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Atakorah YB, Arthur E, Osei-Fosu AK, Novignon J. Economic inequalities in health insurance subscription renewal: Evidence from Ghana's National Health Insurance Scheme. Soc Sci Med 2024; 341:116514. [PMID: 38142607 DOI: 10.1016/j.socscimed.2023.116514] [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: 06/20/2023] [Revised: 12/11/2023] [Accepted: 12/12/2023] [Indexed: 12/26/2023]
Abstract
Ghana's national health insurance scheme (NHIS) is considered a major step towards achieving Universal Health Coverage (UHC) in the country. However, over the years the scheme has faced challenges, including subscription non-renewal, that threaten its sustenance. In this study, we estimate and analyse the nature of economic inequalities in NHIS subscription renewal and determine factors that contribute to the observed inequality. Data from the seventh round of the Ghana Living Standard Survey (GLSS) was used for the study. A sample of 40,170 ever insured individuals was included in the analysis comprising 18,066 males and 22,104 females. We computed concentration indices (CIs) and used linear regression techniques to decompose the CIs. The results show that NHIS renewal is pro-rich [CI = 0.126; P < 0.01] and favored males [CI = 0.110; P < 0.01] and urban dwellers [CI = 0.066; p < 0.01]. Major contributors to the observed inequality in subscription renewal include premium and processing fees payment, access to information, and economic wellbeing. The observed rural-urban and male-female differences in subscription renewal were explained by differences in premium and processing fee payments, education outcomes, employment status and access to information. The findings suggest that interventions that reduce cost barriers to NHIS subscription for the poor, improve physical access to healthcare and improve sensitization efforts should be encouraged.
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Affiliation(s)
- Yaw Boateng Atakorah
- Department of Economics, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
| | - Eric Arthur
- Department of Economics, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Anthony Kofi Osei-Fosu
- Department of Economics, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Jacob Novignon
- Department of Economics, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
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Akweongo P, Gadeka DD, Aryeetey G, Sumboh J, Aheto JMK, Aikins M. Does mobile renewal make health insurance more responsive to clients? A case study of the National Health Insurance Scheme in Ghana. BMJ Glob Health 2023; 7:e011440. [PMID: 38148107 PMCID: PMC10846841 DOI: 10.1136/bmjgh-2022-011440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 12/05/2023] [Indexed: 12/28/2023] Open
Abstract
BACKGROUND In 2018, Ghana's National Health Insurance Authority (NHIA) introduced a mobile strategy to enhance re-enrolment and improve client knowledge of their entitlements. This study investigated how Ghana's mobile strategy has influenced the NHIA's responsiveness to clients in terms of patient rights and entitlements, equity and satisfaction with health services. METHODS We surveyed people (n=1700) in 6 districts who had renewed their insurance in the previous 12 months, using any strategy (mobile or manual). Multiple regression analysis examined correlation between individual characteristics and renewal modality. Policy documents on the mobile programme's design and focus group discussions (n=12) on people's experiences renewing their insurance were analysed thematically. RESULTS While the mobile platform was designed for mobile National Health Insurance Scheme (NHIS) renewal and to provide information about insurance entitlements, few people surveyed (20%) knew about these informational features. Among those who renewed their NHIS coverage, 58% did so on the mobile renewal platform. Mobile renewal was high among those with tertiary education and those in the higher wealth quintiles. Mobile renewal was considered convenient, but required literacy in English, a phone and a mobile money wallet. For those who lacked some or all of these prerequisites but wanted to use mobile renewal, mobile vendors emerged as valued facilitators. CONCLUSION The mobile platform has increased the responsiveness of Ghana's NHIS through offering clients a more convenient mechanism to renew their insurance policies. It does not, however, eliminate the one month waiting period for activating the card, does not provide prompts to reassure clients of their renewal and does not empower most clients with information on entitlements. To improve the adoption and use of the mobile renewal strategy, the NHIA should publicise the platform's information-sharing functions and explore formally engaging mobile vendors.
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Affiliation(s)
- Patricia Akweongo
- Health Policy, Planning
and Management, University of
Ghana School of Public Health, Legon, Accra,
Ghana
| | - Dominic Dormenyo Gadeka
- Health Policy, Planning
and Management, University of
Ghana School of Public Health, Legon, Accra,
Ghana
| | - Genevieve Aryeetey
- Health Policy, Planning
and Management, University of
Ghana School of Public Health, Legon, Accra,
Ghana
| | - Jemima Sumboh
- Health Policy, Planning
and Management, University of
Ghana School of Public Health, Legon, Accra,
Ghana
| | - Justice Moses K Aheto
- Biostatistics, University of
Ghana School of Public Health, Accra, Greater Accra,
Ghana
| | - Moses Aikins
- Health Policy, Planning
and Management, University of
Ghana School of Public Health, Legon, Accra,
Ghana
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Kagaigai A, Thomas Mori A, Anaeli A, Grepperud S. Whether or not to enroll, and stay enrolled? A Tanzanian cross-sectional study on voluntary health insurance. HEALTH POLICY OPEN 2023; 4:100097. [PMID: 37383882 PMCID: PMC10297742 DOI: 10.1016/j.hpopen.2023.100097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 01/21/2023] [Accepted: 04/03/2023] [Indexed: 06/30/2023] Open
Abstract
Lower-middle income countries (LMICs) have invested significant effort into expanding insurance coverage as a means of improving access to health care. However, it has proven challenging to fulfill these ambitions. This study investigates to what extent variables associated with the enrollment decision (stay never-insured or enroll) differ from variables associated with the dropout decision (stay insured or drop out). A cross-sectional survey that included 722 households from rural districts in Tanzania was conducted and multinomial logistic regressions were performed to determine the associations between independent variables and membership status (never-insured, dropouts, or currently insured). Both the decision to enrollment and the decision to drop out were significantly associated with the presence of chronic disease and perceptions about the quality of services provided, insurance scheme management, and traditional healers. The effect of other variables, such as age, gender and educational level of the household head, household income, and perceptions about premium affordability and benefit-premium ratios, varied across the two groups. To improve voluntary health insurance coverage, policymakers must simultaneously increase the enrollment rate among the never-insured and reduce the dropout rate among the insured. Our conclusions suggest that policies to increase insurance scheme enrollment rates should differ for the two uninsured groups.
