particularly those from Bangladesh, to enrol in MHI schemes. METHODS The study analyses the 'Amader Shasthya' MHI scheme operating in Chakaria, a sub-district under Cox's Bazar district, Bangladesh. A household survey was carried out during May-June 2016 among 2,000 households from the scheme coverage area. The Outreville's insurance-demand framework was used to identify enrolment influencing factors. Multivariate logistic regression analysis was carried out to identify significant influencing factors of enrolment. RESULTS Enrolment influencing factors were identified in four dimensions: economic, socio-cultural, demographic and structural. Households with the main income earner having 10+ years of schooling (odds 1.9 [CI 1.2-2.9] compared to illiterate), having financial literacy (odds 1.5 [CI 1.2-1.8] compared to financially illiterate) and being a public/private service holder (odds 1.6 [CI 1.1-2.4] compared to menial labour) were more likely to enrol. Membership in development programmes of NGOs also influenced enrolment decision significantly (odds 1.3 [CI 1.0-1.5]). The presence of chronic illness in household encouraged enrolment (odds 1.5 [CI 1.2-1.8]). Households living closer to health centres were more likely to enrol (odds 2.1 [CI 1.6-2.7]) compared to those living further away. CONCLUSION The findings are expected to have significant implications in terms of designing similar health insurance schemes, particularly in terms of designing demand-driven and context adapted schemes that have greater potential to attract a larger client pool, ensure effective risk pooling and eventually expedite the achievement of universal health coverage in low-resource settings.
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Affiliation(s)
- Shehrin Shaila Mahmood
- a Universal Health Coverage, Health Systems and Population Studies Division , icddr,b , Dhaka , Bangladesh
| | - Syed Manjoor Ahmed Hanifi
- a Universal Health Coverage, Health Systems and Population Studies Division , icddr,b , Dhaka , Bangladesh
| | - Mohammad Nahid Mia
- a Universal Health Coverage, Health Systems and Population Studies Division , icddr,b , Dhaka , Bangladesh
| | - Asiful Haidar Chowdhury
- a Universal Health Coverage, Health Systems and Population Studies Division , icddr,b , Dhaka , Bangladesh
| | - Mahabubur Rahman
- a Universal Health Coverage, Health Systems and Population Studies Division , icddr,b , Dhaka , Bangladesh
| | - Mohammad Iqbal
- a Universal Health Coverage, Health Systems and Population Studies Division , icddr,b , Dhaka , Bangladesh
| | - Abbas Bhuiya
- b Centre for Global Health, Population and Policy , University of Portsmouth , Portsmouth , UK
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Agasha DB, Edwin BMR, Baine SO. Effect of the eQuality Health Bwindi Scheme on Utilization of Health Services at Bwindi Community Hospital in Uganda. Front Public Health 2019; 7:71. [PMID: 31019907 PMCID: PMC6458260 DOI: 10.3389/fpubh.2019.00071] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 03/12/2019] [Indexed: 11/13/2022] Open
Abstract
Introduction: eQuality Health Bwindi (eQHB), a Community Based Health Insurance (CBHI) scheme was launched in March 2010 with the aim of generating income to maintain high quality care as well as increasing access to and utilization of health services at Bwindi Community Hospital (BCH). The main objective of this study was to explore evidence showing that eQHB scheme affected access and utilization of health services at BCH. The evidence generated would be used to inform decision making, policy and scale up of the scheme. Methods and Materials: This study applied qualitative and quantitative research methods. It involved a review of hospital records for the period July 2009-June 2014, a survey of 272 households, four focus group discussions, and six key informant interviews. Both quantitative and qualitative analysis techniques were applied for the analysis. Results: Outpatient attendance, inpatient admissions, and deliveries at the hospital increased by 65, 73, and 27%, respectively between FY 2009/10 and FY 2012/13. Utilization of health services by sick children from insured participants was greater than that of the uninsured members of the community (p-value = 0.0038). BCH services became more affordable. However, opting out of the scheme at a later stage in the review period was attributed to rising unaffordable premiums and co-payments. Failure to afford scheme membership, residing far from BCH and limited understanding of health insurance led to reduced BCH service utilization. Conclusions: eQHB has potential to increase access and utilization of health services at BCH. The challenges are; limited understanding of the concept of health insurance and unaffordable premiums and co-payments set to enable provision of high quality services. Recommendations: Based on these findings, intensified community sensitization on health insurance, establishment of satellite health facilities by BCH to bring services closer to members and transformation of eQHB to a savings/credit society in order to grow savings and subsequently reduce premiums are recommended. Government of Uganda should engage CBHIs countrywide to discuss achievement of UHC and establishment of a national health insurance scheme. A further study to guide setting of affordable premiums and copayments for eQHB is also recommended.
