Endorsement of universal health coverage financial principles in Burkina Faso

Procedural fairness in decision-making for financing a National Health Insurance Scheme: a case study from The Gambia

Achieving universal health coverage (UHC) involves difficult policy choices, and fair processes are critical for building legitimacy and trust. In 2021, The Gambia passed its National Health Insurance (NHI) Act. We explored decision-making processes shaping the financing of the NHI scheme (NHIS) with respect to procedural fairness criteria. We reviewed policy and strategic documents on The Gambia's UHC reforms to identify key policy choices and interviewed policymakers, technocrats, lawmakers, hospital chief executive officers, private sector representatives and civil society organizations (CSOs) including key CSOs left out of the NHIS discussions. Ministerial budget discussions and virtual proceedings of the National Assembly's debate on the NHI Bill were observed. To enhance public scrutiny, Gambians were encouraged to submit views to the National Assembly's committee; however, the procedures for doing so were unclear, and it was not possible to ascertain how these inputs were used. Despite available funds to undertake countrywide public engagement, the public consultations were mostly limited to government institutions, few trade unions and a handful of urban-based CSOs. While this represented an improved approach to public policy-making, several CSOs representing key constituents and advocating for the expansion of exemption criteria for insurance premiums to include more vulnerable groups felt excluded from the process. Overload of the National Assembly's legislative schedule and lack of National Assembly committee quorum were cited as reasons for not engaging in countrywide consultations. In conclusion, although there was an intent from the Executive and National Assembly to ensure transparent, participatory and inclusive decision-making, the process fell short in these aspects. These observations should be seen in the context of The Gambia's ongoing democratic transition where institutions for procedural fairness are expected to progressively improve. Learning from this experience to enhance the procedural fairness of decision-making can promote inclusiveness, ownership and sustainability of the NHIS in The Gambia.

Mandatory membership of community-based mutual health insurance in Senegal: A national survey

With the low adherence to voluntary mutual health insurance, Senegal's policymakers have sought to understand the feasibility of compulsory health insurance membership. This study aims to measure the acceptability of mandatory membership in community-based mutual health insurance (CBHI) and to understand its possible administrative modalities. The study consists of a national survey among a representative population sample selected by marginal quotas. The survey was conducted in 2022 over the phone, with a random composition method involving 914 people. The questionnaire measured the socio-economic characteristics of households, their level of acceptability concerning voluntary and compulsory membership, and their level of confidence in CBHIs and the health system. Respondents preferred voluntary (86%) over mandatory (70%) membership of a CBHI. The gap between voluntary and compulsory membership scores was smaller among women (p = 0.040), people under 35 (p = 0.033), and people with no health coverage (p = 0.011). Voluntary or compulsory membership was correlated (p = 0.000) to trust in current CBHIs and health systems. Lack of trust in the CBHI management has been more disadvantageous for acceptance of the mandatory than the voluntary membership. No particular preference emerged as the preferred administrative channel (e.g. death certificate, identity card, etc.) to enforce the mandatory option. The results confirmed the well-known challenges of building universal health coverage based on CBHIs-a poorly appreciated model whose low performance reduces the acceptability of populations to adhere to it, whether voluntary or mandatory. Suppose Senegal persists in its health insurance approach. In that case, it will be essential to strengthen the performance and funding of CBHIs, and to gain population trust to enable a mandatory or more systemic membership.

Towards achievement of Sustainable Development Goal 3: multilevel analyses of demographic and health survey data on health insurance coverage and maternal healthcare utilisation in sub-Saharan Africa

BACKGROUND

Improving maternal health and achieving universal health coverage (UHC) are important expectations in the global Sustainable Development Goals (SDGs) agenda. While health insurance has been shown as effective in the utilisation of maternal healthcare, there is a paucity of literature on this relationship in sub-Saharan Africa (SSA). We examined the relationship between health insurance coverage and maternal healthcare utilisation using demographic and health survey data.

METHODS

This was a cross-sectional study of 195 651 women aged 15-49 y from 28 countries in SSA. We adopted bivariable and multivariable analyses comprising χ2 test and multilevel binary logistic regression in analysing the data.

RESULTS

The prevalence of maternal healthcare utilisation was 58, 70.6 and 40.7% for antenatal care (ANC), skilled birth attendance (SBA) and postnatal care (PNC), respectively. The prevalence of health insurance coverage was 6.4%. Women covered by health insurance were more likely to utilise ANC (adjusted OR [aOR]=1.48, 95% CI 1.41 to 1.54), SBA (aOR=1.37, 95% CI 1.30 to 1.45) and PNC (aOR=1.42, 95% CI 1.37 to 1.48).