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Affiliation(s)
- Alphoncina Kagaigai
- University of Oslo, Institute of Health and Society, Department of Health Management and Health Economics, P.O. Box, 0315 Oslo, Norway
- Muhimbili University of Health and Allied Sciences, School of Public Health and Social Sciences, Department of Development Studies, P.O. Box, 65001 Dar es Salaam, Tanzania
| | - Amani Thomas Mori
- University of Bergen, Department of Global Health and Primary Health Care, P.O. Box, 5007 Bergen, Norway
| | - Amani Anaeli
- Muhimbili University of Health and Allied Sciences, School of Public Health and Social Sciences, Department of Development Studies, P.O. Box, 65001 Dar es Salaam, Tanzania
| | - Sverre Grepperud
- University of Oslo, Institute of Health and Society, Department of Health Management and Health Economics, P.O. Box, 0315 Oslo, Norway
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Oyando R, Were V, Willis R, Koros H, Kamano JH, Naanyu V, Etyang A, Mugo R, Murphy A, Nolte E, Perel P, Barasa E. Examining the responsiveness of the National Health Insurance Fund to people living with hypertension and diabetes in Kenya: a qualitative study. BMJ Open 2023; 13:e069330. [PMID: 37407061 DOI: 10.1136/bmjopen-2022-069330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/07/2023] Open
Abstract
OBJECTIVES To assess the responsiveness of the National Health Insurance Fund (NHIF) Supa Cover benefit package to the needs of individuals with diabetes and hypertension in Kenya. DESIGN, SETTING AND PARTICIPANTS We carried out a qualitative study and collected data using key informant interviews (n=39) and focus group discussions (n=4) in two purposively selected counties in Western Kenya. Study participants were drawn from NHIF officials, county government officials, health facility managers, healthcare workers and individuals with hypertension and diabetes who were enrolled in NHIF. We analysed data using a thematic approach. RESULTS Study participants reported that the NHIF Supa Cover benefit package expanded access to services for people living with hypertension and diabetes. However, the NHIF members and healthcare workers had inadequate awareness of the NHIF service entitlements. The NHIF benefit package inadequately covered the range of services needed by people living with hypertension and diabetes and the benefits package did not prioritise preventive and promotive services. Sometimes patients were discriminated against by healthcare providers who preferred cash-paying patients, and some NHIF-empanelled health facilities had inadequate structural inputs essential for quality of care. Study participants felt that the NHIF premium for the general scheme was unaffordable, and NHIF members faced additional out-of-pocket costs because of additional payments for services not available or covered. CONCLUSION Whereas NHIF has reduced financial barriers for hypertension and diabetes patients, to enhance its responsiveness to patient needs, NHIF should implement mechanisms to increase benefit package awareness among members and providers. In addition, preventive and promotive services should be included in NHIF's benefits package and mechanisms to monitor and hold contracted providers accountable should be strengthened.
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Affiliation(s)
- Robinson Oyando
- Health Economics Research Unit (HERU), KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Vincent Were
- Health Economics Research Unit (HERU), KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Ruth Willis
- Department of Health Service Research and Policy, London School of Hygiene and Tropical Medicine Faculty of Public Health and Policy, London, UK
| | - Hillary Koros
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Jemima H Kamano
- Department of Medicine, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Violet Naanyu
- Department of Medicine, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
- School of Arts and Social Sciences, Moi University, Eldoret, Kenya
| | - Anthony Etyang
- Department of Epidemiology and Demography, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Richard Mugo
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Adrianna Murphy
- Department of Health Service Research and Policy, London School of Hygiene and Tropical Medicine Faculty of Public Health and Policy, London, UK
| | - Ellen Nolte
- Department of Health Service Research and Policy, London School of Hygiene and Tropical Medicine Faculty of Public Health and Policy, London, UK
| | - Pablo Perel
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Edwine Barasa
- Health Economics Research Unit (HERU), KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Center for Tropical Medicine and Global Health, University of Oxford, Oxford, 01540, UK
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Desalegn M, Lemu T, Tadesse B, Olana T, Kaba Z, Tolossa T. Determinants of enrollment in community based health insurance program among households in East Wollega Zone, west Ethiopia: Unmatched case-control study. J Public Health Res 2023; 12:22799036231187101. [PMID: 37529065 PMCID: PMC10387694 DOI: 10.1177/22799036231187101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 06/21/2023] [Indexed: 08/03/2023] Open
Abstract
Background Ethiopia has launched a community-based health insurance (CBHI) since 2011, which is an innovative financing mechanism to enhance domestic resource mobilization and sustainable health financing. This study assessed determinants of CBHI enrollment among HHs (households) of East Wollega, Ethiopia, 2022. Method and materials Community based unmatched 1:2 case-control study design was conducted between Jan 7and Feb 5/2022 among 428 HHs (144 cases and 284 controls). Cases were selected from HHs who registered for CBHI and currently using CBHI. Controls were from those who do not registered for CBHI membership. Data collected using a semi-structured, interview administered questionnaire. Multivariable logistic regression with SPSS version 25 was employed for analysis and variables were declared statistical significant association at p-value < 0.05, 95% CI. Result Data from 428 (144 cases and 284 controls to CBHI) were collected; a response rate of 98.8%. Statistically lower odds of CBHI enrollment was observed among HHs who have poor knowledge [AOR = 0.48 (95% CI:0.27, 0.85)], perceived not respectful care [AOR = 0.44 (95% CI :0.24, 0.81)], unavailability of laboratory services [AOR = 0.37(95% CI:0.21, 0.66)], inappropriate time of premium payment [AOR = 0.31(95% CI:0.18, 0.52)]. In addition, medium wealth status category [AOR = 0.11(95% CI: 0.03, 0.45)]. Higher odd of CBHI enrollment observed among who have formal education [AOR = 2.39(95% CI: 1.28, 4.48)]. Conclusion and recommendation Educational level, knowledge, time of membership payment, laboratory test availability, perception of respectful care and wealth status were significant determinants of CBHI enrollment status. Hence, the responsible bodies should discuss and decide with community on the appropriate time of premium payment collection, and enhance community education on CBHI benefit package.
