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Osei Afriyie D, Kwesiga B, Achungura G, Tediosi F, Fink G. Effects of Health Insurance on Quality of Care in Low-Income Countries: A Systematic Review. Public Health Rev 2023; 44:1605749. [PMID: 37635905 PMCID: PMC10447888 DOI: 10.3389/phrs.2023.1605749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 07/25/2023] [Indexed: 08/29/2023] Open
Abstract
Objectives: To evaluate the effectiveness of health insurance on quality of care in low-income countries (LICs). Methods: We conducted a systematic review following PRISMA guidelines. We searched seven databases for studies published between 2010 and August 2022. We included studies that evaluated the effects of health insurance on quality of care in LICs using randomized experiments or quasi-experimental study designs. Study outcomes were classified using the Donabedian framework. Results: We included 15 studies out of the 6,129 identified. Available evidence seems to suggest that health insurance has limited effects on structural quality, and its effects on the process of care remain mixed. At the population level, health insurance is linked to improved anthropometric measures for children and biomarkers such as blood pressure and hemoglobin levels. Conclusion: Based on the currently available evidence, it appears that health insurance in LICs has limited effects on the quality of care. Further studies are required to delve into the mechanisms that underlie the impact of health insurance on the quality of care and identify the most effective strategies to ensure quality within insurance programs. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=219984, identifier PROSPERO CRD42020219984.
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Affiliation(s)
- Doris Osei Afriyie
- Department of Epidemiology/Public Health, Swiss Tropical and Public Health Institute (Swiss TPH), Basel, Switzerland
- University of Basel, Basel, Switzerland
| | | | | | - Fabrizio Tediosi
- Department of Epidemiology/Public Health, Swiss Tropical and Public Health Institute (Swiss TPH), Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Günther Fink
- Department of Epidemiology/Public Health, Swiss Tropical and Public Health Institute (Swiss TPH), Basel, Switzerland
- University of Basel, Basel, Switzerland
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Balqis-Ali NZ, Jailani AS, Fun WH, Jawahir S, Sararaks S, Lee GHY. Effect of supplementary private health insurance on inpatient utilisation: Evidence from Malaysia. Heliyon 2023; 9:e14025. [PMID: 36879958 PMCID: PMC9984852 DOI: 10.1016/j.heliyon.2023.e14025] [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: 10/10/2022] [Revised: 02/16/2023] [Accepted: 02/20/2023] [Indexed: 02/25/2023] Open
Abstract
Supplementary private health insurance (PHI) provides better access to healthcare, improves health outcomes, potentially lowers the costs for health systems and supports the social security system. Improperly regulated PHI, however, may aggravate inequity of access towards preferential care and encourage moral hazard among PHI purchasers, altering the health-seeking behaviour, which is often observed through the pattern of health care utilisation. We investigated the effect of PHI ownership on private inpatient care utilisation, its frequency of admission and length of stay by conducting secondary data analysis of the Malaysian National Health Morbidity Survey (NHMS) 2015 data, a nationally representative community health survey. Malaysian adults 18 years of age and above who utilised inpatient healthcare facilities were included. In this cross-sectional study, we addressed the endogeneity effect of health insurance by employing instrumental variable estimation and a two-stage residual inclusion analysis. We found a significant increase in private inpatient utilisation among those who owned PHI compared to those who did not (β = 4.39, p < 0.001). There was no significant difference in the frequency of admission and length of stay. The increase in private inpatient utilisation among PHI owners may reflect the demand for timely care and hospitality provided by the private sector, potentially exacerbating the moral hazard behaviour among PHI owners. Further exploration of this issue could impact future healthcare systems financing designs and PHI regulation.
