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Debalkie Atnafu D, Assefa Alemu Y. Multidimensional determinants of willingness to pay for community-based health insurance in Ethiopia and its implication towards universal health coverage: A narrative synthesis. Prev Med Rep 2023; 36:102474. [PMID: 38116251 PMCID: PMC10728330 DOI: 10.1016/j.pmedr.2023.102474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 09/12/2023] [Accepted: 10/11/2023] [Indexed: 12/21/2023] Open
Abstract
Pooling resources to pay for healthcare services and attain universal health coverage is a viable global agenda, especially for underdeveloped health systems. Ethiopia has implemented community-based health insurance (CBHI) since 2011 to improve healthcare funding. However, comprehensive evidence on the demand and determinants of health insurance in Ethiopia is lacking. Therefore, this review aimed at identifying determinants of willingness to pay (WTP) for CBHI in Ethiopia. A narrative review was conducted using search terms from PubMed, Science Direct, Scopus, African Journal Online, and Google Scholar databases. Screening process considered publication year, settings, English language, and study participants. Newcastle Ottawa tool assessed the quality of included studies. A thematic framework was applied. The review protocol was registered in PROSPERO with an ID number CRD42022296840. The review included 10 studies. The synthesis identified 25 determinants of WTP for CBHI in Ethiopia. Socio-demographic and economic, scheme-related, and health-related determinants of WTP for the CBHI were identified. Determinants of household WTP for CBHI in Ethiopia were multi-dimensional. Socio-demographic, socio-economic, scheme-related, and health-related factors are among the common determinants documented. CBHI is thus an alternative and potential source of financing for the healthcare system, primarily for people with low socioeconomic status and a fragile health system. The health system, socioeconomic leaders, and political figures play a significant role in influencing communities towards WTP for CBHI while increasing government spending on health toward UHC.
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Affiliation(s)
- Desta Debalkie Atnafu
- Department of Health System Management and Health Economics, School of Public Health, Bahir Dar University, Ethiopia
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Doshmangir L, Doshmangir P, Mobasseri K, Khodayari-Zarnaq R, Ahmadi Teymourlouy A, Sergeevich Gordeev V. Factors Affecting Health Policies for Older People in Iran. J Aging Soc Policy 2023; 35:859-881. [PMID: 37125863 DOI: 10.1080/08959420.2023.2205330] [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: 10/21/2021] [Accepted: 01/22/2023] [Indexed: 05/02/2023]
Abstract
Globally, the number and proportion of people aged 60 years and older is growing fast. As people age, health needs become more complex, and the health system's responsiveness to older people's needs requires evidence-informed policies. Hence, this study explores the factors affecting the health policy development process for older people in Iran. We conducted 32 interviewers with people aged 60 years and older and 21 interviews with key informants involved in policy making related to older people. Qualitative data were analyzed using thematic analysis. Actors and stakeholders, policy structure, selected health policy processes, the health care service delivery system, government financial support, and community and culture building are the most influential factors in health policy making for older people. Government policies and health priority interventions are needed to address these influential factors for older people to ensure healthy aging over the life course.
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Affiliation(s)
- Leila Doshmangir
- Department of Health Policy& Management, Tabriz Health Services Management Research Center, School of Management & Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
- Social Determinants of Health Research Center, Health Management &Safety Promotion Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Parinaz Doshmangir
- School of Public Health, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Khorshid Mobasseri
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
- Department of Geriatric Health, Tabriz University of Medical Sciences, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Rahim Khodayari-Zarnaq
- Department of Health Policy& Management, Tabriz Health Services Management Research Center, School of Management & Medical Informatics, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ahmad Ahmadi Teymourlouy
- Department of Health Services Management, School of Health Management & Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Vladimir Sergeevich Gordeev
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
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Alo CN, Akamike IC, Okedo-Alex IN, Nwonwu EU. Determinants of enrolment in health insurance scheme among HIV patients attending a clinic in a tertiary hospital in South-eastern Nigeria. Ghana Med J 2023; 57:13-18. [PMID: 37576375 PMCID: PMC10416277 DOI: 10.4314/gmj.v57i1.3] [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] [Indexed: 08/15/2023] Open
Abstract
Objective The study aimed to assess the determinants of enrolment in health insurance schemes among people living with HIV. Design The study was a cross-sectional study. A pre-tested interviewer-administered questionnaire was used to collect information from 371 HIV clients attending the clinic. Chi-square statistic was used for bi-variate analysis, and analytical decisions were considered significant at a p-value less than 0.05. Logistic regression was done to determine predictors of enrolment in health insurance. Setting The study was carried out in the HIV clinic of Alex Ekwueme Federal University Teaching Hospital Abakaliki, Nigeria. Participants HIV clients attending a clinic. Result Mean age of respondents was 45.4±10.3, and 51.8% were males. Almost all the respondents were Christians. Only 47.7% were married, and most lived in the urban area. Over 70% had at least secondary education, and only 34.5% were civil servants. About 60% of the respondents were enrolled in a health insurance scheme. Being single (AOR: 0.374, CI:0.204-0.688), being self-employed (AOR: 4.088, CI: 2.315-7.217), having a smaller family size (AOR: 0.124, CI: 0.067-0.228), and having the higher income (AOR: 4.142, CI: 2.07-8.286) were predictors of enrolment in a health insurance scheme. Conclusion The study has shown that enrolment in a health insurance scheme is high among PLHIV, and being single, self-employed, having a smaller family size, and having a higher monthly income are predictors of enrolment in the health insurance scheme. Increasing the number of dependants that can be enrolled so that larger families can be motivated to enrol in health insurance is recommended. Funding None declared.
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Affiliation(s)
- Chihurumnanya N Alo
- Department of Community Medicine, Alex Ekwueme Federal University Teaching Hospital Abakaliki Ebonyi State Nigeria
- Department of Community Medicine, Ebonyi State University, Abakaliki, Nigeria
| | - Ifeyinwa C Akamike
- Department of Community Medicine, Alex Ekwueme Federal University Teaching Hospital Abakaliki Ebonyi State Nigeria
| | - Ijeoma N Okedo-Alex
- Department of Community Medicine, Alex Ekwueme Federal University Teaching Hospital Abakaliki Ebonyi State Nigeria
| | - Elizabeth U Nwonwu
- Department of Community Medicine, Alex Ekwueme Federal University Teaching Hospital Abakaliki Ebonyi State Nigeria
- Department of Community Medicine, Ebonyi State University, Abakaliki, Nigeria
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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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Fan X, Su M, Zhao Y, Si Y, Wang D. Effect of Health Insurance Policy on the Health Outcomes of the Middle-Aged and Elderly: Progress Toward Universal Health Coverage. Front Public Health 2022; 10:889377. [PMID: 35937260 PMCID: PMC9354596 DOI: 10.3389/fpubh.2022.889377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 06/13/2022] [Indexed: 11/13/2022] Open
Abstract
This population-based study aims to explore the effect of the integration of the Urban and Rural Residents' Basic Medical Insurance (URRBMI) policy on the health outcomes of the middle-aged and elderly. A total of 13,360 participants in 2011 and 15,082 participants in 2018 were drawn from the China Health and Retirement Longitudinal Study. Health outcomes were evaluated using the prevalence of chronic diseases. A generalized linear mixed model was used to analyze the effect of the URRBMI policy on the prevalence of chronic disease. Prior to the introduction of the URRBMI policy, 67.09% of the rural participants and 73.00% of the urban participants had chronic diseases; after the policy's implementation, 43.66% of the rural participants and 45.48% of the urban participants had chronic diseases. When adjusting for the confounding factors, the generalized linear mixed model showed that the risk of having a chronic disease decreased by 81% [odds ratio (OR) = 0.19; 95% confidence interval (CI): 0.16, 0.23] after the introduction of the policy in the urban participants; in the rural participants, the risk of having a chronic disease was 30% lower (OR = 0.70; 95% CI: 0.60, 0.82) than the risk in the urban participants before the policy and 84% lower (OR = 0.16; 95% CI: 0.14, 0.19) after the implementation of the policy; the differences in the ORs decreased from 0.30 prior to the policy to 0.03 after the policy had been introduced between rural and urban participants when adjusting for the influence of socioeconomic factors on chronic diseases. This study provides evidence of the positive effects of the URRBMI policy on improving the rural population's health outcomes and reducing the gap in health outcomes between rural and urban populations, indicating that the implementation of the URRBMI policy has promoted the coverage of universal health.
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Affiliation(s)
- Xiaojing Fan
- School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, China
| | - Min Su
- School of Public Administration, Inner Mongolia University, Hohhot, China
- *Correspondence: Min Su
| | - Yaxin Zhao
- School of Public Health, Xi'an Jiaotong University Health Science Centre, Xi'an, China
| | - Yafei Si
- School of Risk and Actuarial Studies and Centre of Excellence in Population Aging Research (CEPAR), University of New South Wales, Kensington, NSW, Australia
| | - Duolao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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Bhatia D, Mishra S, Kirubarajan A, Yanful B, Allin S, Di Ruggiero E. Identifying priorities for research on financial risk protection to achieve universal health coverage: a scoping overview of reviews. BMJ Open 2022; 12:e052041. [PMID: 35264342 PMCID: PMC8915291 DOI: 10.1136/bmjopen-2021-052041] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Financial risk protection (FRP) is an indicator of the Sustainable Development Goal 3 universal health coverage (UHC) target. We sought to characterise what is known about FRP in the UHC context and to identify evidence gaps to prioritise in future research. DESIGN Scoping overview of reviews using the Arksey & O'Malley and Levac & Colquhoun framework and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews reporting guidelines. DATA SOURCES MEDLINE, PsycINFO, CINAHL-Plus and PAIS Index were systematically searched for studies published between 1 January 1995 and 20 July 2021. ELIGIBILITY CRITERIA Records were screened by two independent reviewers in duplicate using the following criteria: (1) literature review; (2) focus on UHC achievement through FRP; (3) English or French language; (4) published after 1995 and (5) peer-reviewed. DATA EXTRACTION AND SYNTHESIS Two reviewers extracted data using a standard form and descriptive content analysis was performed to synthesise findings. RESULTS 50 studies were included. Most studies were systematic reviews focusing on low-income and middle-income countries. Study periods spanned 1990 and 2020. While FRP was recognised as a dimension of UHC, it was rarely defined as a concept. Out-of-pocket, catastrophic and impoverishing health expenditures were most commonly used to measure FRP. Pooling arrangements, expansion of insurance coverage and financial incentives were the main interventions for achieving FRP. Evidence gaps pertained to the effectiveness, cost-effectiveness and equity implications of efforts aimed at increasing FRP. Methodological gaps related to trade-offs between single-country and multicountry analyses; lack of process evaluations; inadequate mixed-methods evidence, disaggregated by relevant characteristics; lack of comparable and standardised measurement and short follow-up periods. CONCLUSIONS This scoping overview of reviews characterised what is known about FRP as a UHC dimension and found evidence gaps related to the effectiveness, cost-effectiveness and equity implications of FRP interventions. Theory-informed mixed-methods research using high-quality, longitudinal and disaggregated data is needed to address these objectives.
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Affiliation(s)
- Dominika Bhatia
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Sujata Mishra
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Abirami Kirubarajan
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Bernice Yanful
- Public Health Sciences Division, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Sara Allin
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Erica Di Ruggiero
- Public Health Sciences Division, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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Vu M, Huynh VN, Berg CJ, Allen CG, Nguyen PLH, Tran NA, Srivanjarean Y, Escoffery C. Hepatitis B Testing Among Vietnamese in Metropolitan Atlanta: The Role of Healthcare-Related and Acculturation-Related Factors. J Community Health 2021; 46:767-776. [PMID: 33180219 PMCID: PMC8113341 DOI: 10.1007/s10900-020-00947-0] [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] [Accepted: 10/31/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Compared to other racial/ethnic groups, U.S. Vietnamese have higher Hepatitis B infection prevalence, which is a major liver cancer risk factor. Increased testing could reduce this disparity. It is critical to understand subgroups of U.S. Vietnamese least likely to have been tested for Hepatitis B and design appropriate interventions. We examined healthcare- and acculturation-related factors influencing Hepatitis B testing among U.S. Vietnamese. METHODS Survey data of 100 U.S. Vietnamese attending health fairs/programs hosted by community-based organizations (2017-2018) were analyzed. Healthcare-related predictors included insurance and past 2-year checkup. Acculturation-related predictors included Vancouver Acculturation Index, percentage of lifetime in the U.S., and Vietnamese and English fluency. We conducted a multiple logistic regression controlling for age, sex, education, and household income. RESULTS The sample was an average 37.5 years old and 61.6% female. Insurance coverage was reported by 83.0%. Average percentage of lifetime in the U.S. was 56.8%. Seventy percent reported having received Hepatitis B testing. Hepatitis B testing was associated with health insurance (aOR = 2.61, 95% CI = [1.05-6.47], p = .04) but not any acculturation-related predictors CONCLUSION: Improving insurance coverage and options can be a strategy to increase Hepatitis B testing among U.S. Vietnamese. More education regarding Hepatitis B (e.g., via community-based, culturally-appropriate, lay health worker-led programs) is needed to ensure that individuals are aware of their testing status and pursue appropriate healthcare decisions.