CONCLUSION

Health insurance coverage was an important predictor of maternal healthcare utilisation in our study. To accelerate progress towards the achievement of SDG 3 targets related to the reduction of maternal mortality and achievement of UHC, countries should adopt interventions to increase maternal insurance coverage, which may lead to higher maternal healthcare access and utilisation during pregnancy.

Out-of-pocket payments and catastrophic expenditures due to traffic injuries in Ouagadougou, Burkina Faso

OBJECTIVE

To estimate the out-of-pocket expenditures linked to Road Traffic Injuries in Ouagadougou, Burkina Faso, as well as the prevalence of catastrophic expenditures among those out-of-pocket payments, and to identify the socio-economic determinants of catastrophic expenditures due to Road Traffic Injuries.

METHODS

We surveyed every admission at the only trauma unit of Ouagadougou between January and July 2015 at the time of their admission, 7 days and 30 days later. We estimate a total amount of out-of-pocket expenditures paid by each patient. We considered an expense as catastrophic when it represented 10% at least of the annual global consumption of the patient's household. We used linear models to determine if socio-economic characteristics were associated to a greater or smaller ratio between out-of-pocket payment and global annual consumption.

FINDINGS

We surveyed 1323 Road injury victims three times (admission, Days 7 and 30). They paid in average 46,547 FCFA (83.64 US dollars) for their care, which represent a catastrophic expenditure for 19% of them. Less than 5% of the sample was covered by a health insurance scheme. Household economic status is found to be the first determinant of catastrophic health expenditure occurrence, exhibiting a significant and negative on the ratio between road injury expenditures and global consumption.

CONCLUSION

Our findings highlight the importance of developing health insurance schemes to protect poor households from the economic burden of road traffic injuries and improve equity in front of health shocks.

Contracting of private medical practitioners in a National Health Insurance pilot district: What has been the effect on primary healthcare utilisation indicators?

BACKGROUND

In 2012, the National Department of Health in South Africa started contracting of private medical practitioners (MPs) as part of the first phase of National Health Insurance (NHI) in 11 pilot districts to improve access to healthcare.

AIM

The aim of this study was to describe the effect of contracting private MPs on the utilisation of primary healthcare (PHC) services in public healthcare facilities.

SETTING

A National Health Insurance pilot district compared to a non-pilot district.

METHODS

A quasi-experimental ecological study design was used to compare selected PHC utilisation indicators in the District Health Management Information System from June 2010 to May 2014 between a pilot and a non-pilot district. Both single and controlled interrupted time series analyses were used for comparing before and after implementation of the intervention.

FINDINGS

Single interrupted time series analysis showed an increase in adults remaining on anti-retroviral therapy, clients seen by a nurse practitioner and clients 5 years of age and older in both districts. However, controlled interrupted time series analysis found no difference in all parametres. Despite a decrease in total headcounts in both districts using single interrupted time series analysis, controlled interrupted time series analysis found no differences in all parameters before and after the intervention.

CONCLUSIONS

The increase in utilisation of PHC services in the pilot district may not be attributable to the implementation of contracting private MPs, but likely the result of other healthcare reforms and transitions taking place in both districts around the same time.

Determinants of geographical inequalities for DTP3 vaccine coverage in sub-Saharan Africa

Childhood immunization is one of the most effective health interventions, making it a key indicator of progress towards universal health coverage. In the last decade, improvements in coverage have been made globally, however, slow progress has been documented in sub-Saharan Africa with considerable subnational variations. We explore potential drivers of equitable immunization services based on subnational DTP3 coverage estimates. Using vaccine coverage at the 5 by 5 km area from 2000 to 2016, we quantify inequality using three measures. We assess the shortfall inequality which is the average deviation across subnational units from that with the highest coverage for each country. Secondly we estimate the threshold index, the proportion of children below a globally set subnational coverage target, and lastly, a Gini coefficient representing the within-country distribution of coverage. We use time series analyses to quantify associations with immunization expenditures controlling for country socio-economic and population characteristics. Development assistance, maternal education and governance were associated with reductions in inequality. Furthermore, high quality governance was associated with a stronger relationship between development assistance and reductions in inequality. Results from this analysis also indicate that countries with the lowest coverage suffer the highest inequalities. We highlight growing inequalities among countries which have met national coverage targets such as South Africa and Kenya. In 2016, values for the shortfall inequality ranged from 1% to 43%, the threshold index from 0% to 100% and Gini coefficient from 0.01 to 0.37. Burundi, Comoros, Eswatini, Lesotho, Namibia, Rwanda, and Sao Tome and Principe had the least shortfall inequality (<5%) while Angola, Ethiopia and Nigeria had values greater than 40%. A similar picture was noted for the other dimensions of inequality among these particular countries. Immunization program investments offer promise in addressing inequality, however, domestic mechanisms for resource implementation and accountability should be strengthened to maximize gains in coverage.