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Affiliation(s)
| | - Teferi Lemu
- Lecturer Nekemte Health Science College, Nekemte, Ethiopia
| | - Bekuma Tadesse
- Lecturer Nekemte Health Science College, Nekemte, Ethiopia
| | - Tariku Olana
- Lecturer Nekemte Health Science College, Nekemte, Ethiopia
| | - Zalalem Kaba
- Oromiyaa Regional Health Bureau, Addis Ababa, Ethiopia
| | - Tadesse Tolossa
- Department of Public Health, Institute of Health Sciences, Wollega University, Nekemte, Ethiopia
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Getaneh MM, Bayked EM, Workneh BD, Kahissay MH. Satisfaction of beneficiaries with community-based health insurance and associated factors in Legambo District, North-East Ethiopia: a cross-sectional study. Front Public Health 2023; 11:1127755. [PMID: 37261241 PMCID: PMC10227519 DOI: 10.3389/fpubh.2023.1127755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 04/28/2023] [Indexed: 06/02/2023] Open
Abstract
Background The fundamental concept of community-based health insurance is to strengthen the healthcare financing system to access universal healthcare by reducing costly risk-coping strategies. The scheme's sustainability and the quality of services provided by it are highly dependent on the satisfaction of its beneficiaries. Despite beneficiaries' satisfaction being the key determinant for providing evidence for policy revision and decision-making, it has often been neglected. Therefore, the study investigated the community-based health insurance beneficiaries' satisfaction and associated factors in Legambo district, North-East Ethiopia. Methods The study was conducted in the Legambo district with a community-based cross-sectional study design from October to November 2019. The data were collected from 838 households that had been the beneficiaries of the scheme using multi-stage and systematic random sampling. Twelve trained data collectors were employed and gathered the data using a pre-tested, structured questionnaire. We ran descriptive, bivariate, and logistic regression analyses. A value of p less than 0.05 with a 95% CI was used in multivariate logistic regression to determine the association of variables with the beneficiaries' satisfaction. Results The overall satisfaction level of the beneficiaries of the scheme was 58.6% and was associated with the following factors: merchandize (AOR = 1.92, 95% CI = 1.02-3.63), living in rural areas (AOR = 1.52, 95% CI = 1.02-2.27), an early office opening time (AOR = 3.81, 95% CI = 2.04-7.10), a short time interval to use benefit packages (AOR = 4.85, 95% CI = 2.08-11.31), an inexpensive membership premium (AOR =10.58, 95% CI = 3.56-31.44), availability of laboratory services (AOR =2.95, 95% CI = 1.71-5.09), presence of referral services (AOR =1.93, 95% CI = 1.33-2.80), having immediate care at health facilities (AOR = 1.73, 95% CI = 1.01-2.97) and non-compulsory enrolment (AOR = 6.31, 95% CI = 1.64-24.20). Conclusion The beneficiaries' satisfaction with the scheme was suboptimal and found to be determined by occupation, residence, laboratory and referral services, immediate care, office opening time, time interval to use benefit packages, premium amount, and situation of enrollment, most of which are service-related variables. Thus, to improve the satisfaction level, the stakeholders that should work hard seem to be the health insurance agency (the insurer) and the health facilities (the provider or supplier).
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Affiliation(s)
- Melaknesh Minda Getaneh
- Department of Capacity Building and Operational Research, Ethiopian Pharmaceuticals Supply Services (EPSS), Dessie, Ethiopia
| | - Ewunetie Mekashaw Bayked
- Department of Pharmacy, College of Medicine and Health Sciences (CMHS), Wollo University, Dessie, Ethiopia
| | - Birhanu Demeke Workneh
- Department of Pharmacy, College of Medicine and Health Sciences (CMHS), Wollo University, Dessie, Ethiopia
| | - Mesfin Haile Kahissay
- Department of Pharmaceutics and Social Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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Akafu W, Daba T, Tesfaye E, Teshome F, Akafu T. Determinants of trust in healthcare facilities among community-based health insurance members in the Manna district of Ethiopia. BMC Public Health 2023; 23:171. [PMID: 36698154 PMCID: PMC9878736 DOI: 10.1186/s12889-023-15124-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 01/10/2023] [Accepted: 01/23/2023] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Low-income countries, including Ethiopia, face substantial challenges in financing healthcare services to achieve universal health coverage. Consequently, millions of people suffer and die from health-related conditions. These can be efficiently managed in areas where community-based health insurance (CBHI) is properly implemented and communities have strong trust in healthcare facilities. However, the determinants of community trust in healthcare facilities have been under-researched in Ethiopia. OBJECTIVE To assess the determinants of trust in healthcare facilities among community-based health insurance members in the Manna District of Ethiopia. METHODS A community-based cross-sectional study was conducted from March 01 to 30, 2020 among 634 household heads. A multistage sampling technique was used to recruit the study participants. A structured interviewer-administered questionnaire was used to collect the data. Descriptive statistics were computed as necessary. Multivariable linear regression analyses were performed, and variables with a p-value < 0.05 were considered to have a significant association with households' trust in healthcare facilities. RESULTS In total, 617 households were included in the study, with a response rate of 97.0%. Household age (ß=0.01, 95% CI:0.001, 0.0013), satisfaction with past health services (ß=0.13, 95% CI:0.05, 0.22), perceived quality of services (ß= -0.47, 95% CI: -0.64, -0.29), perceived provider's attitude towards CBHI members (ß = -0.68, 95% CI: -0.88, -0.49), and waiting time (ß= -0.002, 95% CI:- 0.003, -0.001) were determinants of trust in healthcare facilities. CONCLUSION This study showed that respondents' satisfaction with past experiences, older household age, long waiting time, perceived poor quality of services, and perceived unfavorable attitudes of providers towards CBHI members were found to be determinants of trust in healthcare facilities. Thus, there is a need to improve the quality of health services, care providers' attitudes, and clients' satisfaction by reducing waiting time in order to increase clients' trust in healthcare facilities.