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Affiliation(s)
- Milkie Vu
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, 1518 Clifton Rd NE, Atlanta, GA, 30322, USA.
| | - Victoria N Huynh
- Emory College of Arts & Sciences, Emory University, Atlanta, GA, USA
| | - Carla J Berg
- Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, D.C, USA
| | - Caitlin G Allen
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, 1518 Clifton Rd NE, Atlanta, GA, 30322, USA
| | | | - Ngoc-Anh Tran
- Nguyen Hue High School for the Gifted, Hanoi, Vietnam
| | | | - Cam Escoffery
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, 1518 Clifton Rd NE, Atlanta, GA, 30322, USA
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Li C, Tang C, Wang H. Investigating the association of health system characteristics and health care utilization: a multilevel model in China's ageing population. J Glob Health 2020; 10:020802. [PMID: 33312509 PMCID: PMC7719298 DOI: 10.7189/jogh.10.020802] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background To achieve universal health coverage in China, it is necessary to identify access barriers to health care. This study examined the association between health system characteristics and health care utilization in China and identified factors associated with accessing health care among the mid-aged and elderly. Methods Data were obtained from the 2015 China Health and Retirement Longitudinal Study, and 17 370 respondents aged 45 and above were included in the analysis. The dependent variables were the use of outpatient and inpatient care among respondents. Health system characteristics at the provincial level were measured using the density of doctors and ward beds, health expenditure per visit/admission and health financing. A two-level logistic regression model was constructed to examine association between health care utilization and health system characteristics, controlling for predisposing, enabling and need variables. Results Of the 17 370 respondents, 18.3% had utilized outpatient care and 13.7% had utilized inpatient care in 2015. Increases in the share of out-of-pocket (OOP) payments as total health spending at the provincial-level was less likely to be associated with outpatient care utilization (odds ratio (OR) = 0.96, 95% confidence interval (CI) = 0.93-0.98) among the mid-age and elderly population. Increases in the share of OOP payments (OR = 0.98, 95% CI = 0.97-1.00) and health expenditure per admission (OR = 0.20, 95% CI = 0.04-0.88) were less likely to be associated with inpatient care utilization, while increases in the density of beds (OR = 1.26, 95% CI = 1.10-1.43) was more likely to be associated with inpatient care utilization. gross domestic product (GDP) per capita at the provincial level and types of health insurance owned by respondents were significantly related to both inpatient and outpatient care utilization. Conclusions Low affordability of the mid-aged and elderly population is the main barrier to utilizing health care in China. In order to improve access to health care, the government should make more efforts, such as improving health insurance reimbursement rates and implementing prospective provider payment methods, to decrease OOP payment for the ageing population.
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Affiliation(s)
- Chaofan Li
- Tsinghua Shenzhen International Graduate School, Tsinghua University, Shenzhen, Guangdong, China
| | - Chengxiang Tang
- School of Public Administration, Guangzhou University, Guangzhou, Guangdong, China
| | - Haipeng Wang
- Centre for Health Management and Policy Research, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China.,NHC Key Laboratory of Health Economics and Policy Research (Shandong University), Jinan, Shandong, China
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Chanie MG, Ewunetie GE. Determinants of enrollment in community based health insurance among Households in Tach-Armachiho Woreda, North Gondar, Ethiopia, 2019. PLoS One 2020; 15:e0236027. [PMID: 32866152 PMCID: PMC7458327 DOI: 10.1371/journal.pone.0236027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 06/27/2020] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Recently in Ethiopia, there is an increasing movement to implement community based health insurance scheme as integral part of health care financing and remarkable movements has resulted in the spread of the scheme in different parts of the country. Despite such increasing effort, recent empirical evidence shows enrolment has remained low. To identify determinants of enrollment in community based health insurance among households in Tach-Armachiho Woreda, North Gondar, Ethiopia, 2019. METHODS A community based unmatched case control study was conducted Tach-Armachiho Woreda from March to May 2019 among 262 participants (88 cases and 174 controls with case control ratio of 1:2). Study subjects were selected using multi-stage sampling technique. Data were collected using a pretested, structured interviewer administered questioner. Data were entered to Epi-info 7 and exported to SPSS version 20 for analysis. Bivariable and multivariable logistic regression model were used to see the determinants of enrollment in community based health insurance. Adjusted odds ratio with 95% CI at p-value <0.05 in multivariable logistics regression analysis factors were identified as statistically significantly associated. RESULT Female headed households (AOR = 2.79, 95% CI = 1.16, 6.69), Increase in Age (AOR = 1.09, 95% CI = 1.05, 1.13) and negative perception towards community based health insurance (AOR = 0.062, 95% CI = .030, .128) were found to be significant predictors. CONCLUSION This study provides evidence that the decision to enroll in the scheme is shaped by age and a combination of household head sex and perception towards community based health insurance. Implementers aimed at enhancing enrolment ought to act on the bases of this findings.
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Affiliation(s)
- Muluken Genetu Chanie
- School of Public Health, College of Medicine and Health Sciences, Wollo University, Addis Ababa, Ethiopia
| | - Gojjam Eshetie Ewunetie
- Department of Medical Laboratory Sciences, Denbya Primary Hospital, North Gondar, Amhara Regional State, Ethiopia
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Nandi S, Schneider H. Using an equity-based framework for evaluating publicly funded health insurance programmes as an instrument of UHC in Chhattisgarh State, India. Health Res Policy Syst 2020; 18:50. [PMID: 32450870 PMCID: PMC7249418 DOI: 10.1186/s12961-020-00555-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 03/27/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Universal health coverage (UHC) has provided the impetus for the introduction of publicly funded health insurance (PFHI) schemes in the mixed health systems of India and many other low- and middle-income countries. There is a need for a holistic understanding of the pathways of impact of PFHI schemes, including their role in promoting equity of access. METHODS This paper applies an equity-oriented evaluation framework to assess the impacts of PFHI schemes in Chhattisgarh State by synthesising literature from various sources and highlighting knowledge gaps. Data were collected from an extensive review of publications on PFHI schemes in Chhattisgarh since 2009, including empirical studies from the first author's PhD and grey literature such as programme evaluation reports, media articles and civil society campaign documents. The framework was constructed using concepts and frameworks from the health policy and systems research literature on UHC, access and health system building blocks, and is underpinned by the values of equity, human rights and the right to health. RESULTS The analysis finds that evidence of equitable enrolment in Chhattisgarh's PFHI scheme may mask many other inequities. Firstly, equitable enrolment does not automatically lead to the acceptability of the scheme for the poor or to equity in utilisation. Utilisation, especially in the private sector, is skewed towards the areas that have the least health and social need. Secondly, related to this, resource allocation patterns under PFHI deepen the 'infrastructure inequality trap', with resources being effectively transferred from tribal and vulnerable to 'better-off' areas and from the public to the private sector. Thirdly, PFHI fails in its fundamental objective of effective financial protection. Technological innovations, such as the biometric smart card and billing systems, have not provided the necessary safeguards nor led to greater accountability. CONCLUSION The study shows that development of PFHI schemes, within the context of wider neoliberal policies promoting private sector provisioning, has negative consequences for health equity and access. More research is needed on key knowledge gaps related to the impact of PFHI schemes on health systems. An over-reliance on and rapid expansion of PFHI schemes in India is unlikely to achieve UHC.
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Affiliation(s)
- Sulakshana Nandi
- School of Public Health, University of the Western Cape, Bellville, South Africa
- Public Health Resource Network, 29, New Panchsheel Nagar, Raipur, Chhattisgarh 492001 India
| | - Helen Schneider
- School of Public Health, UWC/MRC Health Services to Systems Unit, University of the Western Cape, Bellville, South Africa
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Serra G, Miceli V, Albano S, Corsello G. Perinatal and newborn care in a two years retrospective study in a first level peripheral hospital in Sicily (Italy). Ital J Pediatr 2019; 45:152. [PMID: 31783883 PMCID: PMC6884854 DOI: 10.1186/s13052-019-0751-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 11/21/2019] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Two hundred seventy-five thousand maternal deaths, 2.7 million neonatal deaths, and 2.6 million stillbirths have been estimated in 2015 worldwide, almost all in low-income countries (LICs). Moreover, more than 20 million severe disabilities result from the complications of pregnancy, childbirth or its management each year. A significant decrease of mortality/morbidity rates could be achieved by providing effective perinatal and newborn care also in high-income countries (HICs), especially in peripheral hospitals and/or rural areas, where the number of childbirths per year is often under the minimal threshold recognized by the reference legislation. We report on a 2 years retrospective cohort study, conducted in a first level peripheral hospital in Cefalù, a small city in Sicily (Italy), to evaluate care provided and mortality/morbidity rates. The proposed goal is to improve the quality of care, and the services that peripheral centers can offer. METHODS We collected data from maternity and neonatal records, over a 2-year period from January 2017 to December 2018. The informations analyzed were related to demographic features (age, ethnicity/origin area, residence, educational level, marital status), diagnosis at admission (attendance of birth training courses, parity, type of pregnancy, gestational age, fetal presentation), mode of delivery, obstetric complications, the weight of the newborns, their feeding and eventual transfer to II level hospitals, also through the Neonatal Emergency Transport Service, if the established criteria were present. RESULTS Eight hundred sixteen women were included (age 18-48 years). 179 (22%) attended birth training courses. 763 (93%) were Italian, 53 foreign (7%). 175 (21%) came from outside the province of Palermo. Eight hundred ten were single pregnancies, 6 bigeminal; 783 were at term (96%), 33 preterm (4%, GA 30-41 WG); 434 vaginal deliveries (53%), 382 caesarean sections (47%). One maternal death and 28 (3%) obstetric complications occurred during the study period. The total number of children born to these women was 822, 3 of which stillbirths (3.6‰). 787 (96%) were born at term (>37WG), 35 preterm (4%), 31 of which late preterm. Twenty-one newborns (2.5%) were transferred to II level hospitals. Among them, 3 for moderate/severe prematurity, 18 for mild prematurity/other pathology. The outcome was favorable for all women (except 1 hysterectomy) and the newborns transferred, and no neonatal deaths occurred in the biennium under investigation. Of the remaining 798 newborns, 440 were breastfed at discharge (55%), 337 had a mixed feeding (breastfed/formula fed, 42%) and 21 were formula fed (3%). CONCLUSIONS Although the minimal standard of adequate perinatal care in Italy is >500 childbirths/year, the aims of the Italian legislation concern the rationalization of birth centers as well as the structural, technological and organizational improvement of health facilities. Therefore, specific contexts and critical areas need to be identified and managed. Adequate resources and intervention strategies should be addressed not only to perinatal emergencies, but also to the management of mild prematurity/pathology, especially in vulnerable populations for social or orographic reasons. The increasing availability and spread of health care offers, even in HICs, cannot be separated from the goal of quality of care, which is an ethic and public health imperative.
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Affiliation(s)
- Gregorio Serra
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties "G. D'Alessandro", University of Palermo, Palermo, Italy. .,"G. Giglio" Hospital Institute Foundation, Cefalù, Italy.
| | | | | | - Giovanni Corsello
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties "G. D'Alessandro", University of Palermo, Palermo, Italy
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van Hees SGM, O'Fallon T, Hofker M, Dekker M, Polack S, Banks LM, Spaan EJAM. Leaving no one behind? Social inclusion of health insurance in low- and middle-income countries: a systematic review. Int J Equity Health 2019; 18:134. [PMID: 31462303 PMCID: PMC6714392 DOI: 10.1186/s12939-019-1040-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 08/19/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND One way to achieve universal health coverage (UHC) in low- and middle-income countries (LMIC) is the implementation of health insurance schemes. A robust and up to date overview of empirical evidence assessing and substantiating health equity impact of health insurance schemes among specific vulnerable populations in LMICs beyond the more common parameters, such as income level, is lacking. We fill this gap by conducting a systematic review of how social inclusion affects access to equitable health financing arrangements in LMIC. METHODS We searched 11 databases to identify peer-reviewed studies published in English between January 1995 and January 2018 that addressed the enrolment and impact of health insurance in LMIC for the following vulnerable groups: female-headed households, children with special needs, older adults, youth, ethnic minorities, migrants, and those with a disability or chronic illness. We assessed health insurance enrolment patterns of these population groups and its impact on health care utilization, financial protection, health outcomes and quality of care. RESULTS The comprehensive database search resulted in 44 studies, in which chronically ill were mostly reported (67%), followed by older adults (33%). Scarce and inconsistent evidence is available for individuals with disabilities, female-headed households, ethnic minorities and displaced populations, and no studies were yielded reporting on youth or children with special needs. Enrolment rates seemed higher among chronically ill and mixed or insufficient results are observed for the other groups. Most studies reporting on health care utilization found an increase in health care utilization for insured individuals with a disability or chronic illness and older adults. In general, health insurance schemes seemed to prevent catastrophic health expenditures to a certain extent. However, reimbursements rates were very low and vulnerable individuals had increased out of pocket payments. CONCLUSION Despite a sizeable literature published on health insurance, there is a dearth of good quality evidence, especially on equity and the inclusion of specific vulnerable groups in LMIC. Evidence should be strengthened within health care reform to achieve UHC, by redefining and assessing vulnerability as a multidimensional process and the investigation of mechanisms that are more context specific.
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Affiliation(s)
- Suzanne G M van Hees
- Radboud Institute for Health Sciences (RIHS), Department for Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands.
- Department of Work and Health, HAN University of Applied Sciences, Kapittelweg 33, P.O. Box 6960, 6503GL, Nijmegen, Netherlands.
| | - Timothy O'Fallon
- International Centre for Evidence in Disability, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Marleen Dekker
- African Studies Center, Leiden University, Leiden, The Netherlands
| | - Sarah Polack
- International Centre for Evidence in Disability, London School of Hygiene and Tropical Medicine, London, UK
| | - Lena Morgon Banks
- International Centre for Evidence in Disability, London School of Hygiene and Tropical Medicine, London, UK
| | - Ernst J A M Spaan
- Radboud Institute for Health Sciences (RIHS), Department for Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands
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Enhancing Equitable Access to Assistive Technologies in Canada: Insights from Citizens and Stakeholders. Can J Aging 2019; 39:69-88. [DOI: 10.1017/s0714980819000187] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
RÉSUMÉLes besoins en technologies d’assistance augmentent au Canada, mais l’accès à ces technologies est inégal et fragmentaire, ce qui ferait en sorte que des besoins demeureraient non comblés. Cette étude visait à identifier les valeurs et préférences des citoyens concernant les moyens à utiliser pour favoriser un accès équitable aux technologies d’assistance. Elle visait également à impliquer les décideurs politiques, les parties prenantes et les chercheurs dans des discussions afin d’élaborer des actions dans ce domaine. Au printemps 2017, nous avons organisé trois panels de citoyens et un dialogue avec les parties prenantes. Les principales conclusions des panels ont été incluses dans une synthèse qui a été partagée avec les participants du dialogue. Trente-sept citoyens ont participé aux panels et ont souligné l’importance de l’accès à de l’information fiable, d’un accès équitable aux technologies d’assistance (et ce, quelle que soit la capacité de payer), et de la collaboration. Les vingt-deux participants au dialogue ont fait valoir la nécessité d’un cadre d’orientation pour appuyer l’évolution des pratiques dans l’ensemble au pays. Le cadre d’orientation proposé combinerait des politiques et programmes simplifiés incluant la collecte et l’évaluation de données robustes pour appuyer l’innovation et l’imputabilité à travers le pays.