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Sydavong T, Goto D, Kawata K, Kaneko S, Ichihashi M. Potential demand for voluntary community-based health insurance improvement in rural Lao People's Democratic Republic: A randomized conjoint experiment. PLoS One 2019; 14:e0210355. [PMID: 30620771 PMCID: PMC6324784 DOI: 10.1371/journal.pone.0210355] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Accepted: 12/20/2018] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION In Lao People's Democratic Republic (PDR), community-based health insurance (CBHI) is the only voluntary insurance scheme; it typically targets self-employed people, most of whom reside in rural areas and are dependent on agricultural activities for subsistence. However, until very recently, the enrollment rate has fallen short and failed to reach a large percentage of the target group. To promote the CBHI scheme and increase demand, some supporting components should be considered for inclusion together with the health infrastructure component. OBJECTIVES This paper provides empirical evidence that the benefit package components of hypothetical CBHI schemes have causal effects on enrollment probabilities. Furthermore, we examine the distribution of willingness to pay (WTP) in response to policy changes based on a sample of 5,800 observations. METHODS A randomized conjoint experiment is conducted in rural villages in Savannakhet Province, Lao PDR, to elicit stated preference data. Each respondent ranks three options-two hypothetical alternatives and the CBHI status quo scheme. The levels of seven attributes-insurance coverage for medical consultations, hospitalizations, traffic accidents, pharmaceuticals and transportation; premiums; and prepaid discounts-are randomly and simultaneously assigned to the two alternatives. RESULTS The findings suggest that the average WTP is at least as large as 10.9% of the per capita income of those who live in rural areas, which is higher than the WTP for health insurance averaged across low- and middle-income countries (LMICs) in the literature. The component of round-trip transportation insurance coverage has a significant effect on WTP distribution, particularly increasing the share of the highest bin. CONCLUSION Therefore, the low CBHI scheme enrollment rate in Lao PDR does not necessarily imply low demand among the targeted population, as the finding from the WTP analysis illustrates potential demand for the CBHI scheme. Specifically, if transportation is addressed, enrollment is likely to significantly increase.
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Affiliation(s)
- Thiptaiya Sydavong
- Graduate School for International Development and Cooperation, Hiroshima University, Higashi-hiroshima, Hiroshima, Japan
- Department of Planning and Investment, Savannakhet Provincial Government, Savannakhet, Lao People’s Democratic Republic
| | - Daisaku Goto
- Graduate School for International Development and Cooperation, Hiroshima University, Higashi-hiroshima, Hiroshima, Japan
| | - Keisuke Kawata
- Institute of Social Science, University of Tokyo, Tokyo, Japan
| | - Shinji Kaneko
- Graduate School for International Development and Cooperation, Hiroshima University, Higashi-hiroshima, Hiroshima, Japan
| | - Masaru Ichihashi
- Graduate School for International Development and Cooperation, Hiroshima University, Higashi-hiroshima, Hiroshima, Japan
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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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Aregbeshola BS, Khan SM. Predictors of Enrolment in the National Health Insurance Scheme Among Women of Reproductive Age in Nigeria. Int J Health Policy Manag 2018; 7:1015-1023. [PMID: 30624875 PMCID: PMC6326643 DOI: 10.15171/ijhpm.2018.68] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 07/21/2018] [Indexed: 11/09/2022] Open
Abstract
Background: Despite the implementation of the National Health Insurance Scheme (NHIS) since 2005 in Nigeria, the level of health insurance coverage remains low. The study aims to examine the predictors of enrolment in the NHIS among women of reproductive age in Nigeria.
Methods: Secondary data from the 2013 Nigeria Demographic and Health Survey (NDHS) were utilized to examine factors influencing enrolment in the NHIS among women of reproductive age (n=38 948) in Nigeria. Demographic and socio-economic characteristics of women were determined using univariate, bivariate and multivariate analyses. Data analysis was performed using STATA version 12 software.
Results: We found that 97.9% of women were not covered by health insurance. Multivariate analysis indicated that factors such as age, education, geo-political zone, socio-economic status (SES), and employment status were significant predictors of enrolment in the NHIS among women of reproductive age.
Conclusion: This study concludes that health insurance coverage among women of reproductive age in Nigeria is very low. Additionally, demographic and socio-economic factors were associated with enrolment in the NHIS among women. Therefore, policy-makers need to establish a tax-based health financing mechanism targeted at women who are young, uneducated, from poorest households, unemployed and working in the informal sector of the economy. Extending health insurance coverage to women from poor households and those who work in the informal sector through a tax-financed non-contributory health insurance scheme would accelerate progress towards universal health coverage (UHC).