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Affiliation(s)
- Wakuma Akafu
- Department of Health Policy and Management, Faculty of Public Health, Institute of Health, Jimma University, Jimma, Oromia, Ethiopia.
| | - Teferi Daba
- grid.411903.e0000 0001 2034 9160Department of Health Policy and Management, Faculty of Public Health, Institute of Health, Jimma University, Jimma, Oromia Ethiopia
| | - Edosa Tesfaye
- grid.449817.70000 0004 0439 6014School of Public Health, Institute of Health, Wollega University, Nekemte, Oromia Ethiopia
| | - Firanbon Teshome
- grid.411903.e0000 0001 2034 9160Department of Health, Behavior and Society, Faculty of Public Health, Institute of Health, Jimma University, Jimma, Oromia Ethiopia
| | - Tesfaye Akafu
- grid.411903.e0000 0001 2034 9160Department of Natural Resource Management, Institute of Agriculture and Veterinary Medicine, Jimma University, Jimma, Oromia Ethiopia
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Otieno P, Angeles G, Quiñones S, van Halsema V, Novignon J, Palermo T. Health services availability and readiness moderate cash transfer impacts on health insurance enrolment: evidence from the LEAP 1000 cash transfer program in Ghana. BMC Health Serv Res 2022; 22:599. [PMID: 35509055 PMCID: PMC9066897 DOI: 10.1186/s12913-022-07964-w] [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: 09/22/2021] [Accepted: 04/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Expanding health insurance coverage is a priority under Sustainable Development Goal 3. To address the intersection between poverty and health and remove cost barriers, the government of Ghana established the National Health Insurance Scheme (NHIS). Government further linked NHIS with the Livelihood Empowerment Against Poverty (LEAP) 1000 cash transfer program by waiving premium fees for LEAP 1000 households. This linkage led to increased NHIS enrolment, however, large enrolment gaps remained. One potential reason for failure to enroll may relate to the poor quality of health services. METHODS We examine whether LEAP 1000 impacts on NHIS enrolment were moderated by health facilities' service availability and readiness. RESULTS We find that adults in areas with the highest service availability and readiness are 18 percentage points more likely to enroll in NHIS because of LEAP 1000, compared to program effects of only 9 percentage points in low service availability and readiness areas. Similar differences were seen for enrolment among children (20 v. 0 percentage points) and women of reproductive age (25 v. 10 percentage points). CONCLUSIONS We find compelling evidence that supply-side factors relating to service readiness and availability boost positive impacts of a cash transfer program on NHIS enrolment. Our work suggests that demand-side interventions coupled with supply-side strengthening may facilitate greater population-level benefits down the line. In the quest for expanding financial protection towards accelerating the achievement of universal health coverage, policymakers in Ghana should prioritize the integration of efforts to simultaneously address demand- and supply-side factors. TRIAL REGISTRATION This study is registered in the International Initiative for Impact Evaluation's (3ie) Registry for International Development Impact Evaluations ( RIDIE-STUDY-ID-55942496d53af ).
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Affiliation(s)
- Peter Otieno
- African Population and Health Research Center, P.O. Box 10787-00100, Nairobi, Kenya
| | - Gustavo Angeles
- Department of Maternal and Child Health, UNC Gillings School of Global Public Health, 400 Meadowmont Circle CB #3446, Chapel Hill, NC, USA
| | - Sarah Quiñones
- Department of Epidemiology and Environmental Health, University at Buffalo, SUNY, 270 Farber Hall, Buffalo, NY, USA
| | | | - Jacob Novignon
- Department of Economics, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Tia Palermo
- Department of Epidemiology and Environmental Health, University at Buffalo, SUNY, 270 Farber Hall, Buffalo, NY, USA.
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Kalolo A, Gautier L, De Allegri M. Exploring the Role of Social Representation in Micro-Health Insurance Scheme Enrolment and Retainment in Sub-Saharan Africa: A Scoping Review. Health Policy Plan 2022; 37:915-927. [DOI: 10.1093/heapol/czac036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 03/30/2022] [Accepted: 04/22/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Low enrolment in micro-health insurance (MHI) schemes is a recurring issue affecting the viability of such schemes. Beyond the efforts addressing low subscription and retention in these schemes, little is known on how social representations are related to micro-health insurance schemes enrolment and retention. This scoping review aimed at exploring the role of social representations in shaping enrollment and retention in MHI in sub-Saharan Africa. We reviewed qualitative, quantitative and mixed methods studies conducted between 2004 and 2019 in sub-Saharan Africa. We limited our search to peer-reviewed and grey literature in English and French reporting on social representations of MHI. We defined social representations as conventions, cultural and religious beliefs, local rules and norms, local solidarity practices, political landscape and social cohesion. We applied the framework developed by Arksey and O’Malley and modified by Levac et al. to identify and extract data from relevant studies. We extracted information from a total of 78 studies written in English (60%) and in French (40%) of which 56% were conducted in West Africa. More than half of all studies explored either cultural and religious beliefs (56%) or social conventions (55%) whereas only 37% focused on social cohesion (37%). Only six papers (8%) touched upon all six categories of social representation considered in this study whereas 25% of the papers studied more than three categories. We found that all the studied social representations influence enrollment and retention in MHI schemes. Our findings highlight the paucity of evidence on social representations in relation to MHI schemes. This initial attempt to compile evidence on social representations invites more research on the role those social representations play on the viability of MHI schemes. Our findings call for program design and implementation strategies to consider and adjust to local social representations in order to enhance scheme attractiveness.