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Abubakar I, Aldridge RW, Devakumar D, Orcutt M, Burns R, Barreto ML, Dhavan P, Fouad FM, Groce N, Guo Y, Hargreaves S, Knipper M, Miranda JJ, Madise N, Kumar B, Mosca D, McGovern T, Rubenstein L, Sammonds P, Sawyer SM, Sheikh K, Tollman S, Spiegel P, Zimmerman C. The UCL-Lancet Commission on Migration and Health: the health of a world on the move. Lancet 2018; 392:2606-2654. [PMID: 30528486 PMCID: PMC7612863 DOI: 10.1016/s0140-6736(18)32114-7] [Citation(s) in RCA: 398] [Impact Index Per Article: 66.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 08/27/2018] [Accepted: 08/29/2018] [Indexed: 12/22/2022]
Abstract
With one billion people on the move or having moved in 2018, migration is a global reality, which has also become a political lightning rod. Although estimates indicate that the majority of global migration occurs within low-income and middle-income countries (LMICs), the most prominent dialogue focuses almost exclusively on migration from LMICs to high-income countries (HICs). Nowadays, populist discourse demonises the very same individuals who uphold economies, bolster social services, and contribute to health services in both origin and destination locations. Those in positions of political and economic power continue to restrict or publicly condemn migration to promote their own interests. Meanwhile nationalist movements assert so-called cultural sovereignty by delineating an us versus them rhetoric, creating a moral emergency. In response to these issues, the UCL-Lancet Commission on Migration and Health was convened to articulate evidence-based approaches to inform public discourse and policy. The Commission undertook analyses and consulted widely, with diverse international evidence and expertise spanning sociology, politics, public health science, law, humanitarianism, and anthropology. The result of this work is a report that aims to be a call to action for civil society, health leaders, academics, and policy makers to maximise the benefits and reduce the costs of migration on health locally and globally. The outputs of our work relate to five overarching goals that we thread throughout the report. First, we provide the latest evidence on migration and health outcomes. This evidence challenges common myths and highlights the diversity, dynamics, and benefits of modern migration and how it relates to population and individual health. Migrants generally contribute more to the wealth of host societies than they cost. Our Article shows that international migrants in HICs have, on average, lower mortality than the host country population. However, increased morbidity was found for some conditions and among certain subgroups of migrants, (eg, increased rates of mental illness in victims of trafficking and people fleeing conflict) and in populations left behind in the location of origin. Currently, in 2018, the full range of migrants’ health needs are difficult to assess because of poor quality data. We know very little, for example, about the health of undocumented migrants, people with disabilities, or lesbian, gay, bisexual, transsexual, or intersex (LGBTI) individuals who migrate or who are unable to move. Second, we examine multisector determinants of health and consider the implication of the current sector-siloed approaches. The health of people who migrate depends greatly on structural and political factors that determine the impetus for migration, the conditions of their journey, and their destination. Discrimination, gender inequalities, and exclusion from health and social services repeatedly emerge as negative health influences for migrants that require cross-sector responses. Third, we critically review key challenges to healthy migration. Population mobility provides economic, social, and cultural dividends for those who migrate and their host communities. Furthermore, the right to the highest attainable standard of health, regardless of location or migration status, is enshrined in numerous human rights instruments. However, national sovereignty concerns overshadow these benefits and legal norms. Attention to migration focuses largely on security concerns. When there is conjoining of the words health and migration, it is either focused on small subsets of society and policy, or negatively construed. International agreements, such as the UN Global Compact for Migration and the UN Global Compact on Refugees, represent an opportunity to ensure that international solidarity, unity of intent, and our shared humanity triumphs over nationalist and exclusionary policies, leading to concrete actions to protect the health of migrants. Fourth, we examine equity in access to health and health services and offer evidence-based solutions to improve the health of migrants. Migrants should be explicitly included in universal health coverage commitments. Ultimately, the cost of failing to be health-inclusive could be more expensive to national economies, health security, and global health than the modest investments required. Finally, we look ahead to outline how our evidence can contribute to synergistic and equitable health, social, and economic policies, and feasible strategies to inform and inspire action by migrants, policy makers, and civil society. We conclude that migration should be treated as a central feature of 21st century health and development. Commitments to the health of migrating populations should be considered across all Sustainable Development Goals (SDGs) and in the implementation of the Global Compact for Migration and Global Compact on Refugees. This Commission offers recommendations that view population mobility as an asset to global health by showing the meaning and reality of good health for all. We present four key messages that provide a focus for future action.
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Affiliation(s)
- Ibrahim Abubakar
- Institute for Global Health, University College London, London, UK.
| | - Robert W Aldridge
- Institute for Health Informatics, University College London, London, UK
| | - Delan Devakumar
- Institute for Global Health, University College London, London, UK
| | - Miriam Orcutt
- Institute for Global Health, University College London, London, UK
| | - Rachel Burns
- Institute for Global Health, University College London, London, UK
| | - Mauricio L Barreto
- Centre for Data and Knowledge Integration for Health, Fundação Oswaldo Cruz, Salvador-Bahia, Brazil
| | - Poonam Dhavan
- International Organization for Migration, Geneva, Switzerland
| | - Fouad M Fouad
- Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Nora Groce
- Leonard Cheshire Centre, Institute of Epidemiology and Healthcare, University College London, London, UK
| | - Yan Guo
- School of Public Health, Peking University, Beijing, China
| | - Sally Hargreaves
- Institute of Infection and Immunity, St George's, University of London, London, UK; International Health Unit, Section of Infectious Diseases and Immunity, Imperial College London, London, UK
| | - Michael Knipper
- Institute for the History of Medicine, Justus Liebig University Giessen, Giessen, Germany
| | - J Jaime Miranda
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Nyovani Madise
- African Institute for Development Policy, Lilongwe, Malawi; Centre for Global Health, Population, Poverty and Policy, University of Southampton, Southampton, UK
| | - Bernadette Kumar
- Norwegian Centre for Minority Health Research, Oslo, Norway; Department of Community Medicine and Global Health, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Davide Mosca
- International Organization for Migration, Geneva, Switzerland
| | - Terry McGovern
- Program on Global Health Justice and Governance, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Leonard Rubenstein
- Center for Public Health and Human Rights, Johns Hopkins University, Baltimore, MD, USA; Johns Hopkins Bloomberg School of Public Health, and Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
| | - Peter Sammonds
- Institute for Risk and Disaster Reduction, University College London, London, UK
| | - Susan M Sawyer
- Department of Paediatrics, University of Melbourne, University of Melbourne, Parkville, VIC, Australia; Centre for Adolescent Health, and Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC, Australia
| | - Kabir Sheikh
- Public Health Foundation of India, Institutional Area Gurgaon, India; Nossal Institute of Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - Stephen Tollman
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Paul Spiegel
- Department of International Health, Johns Hopkins University, Baltimore, MD, USA; Johns Hopkins Center for Humanitarian Health, Johns Hopkins University, Baltimore, MD, USA
| | - Cathy Zimmerman
- Gender, Violence and Health Centre, London School of Hygiene and Tropical Medicine, London, UK
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Kansanga MM, Asumah Braimah J, Antabe R, Sano Y, Kyeremeh E, Luginaah I. Examining the association between exposure to mass media and health insurance enrolment in Ghana. Int J Health Plann Manage 2018; 33:e531-e540. [DOI: 10.1002/hpm.2505] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 01/19/2018] [Accepted: 01/22/2018] [Indexed: 11/08/2022] Open
Affiliation(s)
| | | | - Roger Antabe
- Department of GeographyWestern University London Ontario Canada
| | - Yuji Sano
- Department of SociologyWestern University London Ontario Canada
| | | | - Isaac Luginaah
- Department of GeographyWestern University London Ontario Canada
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16
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Kandel N. Nepal Health Insurance Bill: Possible Challenges and Way Forwards. JNMA J Nepal Med Assoc 2018; 56:633-639. [PMID: 30376011 PMCID: PMC8997309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Nepal has one of the highest proportions of out of pocket expenditures on health and one quarter of the people is living below poverty line. In recent time, there is some increase of the health budget but country still relies on development partners. The endorsement of the national health insurance bill has enabled government to establish the national health insurance scheme through development of adequate policies, strategies and mechanisms for implementation at national and federal level. The scheme has many challenges to address on governance and leadership, financing, information, health services, workforce, and essential medicines and technologies. Therefore, it is imperative to establish a robust mechanism like a "tree", which has strong roots of building blocks of health systems, which produces fruits that ensure improved responsiveness, efficiency and equity and financial protection. It is necessary to learn and apply from the experiences of other countries while implementing the national health insurance scheme. Keywords: bill; health; insurance; Nepal.
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Affiliation(s)
- Nirmal Kandel
- Public Health Specialist, Geneva, Switzerland,Correspondence: Dr. Nirmal Kandel, Public Health Specialist, Geneva, Switzerland.
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Nandi S, Schneider H, Dixit P. Hospital utilization and out of pocket expenditure in public and private sectors under the universal government health insurance scheme in Chhattisgarh State, India: Lessons for universal health coverage. PLoS One 2017; 12:e0187904. [PMID: 29149181 PMCID: PMC5693461 DOI: 10.1371/journal.pone.0187904] [Citation(s) in RCA: 37] [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: 04/04/2017] [Accepted: 10/28/2017] [Indexed: 11/19/2022] Open
Abstract
Research on impact of publicly financed health insurance has paid relatively little attention to the nature of healthcare provision the schemes engage. India's National Health Insurance Scheme or RSBY was made universal by Chhattisgarh State in 2012. In the State, public and private sectors provide hospital services in a context of extensive gender, social, economic and geographical inequities. This study examined enrolment, utilization (public and private) and out of pocket (OOP) expenditure for the insured and uninsured, in Chhattisgarh. The Chhattisgarh State Central sample (n = 6026 members) of the 2014 National Sample Survey (71st Round) on Health was extracted and analyzed. Variables of enrolment, hospitalization, out of pocket (OOP) expenditure and catastrophic expenditure were descriptively analyzed. Multivariate analyses of factors associated with enrolment, hospitalization (by sector) and OOP expenditure were conducted, taking into account gender, socio-economic status, residence, type of facility and ailment. Insurance coverage was 38.8%. Rates of hospitalization were 33/1000 population among the insured and 29/1000 among the uninsured. Of those insured and hospitalized, 67.2% utilized the public sector. Women, rural residents, Scheduled Tribes and poorer groups were more likely to utilize the public sector for hospitalizations. Although the insured were less likely to incur out of pocket (OOP) expenditure, 95.1% of insured private sector users and 66.0% of insured public sector users, still incurred costs. Median OOP payments in the private sector were eight times those in the public sector. Of households with at least one member hospitalized, 35.5% experienced catastrophic health expenditures (>10% monthly household consumption expenditure). The study finds that despite insurance coverage, the majority still incurred OOP expenditure. The public sector was nevertheless less expensive, and catered to the more vulnerable groups. It suggests the need to further examine the roles of public and private sectors in financial risk protection through government health insurance.
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Affiliation(s)
- Sulakshana Nandi
- Public Health Resource Network, India, Raipur, Chhattisgarh, India
- School of Public Health, University of the Western Cape, Bellville, South Africa
| | - Helen Schneider
- School of Public Health, UWC/MRC Health Services to Systems Unit, University of the Western Cape, Bellville, South Africa
| | - Priyanka Dixit
- School of Health Systems Studies (SHSS), Tata Institute of Social Sciences (TISS), Mumbai, India
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Herrera CA, Lewin S, Paulsen E, Ciapponi A, Opiyo N, Pantoja T, Rada G, Wiysonge CS, Bastías G, Garcia Marti S, Okwundu CI, Peñaloza B, Oxman AD. Governance arrangements for health systems in low-income countries: an overview of systematic reviews. Cochrane Database Syst Rev 2017; 9:CD011085. [PMID: 28895125 PMCID: PMC5618451 DOI: 10.1002/14651858.cd011085.pub2] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Governance arrangements include changes in rules or processes that determine authority and accountability for health policies, organisations, commercial products and health professionals, as well as the involvement of stakeholders in decision-making. Changes in governance arrangements can affect health and related goals in numerous ways, generally through changes in authority, accountability, openness, participation and coherence. A broad overview of the findings of systematic reviews can help policymakers, their technical support staff and other stakeholders to identify strategies for addressing problems and improving the governance of their health systems. OBJECTIVES To provide an overview of the available evidence from up-to-date systematic reviews about the effects of governance arrangements for health systems in low-income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on governance arrangements and informing refinements of the framework for governance arrangements outlined in the overview. METHODS We searched Health Systems Evidence in November 2010 and PDQ Evidence up to 17 December 2016 for systematic reviews. We did not apply any date, language or publication status limitations in the searches. We included well-conducted systematic reviews of studies that assessed the effects of governance arrangements on patient outcomes (health and health behaviours), the quality or utilisation of healthcare services, resource use (health expenditures, healthcare provider costs, out-of-pocket payments, cost-effectiveness), healthcare provider outcomes (such as sick leave), or social outcomes (such as poverty, employment) and that were published after April 2005. We excluded reviews with limitations that were important enough to compromise the reliability of the findings of the review. Two overview authors independently screened reviews, extracted data and assessed the certainty of evidence using GRADE. We prepared SUPPORT Summaries for eligible reviews, including key messages, 'Summary of findings' tables (using GRADE to assess the certainty of the evidence) and assessments of the relevance of findings to low-income countries. MAIN RESULTS We identified 7272 systematic reviews and included 21 of them in this overview (19 primary reviews and 2 supplementary reviews). We focus here on the results of the 19 primary reviews, one of which had important methodological limitations. The other 18 were reliable (with only minor limitations).We grouped the governance arrangements addressed in the reviews into five categories: authority and accountability for health policies (three reviews); authority and accountability for organisations (two reviews); authority and accountability for commercial products (three reviews); authority and accountability for health professionals (seven reviews); and stakeholder involvement (four reviews).Overall, we found desirable effects for the following interventions on at least one outcome, with moderate- or high-certainty evidence and no moderate- or high-certainty evidence of undesirable effects. Decision-making about what is covered by health insurance- Placing restrictions on the medicines reimbursed by health insurance systems probably decreases the use of and spending on these medicines (moderate-certainty evidence). Stakeholder participation in policy and organisational decisions- Participatory learning and action groups for women probably improve newborn survival (moderate-certainty evidence).- Consumer involvement in preparing patient information probably improves the quality of the information and patient knowledge (moderate-certainty evidence). Disclosing performance information to patients and the public- Disclosing performance data on hospital quality to the public probably encourages hospitals to implement quality improvement activities (moderate-certainty evidence).- Disclosing performance data on individual healthcare providers to the public probably leads people to select providers that have better quality ratings (moderate-certainty evidence). AUTHORS' CONCLUSIONS Investigators have evaluated a wide range of governance arrangements that are relevant for low-income countries using sound systematic review methods. These strategies have been targeted at different levels in health systems, and studies have assessed a range of outcomes. Moderate-certainty evidence shows desirable effects (with no undesirable effects) for some interventions. However, there are important gaps in the availability of systematic reviews and primary studies for the all of the main categories of governance arrangements.