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Affiliation(s)
- Bolaji Samson Aregbeshola
- Department of Community Health & Primary Care, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Samina Mohsin Khan
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
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Thi Thuy Nga N, FitzGerald G, Dunne M. Family-Based Health Insurance for Informal Sector Workers in Vietnam: Why Does Enrolment Remain Low? Asia Pac J Public Health 2018; 30:699-707. [PMID: 30345787 DOI: 10.1177/1010539518807601] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Providing financial protection to the whole population is a top health policy priority of many countries. However, expanding social health insurance coverage to the "informal sector worker" is a challenge in many developing countries. This study analyzed the reasons for the limited coverage of health insurance for informal sector workers. Direct interviews were carried out with 391 uninsured households in Vietnam, followed by in-depth interviews with 11 key stakeholders. The study offers several possible explanations for the low enrollment in family-based health insurance scheme at both the demand and supply sides, such as inability to pay the premium, lack of information, perceived poor quality of primary health care services, and complicated enrollment procedures. The study suggests that a partial government subsidy and improvement in the quality of primary health care are crucial strategies for health insurance expansion for the informal sector workers and their families.
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Affiliation(s)
| | - Gerard FitzGerald
- Queensland University of Technology, Kelvin Grove, Queensland, Australia
| | - Michael Dunne
- Queensland University of Technology, Kelvin Grove, Queensland, Australia
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Haven N, Dobson AE, Yusuf K, Kellermann S, Mutahunga B, Stewart AG, Wilkinson E. Community-Based Health Insurance Increased Health Care Utilization and Reduced Mortality in Children Under-5, Around Bwindi Community Hospital, Uganda Between 2015 and 2017. Front Public Health 2018; 6:281. [PMID: 30356909 PMCID: PMC6190927 DOI: 10.3389/fpubh.2018.00281] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Accepted: 09/11/2018] [Indexed: 01/25/2023] Open
Abstract
Introduction: Out-of-pocket fees to pay for health care prevent poor people from accessing health care and drives millions into poverty every year. This obstructs progress toward the World Health Organization goal of universal health care. Community-based health insurance (CBHI) improves access to health care primarily by reducing the financial risk. The association of CBHI with reduced under-5 mortality was apparent in some voluntary schemes. This study evaluated the impact of eQuality Health Bwindi CBHI scheme on health care utilization and under-5 mortality in rural south-western Uganda. Methods: This was a retrospective cross-sectional study using routine electronic data on health insurance status, health care utilization, place of birth, and deaths for children aged under-5 in the catchment area of Bwindi Community Hospital, Uganda between January 2015 and June 2017. Data was extracted from four electronic databases and cross matched. To assess the association with health insurance, we measured the difference between those with and without insurance; in terms of being born in a health facility, outpatient attendance, inpatient admissions, length of stay and mortality. Associations were assessed by Chi-Square tests with p-values < 0.05 and 95% confidence intervals. For variables found to be significant at this level, multivariable logistic regression was done to control for possible confounders. Results: Of the 16,464 children aged under-5 evaluated between January 2015 and June 2017, 10% were insured all of the time 19% were insured for part of the period, and 71% were never insured. Ever having had health insurance reduced the risk of death by 36% [aOR; 0.64, p = 0.009]. While children were insured, they visited outpatients ten times more, and were four times more likely to be admitted. If admitted, they had a significantly shorter length of stay. If mother was uninsured, children were less likely to be born in a health facility [adjusted odds ratio (aOR) 2.82, p < 0.001]. Conclusion: This study demonstrated that voluntary CBHI increased health care utilization and reduced mortality for children under-5. But the scheme required appreciable outside subsidy, which limits its wider application and replicability. While CBHIs can contribute to progress toward Universal Health Care they cannot always be afforded.