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Affiliation(s)
- Albino Kalolo
- Department of Public Health, St. Francis University College of Health and Allied Sciences, P.O. Box 175, Ifakara, Tanzania
| | - Lara Gautier
- Département de Gestion, d’Évaluation et de Politique de Santé, École de Santé Publique de l’Université de Montréal, Montreal, Canada
- Centre de recherche en santé publique, Université de Montréal et CIUSSS du Centre-Sud-de-l’Île-de-Montréal, Montreal, Canada
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, University Hospital and Medical Faculty, University of Heidelberg, Germany
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Tan RTH, Abdul Rasid SZ, Wan Ismail WK, Tobechan J, Tan ETY, Yusof AN, Low JH. Willingness to Pay for National Health Insurance: A Contingent Valuation Study Among Patients Visiting Public Hospitals in Melaka, Malaysia. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2022; 20:255-267. [PMID: 34927225 DOI: 10.1007/s40258-021-00691-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/13/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND The Malaysian public healthcare system is tax funded, with healthcare costs highly subsidized by the Government. The current health financing is not sustainable to cover all the healthcare resources. Introducing a national health insurance (NHI), a prepayment method, would protect the population from financial hardship by reducing out-of-pocket payment, minimizing the barrier to accessing health and achieving equitable healthcare. Studies on the willingness to pay (WTP) for NHI are available in different contexts; however, little was found in Malaysia. In addition, factors affecting the WTP for NHI have been less researched in the Malaysian context. OBJECTIVE This study investigates the WTP for NHI and factors influencing it in Melaka, Malaysia. METHOD Using the contingent valuation method, the researchers distributed a pre-tested self-administered questionnaire to 489 respondents in three leading public hospitals from 1 to 9 November 2019. Multi-stage sampling forms the selection of respondents. Respondents were presented with a hypothetical scenario on NHI and asked whether they would be willing to pay for NHI. Chi-square was used to examine the association between categorical independent variables and WTP for NHI, and binary logistic regression was applied to determine the variables with the most predictive effect towards WTP for NHI. RESULTS Out of 462 usable responses, 344 respondents (74.5%) were willing to pay for NHI. The majority (51.3%) of the respondents were willing to pay 15 Malaysian Ringgit (3.70 US dollars) or more for the NHI scheme. Chi-square analysis revealed that age, marital status, education level, employment status, chronic diseases, and perception towards NHI were significantly associated with WTP for NHI. Binary regression analysis found that marital status and perception towards NHI have the most predictive effect on respondents' WTP for NHI. CONCLUSION This study revealed that the majority of the respondents are willing to pay for NHI if implemented in Malaysia. The findings lay a foundation for implementing a future NHI framework in Malaysia and reference future health financing research.
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Affiliation(s)
- Robin Tiow Heng Tan
- Pharmaceutical Services Division, Melaka State Health Department, Ministry of Health, Melaka, Malaysia.
| | - Siti Zaleha Abdul Rasid
- Azman Hashim International Business School, Universiti Teknologi Malaysia, Kuala Lumpur, Malaysia
- University of Business and Technology, Jeddah, Saudi Arabia
| | | | - Janiza Tobechan
- Melaka General Hospital, Ministry of Health, Melaka, Malaysia
| | | | | | - Jia Hui Low
- Jasin Hospital, Ministry of Health, Melaka, Malaysia
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Akweongo P, Voetagbe E, Tediosi F, Gadeka DD, Salari P, Aikins M. Community perceptions of enrolment of indigents into the National Health Insurance Scheme in Ghana: a case study of the Livelihood Empowerment against Poverty Programme. Glob Health Res Policy 2022; 7:4. [PMID: 35090567 PMCID: PMC8796334 DOI: 10.1186/s41256-022-00238-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 08/08/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Livelihood Empowerment against Poverty (LEAP) programme in Ghana as part of its beneficiary programme, identifies the poor/indigents for exemptions from premium payments in the National Health Insurance Scheme (NHIS). This paper sought to understand community perceptions of enrolling the poor in the NHIS through LEAP in order to inform policy. METHODS The study adopted a descriptive cross-sectional study design by using a qualitative approach. The study was conducted in three geographical regions of Ghana: Greater Accra, Brong-Ahafo and Northern region representing the three ecological zones of Ghana between October 2017 and February 2018. The study population included community members, health workers, NHIS staff and social welfare officers/social development officers. Eighty-one in-depth interviews and 23 Focus Group Discussions were conducted across the three regions. Data were analysed thematically and verbatim quotes from participants were used to support the views of participants. RESULTS The study shows that participants were aware of the existence of LEAP and its benefits. There was, however, a general belief that the process of LEAP had been politicized and therefore favours only people who were sympathizers of the ruling government as they got enrolled into the NHIS. Participants held the view that the process of selecting beneficiaries lacked transparency, thus, they were not satisfied with the selection process. However, the study shows the ability of the community to identify the poor. The study reports varying concepts of poverty and its identification across the three ecological zones of Ghana. CONCLUSION There is a general perception of politicization and lack of transparency of the selection of the poor into the NHIS through the LEAP programme in Ghana. Community-based approaches in the selection of the indigent are recommended to safeguard the NHIS-LEAP beneficiary process.