A Hybrid Decision-Making Approach for the Service and Financial-Based Measurement of Universal Health Coverage for the E7 Economies

The aim of this study is to measure universal health coverage in Emerging 7 (E7) economies. Within this framework, five different dimensions and 14 different criteria are selected by considering the explanations of World Health Organization and United Nations regarding universal health coverage. While weighting the dimensions and criteria, the Decision-making Trial and Evaluation Laboratory (DEMATEL) is considered with the triangular fuzzy numbers. Additionally, Multi-Objective Optimization on the basis of Ratio Analysis (MOORA) approach is used to rank E7 economies regarding Universal Health Coverage (UHC) performance. The novelty of this study is that both service and financial based factors are taken into consideration at the same time. Additionally, fuzzy DEMATEL and MOORA methodologies are firstly used in this study with respect to the evaluation of universal health coverage. The findings show that catastrophic out of pocket health spending, pushed below an international poverty line and annual growth rate of real Gross Domestic Product (GDP) per capita are the most significant criteria for universal health coverage performance. Moreover, it is also concluded that Russia is the country that has the highest universal health coverage performance whereas China, India and Brazil are in the last ranks. It can be understood that macroeconomic conditions play a very significant role on the performance of universal health coverage. Hence, economic conditions should be improved in these countries to have better universal health coverage performance. Furthermore, it is necessary to establish programs that provide exemptions or lower out-of-pocket expenditures which will not prevent the use of health services. This situation can protect people against the financial risks related to health expenditures. In addition to them, it is also obvious that high population has also negative influence on the countries such as, China and India. It indicates that it would be appropriate for these countries to make population planning for this purpose.

A multi-country study of the economic burden of dengue fever based on patient-specific field surveys in Burkina Faso, Kenya, and Cambodia

BACKGROUND

Dengue fever is a rapidly growing public health problem in many parts of the tropics and sub-tropics in the world. While there are existing studies on the economic burden of dengue fever in some of dengue-endemic countries, cost components are often not standardized, making cross-country comparisons challenging. Furthermore, no such studies have been available in Africa.

METHODS/PRINCIPAL FINDINGS

A patient-specific survey questionnaire was developed and applied in Burkina Faso, Kenya, and Cambodia in a standardized format. Multiple interviews were carried out in order to capture the entire cost incurred during the period of dengue illness. Both private (patient's out-of-pocket) and public (non-private) expenditure were accessed to understand how the economic burden of dengue is distributed between private and non-private payers. A substantial number of dengue-confirmed patients were identified in all three countries: 414 in Burkina Faso, 149 in Kenya, and 254 in Cambodia. The average cost of illness for dengue fever was $26 (95% CI $23-$29) and $134 (95% CI $119-$152) per inpatient in Burkina Faso and Cambodia, respectively. In the case of outpatients, the average economic burden per episode was $13 (95% CI $23-$29) in Burkina Faso and $23 (95% CI $19-$28) in Kenya. Compared to Cambodia, public contributions were trivial in Burkina Faso and Kenya, reflecting that a majority of medical costs had to be directly borne by patients in the two countries.

CONCLUSIONS/SIGNIFICANCE

The cost of illness for dengue fever is significant in the three countries. In particular, the current study sheds light on the potential economic burden of the disease in Burkina Faso and Kenya where existing evidence is sparse in the context of dengue fever, and underscores the need to achieve Universal Health Coverage. Given the availability of the current (CYD-TDV) and second-generation dengue vaccines in the near future, our study outcomes can be used to guide decision makers in setting health policy priorities.

Terrorist attack of 15 January 2016 in Ouagadougou: how resilient was Burkina Faso's health system?

In Africa, health systems are often not very responsive. Their resilience is often tested by health or geopolitical crises. The Ebola epidemic, for instance, exposed the fragility of health systems, and recent terrorist attacks have required countries to respond to urgent situations. Up until 2014, Burkina Faso's health system strongly resisted these pressures and reforms had always been minor. However, since late 2014, Burkina Faso has had to contend with several unprecedented crises. In October 2014, there was a popular insurrection. Then, in September 2015, the Security Regiment of the deposed president attempted a coup d'état. Finally, on 15 January 2016, a terrorist attack occurred in the capital, Ouagadougou. These events involved significant human injury and casualties. In these crises, the Burkinabè health system was sorely tried, testing its responsiveness, resiliency and adaptability. We describe the management of the recent terrorist attack from the standpoint of health system resilience. It would appear that the multiple crises that had occurred within the previous 2 years led to appropriate management of that terrorist attack thanks to the rapid mobilisation of personnel and good communication between centres. For example, the health system had put in place a committee and an emergency response plan, adapted blood bank services and psychology services, and made healthcare free for victims. Nevertheless, the system encountered several challenges, including the development of framework documents for resources (financial, material and human) and their use and coordination in crisis situations.