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Affiliation(s)
- Nahabwe Haven
- Church of Uganda Bwindi Community Hospital, Kinkizi Diocese, Kanungu, Uganda
| | - Andrew E. Dobson
- Church of Uganda Bwindi Community Hospital, Kinkizi Diocese, Kanungu, Uganda
| | - Kuule Yusuf
- Church of Uganda Bwindi Community Hospital, Kinkizi Diocese, Kanungu, Uganda
| | - Scott Kellermann
- Church of Uganda Bwindi Community Hospital, Kinkizi Diocese, Kanungu, Uganda
| | - Birungi Mutahunga
- Church of Uganda Bwindi Community Hospital, Kinkizi Diocese, Kanungu, Uganda
| | - Alex G. Stewart
- College of Life and Environmental Science, University of Exeter, Exeter, United Kingdom
| | - Ewan Wilkinson
- Institute of Medicine, University of Chester, Chester, United Kingdom
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Baine SO, Kakama A, Mugume M. Development of the Kisiizi hospital health insurance scheme: lessons learned and implications for universal health coverage. BMC Health Serv Res 2018; 18:455. [PMID: 29903016 PMCID: PMC6003105 DOI: 10.1186/s12913-018-3266-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 05/31/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Kisiizi Hospital Health Insurance scheme started in 1996 to; improve access to health services, and provide a stable source of funding and reduce bad debts to Kisiizi hospital. Objectives of this study were; to describe Kisiizi Hospital Health Insurance scheme and to document lessons learned and implications for universal health coverage. METHODS This was a descriptive cross-sectional study. Data from different sources were triangulated and thematically analysed. RESULTS Most households (96%) were organized in Engozi societies (e-Societies), met monthly, and made financial contributions. Cultural solidarity in e-Societies provided a platform for the Kisiizi hospital health insurance scheme establishment, operation and made it compulsory for members. e-Societies disciplinary measures and fear of high out-of-pocket payment for health care enforced enrolment, retention and increased membership. Community sensitisation and community participation in setting premiums and co-payments provided for better understanding of health insurance and rendered them acceptable, affordable and equitable. Membership increased from 330 in 1996 to 38,400 families in 2017. Kisiizi hospital health insurance scheme covered only health services obtained from Kisiizi hospital. Kisiizi hospital health insurance scheme offered no exemption, credit and referral facilities. e-Societies sometimes paid premiums for members from savings and offered them loans to. Kisiizi hospital provided good quality health services, which were easily accessed by insured members. Kisiizi hospital got a stable source of funding and reduced debt burden. CONCLUSIONS Kisiizi hospital health insurance scheme improved access to health services, provided a stable source of funding and reduced bad debts to the hospital. Internal and external factors to e-Society enforced enrolment and retention of members in Kisiizi hospital health insurance scheme. Good quality health services at Kisiizi hospital demonstrated value for money and offered incentives for enrolment and retention, and coverage expansion. Community sensitization and participation in setting premiums and co-payments rendered Kisiizi hospital health insurance scheme acceptable, affordable and catered for equity. Insured members enjoyed benefits; protection against catastrophic health spending, impoverishment, and easy access to quality health care.
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Affiliation(s)
- Sebastian Olikira Baine
- Department of Health Policy, Planning and Management, Makerere University College of Health Sciences, School of Public Health, P. O. Box 7072, Kampala, Uganda
| | - Alex Kakama
- Kisiizi Hospital Health Insurance Scheme, Kisiizi Hospital, P. O. Box 109, Kabale, Uganda
| | - Moses Mugume
- Kisiizi Hospital Health Insurance Scheme, Kisiizi Hospital, P. O. Box 109, Kabale, Uganda
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Atafu A, Kwon S. Adverse selection and supply-side factors in the enrollment in community-based health insurance in Northwest Ethiopia: A mixed methodology. Int J Health Plann Manage 2018; 33:902-914. [PMID: 29781157 DOI: 10.1002/hpm.2546] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 04/19/2018] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Since 2010, the Ethiopian government introduced different measures to implement community-based health insurance (CBHI) schemes to improve access to health service and reduce the catastrophic effect of health care costs. OBJECTIVES The aim of this study was to examine the determinants of enrollment in CBHI in Northwest Ethiopia. METHODS In this study, we utilized a mix of quantitative (multivariate logistic regression applied to population survey linked with health facility survey) and qualitative (focus group discussion and in-depth interview) methods to better understand the factors that affect CBHI enrollment. RESULTS The study revealed important factors, such as household, informal association, and health facility, as barriers to CBHI enrollment. Age and educational status, self-rated health status, perceived quality of health services, knowledge, and information (awareness) about CBHI were among the characteristics of individual household head, affecting enrollment. Household size and participation in an informal association, such as local credit associations, were also positively associated with CBHI enrollment. Additionally, health facility factors like unavailability of laboratory tests were the main factor that hinders CBHI enrollment. CONCLUSIONS This study showed a possibility of adverse selection in CBHI enrollment. Additionally, perceived quality of health services, knowledge, and information (awareness) are positively associated with CBHI enrollment. Therefore, policy interventions to mitigate adverse selection as well as provision of social marketing activities are crucial to increase enrollment in CBHI. Furthermore, policy interventions that enhance the capacity of health facilities and schemes to provide the promised services are necessary.