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Affiliation(s)
- Cristian A Herrera
- Pontificia Universidad Católica de ChileDepartment of Public Health, School of MedicineMarcoleta 434SantiagoChile
- Pontificia Universidad Católica de ChileEvidence Based Health Care ProgramSantiagoChile
| | - Simon Lewin
- Norwegian Institute of Public HealthPO Box 4404OsloNorway0403
- South African Medical Research CouncilHealth Systems Research UnitPO Box 19070TygerbergSouth Africa7505
| | | | - Agustín Ciapponi
- Institute for Clinical Effectiveness and Health Policy (IECS‐CONICET)Argentine Cochrane CentreDr. Emilio Ravignani 2024Buenos AiresCapital FederalArgentinaC1414CPV
| | - Newton Opiyo
- CochraneCochrane Editorial UnitSt Albans House, 57‐59 HaymarketLondonUKSW1Y 4QX
| | - Tomas Pantoja
- Pontificia Universidad Católica de ChileEvidence Based Health Care ProgramSantiagoChile
- Pontificia Universidad Católica de ChileDepartment of Family Medicine, Faculty of MedicineCentro Medico San Joaquin, Vicuña Mackenna 4686MaculSantiagoChile
| | - Gabriel Rada
- Pontificia Universidad Católica de ChileEvidence Based Health Care ProgramSantiagoChile
- Pontificia Universidad Católica de ChileDepartment of Internal Medicine and Evidence‐Based Healthcare Program, Faculty of MedicineLira 44, Decanato Primer pisoSantiagoChile
| | - Charles S Wiysonge
- South African Medical Research CouncilCochrane South AfricaFrancie van Zijl Drive, Parow ValleyCape TownWestern CapeSouth Africa7505
- Stellenbosch UniversityCentre for Evidence‐based Health Care, Faculty of Medicine and Health SciencesCape TownSouth Africa
| | - Gabriel Bastías
- Pontificia Universidad Católica de ChileDepartment of Public Health, School of MedicineMarcoleta 434SantiagoChile
| | - Sebastian Garcia Marti
- Institute for Clinical Effectiveness and Health PolicyBuenos AiresCapital FederalArgentinaC1056ABH
| | - Charles I Okwundu
- Stellenbosch UniversityCentre for Evidence‐based Health Care, Faculty of Medicine and Health SciencesCape TownSouth Africa
| | - Blanca Peñaloza
- Pontificia Universidad Católica de ChileEvidence Based Health Care ProgramSantiagoChile
- Pontificia Universidad Católica de ChileDepartment of Family Medicine, Faculty of MedicineCentro Medico San Joaquin, Vicuña Mackenna 4686MaculSantiagoChile
| | - Andrew D Oxman
- Norwegian Institute of Public HealthPO Box 4404OsloNorway0403
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Analysing the Influence of Health Insurance Status on Peoples' Health Seeking Behaviour in Rural Ghana. J Trop Med 2017; 2017:8486451. [PMID: 28567060 PMCID: PMC5439069 DOI: 10.1155/2017/8486451] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 03/19/2017] [Indexed: 11/17/2022] Open
Abstract
This paper examines the influence of health insurance status on healthcare use in rural Ghana using 286 sampled respondents from four rural communities in the Bekwai Municipality. Data were obtained using structured interview and Pearson's Chi square and bivariate regressions were used to analyse data. The results show low healthcare utilization among study participants, with most respondents having irregular use (43.5%) or rare use (43.3%). Respondents with health insurance utilized healthcare more than those without health insurance, the results being statistically significant (df = 4; n = 283, p = 0.000). The bivariate analysis revealed that health insurance status has a positive and significant influence on utilization (β = 1.284; p value = 0.000). The study recommends promotion and improvement of services of the National Health Insurance Scheme as effective strategy to improve healthcare consumption by the rural people. The expansion of health insurance services to all sections of the population is also recommended.
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Delavallade C. Quality Health Care and Willingness to Pay for Health Insurance Retention: A Randomized Experiment in Kolkata Slums. HEALTH ECONOMICS 2017; 26:619-638. [PMID: 27028701 DOI: 10.1002/hec.3337] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 11/12/2015] [Accepted: 02/09/2016] [Indexed: 06/05/2023]
Abstract
The low quality of health care in developing countries reduces the poor's incentives to use quality health services and their demand for health insurance. Using data from a field experiment in India, I show that randomly offering insurance policyholders a free preventive checkup with a qualified doctor has a twofold effect: receiving this additional benefit raises willingness to pay to renew health insurance by 53%, doubling the likelihood of hypothetical renewal; exposed individuals are 10 percentage points more likely to consult a qualified practitioner when ill after the checkup. Both effects are concentrated on poorer households. There is no effect on health knowledge and healthcare spending. This suggests that exposing insured households to quality preventive care can be a cost-effective way of raising the demand for quality health care and retaining policyholders in the insurance scheme. Copyright © 2016 John Wiley & Sons, Ltd.
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Joseph C, Maluka SO. Do Management and Leadership Practices in the Context of Decentralisation Influence Performance of Community Health Fund? Evidence From Iramba and Iringa Districts in Tanzania. Int J Health Policy Manag 2017; 6:257-265. [PMID: 28812813 PMCID: PMC5417147 DOI: 10.15171/ijhpm.2016.130] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 12/24/2016] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND In early 1990s, Tanzania like other African countries, adopted health sector reform (HSR). The most strongly held centralisation system that informed the nature of services provision including health was, thus, disintegrated giving rise to decentralisation system. It was within the realm of HSR process, user fees were introduced in the health sector. Along with user fees, various types of health insurances, including the Community Health Fund (CHF), were introduced. While the country's level of enrolment in the CHF is low, there are marked variations among districts. This paper highlights the role of decentralised health management and leadership practices in the uptake of the CHF in Tanzania. METHODS A comparative exploratory case study of high and low performing districts was carried out. In-depth interviews were conducted with the members of the Council Health Service Board (CHSB), Council Health Management Team (CHMT), Health Facility Committees (HFCs), in-charges of health facilities, healthcare providers, and Community Development Officers (CDOs). Minutes of the meetings of the committees and district annual health plans and district annual implementation reports were also used to verify and triangulate the data. Thematic analysis was adopted to analyse the collected data. We employed both inductive and deductive (mixed coding) to arrive to the themes. RESULTS There were no differences in the level of education and experience of the district health managers in the two study districts. Almost all district health managers responsible for the management of the CHF had attended some training on management and leadership. However, there were variations in the personal initiatives of the top-district health leaders, particularly the district health managers, the council health services board and local government officials. Similarly, there were differences in the supervision mechanisms, and incentives available for the health providers, HFCs and board members in the two study districts. CONCLUSION This paper adds to the stock of knowledge on CHFs functioning in Tanzania. By comparing the best practices with the worst practices, the paper contributes valuable insights on how CHF can be scaled up and maintained. The study clearly indicates that the performance of the community-based health financing largely depends on the personal initiatives of the top-district health leaders, particularly the district health managers and local government officials. This implies that the regional health management team (RHMT) and the Ministry of Health and Social Welfare (MoHSW) should strengthen supportive supervision mechanisms to the district health managers and health facilities. More important, there is need for the MoHSW to provide opportunities for the well performing districts to share good practices to other districts in order to increase uptake of the community-based health insurance.
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Affiliation(s)
| | - Stephen Oswald Maluka
- Institute of Development Studies, University of Dar es Salaam, Dar es Salaam, Tanzania
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Mathauer I, Behrendt T. State budget transfers to Health Insurance to expand coverage to people outside formal sector work in Latin America. BMC Health Serv Res 2017; 17:145. [PMID: 28209145 PMCID: PMC5314689 DOI: 10.1186/s12913-017-2004-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 01/11/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Contributory social health insurance for formal sector employees only has proven challenging for moving towards universal health coverage (UHC). This is because the informally employed and the poor usually remain excluded. One way to expand UHC is to fully or partially subsidize health insurance contributions for excluded population groups through government budget transfers. This paper analyses the institutional design features of such government subsidization arrangements in Latin America and assesses their performance with respect to UHC progress. The aim is to identify UHC conducive institutional design features of such arrangements. METHODS A literature search provided the information to analyse institutional design features, with a focus on the following aspects: eligibility/enrolment rules, financing and pooling arrangements, and purchasing and benefit package design. Based on secondary data analysis, UHC progress is assessed in terms of improved population coverage, financial protection and access to needed health care services. RESULTS Such government subsidization arrangements currently exist in eight countries of Latin America (Bolivia, Chile, Colombia, Costa Rica, Dominican Republic, Mexico, Peru, Uruguay). Institutional design features and UHC related performance vary significantly. Notably, countries with a universalist approach or indirect targeting have higher population coverage rates. Separate pools for the subsidized maintain inequitable access. The relatively large scopes of the benefit packages had a positive impact on financial protection and access to care. DISCUSSION AND CONCLUSION In the long term, merging different schemes into one integrated health financing system without opt-out options for the better-off is desirable, while equally expanding eligibility to cover those so far excluded. In the short and medium term, the harmonization of benefit packages could be a priority. UHC progress also depends on substantial supply side investments to ensure the availability of quality services, particularly in rural areas. Future research should generate more evidence on the implementation process and impact of subsidization arrangements on UHC progress.
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Affiliation(s)
- Inke Mathauer
- Department of Health Systems Governance and Financing, World Health Organization, Avenue Appia, 1211 Geneva, Switzerland
| | - Thorsten Behrendt
- Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), Friedrich-Ebert-Allee 36, 53113 Bonn, Germany
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Gotsadze G, Zoidze A, Rukhadze N, Shengelia N, Chkhaidze N. An impact evaluation of medical insurance for poor in Georgia: preliminary results and policy implications. Health Policy Plan 2016; 30 Suppl 1:i2-13. [PMID: 25759451 DOI: 10.1093/heapol/czu095] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE The objective of this article is to assess the impact of the new health financing reform in Georgia-'medical insurance for the poor (MIP)'-which uses private insurance companies and delivers state-subsidized health benefits to the poorest groups of the Georgian population. METHODS To evaluate the reform we looked at access to health care services and financial protection against health care costs, which are two key dimensions proposed for the universal coverage plans. The data from two nationally representative Health Utilization and Expenditure Surveys (2007 and 2010) were used, and a difference-in-difference method of evaluation was applied. FINDINGS The MIP was not found to have a significant impact on service utilization growth nationwide, but in the capital city the MIP insured were 12% more likely to use formal health services and 7.6% more likely to use hospitals as compared with other areas of the country. The MIP impact on out-of-pocket health expenditures was greater in reducing costs of accessing services. The cost reductions were sizable and more pronounced among the poorest. Finally, the MIP significantly increased the odds of obtaining free benefits by insured individuals as compared with the control group. Such an increase was most noticeable for the poorest third of the population. CONCLUSIONS Marginal changes in access to services and the geographically diverse impact of the MIP on service utilization points to other factors affecting health-seeking behaviour of the insured. These other factors include private insurer behaviour that may have used strategies for reducing claims and managing utilization. Equity impact of the MIP and improved financial protection, especially for the poor, are benefits to be retained by government policies when universal health coverage is rolled out nationwide and all citizens will be covered. The role of private insurance companies as financial intermediaries of the publicly funded programme needs further evaluation before moving forward.