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Affiliation(s)
- Nur Zahirah Balqis-Ali
- Institute for Health Systems Research, National Institutes of Health, Ministry of Health, Block B2, No. 1, Jalan Setia Murni U13/52, Seksyen U13 Bandar Setia Alam, 40170 Shah Alam, Selangor Malaysia
| | - Anis-Syakira Jailani
- Institute for Health Systems Research, National Institutes of Health, Ministry of Health, Block B2, No. 1, Jalan Setia Murni U13/52, Seksyen U13 Bandar Setia Alam, 40170 Shah Alam, Selangor Malaysia
| | - Weng Hong Fun
- Institute for Health Systems Research, National Institutes of Health, Ministry of Health, Block B2, No. 1, Jalan Setia Murni U13/52, Seksyen U13 Bandar Setia Alam, 40170 Shah Alam, Selangor Malaysia
| | - Suhana Jawahir
- Institute for Health Systems Research, National Institutes of Health, Ministry of Health, Block B2, No. 1, Jalan Setia Murni U13/52, Seksyen U13 Bandar Setia Alam, 40170 Shah Alam, Selangor Malaysia
| | - Sondi Sararaks
- Institute for Health Systems Research, National Institutes of Health, Ministry of Health, Block B2, No. 1, Jalan Setia Murni U13/52, Seksyen U13 Bandar Setia Alam, 40170 Shah Alam, Selangor Malaysia
| | - Grace H Y Lee
- Department of Economics, School of Business, Monash University Malaysia, Jalan Lagoon Selatan, Bandar Sunway, 47500 Subang Jaya, Selangor Malaysia
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Marume A, Archary M, Mahomed S. Predictors of stunting among children aged 6-59 months, Zimbabwe. Public Health Nutr 2023; 26:1-14. [PMID: 36621006 PMCID: PMC10131138 DOI: 10.1017/s1368980023000046] [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: 04/02/2021] [Revised: 09/15/2022] [Accepted: 12/05/2022] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Stunted children have an increased risk of diminished cognitive development, diabetes, degenerative and CVD later in life. Numerous modifiable factors decrease the risk of stunting in children. This study aimed to assess the role of the individual, household and social factors on stunting in Zimbabwean children. DESIGN A 1:2 unmatched case-control study. SETTING This study was conducted in two predominantly rural provinces (one with the highest national prevalence of stunting and one with the lowest prevalence) in Zimbabwe. PARTICIPANTS Data were obtained from the caregivers of 150 children aged between 6 and 59 months with stunting and from the caregivers of 300 children without stunting. RESULTS Multiple (39) correlates of stunting were identified. Child's age, birth length, birth weight, and weight-for-age outcome (child-related factors), caregiver's age, maternal HIV status, occupation, and education (parental factors), breast-feeding status, number of meals, and dietary quality (dietary factors), child's appetite, diarrhoeal and worm infection (childhood illnesses), income status, access to safe water, access to a toilet, health clubs and maternal support in infant feeding (household, socio-cultural factors) were all found to be significant predictors of childhood stunting. CONCLUSION Nearly all aspects under review from the individual-, household- to social-level factors were significantly associated with childhood stunting. These findings add to the growing body of evidence supporting the WHO stunting framework and strengthen the need to focus interventions on a multi-sectoral approach to effectively address stunting in high prevalence countries.
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Affiliation(s)
- Anesu Marume
- College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
- Ministry of Health and Child Care, Parirenyatwa Hospital, A178 Avondale, Harare, Zimbabwe
| | - Moherndran Archary
- College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
- King Edward VIII Hospital, Durban, South Africa
| | - Saajida Mahomed
- College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
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Aziz N, Liu T, Yang S, Zukiewicz-Sobczak W. Causal relationship between health insurance and overall health status of children: Insights from Pakistan. Front Public Health 2022; 10:934007. [PMID: 36568764 PMCID: PMC9768499 DOI: 10.3389/fpubh.2022.934007] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 10/18/2022] [Indexed: 12/12/2022] Open
Abstract
Evaluating the impact of health insurance always remains a methodologically challenging endeavor due to the absence of sample randomization. This paper evaluates the impact of health insurance on the health status of children in Pakistan using the data of the Multiple Indicator Cluster Survey (MICS) for Punjab, Pakistan, from 2017 to 2018. The study adopted the propensity score matching (PSM) method to address the sample selection bias. The sample is matched on potential covariates such as mother characteristics (education level), household head characteristics (gender, age, and education), and other household conditions (such as home dwelling, internet access, wealth index, migration member, number of children residing in the home, as child illness, etc.). The findings revealed that children with insurance have considerably better health than non-insured, at a 1% significance level. The results confirm that health insurance is not a luxury but a need that improves children's overall health. In this regard, governments should enhance and expand programs related to health insurance, especially for children. Health insurance programs will not only help poor people but also improve the overall infrastructure of health services in the country.
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Affiliation(s)
- Noshaba Aziz
- School of Economics, Shandong University of Technology, Zibo, China
| | - Tinghua Liu
- School of Economics, Shandong University of Technology, Zibo, China
| | - Shaoxiong Yang
- College of Economics and Management, Northwest A&F University, Xianyang, China
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Nannini M, Biggeri M, Putoto G. Health Coverage and Financial Protection in Uganda: A Political Economy Perspective. Int J Health Policy Manag 2022; 11:1894-1904. [PMID: 34634869 PMCID: PMC9808243 DOI: 10.34172/ijhpm.2021.116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 08/23/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND As countries health financing policies are expected to support progress towards universal health coverage (UHC), an analysis of these policies is particularly relevant in low- and middle-income countries (LMICs). In 2001, the government of Uganda abolished user-fees to improve accessibility to health services for the population. However, after almost 20 years, the incidence of catastrophic health expenditures is still very high, and the health financing system does not provide a pooled prepayment scheme at national level such as an integrated health insurance scheme. This article aims at analysing the Ugandan experience of health financing reforms with a specific focus on financial protection. Financial protection represents a key pillar of UHC and has been central to health systems reforms even before the launch of the UHC definition. METHODS The qualitative study adopts a political economy perspective and it is based on a desk review of relevant documents and a multi-level stakeholder analysis based on 60 key informant interviews (KIIs) in the health sector. RESULTS We find that the current political situation is not yet conducive for implementing a UHC system with widespread financial protection: dominant interests and ideologies do not create a net incentive to implement a comprehensive scheme for this purpose. The health financing landscape remains extremely fragmented, and community-based initiatives to improve health coverage are not supported by a clear government stewardship. CONCLUSION By examining the negotiation process for health financing reforms through a political economy perspective, this article intends to advance the debate about politically-tenable strategies for achieving UHC and widespread financial protection for the population in LMICs.