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Affiliation(s)
| | | | - Fabrizio Tediosi
- Swiss Tropical and Public Health Institute (Swiss TPH), Socintrasse 57, 4051, Basel, Switzerland
| | | | - Paola Salari
- Institute of Pharmaceutical Medicine (ECPM), University of Basel, Basel, Switzerland
| | - Moses Aikins
- School of Public Health, University of Ghana, Accra, Ghana
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Sataru F, Twumasi-Ankrah K, Seddoh A. An Analysis of Catastrophic Out-of-Pocket Health Expenditures in Ghana. FRONTIERS IN HEALTH SERVICES 2022; 2:706216. [PMID: 36925853 PMCID: PMC10012771 DOI: 10.3389/frhs.2022.706216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 01/18/2022] [Indexed: 11/13/2022]
Abstract
Introduction Ghana implemented a universal health coverage scheme aimed at attaining financial risk protection against catastrophic out-of-pocket health expenditures. The effort has yielded mixed benefits for the different socio-economic profiles of the population. The present study estimates the incidence of catastrophic payments among Ghanaian households. Methods The study analyzed the round seven dataset of the Ghana Living Standards Survey collected between 2016 and 2017. We estimated the incidence and intensity of catastrophic payments for total household consumption and non-food consumption for a range of thresholds. The analysis further weighted the measures of catastrophic payments to determine the distribution sensitivity. Results As the threshold increased from 10 to 25% of total household consumption, the incidence of catastrophic payments dropped from 1.0 to 0.1%. At the 40% threshold of non-food consumption, the estimated incidence was 0.2%. For both total household consumption and non-food consumption, the concentration indices were negative at all the thresholds. The results were indicative of a higher concentration of financial catastrophe among the poorest households and significant inequalities in the incidence between the poorest and richest households. Conclusion The study confirmed the declining trend in the general incidence of catastrophic health expenditures in Ghana. However, the incidence and risk of financial catastrophe remained disproportionately higher among the poorest households, which is instructive of gaps in financial risk protection coverage. The Ghana National Health Insurance Scheme must therefore strengthen its targeting and enrolment of this sub-population group to reduce their vulnerability to catastrophic payments.
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Affiliation(s)
| | - Kwame Twumasi-Ankrah
- Department of General Studies, School of Human Development, Heritage Christian College, Accra, Ghana
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Hamid SA, Khanam M, Azim MR, Islam MS. Health insurance for university students in Bangladesh: A novel experiment. Health Sci Rep 2021; 4:e382. [PMID: 34622018 PMCID: PMC8485632 DOI: 10.1002/hsr2.382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 07/14/2021] [Accepted: 08/02/2021] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND AND AIMS Bangladesh requires some pragmatic initiatives for using its immense potentiality to flourish health insurance. Introducing group health insurance for university students is a groundbreaking idea for stepping toward social health insurance in Bangladesh. This article examined the effect of the health insurance initiative for the university students introduced by the Institute of Health Economics, University of Dhaka, on attitude toward insurance and protecting financial risk against health care expenditure. METHOD We used both management information system (MIS) and primary data obtained through mixed methods. We collected the quantitative data from a baseline survey on 310 students and a year-end survey on 151 students. We used bivariate tools to analyze the data. RESULTS The results show that the mean score of attitude toward health insurance in the year-end survey (4.04) was significantly higher than the baseline score (3.21). Results also show that a significantly higher percentage of the students reported insurance as "useful" in the year-end survey (83.74%) than the baseline survey (40.40%). The results also reflectes that the scheme has a substantial impact on reducing the out-of-pocket spending for health care, especially for in-patient care, and the anxiety regarding the financing of health care among the students. There is also an indication of sustainability and the feasibility of scaling up such a scheme across the country. CONCLUSIONS Introducing such health insurance by all the universities may guide the nation toward large-scale group health insurance and social health insurance.
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Affiliation(s)
- Syed Abdul Hamid
- Institute of Health Economics University of Dhaka Dhaka Bangladesh
- Research Division, Universal Research Care Ltd Dhaka Bangladesh
| | - Moriam Khanam
- Institute of Health Economics University of Dhaka Dhaka Bangladesh
| | - Md Ragaul Azim
- Institute of Health Economics University of Dhaka Dhaka Bangladesh
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Abraham E, Gray C, Fagbamigbe A, Tediosi F, Otesinky B, Haafkens J, Mhalu G, Mtenga S. Barriers and facilitators to health insurance enrolment among people working in the informal sector in Morogoro, Tanzania. AAS Open Res 2021. [DOI: 10.12688/aasopenres.13289.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Health insurance is a crucial pathway towards the achievement of universal health coverage. In Tanzania, health-financing reforms are underway to speed up universal health coverage in the informal sector. Despite improved Community Health Fund (iCHF) rollout, iCHF enrolment remains a challenge in the informal sector. This study aimed to explore the perspectives of local women food vendors (LWFV) and Bodaboda (motorcycle taxi) drivers on factors that challenge and facilitate their enrolment in iCHF. Methods: A qualitative study was conducted in Morogoro Municipality through in-depth interviews with LWFV (n=24) and Bodaboda drivers (n=26), and two focus group discussions with LWFV (n=8) and Bodaboda drivers (n=8). Theory of planned behaviour (TPB) constructs (attitude, subjective norms, and perceived control) provided a framework for the study and informed a thematic analysis focusing on the barriers and facilitators of iCHF enrolment. Results: The views of LWFV and Bodaboda drivers on factors that influence iCHF enrolment converged. Three main barriers emerged: lack of knowledge about the iCHF (attitude); negative views from friends and families (subjective norms); and inability to overcome challenges, such as the quality and range of health services available to iCHF members and iCHF not being accepted at non-government facilities (perceived control). A number of facilitators were identified, including opinions that enrolling to iCHF made good financial sense (attitude), encouragement from already-enrolled friends and relatives (subjective norms) and the belief that enrolment payment is affordable (perceived control). Conclusions: Results suggest that positive attitudes supported by perceived control and encouragement from significant others could potentially motivate LWFV and Bodaboda drivers to enroll in iCHF. However, more targeted information about the scheme is needed for individuals in the informal sector. There is also a need to ensure that quality health services are available, including coverage for non-communicable diseases (NCDs), and that non-government facilities accept iCHF.