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Affiliation(s)
- George Gotsadze
- Curatio International Foundation, 37d Chavchavadze Avenue, 0162 Tbilisi, Georgia
| | - Akaki Zoidze
- Curatio International Foundation, 37d Chavchavadze Avenue, 0162 Tbilisi, Georgia
| | - Natia Rukhadze
- Curatio International Foundation, 37d Chavchavadze Avenue, 0162 Tbilisi, Georgia
| | - Natia Shengelia
- Curatio International Foundation, 37d Chavchavadze Avenue, 0162 Tbilisi, Georgia
| | - Nino Chkhaidze
- Curatio International Foundation, 37d Chavchavadze Avenue, 0162 Tbilisi, Georgia
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Yang L, Sun L, Wen L, Zhang H, Li C, Hanson K, Fang H. Financing strategies to improve essential public health equalization and its effects in China. Int J Equity Health 2016; 15:194. [PMID: 27905941 PMCID: PMC5134004 DOI: 10.1186/s12939-016-0482-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 11/15/2016] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND In 2009, China launched a health reform to promote the equalization of national essential public health services package (NEPHSP). The present study aimed to describe the financing strategies and mechanisms to improve access to public health for all, identify the strengths and weaknesses of the different approaches, and showed evidence on equity improvement among different regions. METHODS We reviewed the relevant literatures and identified 208 articles after screening and quality assessment and conducted six key informants' interviews. Secondary data on national and local government health expenditures, NEPHSP coverage and health indicators in 2003-2014 were collected, descriptive and equity analyses were used. RESULTS Before 2009, the government subsidy to primary care institutions (PCIs) were mainly used for basic construction and a small part of personnel expenses. Since 2009, the new funds for NEPHSP have significantly expanded service coverage and population coverage. These funds have been allocated by central, provincial, municipal and county governments at different proportions in China's tax distribution system. Due to the fiscal transfer payment, the Central Government allocated more subsides to less-developed western regions and all the funds were managed in a specific account. Several types of payment methods have been adopted including capitation, pay for performance (P4P), pay for service items, global budget and public health voucher, to address issues from both the supply and demand sides. The equalization of NEPHSP did well through the establishment of health records, systematic care of children and maternal women, etc. Our data showed that the gap between the eastern, central and western regions narrowed. However the coverage for migrants was still low and performance was needed improving in effectiveness of managing patients with chronic diseases. CONCLUSIONS The delivery of essential public health services was highly influenced by public fiscal policy, and the implementation of health reform since 2009 has led the public health development towards the right direction. However China still needs to increase the fiscal investments to expand service coverage as well as promote the quality of public health services and equality among regions. Independent scientific monitoring and evaluation are also needed.
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Affiliation(s)
- Li Yang
- School of Public Health, Peking University Health Science Center, Beijing, China
| | - Li Sun
- School of Public Health, Peking University Health Science Center, Beijing, China
| | - Liankui Wen
- School of Public Health, Peking University Health Science Center, Beijing, China
| | - Huyang Zhang
- China Center for Health Development Studies, Peking University, No 38 Xueyuan Road, Haidian District, Beijing, China
| | - Chenyang Li
- China Center for Health Development Studies, Peking University, No 38 Xueyuan Road, Haidian District, Beijing, China
| | - Kara Hanson
- London School of Hygiene and Tropical Medicine, London, UK
| | - Hai Fang
- China Center for Health Development Studies, Peking University, No 38 Xueyuan Road, Haidian District, Beijing, China
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Vilcu I, Probst L, Dorjsuren B, Mathauer I. Subsidized health insurance coverage of people in the informal sector and vulnerable population groups: trends in institutional design in Asia. Int J Equity Health 2016; 15:165. [PMID: 27716301 PMCID: PMC5050723 DOI: 10.1186/s12939-016-0436-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 09/06/2016] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Many low- and middle-income countries with a social health insurance system face challenges on their road towards universal health coverage (UHC), especially for people in the informal sector and vulnerable population groups or the informally employed. One way to address this is to subsidize their contributions through general government revenue transfers to the health insurance fund. This paper provides an overview of such health financing arrangements in Asian low- and middle-income countries. The purpose is to assess the institutional design features of government subsidized health insurance type arrangements for vulnerable and informally employed population groups and to explore how these features contribute to UHC progress. METHODS This regional study is based on a literature search to collect country information on the specific institutional design features of such subsidization arrangements and data related to UHC progress indicators, i.e. population coverage, financial protection and access to care. The institutional design analysis focuses on eligibility rules, targeting and enrolment procedures; financing arrangements; the pooling architecture; and benefit entitlements. RESULTS Such financing arrangements currently exist in 8 countries with a total of 14 subsidization schemes. The most frequent groups covered are the poor, older persons and children. Membership in these arrangements is mostly mandatory as is full subsidization. An integrated pool for both the subsidized and the contributors exists in half of the countries, which is one of the most decisive features for equitable access and financial protection. Nonetheless, in most schemes, utilization rates of the subsidized are higher compared to the uninsured, but still lower compared to insured formal sector employees. Total population coverage rates, as well as a higher share of the subsidized in the total insured population are related with broader eligibility criteria. CONCLUSIONS Overall, government subsidized health insurance type arrangements can be effective mechanism to help countries progress towards UHC, yet there is potential to improve on institutional design features as well as implementation.
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Affiliation(s)
- Ileana Vilcu
- Department of Health Systems Governance and Financing, World Health Organization, Avenue Appia, Geneva, 1211 Switzerland
| | - Lilli Probst
- Department of Health Systems Governance and Financing, World Health Organization, Avenue Appia, Geneva, 1211 Switzerland
| | - Bayarsaikhan Dorjsuren
- Department of Health Systems Governance and Financing, World Health Organization, Avenue Appia, Geneva, 1211 Switzerland
| | - Inke Mathauer
- Department of Health Systems Governance and Financing, World Health Organization, Avenue Appia, Geneva, 1211 Switzerland
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Mathauer I, Theisling M, Mathivet B, Vilcu I. State budget transfers to health insurance funds: extending universal health coverage in low- and middle-income countries of the WHO European Region. Int J Equity Health 2016; 15:57. [PMID: 27038787 PMCID: PMC4818884 DOI: 10.1186/s12939-016-0321-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 02/15/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Many low-and middle-income countries (LMIC) of the World Health Organization (WHO) European Region have introduced social health insurance payroll taxes after the political transition in the late 1980s, combined with budget transfers to allow for exempting specific population groups from paying contributions, such as those outside formal sector work and in particular vulnerable groups. This paper assesses the institutional design aspects of such financing arrangements and their performance with respect to universal health coverage progress in LMIC of the European region. METHODS The study is based on a literature review and review of secondary databases for the performance assessment. RESULTS Such financing arrangements currently exist in 13 LMIC of that region, with strong commonalities in institutional design: This includes a wide range of different eligible population groups, mostly mandatory membership, integrated pools for both the exempted and contributors, and relatively comprehensive benefit packages. Performance is more varied. Enrolment rates range from about 65 % to above 95 %, and access to care and financial protection has improved in several countries. Yet, inequities between income quintiles persist. CONCLUSIONS Budget transfers to health insurance arrangements have helped to deepen UHC or maintain achievements with respect to UHC in these European LMICs by covering those outside formal sector work, and in particular vulnerable population groups. However, challenges remain: a comprehensive benefit package on paper is not enough as long as supply side constraints and quality gaps as well as informal payments prevail. A key policy question is how to reach those so far uncovered.
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Affiliation(s)
- Inke Mathauer
- />Department of Health Systems Governance and Financing, World Health Organization, Avenue Appia, 1211 Geneva, Switzerland
| | - Mareike Theisling
- />Health, Population Policy, Social Security Division, Federal Ministry for Economic Cooperation and Development, Bonn, Germany
| | - Benoit Mathivet
- />Department of Health Systems Governance and Financing, World Health Organization, Avenue Appia, 1211 Geneva, Switzerland
| | - Ileana Vilcu
- />Consultant with the World Health Organization at the time of writing from October 2014 to December 2015, Avenue Appia, 1211 Geneva, Switzerland
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Vilcu I, Mathauer I. State budget transfers to Health Insurance Funds for universal health coverage: institutional design patterns and challenges of covering those outside the formal sector in Eastern European high-income countries. Int J Equity Health 2016; 15:7. [PMID: 26767970 PMCID: PMC4714511 DOI: 10.1186/s12939-016-0295-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 01/05/2016] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Many countries from the European region, which moved from a government financed and provided health system to social health insurance, would have had the risk of moving away from universal health coverage if they had followed a "traditional" approach. The Eastern European high-income countries studied in this paper managed to avoid this potential pitfall by using state budget revenues to explicitly pay health insurance contributions on behalf of certain (vulnerable) population groups who have difficulties to pay these contributions themselves. The institutional design aspects of their government revenue transfer arrangements are analysed, as well as their impact on universal health coverage progress. METHODS This regional study is based on literature review and review of databases for the performance assessment. The analytical framework focuses on the following institutional design features: rules on eligibility for contribution exemption, financing and pooling arrangements, and purchasing arrangements and benefit package design. RESULTS More commonalities than differences can be identified across countries: a broad range of groups eligible for exemption from payment of health insurance contributions, full state contributions on behalf of the exempted groups, mostly mandatory participation, integrated pools for both the exempted and contributors, and relatively comprehensive benefit packages. In terms of performance, all countries have high total population coverage rates, but there are still challenges regarding financial protection and access to and utilization of health care services, especially for low income people. CONCLUSION Overall, government revenue transfer arrangements to exempt vulnerable groups from contributions are one option to progress towards universal health coverage.
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Affiliation(s)
- Ileana Vilcu
- Consultant with the World Health Organization from October 2014 to December 2015, Avenue Appia, 1211, Geneva, Switzerland.
| | - Inke Mathauer
- Department of Health Systems Governance and Financing, World Health Organization, Avenue Appia, 1211, Geneva, Switzerland.
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Adebayo EF, Uthman OA, Wiysonge CS, Stern EA, Lamont KT, Ataguba JE. A systematic review of factors that affect uptake of community-based health insurance in low-income and middle-income countries. BMC Health Serv Res 2015; 15:543. [PMID: 26645355 PMCID: PMC4673712 DOI: 10.1186/s12913-015-1179-3] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Accepted: 11/18/2015] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Low-income and middle-income countries (LMICs) have difficulties achieving universal financial protection, which is primordial for universal health coverage. A promising avenue to provide universal financial protection for the informal sector and the rural populace is community-based health insurance (CBHI). We systematically assessed and synthesised factors associated with CBHI enrolment in LMICs. METHODS We searched PubMed, Scopus, ERIC, PsychInfo, Africa-Wide Information, Academic Search Premier, Business Source Premier, WHOLIS, CINAHL, Cochrane Library, conference proceedings, and reference lists for eligible studies available by 31 October 2013; regardless of publication status. We included both quantitative and qualitative studies in the review. RESULTS Both quantitative and qualitative studies demonstrated low levels of income and lack of financial resources as major factors affecting enrolment. Also, poor healthcare quality (including stock-outs of drugs and medical supplies, poor healthcare worker attitudes, and long waiting times) was found to be associated with low CBHI coverage. Trust in both the CBHI scheme and healthcare providers were also found to affect enrolment. Educational attainment (less educated are willing to pay less than highly educated), sex (men are willing to pay more than women), age (younger are willing to pay more than older individuals), and household size (larger households are willing to pay more than households with fewer members) also influenced CBHI enrolment. CONCLUSION In LMICs, while CBHI schemes may be helpful in the short term to address the issue of improving the rural population and informal workers' access to health services, they still face challenges. Lack of funds, poor quality of care, and lack of trust are major reasons for low CBHI coverage in LMICs. If CBHI schemes are to serve as a means to providing access to health services, at least in the short term, then attention should be paid to the issues that militate against their success.
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Affiliation(s)
- Esther F Adebayo
- Centre for Evidence-based Health Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
- School of Public Health and Family Medicine, University of Cape Town, Observatory, South Africa.
| | - Olalekan A Uthman
- Centre for Evidence-based Health Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
- Warwick-Centre for Applied Health Research and Delivery (WCAHRD), Division of Health Sciences, Warwick Medical School, The university of Warwick, Coventry, CV4 7AL, UK.
- Liverpool School of Tropical Medicine, International Health Group, Liverpool, Merseyside, UK.
| | - Charles S Wiysonge
- Centre for Evidence-based Health Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa.
| | - Erin A Stern
- Women's Health Research Unit, School of Public Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | - Kim T Lamont
- Soweto Cardiovascular Research Unit, University of the Witwatersrand, Johannesburg, South Africa.
| | - John E Ataguba
- Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Observatory, South Africa.
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Sharma G, Mathai M, Dickson KE, Weeks A, Hofmeyr GJ, Lavender T, Day LT, Mathews JE, Fawcus S, Simen-Kapeu A, de Bernis L. Quality care during labour and birth: a multi-country analysis of health system bottlenecks and potential solutions. BMC Pregnancy Childbirth 2015; 15 Suppl 2:S2. [PMID: 26390886 PMCID: PMC4577867 DOI: 10.1186/1471-2393-15-s2-s2] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Good outcomes during pregnancy and childbirth are related to availability, utilisation and effective implementation of essential interventions for labour and childbirth. The majority of the estimated 289,000 maternal deaths, 2.8 million neonatal deaths and 2.6 million stillbirths every year could be prevented by improving access to and scaling up quality care during labour and birth. METHODS The bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the Every Newborn Action Plan process. Country workshops engaged technical experts to complete the survey tool, which is designed to synthesise and grade health system "bottlenecks", factors that hinder the scale up, of maternal-newborn intervention packages. We used quantitative and qualitative methods to analyse the bottleneck data, combined with literature review, to present priority bottlenecks and actions relevant to different health system building blocks for skilled birth attendance and basic and comprehensive emergency obstetric care. RESULTS Across 12 countries the most critical bottlenecks identified by workshop participants for skilled birth attendance were health financing (10 out of 12 countries) and health workforce (9 out of 12 countries). Health service delivery bottlenecks were found to be the most critical for both basic and comprehensive emergency obstetric care (9 out of 12 countries); health financing was identified as having critical bottlenecks for comprehensive emergency obstetric care (9 out of 12 countries). Solutions to address health financing bottlenecks included strengthening national financing mechanisms and removing financial barriers to care seeking. For addressing health workforce bottlenecks, improved human resource planning is needed, including task shifting and improving training quality. For health service delivery, proposed solutions included improving quality of care and establishing public private partnerships. CONCLUSIONS Progress towards the 2030 targets for ending preventable maternal and newborn deaths is dependent on improving quality of care during birth and the immediate postnatal period. Strengthening national health systems to improve maternal and newborn health, as a cornerstone of universal health coverage, will only be possible by addressing specific health system bottlenecks during labour and birth, including those within health workforce, health financing and health service delivery.