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Affiliation(s)
- Maria Nannini
- Department of Economics and Management, University of Florence, Florence, Italy
| | - Mario Biggeri
- Department of Economics and Management, University of Florence, Florence, Italy
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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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Nshakira-Rukundo E, Mussa EC, Nshakira N, Gerber N, von Braun J. Impact of community-based health insurance on utilisation of preventive health services in rural Uganda: a propensity score matching approach. INTERNATIONAL JOURNAL OF HEALTH ECONOMICS AND MANAGEMENT 2021; 21:203-227. [PMID: 33566252 PMCID: PMC8192361 DOI: 10.1007/s10754-021-09294-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 01/25/2021] [Indexed: 06/12/2023]
Abstract
The effect of voluntary health insurance on preventive health has received limited research attention in developing countries, even when they suffer immensely from easily preventable illnesses. This paper surveys households in rural south-western Uganda, which are geographically serviced by a voluntary Community-based health insurance scheme, and applied propensity score matching to assess the effect of enrolment on using mosquito nets and deworming under-five children. We find that enrolment in the scheme increased the probability of using a mosquito net by 26% and deworming by 18%. We postulate that these findings are partly mediated by information diffusion and social networks, financial protection, which gives households the capacity to save and use service more, especially curative services that are delivered alongside preventive services. This paper provides more insight into the broader effects of health insurance in developing countries, beyond financial protection and utilisation of hospital-based services.
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Affiliation(s)
- Emmanuel Nshakira-Rukundo
- Center for Development Research (ZEF), University of Bonn, Genscherallee 3, 53117, Bonn, Germany.
- Institute for Food and Resource Economics, University of Bonn, Nussallee 19, 53115, Bonn, Germany.
| | - Essa Chanie Mussa
- Department of Agriculture Economics, University of Gondar, Gondar, Ethiopia
| | | | - Nicolas Gerber
- Center for Development Research (ZEF), University of Bonn, Genscherallee 3, 53117, Bonn, Germany
| | - Joachim von Braun
- Center for Development Research (ZEF), University of Bonn, Genscherallee 3, 53117, Bonn, Germany
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Hernández-Vásquez A, Pisfil-Benites N, Vargas-Fernández R, Azañedo D. Nutritional status and effective verbal communication in Peruvian children: A secondary analysis of the 2019 Demographic and Health Survey. PLoS One 2021; 16:e0246542. [PMID: 33600423 PMCID: PMC7891687 DOI: 10.1371/journal.pone.0246542] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 01/20/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND To estimate the impact of stunting on the development of effective verbal communication (EVC) in children aged 24 to 36 months. METHODS We conducted a retrospective, quasi-experimental study design using data from 4452 children between 24 and 36 months of age available in the Early Childhood Development (ECD) section of the Demographic and Family Health Survey (ENDES) 2019 survey. Achievement of EVC was considered as the dependent variable. After propensity score matching analysis, a total 601 children were included in the exposed (children with stunting) and 3848 in the unexposed group (children without stunting). The psmatch2 Stata software command was used to estimate the impact of stunting on EVC with a level of 5% for significance. RESULTS The EVC indicator was achieved by 57.4% of the children between 24 and 36 months of age evaluated, while the prevalence of stunting in this population was 14%. The evaluation of impact showed that the group exposed to stunting was 8% less likely to show EVC compared to the unexposed group (ATT -0.08; 95% CI -0.106 to -0.054; p<0.001). CONCLUSIONS The presence of stunting was found to have a significant impact on the propensity to show EVC in Peruvian children between 24 and 36 months of age. Strengthening of strategies for reducing malnutrition in vulnerable areas, as well as those directly affecting EVC is a priority for diminishing gaps in the achievement of this indicator in our country.
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Affiliation(s)
- Akram Hernández-Vásquez
- Centro de Excelencia en Investigaciones Económicas y Sociales, Vicerrectorado de Investigación, Universidad San Ignacio de Loyola, Lima, Peru
| | - Nilthon Pisfil-Benites
- Facultad de Economía y Planificación, Universidad Nacional Agraria de la Molina, Lima, Peru
| | | | - Diego Azañedo
- Instituto de Investigación, Universidad Católica los Ángeles de Chimbote, Chimbote, Peru
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