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Affiliation(s)
- Asmamaw Atafu
- Graduate School of Public Health, Seoul National University, Seoul, South Korea.,Department of Health Service Management and Economics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Soonman Kwon
- Graduate School of Public Health, Seoul National University, Seoul, South Korea
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Kotoh AM, Aryeetey GC, Van der Geest S. Factors That Influence Enrolment and Retention in Ghana' National Health Insurance Scheme. Int J Health Policy Manag 2018; 7:443-454. [PMID: 29764108 PMCID: PMC5953527 DOI: 10.15171/ijhpm.2017.117] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 09/23/2017] [Indexed: 11/21/2022] Open
Abstract
Background: The government of Ghana introduced the National Health Insurance Scheme (NHIS) in 2004 with the goal of achieving universal coverage within 5 years. Evidence, however, shows that expanding NHIS coverage and especially retaining members have remained a challenge. A multilevel perspective was employed as a conceptual framework and methodological tool to examine why enrolment and retention in the NHIS remains low.
Methods: A household survey was conducted after 20 months educational and promotional activities aimed at improving enrolment and retention rates in 15 communities in the Central and Eastern Regions (ERs) of Ghana. Observation, indepth interviews and informal conversations were used to collect qualitative data. Forty key informants (community members, health providers and district health insurance schemes’ [DHISs] staff) purposely selected from two casestudy communities in the Central Region (CR) were interviewed. Several community members, health providers and DHISs’ staff were also engaged in informal conversations in the other five communities in the region. Also, four staff of the Ministry of Health (MoH), Ghana Health Service (GHS) and National Health Insurance Authority (NHIA) were engaged in in-depth interviews. Descriptive statistics was used to analyse quantitative data. Qualitative data was analysed using thematic content analysis.
Results: The results show that factors that influence enrolment and retention in the NHIS are multi-dimensional and cut across all stakeholders. People enrolled and renewed their membership because of NHIS’ benefits and health providers’ positive behaviour. Barriers to enrolment and retention included: poverty, traditional risk-sharing arrangements influence people to enrol or renew their membership only when they need healthcare, dissatisfaction about health providers’ behaviour and service delivery challenges.
Conclusion: Given the multi-dimensional nature of barriers to enrolment and retention, we suggest that the NHIA should engage DHISs, health providers and other stakeholders to develop and implement intervention activities to eliminate corruption, shortage of drugs in health facilities and enforce the compulsory enrolment stated in the NHIS policy to move the scheme towards universal coverage.
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Affiliation(s)
| | | | - Sjaak Van der Geest
- Department of Sociology and Anthropology, University of Amsterdam, Amsterdam, The Netherlands
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Biggeri M, Nannini M, Putoto G. Assessing the feasibility of community health insurance in Uganda: A mixed-methods exploratory analysis. Soc Sci Med 2018; 200:145-155. [PMID: 29421461 DOI: 10.1016/j.socscimed.2018.01.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 01/13/2018] [Accepted: 01/19/2018] [Indexed: 11/17/2022]
Abstract
Community health insurance (CHI) aims to provide financial protection and facilitate health care access among poor rural populations. Given common operational challenges that hamper the full development of the scheme, there is need to undertake systematic feasibility studies. These are scarce in the literature and usually they do not provide a comprehensive analysis of the local context. The present research intends to adopt a mixed-methods approach to assess ex-ante the feasibility of CHI. In particular, eight preconditions are proposed to inform the viability of introducing the micro insurance. A case study located in rural northern Uganda is presented to test the effectiveness of the mixed-methods procedure for the feasibility purpose. A household survey covering 180 households, 8 structured focus group discussions, and 40 key informant interviews were performed between October and December 2016 in order to provide a complete and integrated analysis of the feasibility preconditions. Through the data collected at the household level, the population health seeking behaviours and the potential insurance design were examined; econometric analyses were carried out to investigate the perception of health as a priority need and the willingness to pay for the scheme. The latter component, in particular, was analysed through a contingent valuation method. The results validated the relevant feasibility preconditions. Econometric estimates demonstrated that awareness of catastrophic health expenditures and the distance to the hospital play a critical influence on household priorities and willingness to pay. Willingness is also significantly affected by socio-economic status and basic knowledge of insurance principles. Overall, the mixed-methods investigation showed that a comprehensive feasibility analysis can shape a viable CHI model to be implemented in the local context.
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Affiliation(s)
- M Biggeri
- Department of Economics and Management, University of Florence, Florence, Italy.
| | - M Nannini
- Department of Economics and Management, University of Florence, Florence, Italy.
| | - G Putoto
- Doctors with Africa CUAMM, Padova, Italy.