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Affiliation(s)
- Gaurav Sharma
- Maternal, Adolescent, Reproductive and Child Health (MARCH) Centre, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, United Kingdom
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Matthews Mathai
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland
| | - Kim E Dickson
- Health Section, Programme Division, UNICEF Headquarters, 3 United Nations Plaza, New York, 10017, USA
| | - Andrew Weeks
- Sanyu Research Unit, University of Liverpool, c/o Liverpool Women's Hospital, Crown Street, Liverpool, L8 7SS, UK
| | - G Justus Hofmeyr
- Department of Obstetrics and Gynaecology, East London Hospital Complex, University of the Witwatersrand, University of Fort Hare, Eastern Cape Department of Health, East London, South Africa
| | - Tina Lavender
- University of Manchester School of Nursing, Midwifery & Social Work, Jean McFarlane Building University Place, Oxford Road, Manchester, M13 9PL, UK
| | - Louise Tina Day
- LAMB, Integrated Rural Health & Development, Dinajpur, 5250, Bangladesh
| | - Jiji Elizabeth Mathews
- Department of Obstetrics and Gynaecology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Sue Fawcus
- Department of Obstetrics & Gynaecology, University of Cape Town, Observatory 7925, Cape Town, South Africa
| | - Aline Simen-Kapeu
- Health Section, Programme Division, UNICEF Headquarters, 3 United Nations Plaza, New York, 10017, USA
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Dickson KE, Kinney MV, Moxon SG, Ashton J, Zaka N, Simen-Kapeu A, Sharma G, Kerber KJ, Daelmans B, Gülmezoglu AM, Mathai M, Nyange C, Baye M, Lawn JE. Scaling up quality care for mothers and newborns around the time of birth: an overview of methods and analyses of intervention-specific bottlenecks and solutions. BMC Pregnancy Childbirth 2015; 15 Suppl 2:S1. [PMID: 26390820 PMCID: PMC4578819 DOI: 10.1186/1471-2393-15-s2-s1] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2023] Open
Abstract
BACKGROUND The Every Newborn Action Plan (ENAP) and Ending Preventable Maternal Mortality targets cannot be achieved without high quality, equitable coverage of interventions at and around the time of birth. This paper provides an overview of the methodology and findings of a nine paper series of in-depth analyses which focus on the specific challenges to scaling up high-impact interventions and improving quality of care for mothers and newborns around the time of birth, including babies born small and sick. METHODS The bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the ENAP process. Country workshops engaged technical experts to complete a tool designed to synthesise "bottlenecks" hindering the scale up of maternal-newborn intervention packages across seven health system building blocks. We used quantitative and qualitative methods and literature review to analyse the data and present priority actions relevant to different health system building blocks for skilled birth attendance, emergency obstetric care, antenatal corticosteroids (ACS), basic newborn care, kangaroo mother care (KMC), treatment of neonatal infections and inpatient care of small and sick newborns. RESULTS The 12 countries included in our analysis account for the majority of global maternal (48%) and newborn (58%) deaths and stillbirths (57%). Our findings confirm previously published results that the interventions with the most perceived bottlenecks are facility-based where rapid emergency care is needed, notably inpatient care of small and sick newborns, ACS, treatment of neonatal infections and KMC. Health systems building blocks with the highest rated bottlenecks varied for different interventions. Attention needs to be paid to the context specific bottlenecks for each intervention to scale up quality care. Crosscutting findings on health information gaps inform two final papers on a roadmap for improvement of coverage data for newborns and indicate the need for leadership for effective audit systems. CONCLUSIONS Achieving the Sustainable Development Goal targets for ending preventable mortality and provision of universal health coverage will require large-scale approaches to improving quality of care. These analyses inform the development of systematic, targeted approaches to strengthening of health systems, with a focus on overcoming specific bottlenecks for the highest impact interventions.
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Affiliation(s)
- Kim E Dickson
- Health Section, Programme Division, UNICEF Headquarters, 3 United Nations Plaza, New York, NY, 10017, USA
| | - Mary V Kinney
- Saving Newborn Lives, Save the Children, 2000 L Street NW, Suite 500, Washington, DC 20036, USA
| | - Sarah G Moxon
- Saving Newborn Lives, Save the Children, 2000 L Street NW, Suite 500, Washington, DC 20036, USA
- Maternal, Adolescent, Reproductive and Child Health (MARCH) Centre, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Joanne Ashton
- 5919 N Placita del Conde, Tucson, Arizona 85718, USA
| | - Nabila Zaka
- Health Section, Programme Division, UNICEF Headquarters, 3 United Nations Plaza, New York, NY, 10017, USA
| | - Aline Simen-Kapeu
- Health Section, Programme Division, UNICEF Headquarters, 3 United Nations Plaza, New York, NY, 10017, USA
| | - Gaurav Sharma
- Maternal, Adolescent, Reproductive and Child Health (MARCH) Centre, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Kate J Kerber
- 5919 N Placita del Conde, Tucson, Arizona 85718, USA
| | - Bernadette Daelmans
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Avenue Appia 20, 1211 Geneva 27, Switzerland
| | - A Metin Gülmezoglu
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, 20 Avenue Appia, CH-1211, Geneva, Switzerland
| | - Matthews Mathai
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Avenue Appia 20, 1211 Geneva 27, Switzerland
| | - Christabel Nyange
- Health Section, Programme Division, UNICEF Headquarters, 3 United Nations Plaza, New York, NY, 10017, USA
- Ross University Medical School, 2300 SW 145th Avenue, Miramar, FL, 33027, USA
| | - Martina Baye
- National Program for Reduction of Maternal Newborn and Child Mortality, Ministry of Public Health Cameroon, Cameroon
| | - Joy E Lawn
- Maternal, Adolescent, Reproductive and Child Health (MARCH) Centre, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
- 5919 N Placita del Conde, Tucson, Arizona 85718, USA
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Mohammed S, Aji B, Bermejo JL, Souares A, Dong H, Sauerborn R. User experience with a health insurance coverage and benefit-package access: implications for policy implementation towards expansion in Nigeria. Health Policy Plan 2015; 31:346-55. [PMID: 26261105 DOI: 10.1093/heapol/czv068] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2015] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Developing countries are devising strategies and mechanisms to expand coverage and benefit-package access for their citizens through national health insurance schemes (NHIS). In Nigeria, the scheme aims to provide affordable healthcare services to insured-persons and their dependants. However, inclusion of dependants is restricted to four biological children and a spouse per user. This study assesses the progress of implementation of the NHIS in Nigeria, relating to coverage and benefit-package access, and examines individual factors associated with the implementation, according to users' perspectives. METHODS A retrospective, cross-sectional survey was done between October 2010 and March 2011 in Kaduna state and 796 users were randomly interviewed. Questions regarding coverage of immediate-family members and access to benefit-package for treatment were analysed. Indicators of coverage and benefit-package access were each further aggregated and assessed by unit-weighted composite. The additive-ordinary least square regression model was used to identify user factors that may influence coverage and benefit-package access. RESULTS With respect to coverage, immediate-dependants were included for 62.3% of the users, and 49.6 rated this inclusion 'good' (49.6%). In contrast, 60.2% supported the abolishment of the policy restriction for non-inclusion of enrolees' additional children and spouses. With respect to benefit-package access, 82.7% of users had received full treatments, and 77.6% of them rated this as 'good'. Also, 14.4% of users had been refused treatments because they could not afford them. The coverage of immediate-dependants was associated with age, sex, educational status, children and enrolment duration. The benefit-package access was associated with types of providers, marital status and duration of enrolment. CONCLUSION This study revealed that coverage of family members was relatively poor, while benefit-package access was more adequate. Non-inclusion of family members could hinder effective coverage by the scheme. Potential policy implications towards effective coverage and benefit-package access are discussed.
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Affiliation(s)
- Shafiu Mohammed
- Institute of Public Health, Medical Faculty, Heidelberg University, Heidelberg, Germany, Institute of Public Health, Medical Faculty, Heidelberg University, Heidelberg, Germany,
| | - Budi Aji
- Institute of Public Health, Medical Faculty, Heidelberg University, Heidelberg, Germany, School of Public Health, Faculty of Medicine and Health Sciences, Jenderal Soedirman University, Purwokerto, Central Java, Indonesia
| | - Justo Lorenzo Bermejo
- Institute of Medical Biometry and Informatics (IMBI), University Hospital Heidelberg, Heidelberg, Germany and
| | - Aurelia Souares
- Institute of Public Health, Medical Faculty, Heidelberg University, Heidelberg, Germany
| | - Hengjin Dong
- Institute of Public Health, Medical Faculty, Heidelberg University, Heidelberg, Germany, Center for Health Policy Studies, Zhejiang University School of Medicine, Zhejiang, China
| | - Rainer Sauerborn
- Institute of Public Health, Medical Faculty, Heidelberg University, Heidelberg, Germany
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Oyewale TO, Mavundla TR. Socioeconomic factors contributing to exclusion of women from maternal health benefit in Abuja, Nigeria. Curationis 2015; 38:1272. [PMID: 26244461 PMCID: PMC6091667 DOI: 10.4102/curationis.v38i1.1272] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2014] [Revised: 11/16/2014] [Accepted: 01/13/2015] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND An understanding of the predictive effect of socioeconomic characteristics (SECs) of women on maternal healthcare service utilisation is essential in order to maximise maternal health benefits and outcomes for the newborn. OBJECTIVES To describe how SECs of women contribute to their exclusion from maternal health benefits in Abuja Municipal Areas Council (AMAC) in Abuja, Nigeria. METHOD A non-experimental, facility-based cross-sectional survey was done. Data were collected from 384 respondents using a structured interviewer-administered questionnaire. The participants were sampled randomly at antenatal care (ANC) clinics in the five district hospitals in AMAC. Data analysis included descriptive statistics, cross-tabulations and measures of inequality. Logistic regression analysis was used to test the relationship between SECs (predictors) and maternal healthcare service utilisation. RESULTS There were differentials in the utilisation of maternal healthcare services (ANC, delivery care, post natal care [PNC] and contraceptive services) amongst women with different SECs; and the payment system for maternal healthcare services was regressive. There were inconsistencies in the predictive effect of the SECs of women included in this study (age,education, birth order, location of residence, income group and coverage by health insurance) on maternal healthcare service utilisation when considered independently (bivariate analysis) as opposed to when considered together (logistic regression), with the exception of birth order, which showed consistent effect. CONCLUSION SECs of women were predictive factors of utilisation of maternal healthcare services. There is a need for targeted policy measures and programme actions toward multiple SECs of women in their natural co-existing state in order to optimise maternal health benefits.
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Langlois EV, Ranson MK, Bärnighausen T, Bosch-Capblanch X, Daniels K, El-Jardali F, Ghaffar A, Grimshaw J, Haines A, Lavis JN, Lewin S, Meng Q, Oliver S, Pantoja T, Straus S, Shemilt I, Tovey D, Tugwell P, Waddington H, Wilson M, Yuan B, Røttingen JA. Advancing the field of health systems research synthesis. Syst Rev 2015; 4:90. [PMID: 26159806 PMCID: PMC4498528 DOI: 10.1186/s13643-015-0080-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 06/17/2015] [Indexed: 11/10/2022] Open
Abstract
Those planning, managing and working in health systems worldwide routinely need to make decisions regarding strategies to improve health care and promote equity. Systematic reviews of different kinds can be of great help to these decision-makers, providing actionable evidence at every step in the decision-making process. Although there is growing recognition of the importance of systematic reviews to inform both policy decisions and produce guidance for health systems, a number of important methodological and evidence uptake challenges remain and better coordination of existing initiatives is needed. The Alliance for Health Policy and Systems Research, housed within the World Health Organization, convened an Advisory Group on Health Systems Research (HSR) Synthesis to bring together different stakeholders interested in HSR synthesis and its use in decision-making processes. We describe the rationale of the Advisory Group and the six areas of its work and reflects on its role in advancing the field of HSR synthesis. We argue in favour of greater cross-institutional collaborations, as well as capacity strengthening in low- and middle-income countries, to advance the science and practice of health systems research synthesis. We advocate for the integration of quasi-experimental study designs in reviews of effectiveness of health systems intervention and reforms. The Advisory Group also recommends adopting priority-setting approaches for HSR synthesis and increasing the use of findings from systematic reviews in health policy and decision-making.
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Affiliation(s)
- Etienne V Langlois
- Alliance for Health Policy and Systems Research, World Health Organization, 20 avenue Appia, 1211, Geneva, Switzerland.
| | - Michael K Ranson
- World Bank Group, 3 Chemin Louis-Dunant, Post Office Box 66 CH, 1211, Geneva, Switzerland.
| | - Till Bärnighausen
- Department of Global Health and Population, Harvard School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA.
- Wellcome Trust Africa Centre for Health and Population Studies, University of KwaZulu-Natal, R618 en route to Hlabisa, Somkhele A2074 Rd, Mtubatuba, 3935, South Africa.
| | - Xavier Bosch-Capblanch
- Swiss Tropical and Public Health Institute, Socinstrasse 57, 4051, Basel, Switzerland.
- University of Basel, Petersplatz 1, 4003, Basel, Switzerland.
| | - Karen Daniels
- Health Systems Research Unit, South African Medical Research Council, Francie van Zijl Drive Parowvallei, Cape , PO Box 19070 , 7505, , Tygerberg, South Africa.
| | - Fadi El-Jardali
- Department of Health Management and Policy, Center for Systematic Reviews of Health Policy and Systems Research (SPARK), Faculty of Health Sciences, Van Dyck Hall, American University of Beirut, PO Box 11-0236, Riad El-Solh, Beirut, 1107 2020, Lebanon.
| | - Abdul Ghaffar
- Alliance for Health Policy and Systems Research, World Health Organization, 20 avenue Appia, 1211, Geneva, Switzerland.
| | - Jeremy Grimshaw
- Ottawa Hospital Research Institute & Department of Medicine, University of Ottawa, 725 Parkdale Ave, Ottawa, ON, K1Y 4E9, Canada.
| | - Andy Haines
- Departments of Social and Environmental Health Research and of Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - John N Lavis
- Department of Global Health and Population, Harvard School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA.