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Nshakira-Rukundo E, Mussa EC, Cho MJ. Dropping out of voluntary community-based health insurance in rural Uganda: Evidence from a cross-sectional study in rural south-western Uganda. PLoS One 2021; 16:e0253368. [PMID: 34270556 PMCID: PMC8284644 DOI: 10.1371/journal.pone.0253368] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 06/04/2021] [Indexed: 11/30/2022] Open
Abstract
AIM Community Based Health Insurance (CBHI) schemes have become central to health systems financing as avenues of achieving universal health coverage in developing countries. Yet, while emphasis in research and policy has mainly concentrated on enrolment, very little has been apportioned to high rates of dropping out after initial enrolment. The main aim of this study is to understand the factors behind CBHI dropping out through a cross-sectional quantitative research design to gain insights into curtailing the drop out of CBHI in Uganda. METHODS The survey for the quantitative research component took place between August 2015 and March 2016 covering 464 households with under-5 children in south-western Uganda. To understand the factors associated with dropping out of CBHI, we employ a multivariate logistic regression on a subsample of 251 households who were either currently enrolled or had enrolled at one time and later dropped out. RESULTS Overall, we find that 25.1 percent of the households that had ever enrolled in insurance reported dropping out. Household socioeconomic status (wealth) was one of the key factors that associated with dropping out. Larger household sizes and distance from the hospital were significantly associated with dropping out. More socially connected households were less likely to drop out revealing the influence of community social capital in keeping households insured. CONCLUSION The findings have implications for addressing equity and inclusion concerns in community-based health insurance programmes such as one in south-western Uganda. Even when community based informal system aim for inclusion of the poorest, they are not enough and often the poorest of the poor slip into the cracks and remain uninsured or drop out. Moreover, policy interventions toward curtailing high dropout rates should be considered to ensure financial sustainability of CBHI schemes.
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Affiliation(s)
- Emmanuel Nshakira-Rukundo
- Institute for Food and Resource Economics, University of Bonn, Bonn, Germany
- Apata Insights, Kampala, Uganda
| | - Essa Chanie Mussa
- Department of Agriculture Economics, University of Gondar, Gondar, Ethiopia
| | - Min Jung Cho
- Faculty Governance and Global Affairs, Leiden University College, The Hague, Netherlands
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Demissie GD, Atnafu A. Barriers and Facilitators of Community-Based Health Insurance Membership in Rural Amhara Region, Northwest Ethiopia: A Qualitative Study. CLINICOECONOMICS AND OUTCOMES RESEARCH 2021; 13:343-348. [PMID: 33976557 PMCID: PMC8106446 DOI: 10.2147/ceor.s293847] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 04/09/2021] [Indexed: 11/23/2022] Open
Abstract
Background More than 150 million people encounter huge cost of health expenses every year, and most of these treatment seekers face poverty owing to out-of-pocket payments. Community-based health insurance (CBHI) won popularity as a makeshift health financing mechanism for out-of-pocket payments in poor communities. The aim of this study was therefore to explore the facilitators and impediments of enrollment to community-based health insurance in rural parts of the Amhara region, Ethiopia. Methods Focus Group Discussion (FGD) was the main data collection instrument supplemented by key informant interview (KII). The FGD participants were selected using a purposive sampling technique. The participants were therefore selected based on their membership status of CBHI (members or non-members). Six FGDs and four KIIs were conducted in November 2019 in three districts. Before analyzing the data, all FGDs and KIIs were transcribed and transferred into ATLAS.ti version 7.1 software. An inductive thematic analysis approach was done, that is, on the basis of major themes emerged from the data. Results Low level of awareness, perception of high amount of premium, poor perception of quality of services and lack of trust are the barriers to join community-based health insurance. Conclusion There has been low level of awareness and misconception about community-based health insurance. The major reason to decline to join CBHI was low capacity to pay the premium.
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Affiliation(s)
- Getu Debalkie Demissie
- Department of Health Education and Behavioral Sciences, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Asmamaw Atnafu
- Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Kagaigai A, Anaeli A, Mori AT, Grepperud S. Do household perceptions influence enrolment decisions into community-based health insurance schemes in Tanzania? BMC Health Serv Res 2021; 21:162. [PMID: 33607977 PMCID: PMC7893739 DOI: 10.1186/s12913-021-06167-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 02/10/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Several countries including Tanzania, have established voluntary non-profit insurance schemes, commonly known as community-based health insurance schemes (CBHIs), that typically target rural populations and the informal sector. This paper considers the importance of household perceptions towards CBHIs in Tanzania and their role in explaining the enrolment decision of households. METHODS This was a cross-sectional household survey that involved 722 households located in Bahi and Chamwino districts in the Dodoma region. A three-stage sampling procedure was used, and the data were analyzed using both factor analysis (FA) and principal component analysis (PCA). Statistical tests such as Bartlett's test of sphericity, Kaiser-Meyer-Olkin (KMO) for sampling adequacy, and Cronbach's alpha test for internal consistency and scale reliability were performed to examine the suitability of the data for PCA and FA. Finally, multivariate logistic regressions were run to determine the associations between the identified factors and the insurance enrolment status. RESULTS The PCA identified seven perception factors while FA identified four factors. The quality of healthcare services, preferences (social beliefs), and accessibility to insurance scheme administration (convenience) were the most important factors identified by the two methods. Multivariate logistic regressions showed that the factors identified from the two methods differed somewhat in importance when considered as independent predictors of the enrollment status. The most important perception factors in terms of strength of association (odds ratio) and statistical significance were accessibility to insurance scheme administration (convenience), preferences (beliefs), and the quality of health care services. However, age and income were the only socio-demographic characteristics that were statistically significant. CONCLUSION Household perceptions were found to influence households' decisions to enroll in CBHIs. Policymakers should recognize and consider these perceptions when designing policies and programs that aim to increase the enrolment into CBHIs.
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Affiliation(s)
- Alphoncina Kagaigai
- Department of Health Management and Health Economics, University of Oslo, P.O. Box 0315, Oslo, Norway.