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Andoh-Adjei FX, van der Wal R, Nsiah-Boateng E, Asante FA, van der Velden K, Spaan E. Does a provider payment method affect membership retention in a health insurance scheme? a mixed method study of Ghana's capitation payment for primary care. BMC Health Serv Res 2018; 18:52. [PMID: 29378567 PMCID: PMC5789689 DOI: 10.1186/s12913-018-2859-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Accepted: 01/18/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ghana introduced a National Health Insurance Scheme (NHIS) in 2003 applying fee-for-service method for paying NHIS-credentialed health care providers. The National Health Insurance Authority (NHIA) later introduced diagnosis-related-grouping (DRG) payment to contain cost without much success. The NHIA then introduced capitation payment, a decision that attracted complaints of falling enrolment and renewal rates from stakeholders. This study was done to provide evidence on this trend to guide policy debate on the issue. METHODS We applied mixed method design to the study. We did a trend analysis of NHIS membership data in Ashanti, Volta and Central regions to assess growth rate; performed independent-sample t-test to compare sample means of the three regions and analysed data from individual in-depth interviews to determine any relationship between capitation payment and subscribers' renewal decision. RESULTS Results of new enrolment data analysis showed differences in mean growth rates between Ashanti (M = 30.15, SE 3.03) and Volta (M = 40.72, SE 3.10), p = 0.041; r = 0. 15; and between Ashanti and Central (M = 47.38, SE6.49) p = 0.043; r = 0. 42. Analysis of membership renewal data, however, showed no significant differences in mean growth rates between Ashanti (M = 65.47, SE 6.67) and Volta (M = 69.29, SE 5.04), p = 0.660; r = 0.03; and between Ashanti and Central (M = 50.51, SE 9.49), p = 0.233. Analysis of both new enrolment and renewal data also showed no significant differences in mean growth rates between Ashanti (M = - 13.76, SE 17.68) and Volta (M = 5.48, SE 5.50), p = 0.329; and between Ashanti and Central (M = - 6.47, SE 12.68), p = 0.746. However, capitation payment had some effect in Ashanti compared with Volta (r = 0. 12) and Central (r = 0. 14); but could not be sustained beyond 2012. Responses from the in-depth interviews did not also show that capitation payment is a key factor in subscribers' renewal decision. CONCLUSION Capitation payment had a small but unsustainable effect on membership growth rate in the Ashanti region. Factors other than capitation payment may have played a more significant role in subscribers' enrolment and renewal decisions in the Ashanti region of Ghana.
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Affiliation(s)
| | - Renske van der Wal
- Radboud Institute for Health Sciences, Department for Health Evidence, Radboud University Medical Centre-Netherlands, Nijmegen, Netherlands
| | | | - Felix Ankomah Asante
- Institute of Statistical, Social and Economic Research (ISSER) University of Ghana, Legon-, Accra, Ghana
| | - Koos van der Velden
- Radboud Institute for Health Science, Department for Primary and Community Health, Radboud University Medical Centre-Netherlands, Nijmegen, Netherlands
| | - Ernst Spaan
- Radboud Institute for Health Sciences, Department for Health Evidence, Radboud University Medical Centre-Netherlands, Nijmegen, Netherlands
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Fadlallah R, El-Jardali F, Hemadi N, Morsi RZ, Abou Samra CA, Ahmad A, Arif K, Hishi L, Honein-AbouHaidar G, Akl EA. Barriers and facilitators to implementation, uptake and sustainability of community-based health insurance schemes in low- and middle-income countries: a systematic review. Int J Equity Health 2018; 17:13. [PMID: 29378585 PMCID: PMC5789675 DOI: 10.1186/s12939-018-0721-4] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 01/08/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Community-based health insurance (CBHI) has evolved as an alternative health financing mechanism to out of pocket payments in low- and middle-income countries (LMICs), particularly in areas where government or employer-based health insurance is minimal. This systematic review aimed to assess the barriers and facilitators to implementation, uptake and sustainability of CHBI schemes in LMICs. METHODS We searched six electronic databases and grey literature. We included both quantitative and qualitative studies written in English language and published after year 1992. Two reviewers worked in duplicate and independently to complete study selection, data abstraction, and assessment of methodological features. We synthesized the findings based on thematic analysis and categorized according to the ecological model into individual, interpersonal, community and systems levels. RESULTS Of 15,510 citations, 51 met the eligibility criteria. Individual factors included awareness and understanding of the concept of CBHI, trust in scheme and scheme managers, perceived service quality, and demographic characteristics, which influenced enrollment and sustainability. Interpersonal factors such as household dynamics, other family members enrolled in the scheme, and social solidarity influenced enrollment and renewal of membership. Community-level factors such as culture and community involvement in scheme development influenced enrollment and sustainability of scheme. Systems-level factors encompassed governance, financial and delivery arrangement. Government involvement, accountability of scheme management, and strong policymaker-implementer relation facilitated implementation and sustainability of scheme. Packages that covered outpatient and inpatient care and those tailored to community needs contributed to increased enrollment. Amount and timing of premium collection was reported to negatively influence enrollment while factors reported as threats to sustainability included facility bankruptcy, operating on small budgets, rising healthcare costs, small risk pool, irregular contributions, and overutilization of services. At the delivery level, accessibility of facilities, facility environment, and health personnel influenced enrollment, service utilization and dropout rates. CONCLUSION There are a multitude of interrelated factors at the individual, interpersonal, community and systems levels that drive the implementation, uptake and sustainability of CBHI schemes. We discuss the implications of the findings at the policy and research level. TRIAL REGISTRATION The review protocol is registered in PROSPERO International prospective register of systematic reviews (ID = CRD42015019812 ).