- Department of Clinical Epidemiology & Biostatistics, Department of Political Science, and McMaster Health Forum, PPD/CHEPA, McMaster University, 1280 Main Street West, CRL-209, Hamilton, ON, L8S 4K1, Canada.
| | - Simon Lewin
- Health Systems Research Unit, South African Medical Research Council, Francie van Zijl Drive Parowvallei, Cape , PO Box 19070 , 7505, , Tygerberg, South Africa.
- Cochrane Effective Practice and Organisation of Care Group (EPOC) Satellite, Norwegian Knowledge Centre for the Health Services, Box 7004, St. Olavs plass, 0130, Oslo, Norway.
| | - Qingyue Meng
- China Centre for Health Development Studies, Peking University, PO 505, XueYuan Road 38, Haidian District, Beijing, 100191, China.
| | - Sandy Oliver
- Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-Centre), UCL Institute of Education, University College London, 20 Bedford Way, London, WC1H 0AL, UK.
| | - Tomás Pantoja
- Departamento de Medicina Familiar, Escuela de Medicina, Pontificia Universidad Católica de Chile, Avenida Libertador Bernardo O Higgins 340, Santiago, Chile.
| | - Sharon Straus
- St. Michael's hospital, Li Ka Shing Knowledge Institute, 30 Bond St, Toronto, ON, M5B 1W8, Canada.
| | - Ian Shemilt
- Behaviour and Health Research Unit, School of Clinical Medicine, University of Cambridge, Box 113 Cambridge Biomedical Campus Forvie Site, Robinson Way, Cambridge, CB2 0SR, UK.
| | - David Tovey
- Cochrane, St Albans House, 57-59 Haymarket, London, SW1Y 4QX, UK.
| | - Peter Tugwell
- Department of Medicine, Centre for Global Health, WHO Collaborating Centre for Knowledge Translation and Health Technology Assessment in Health Equity, Institute of Population Health, Bruyère Research Institute, University of Ottawa, 85 Primrose Avenue, Office 302, Ottawa, ON, K1R 6M1, Canada.
| | - Hugh Waddington
- International Initiative for Impact Evaluation, 36 Gordon Square, London, WC1H 0PD, UK.
| | - Mark Wilson
- Cochrane, St Albans House, 57-59 Haymarket, London, SW1Y 4QX, UK.
| | - Beibei Yuan
- China Centre for Health Development Studies, Peking University, PO 505, XueYuan Road 38, Haidian District, Beijing, 100191, China.
| | - John-Arne Røttingen
- Department of Global Health and Population, Harvard School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA.
- Department of Health Management and Health Economics, Faculty of Medicine, Institute of Health and Society, University of Oslo, Postboks 1089, Blindern, 0317, Oslo, Norway.
- Division of Infectious Disease Control, Norwegian Institute of Public Health, PO Box 4404, , N-0403, Oslo, Norway.
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Tang S. Tackling challenges of TB/MDRTB in China: concerted actions are imperative. Infect Dis Poverty 2015; 4:19. [PMID: 25908975 PMCID: PMC4407541 DOI: 10.1186/s40249-015-0050-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 03/17/2015] [Indexed: 11/10/2022] Open
Abstract
China is the second largest TB epidemic with the most number of people infected with multi-drug resistant (MDR). Over the past decade, a large number of TB control projects have been funded by the government of China and international organizations, and epidemic in China has been effectively controlled. However TB control in China still faced many challenges. Strategies to address these challenges may include integrating the national TB control program into health insurance schemes, strengthening TB case management through involving the Chinese hospital in national TB control program, and reforming payment methods for TB care as part of health system reform in China.
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Affiliation(s)
- Shenglan Tang
- Duke Global Health Institute, Duke University, Durham, USA ; Duke Kunshan University, Global Health Research Center, Kunshan, China
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Bell CF, Kurosky SK, Candrilli SD. Muscular dystrophy-related hospitalizations among male pediatric patients in the United States. Hosp Pract (1995) 2015; 43:180-185. [PMID: 25833749 DOI: 10.1080/21548331.2015.1033375] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVE While the economic burden of muscular dystrophy (MD) has been well documented, little is known of specific costs associated with Duchenne muscular dystrophy (DMD), the most prevalent form of MD. This study assessed trends in MD-related hospitalizations and costs among young males, which may reflect utilization of the DMD population in the United States. STUDY DESIGN A retrospective observational study of hospitalizations of males aged 0-20 years with a primary diagnosis code for MD was conducted using data from a weighted, nationally representative database of pediatric hospitalizations in the US. Rates, characteristics and cost of MD-related hospitalizations were compared to hospitalizations not related to MD. RESULTS The rate of MD-related hospitalizations increased by 9% between 2000 and 2006 and then decreased by 13% in 2009. The mean length of stay for discharges related to MD was approximately 9 days during each study year. The most frequent observed diagnoses (other than MD) and procedures were for respiratory-related complications. The mean total costs for MD-related discharges increased across the study period from $26,785 in 2000 to $42,751 in 2009. CONCLUSION This study provides baseline and trend data describing hospitalizations of male pediatric patients with MD that may be used as baseline measurements for assessment of the impact of new strategies for managing the disease. Further assessment of the burden and the clinical, economic, and humanistic impacts of DMD is warranted.
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Borghi J, Makawia S, Kuwawenaruwa A. The administrative costs of community-based health insurance: a case study of the community health fund in Tanzania. Health Policy Plan 2015; 30:19-27. [PMID: 24334331 PMCID: PMC4287190 DOI: 10.1093/heapol/czt093] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2013] [Indexed: 12/03/2022] Open
Abstract
Community-based health insurance expansion has been proposed as a financing solution for the sizable informal sector in low-income settings. However, there is limited evidence of the administrative costs of such schemes. We assessed annual facility and district-level costs of running the Community Health Fund (CHF), a voluntary health insurance scheme for the informal sector in a rural and an urban district from the same region in Tanzania. Information on resource use, CHF membership and revenue was obtained from district managers and health workers from two facilities in each district. The administrative cost per CHF member household and the cost to revenue ratio were estimated. Revenue collection was the most costly activity at facility level (78% of total costs), followed by stewardship and management (13%) and pooling of funds (10%). Stewardship and management was the main activity at district level. The administration cost per CHF member household ranged from USD 3.33 to USD 12.12 per year. The cost to revenue ratio ranged from 50% to 364%. The cost of administering the CHF was high relative to revenue generated. Similar studies from other settings should be encouraged.
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Affiliation(s)
- Josephine Borghi
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK and Ifakara Health Institute, Kiko Avenue, Plot 463, Kiko Avenue Mikocheni, P.O. Box 78, 373 Dar es Salaam, Tanzania London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK and Ifakara Health Institute, Kiko Avenue, Plot 463, Kiko Avenue Mikocheni, P.O. Box 78, 373 Dar es Salaam, Tanzania
| | - Suzan Makawia
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK and Ifakara Health Institute, Kiko Avenue, Plot 463, Kiko Avenue Mikocheni, P.O. Box 78, 373 Dar es Salaam, Tanzania
| | - August Kuwawenaruwa
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK and Ifakara Health Institute, Kiko Avenue, Plot 463, Kiko Avenue Mikocheni, P.O. Box 78, 373 Dar es Salaam, Tanzania
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Atinga RA, Abiiro GA, Kuganab-Lem RB. Factors influencing the decision to drop out of health insurance enrolment among urban slum dwellers in Ghana. Trop Med Int Health 2014; 20:312-21. [DOI: 10.1111/tmi.12433] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Roger A. Atinga
- Department of Public Administration and Health Services Management; University of Ghana Business School; Legon, Accra Ghana
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Jia L, Yuan B, Huang F, Lu Y, Garner P, Meng Q. Strategies for expanding health insurance coverage in vulnerable populations. Cochrane Database Syst Rev 2014; 2014:CD008194. [PMID: 25425010 PMCID: PMC4455226 DOI: 10.1002/14651858.cd008194.pub3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Health insurance has the potential to improve access to health care and protect people from the financial risks of diseases. However, health insurance coverage is often low, particularly for people most in need of protection, including children and other vulnerable populations. OBJECTIVES To assess the effectiveness of strategies for expanding health insurance coverage in vulnerable populations. SEARCH METHODS We searched Cochrane Central Register of Controlled Trials (CENTRAL), part of The Cochrane Library. www.thecochranelibrary.com (searched 2 November 2012), PubMed (searched 1 November 2012), EMBASE (searched 6 July 2012), Global Health (searched 6 July 2012), IBSS (searched 6 July 2012), WHO Library Database (WHOLIS) (searched 1 November 2012), IDEAS (searched 1 November 2012), ISI-Proceedings (searched 1 November 2012),OpenGrey (changed from OpenSIGLE) (searched 1 November 2012), African Index Medicus (searched 1 November 2012), BLDS (searched 1 November 2012), Econlit (searched 1 November 2012), ELDIS (searched 1 November 2012), ERIC (searched 1 November 2012), HERDIN NeON Database (searched 1 November 2012), IndMED (searched 1 November 2012), JSTOR (searched 1 November 2012), LILACS(searched 1 November 2012), NTIS (searched 1 November 2012), PAIS (searched 6 July 2012), Popline (searched 1 November 2012), ProQuest Dissertation &Theses Database (searched 1 November 2012), PsycINFO (searched 6 July 2012), SSRN (searched 1 November 2012), Thai Index Medicus (searched 1 November 2012), World Bank (searched 2 November 2012), WanFang (searched 3 November 2012), China National Knowledge Infrastructure (CHKD-CNKI) (searched 2 November 2012).In addition, we searched the reference lists of included studies and carried out a citation search for the included studies via Web of Science to find other potentially relevant studies. SELECTION CRITERIA Randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after (CBA) studies and Interrupted time series (ITS) studies that evaluated the effects of strategies on increasing health insurance coverage for vulnerable populations. We defined strategies as measures to improve the enrolment of vulnerable populations into health insurance schemes. Two categories and six specified strategies were identified as the interventions. DATA COLLECTION AND ANALYSIS At least two review authors independently extracted data and assessed the risk of bias. We undertook a structured synthesis. MAIN RESULTS We included two studies, both from the United States. People offered health insurance information and application support by community-based case managers were probably more likely to enrol their children into health insurance programmes (risk ratio (RR) 1.68, 95% confidence interval (CI) 1.44 to 1.96, moderate quality evidence) and were probably more likely to continue insuring their children (RR 2.59, 95% CI 1.95 to 3.44, moderate quality evidence). Of all the children that were insured, those in the intervention group may have been insured quicker (47.3 fewer days, 95% CI 20.6 to 74.0 fewer days, low quality evidence) and parents may have been more satisfied on average (satisfaction score average difference 1.07, 95% CI 0.72 to 1.42, low quality evidence).In the second study applications were handed out in emergency departments at hospitals, compared to not handing out applications, and may have had an effect on enrolment (RR 1.5, 95% CI 1.03 to 2.18, low quality evidence). AUTHORS' CONCLUSIONS Community-based case managers who provide health insurance information, application support, and negotiate with the insurer probably increase enrolment of children in health insurance schemes. However, the transferability of this intervention to other populations or other settings is uncertain. Handing out insurance application materials in hospital emergency departments may help increase the enrolment of children in health insurance schemes. Further studies evaluating the effectiveness of different strategies for expanding health insurance coverage in vulnerable population are needed in different settings, with careful attention given to study design.
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Affiliation(s)
- Liying Jia
- Shandong UniversityCenter for Health Management and Policy, Key Lab for Health Economics and Policy Research, Ministry of HealthJinanShandongChina250012
- Ministry of HealthKey Lab for Health Economics and Policy ResearchShandongChina
| | - Beibei Yuan
- Peking UniversityChina Center for Health Development Studies (CCHDS)38 Xueyuan RoadBeijingBeijingChina100191
| | - Fei Huang
- Shandong UniversityCenter for Health Management and PolicyJinanChina
| | - Ying Lu
- Shandong UniversityCenter for Health Management and PolicyJinanChina
| | - Paul Garner
- Liverpool School of Tropical MedicineDepartment of Clinical SciencesPembroke PlaceLiverpoolMerseysideUKL3 5QA
| | - Qingyue Meng
- Peking UniversityChina Center for Health Development Studies (CCHDS)38 Xueyuan RoadBeijingBeijingChina100191
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Dickson KE, Simen-Kapeu A, Kinney MV, Huicho L, Vesel L, Lackritz E, de Graft Johnson J, von Xylander S, Rafique N, Sylla M, Mwansambo C, Daelmans B, Lawn JE. Every Newborn: health-systems bottlenecks and strategies to accelerate scale-up in countries. Lancet 2014; 384:438-54. [PMID: 24853600 DOI: 10.1016/s0140-6736(14)60582-1] [Citation(s) in RCA: 231] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Universal coverage of essential interventions would reduce neonatal deaths by an estimated 71%, benefit women and children after the first month, and reduce stillbirths. However, the packages with the greatest effect (care around birth, care of small and ill newborn babies), have low and inequitable coverage and are the most sensitive markers of health system function. In eight of the 13 countries with the most neonatal deaths (55% worldwide), we undertook a systematic assessment of bottlenecks to essential maternal and newborn health care, involving more than 600 experts. Of 2465 bottlenecks identified, common constraints were found in all high-burden countries, notably regarding the health workforce, financing, and service delivery. However, bottlenecks for specific interventions might differ across similar health systems. For example, the implementation of kangaroo mother care was noted as challenging in the four Asian country workshops, but was regarded as a feasible aspect of preterm care by respondents in the four African countries. If all high-burden countries achieved the neonatal mortality rates of their region's fastest progressing countries, then the mortality goal of ten or fewer per 1000 livebirths by 2035 recommended in this Series and the Every Newborn Action Plan would be exceeded. We therefore examined fast progressing countries to identify strategies to reduce neonatal mortality. We identified several key factors: (1) workforce planning to increase numbers and upgrade specific skills for care at birth and of small and ill newborn babies, task sharing, incentives for rural health workers; (2) financial protection measures, such as expansion of health insurance, conditional cash transfers, and performance-based financing; and (3) dynamic leadership including innovation and community empowerment. Adapting from the 2005 Lancet Series on neonatal survival and drawing on this Every Newborn Series, we propose a country-led, data-driven process to sharpen national health plans, seize opportunities to address the quality gap for care at birth and care of small and ill newborn babies, and systematically scale up care to reach every mother and newborn baby, particularly the poorest.