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Affiliation(s)
- Racha Fadlallah
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
- Center for Systematic Review in Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon
| | - Fadi El-Jardali
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
- Center for Systematic Review in Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON Canada
| | - Nour Hemadi
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
- Center for Systematic Review in Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon
| | - Rami Z. Morsi
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Clara Abou Abou Samra
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Ali Ahmad
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Khurram Arif
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Lama Hishi
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | | | - Elie A. Akl
- Center for Systematic Review in Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON Canada
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
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Duku SKO, Nketiah-Amponsah E, Janssens W, Pradhan M. Perceptions of healthcare quality in Ghana: Does health insurance status matter? PLoS One 2018; 13:e0190911. [PMID: 29338032 PMCID: PMC5770037 DOI: 10.1371/journal.pone.0190911] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 12/22/2017] [Indexed: 11/19/2022] Open
Abstract
This study's objective is to provide an alternative explanation for the low enrolment in health insurance in Ghana by analysing differences in perceptions between the insured and uninsured of the non-technical quality of healthcare. It further explores the association between insurance status and perception of healthcare quality to ascertain whether insurance status matters in the perception of healthcare quality. Data from a survey of 1,903 households living in the catchment area of 64 health centres were used for the analysis. Two sample independent t-tests were employed to compare the average perceptions of the insured and uninsured on seven indicators of non-technical quality of healthcare. A generalised ordered logit regression, controlling for socio-economic characteristics and clustering at the health facility level, tested the association between insurance status and perceived quality of healthcare. The perceptions of the insured were found to be significantly more negative than the uninsured and those of the previously insured were significantly more negative than the never insured. Being insured was associated with a significantly lower perception of healthcare quality. Thus, once people are insured, they tend to perceive the quality of healthcare they receive as poor compared to those without insurance. This study demonstrated that health insurance status matters in the perceptions of healthcare quality. The findings also imply that perceptions of healthcare quality may be shaped by individual experiences at the health facilities, where the insured and uninsured may be treated differently. Health insurance then becomes less attractive due to the poor perception of the healthcare quality provided to individuals with insurance, resulting in low demand for health insurance in Ghana. Policy makers in Ghana should consider redesigning, reorganizing, and reengineering the National Healthcare Insurance Scheme to ensure the provision of better quality healthcare for both the insured and uninsured.
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Affiliation(s)
- Stephen Kwasi Opoku Duku
- Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
- Faculty of Economics and Business Administration, Free University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
| | | | - Wendy Janssens
- Faculty of Economics and Business Administration, Free University of Amsterdam, Amsterdam, The Netherlands
| | - Menno Pradhan
- Faculty of Economics and Business Administration, Free University of Amsterdam, Amsterdam, The Netherlands
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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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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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48
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Mugisha JO, Schatz EJ, Negin J, Mwaniki P, Kowal P, Seeley J. Timing of Most Recent Health Care Visit by Older People Living With and Without HIV. Int J Aging Hum Dev 2016; 85:18-32. [PMID: 27913758 DOI: 10.1177/0091415016680071] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The objective of this article is to document factors associated with the recency of health-care service utilization by people aged 50 years and over living with and without HIV in Uganda. A survey was conducted with 510 Ugandans aged 50 and older, living with and without HIV. The survey included information on sociodemographic characteristics, health state, self-reported chronic conditions, and timing of most recent visit to a health-care facility (time since last visit [TSLV]). We use ordinal logistic regression to identify independent factors associated TSLV. Independent factors associated with TSLV (>6 months) include age, OR = 2.40 [95% CI 1.08-5.37] for those aged 80 years and above, urban respondents, OR = 0.6 [95%CI 0.38-0.94], HIV-positive respondents, OR = 0.33 [95%CI 0.18-0.59], and better health. To understand the meaning of these finding, further investigation should examine (a) how best to define and measure older persons' health-care service needs and (b) older persons' decision-making processes around the timing of their access to health-care facilities.