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Affiliation(s)
| | | | - Mary V Kinney
- Saving Newborn Lives, Save the Children, Cape Town, South Africa
| | - Luis Huicho
- Universidad Peruana Cayetano Heredia, Universidad Nacional Mayor de San Marcos and Instituto Nacional de Salud del Niño, Lima, Peru
| | | | - Eve Lackritz
- Global Alliance for Preventing Prematurity and Stillbirths, Seattle, WA, USA
| | | | - Severin von Xylander
- Maternal, Child and Adolescent Health Department, World Health Organization, Geneva, Switzerland
| | | | - Mariame Sylla
- UNICEF, West and Central Africa Regional Office, Dakar, Senegal
| | | | - Bernadette Daelmans
- Maternal, Child and Adolescent Health Department, World Health Organization, Geneva, Switzerland
| | - Joy E Lawn
- Saving Newborn Lives, Save the Children, Cape Town, South Africa; Centre for Maternal Reproductive and Child Health, London School of Hygiene and Tropical Medicine, London, UK
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Frimpong JA, Helleringer S, Awoonor-Williams JK, Aguilar T, Phillips JF, Yeji F. The complex association of health insurance and maternal health services in the context of a premium exemption for pregnant women: a case study in Northern Ghana. Health Policy Plan 2013; 29:1043-53. [PMID: 24262280 DOI: 10.1093/heapol/czt086] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Health insurance premium exemptions for pregnant women are a strategy to increase coverage of maternal health services in sub-Saharan countries. We examine health insurance registration among pregnant women before or after the introduction of a premium exemption, and test whether registration increases utilization of maternal health services. METHODS Data were drawn from a retrospective cohort study of 1641 women having given birth between January 2008 and August 2010 in two impoverished districts of Northern Ghana. Among those, 1411 became pregnant after premium exemption was adopted in July 2008. We compared registration rates before and after the exemption. We used logistic regressions to measure the association between insurance registration and receipt of essential maternal health interventions in the context of the premium exemption. We tested whether this association varied across levels of the health system [e.g. hospitals and health centres (HCs) vs community health compounds (CHC)]. RESULTS Health insurance registration increased significantly among pregnant women after adoption of the premium exemption. Coverage of clinical and diagnostic services was high, but antenatal care (ANC) clients received only partial counselling about safe motherhood (e.g. pregnancy-related danger signs). Three out of four clients who sought ANC in hospitals and HCs delivered at a health facility vs. slightly more than 50% among clients of CHC. In hospitals and HCs, National Health Insurance Scheme (NHIS) registration was associated with higher quality of services. In CHCs, NHIS registrants received fewer diagnostic tests, were less extensively counselled about safe motherhood and were less likely to be vaccinated against tetanus toxoid than non-registered clients. Among CHCs clients, being a NHIS registrant was however associated with an increased likelihood of delivering at a health facility. CONCLUSIONS In the context of premium exemptions, association of health insurance with use of maternal health services, and quality of services received, depends on place where pregnant women seek ANC.
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Affiliation(s)
- Jemima A Frimpong
- Department of Health Policy and Management, Mailman School of Public Health, Columbia University, 600 West 168th Street, 6th Floor, New York, NY 10032, USA, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY 10032, USA, Ghana Health Service, Upper East Regional Directorate, Bolgatanga, Ghana, National Center for Disaster Preparedness, Mailman School of Public Health, Columbia University, 215 West 125th Street, Suite 303, New York, NY 10027 and Ghana Health Service, Navrongo Health Research Centre, Box 114, Navrongo, Ghana
| | - Stéphane Helleringer
- Department of Health Policy and Management, Mailman School of Public Health, Columbia University, 600 West 168th Street, 6th Floor, New York, NY 10032, USA, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY 10032, USA, Ghana Health Service, Upper East Regional Directorate, Bolgatanga, Ghana, National Center for Disaster Preparedness, Mailman School of Public Health, Columbia University, 215 West 125th Street, Suite 303, New York, NY 10027 and Ghana Health Service, Navrongo Health Research Centre, Box 114, Navrongo, Ghana
| | - John Koku Awoonor-Williams
- Department of Health Policy and Management, Mailman School of Public Health, Columbia University, 600 West 168th Street, 6th Floor, New York, NY 10032, USA, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY 10032, USA, Ghana Health Service, Upper East Regional Directorate, Bolgatanga, Ghana, National Center for Disaster Preparedness, Mailman School of Public Health, Columbia University, 215 West 125th Street, Suite 303, New York, NY 10027 and Ghana Health Service, Navrongo Health Research Centre, Box 114, Navrongo, Ghana
| | - Thomas Aguilar
- Department of Health Policy and Management, Mailman School of Public Health, Columbia University, 600 West 168th Street, 6th Floor, New York, NY 10032, USA, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY 10032, USA, Ghana Health Service, Upper East Regional Directorate, Bolgatanga, Ghana, National Center for Disaster Preparedness, Mailman School of Public Health, Columbia University, 215 West 125th Street, Suite 303, New York, NY 10027 and Ghana Health Service, Navrongo Health Research Centre, Box 114, Navrongo, Ghana
| | - James F Phillips
- Department of Health Policy and Management, Mailman School of Public Health, Columbia University, 600 West 168th Street, 6th Floor, New York, NY 10032, USA, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY 10032, USA, Ghana Health Service, Upper East Regional Directorate, Bolgatanga, Ghana, National Center for Disaster Preparedness, Mailman School of Public Health, Columbia University, 215 West 125th Street, Suite 303, New York, NY 10027 and Ghana Health Service, Navrongo Health Research Centre, Box 114, Navrongo, Ghana
| | - Francis Yeji
- Department of Health Policy and Management, Mailman School of Public Health, Columbia University, 600 West 168th Street, 6th Floor, New York, NY 10032, USA, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY 10032, USA, Ghana Health Service, Upper East Regional Directorate, Bolgatanga, Ghana, National Center for Disaster Preparedness, Mailman School of Public Health, Columbia University, 215 West 125th Street, Suite 303, New York, NY 10027 and Ghana Health Service, Navrongo Health Research Centre, Box 114, Navrongo, Ghana
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Zoidze A, Rukhazde N, Chkhatarashvili K, Gotsadze G. Promoting universal financial protection: health insurance for the poor in Georgia--a case study. Health Res Policy Syst 2013; 11:45. [PMID: 24228796 PMCID: PMC3827822 DOI: 10.1186/1478-4505-11-45] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Accepted: 10/30/2013] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The present study focuses on the program "Medical Insurance for the Poor (MIP)" in Georgia. Under this program, the government purchased coverage from private insurance companies for vulnerable households identified through a means testing system, targeting up to 23% of the total population. The benefit package included outpatient and inpatient services with no co-payments, but had only limited outpatient drug benefits. This paper presents the results of the study on the impact of MIP on access to health services and financial protection of the MIP-targeted and general population. METHODS With a holistic case study design, the study employed a range of quantitative and qualitative methods. The methods included document review and secondary analysis of the data obtained through the nationwide household health expenditure and utilisation surveys 2007-2010 using the difference-in-differences method. RESULTS The study findings showed that MIP had a positive impact in terms of reduced expenditure for inpatient services and total household health care costs, and there was a higher probability of receiving free outpatient benefits among the MIP-insured. However, MIP insurance had almost no effect on health services utilisation and the households' expenditure on outpatient drugs, including for those with MIP insurance, due to limited drug benefits in the package and a low claims ratio. In summary, the extended MIP coverage and increased financial access provided by the program, most likely due to the exclusion of outpatient drug coverage from the benefit package and possibly due to improper utilisation management by private insurance companies, were not able to reverse adverse effects of economic slow-down and escalating health expenditure. MIP has only cushioned the negative impact for the poorest by decreasing the poor/rich gradient in the rates of catastrophic health expenditure. CONCLUSIONS The recent governmental decision on major expansion of MIP coverage and inclusion of additional drug benefit will most likely significantly enhance the overall MIP impact and its potential as a viable policy instrument for achieving universal coverage. The Georgian experience presented in this paper may be useful for other low- and middle-income countries that are contemplating ways to ensure universal coverage for their populations.
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Affiliation(s)
- Akaki Zoidze
- Curatio International Foundation, P.O. Box 110, Tbilisi 380079, Georgia
| | - Natia Rukhazde
- Curatio International Foundation, P.O. Box 110, Tbilisi 380079, Georgia
| | | | - George Gotsadze
- Curatio International Foundation, P.O. Box 110, Tbilisi 380079, Georgia
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Chopra M, Sharkey A, Dalmiya N, Anthony D, Binkin N. Strategies to improve health coverage and narrow the equity gap in child survival, health, and nutrition. Lancet 2012; 380:1331-40. [PMID: 22999430 DOI: 10.1016/s0140-6736(12)61423-8] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Implementation of innovative strategies to improve coverage of evidence-based interventions, especially in the most marginalised populations, is a key focus of policy makers and planners aiming to improve child survival, health, and nutrition. We present a three-step approach to improvement of the effective coverage of essential interventions. First, we identify four different intervention delivery channels--ie, clinical or curative, outreach, community-based preventive or promotional, and legislative or mass media. Second, we classify which interventions' deliveries can be improved or changed within their channel or by switching to another channel. Finally, we do a meta-review of both published and unpublished reviews to examine the evidence for a range of strategies designed to overcome supply and demand bottlenecks to effective coverage of interventions that improve child survival, health, and nutrition. Although knowledge gaps exist, several strategies show promise for improving coverage of effective interventions-and, in some cases, health outcomes in children-including expanded roles for lay health workers, task shifting, reduction of financial barriers, increases in human-resource availability and geographical access, and use of the private sector. Policy makers and planners should be informed of this evidence as they choose strategies in which to invest their scarce resources.
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Affiliation(s)
- Mickey Chopra
- Health Section, UNICEF, UN Plaza, New York, NY 10017, USA
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Abstract
BACKGROUND This study was the first of its kind to analyze the finance protection in New Rural Cooperative Medical Scheme in China using a claim database analysis. METHODS A claim database analysis of all hospitalizations reimbursed from the New Rural Cooperative Medical Scheme between January 2005 and December 2008 in Panyu district of Guangzhou covering 108,414 discharges was conducted to identify the difference in real reimbursement rate among 5 hospitalization cost categories by sex, age, and hospital type and to investigate the distributions of hospital-type choices among age and hospitalization cost categories. RESULTS The share of total cost reimbursed was only 34% on average, and increased with age but decreased with higher hospitalization cost, undermining catastrophic coverage. Older people were more likely to be hospitalized at lower level hospitals with higher reimbursement rate. The mean cost per hospitalization and average length of stay increased whereas the real reimbursement rate decreased with hospital level among the top 4 diseases with the same ICD-10 diagnostic code (3-digit level) for each age group. CONCLUSIONS Providing better protection against costly medical needs will require shifting the balance of objectives somewhat away from cost control toward more generous reimbursement, expanding the list of treatments that the insurance will cover, or some other policy to provide adequate care at lower cost facilities where more of the cost is now covered.
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Meng Q, Yuan B, Jia L, Wang J, Garner P. Outreach strategies for expanding health insurance coverage in children. Cochrane Database Syst Rev 2010:CD008194. [PMID: 20687096 DOI: 10.1002/14651858.cd008194.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Health insurance has the potential to improve access to health care and protect people from healthcare costs when they are ill. However, coverage is often low, particularly in people most in need of protection. OBJECTIVES To assess the effectiveness of outreach strategies for expanding insurance coverage of children who are eligible for health insurance schemes. SEARCH STRATEGY We searched the Cochrane Effective Practice and Organisation of Care Group (EPOC) Specialised Register (The Cochrane Library 2009, Issue 2), PubMed (January 1951 to January 2010), EMBASE (January 1966 to April 2009), PsycINFO (January 1967 to April 2009) and other relevant databases and websites. In addition, we searched the reference lists of included studies and relevant reviews, and carried out a citation search for included studies to find more potentially relevant studies. SELECTION CRITERIA Randomised controlled trials, controlled clinical trials, controlled before-after studies and interrupted time series which evaluated the effects of outreach strategies on increasing health insurance coverage for children. We defined outreach strategies as measures to improve the implementation of existing health insurance to enrol more eligible populations. This included increasing awareness of schemes, modifying enrolment, improving management and organis ation of insurance schemes, and mixed strategies. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed the risk of bias . We narratively summari sed the data. MAIN RESULTS We included two studies, both from the United States. One randomised controlled trial study with a low risk of bias showed that community- based case managers who provided health insurance information, application support, and negotiated with the insurer were effective in enrolling and maintaining enrolment of Latino American children into health insurance schemes (n = 257). The second quasi-randomised controlled trial, with an unclear risk of bias (n = 223), indicated that handing out insurance application materials in hospital emergenc y departments can increase enrolment of children into health insurance. AUTHORS' CONCLUSIONS The two studies included in this review provide evidence that in the US providing health insurance information and application assistance, and handing out application materials in hospital emergency departments can probably both improve insurance coverage of children. Further studies evaluating the effectiveness of different outreach strategies for expanding health insurance coverage of children in different countries are needed, with careful attention given to study design.
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Affiliation(s)
- Qingyue Meng
- Center for Health Management and Policy, Shandong University, Wenhua Xi Road 44, Jinan, Shandong, China, 250012
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