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Affiliation(s)
- Joseph O Mugisha
- 1 MRC/UVRI, Uganda Research Unit on AIDS, Entebbe, Uganda.,2 Department of Health Sciences, University of Missouri, Columbia, USA
| | - Enid J Schatz
- 2 Department of Health Sciences, University of Missouri, Columbia, USA
| | - Joel Negin
- 3 School of Public Health, University of Sydney, Sydney, Australia
| | - Paul Mwaniki
- 1 MRC/UVRI, Uganda Research Unit on AIDS, Entebbe, Uganda
| | - Paul Kowal
- 4 World Health Organization Study on global AGEing and adult health, Geneva, Switzerland.,5 Research Centre for Generational Health and Ageing, University of Newcastle, NSW, Australia
| | - Janet Seeley
- 1 MRC/UVRI, Uganda Research Unit on AIDS, Entebbe, Uganda.,6 London School of Hygiene and Tropical Medicine, London, UK
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49
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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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Ekirapa-Kiracho E, Namazzi G, Tetui M, Mutebi A, Waiswa P, Oo H, Peters DH, George AS. Unlocking community capabilities for improving maternal and newborn health: participatory action research to improve birth preparedness, health facility access, and newborn care in rural Uganda. BMC Health Serv Res 2016; 16:638. [PMID: 28185592 PMCID: PMC5123379 DOI: 10.1186/s12913-016-1864-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Community capacities and resources must be harnessed to complement supply side initiatives addressing high maternal and neonatal mortality rates in Uganda. This paper reflects on gains, challenges and lessons learnt from working with communities to improve maternal and newborn health in rural Uganda. METHODS A participatory action research project was supported from 2012 to 2015 in three eastern districts. This project involved working with households, saving groups, sub county and district leaders, transporters and village health teams in diagnosing causes of maternal and neonatal mortality and morbidity, developing action plans to address these issues, taking action and learning from action in a cyclical manner. This paper draws from project experience and documentation, as well as thematic analysis of 20 interviews with community and district stakeholders and 12 focus group discussions with women who had recently delivered and men whose wives had recently delivered. RESULTS Women and men reported increased awareness about birth preparedness, improved newborn care practices and more male involvement in maternal and newborn health. However, additional direct communication strategies were required to reach more men beyond the minority who attended community dialogues and home visits. Saving groups and other saving modalities were strengthened, with money saved used to meet transport costs, purchase other items needed for birth and other routine household needs. However saving groups required significant support to improve income generation, management and trust among members. Linkages between savings groups and transport providers improved women's access to health facilities at reduced cost. Although village health teams were a key resource for providing information, their efforts were constrained by low levels of education, inadequate financial compensation and transportation challenges. Ensuring that the village health teams and savings groups functioned required regular supervision, review meetings and payment for supervisors to visit. CONCLUSIONS This participatory program, which focused on building the capacity of community stakeholders, was able to improve local awareness of maternal and newborn health practices and instigate local action to improve access to healthcare. Collaborative problem solving among diverse stakeholders, continuous support and a participatory approach that allowed flexibility were essential project characteristics that enabled overcoming of challenges faced.
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Affiliation(s)
- Elizabeth Ekirapa-Kiracho
- Department of Health Policy Planning and Management, Makerere University School of Public Health, Mulago Hill Road, Kampala, Uganda
| | - Gertrude Namazzi
- Department of Health Policy Planning and Management, Makerere University School of Public Health, Mulago Hill Road, Kampala, Uganda
| | - Moses Tetui
- Department of Health Policy Planning and Management, Makerere University School of Public Health, Mulago Hill Road, Kampala, Uganda
- Department of Public Health and Clinical Medicine, Epidemiology and Global Health Unit, Umeå University, 901 87 Umeå, Sweden
| | - Aloysius Mutebi
- Department of Health Policy Planning and Management, Makerere University School of Public Health, Mulago Hill Road, Kampala, Uganda
| | - Peter Waiswa
- Department of Health Policy Planning and Management, Makerere University School of Public Health, Mulago Hill Road, Kampala, Uganda
- Division of Global Health (IHCAR), Department of Public Health Sciences, Karolinska Institute, Stockholm, Sweden
| | - Htet Oo
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - David H. Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Asha S. George
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
- South African Research Chair, School of Public Health, University of the Western Cape, Cape Town, South Africa
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