- Department of Development Studies, Muhimbili University of Health and Allied Sciences, P.O. Box 65001, Dar es Salaam, Tanzania.
| | - Amani Anaeli
- Department of Development Studies, Muhimbili University of Health and Allied Sciences, P.O. Box 65001, Dar es Salaam, Tanzania
| | - Amani Thomas Mori
- Department of Global Public Health and Primary Care, University of Berge, P.O. Box 7804, 5020, Bergen, Norway
| | - Sverre Grepperud
- Department of Health Management and Health Economics, University of Oslo, P.O. Box 0315, Oslo, Norway
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Amani PJ, Tungu M, Hurtig AK, Kiwara AD, Frumence G, San Sebastián M. Responsiveness of health care services towards the elderly in Tanzania: does health insurance make a difference? A cross-sectional study. Int J Equity Health 2020; 19:179. [PMID: 33046058 PMCID: PMC7549195 DOI: 10.1186/s12939-020-01270-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 08/25/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Responsiveness has become an important health system performance indicator in evaluating the ability of health care systems to meet patients' expectations. However, its measurement in sub-Saharan Africa remains scarce. This study aimed to assess the responsiveness of the health care services among the insured and non-insured elderly in Tanzania and to explore the association of health insurance (HI) with responsiveness in this population. METHODS A community-based cross-sectional study was conducted in 2017 where a pre-tested household survey, administered to the elderly (60 + years) living in Igunga and Nzega districts, was applied. Participants with and without health insurance who attended outpatient and inpatient health care services in the past three and 12 months were selected. Responsiveness was measured based on the short version of the World Health Organization (WHO) multi-country responsiveness survey study, which included the dimensions of quality of basic amenities, choice, confidentiality, autonomy, communication and prompt attention. Quantile regression was used to assess the specific association of the responsiveness index with health insurance adjusted for sociodemographic factors. RESULTS A total of 1453 and 744 elderly, of whom 50.1 and 63% had health insurance, used outpatient and inpatient health services, respectively. All domains were rated relatively highly but the uninsured elderly reported better responsiveness in all domains of outpatient and inpatient care. Waiting time was the dimension that performed worst. Possession of health insurance was negatively associated with responsiveness in outpatient (- 1; 95% CI: - 1.45, - 0.45) and inpatient (- 2; 95% CI: - 2.69, - 1.30) care. CONCLUSION The uninsured elderly reported better responsiveness than the insured elderly in both outpatient and inpatient care. Special attention should be paid to those dimensions, like waiting time, which ranked poorly. Further research is necessary to reveal the reasons for the lower responsiveness noted among insured elderly. A continuous monitoring of health care system responsiveness is recommended.
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Affiliation(s)
- Paul Joseph Amani
- Department of Health Systems Management, School of Public Administration and Management, Mzumbe University, Morogoro, Tanzania.
- Epidemiology and Global Health, Umeå International School of Public Health, Umeå University, Umeå, Sweden.
| | - Malale Tungu
- Epidemiology and Global Health, Umeå International School of Public Health, Umeå University, Umeå, Sweden
- Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Anna-Karin Hurtig
- Epidemiology and Global Health, Umeå International School of Public Health, Umeå University, Umeå, Sweden
| | - Angwara Denis Kiwara
- Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Gasto Frumence
- Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Miguel San Sebastián
- Epidemiology and Global Health, Umeå International School of Public Health, Umeå University, Umeå, Sweden
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Christmals CD, Aidam K. Implementation of the National Health Insurance Scheme (NHIS) in Ghana: Lessons for South Africa and Low- and Middle-Income Countries. Risk Manag Healthc Policy 2020; 13:1879-1904. [PMID: 33061721 PMCID: PMC7537808 DOI: 10.2147/rmhp.s245615] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 06/30/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND South Africa is having difficulties in rolling out the National Health Insurance(NHI) policy. There are ongoing arguments on whether the NHI will provide access to quality and equitable healthcare it is intended to and whether South Africa is ready to implement the policy. Many stakeholders believe the country needs more preparation if the policy will be successful. Ghana, on the other hand, has successfully implemented the National Health Insurance Scheme(NHIS) for over 15 years. OBJECTIVE This paper sought to explore the implementation of the NHIS in Ghana and the lessons South Africa and other low- and middle-income countries can learn from such a process. METHODS A scoping review was conducted using the Joanna Brigs Institute's System for the Unified Management, Assessment and Review of Information (SUMARI) and Mendeley reference manager to manage the review process. Journal articles published on the NHIS in Ghana from January 2003 to December 2018 were searched from Science Direct, PubMed, Scopus, CINAHL, and Medline using the keywords: Ghana, Health, and Insurance. RESULTS The implementation of the NHIS has provided access to healthcare for the Ghanaian population, especially to poor and vulnerable . Despite the successful implementation of the NHIS in Ghana, the scheme is challenged with poor coverage; poor quality of care; corruption and ineffective governance; poor stakeholder participation; lack of clarity on concepts in the policy; intense political influence; and poor financing. CONCLUSION The marked inequity in the South African health system makes the implementation of the NHI inevitable. The challenges experienced in the implementation of the NHIS in Ghana are not new to the South African healthcare system. South Africa must learn from the experiences of Ghana,a context that shares common socio-cultural and economic factors and disease burden,in order to successfully implement the NHI.
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Affiliation(s)
- Christmal Dela Christmals
- Research on the Health Workforce for Equity and Quality, Centre for Health Policy, School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Kizito Aidam
- Department of Bacteriology, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
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Dao A. What it means to say "I Don't have any money to buy health insurance" in rural Vietnam: How anticipatory activities shape health insurance enrollment. Soc Sci Med 2020; 266:113335. [PMID: 32932002 DOI: 10.1016/j.socscimed.2020.113335] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 06/29/2020] [Accepted: 08/25/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Amy Dao
- Department of Geography and Anthropology, Cal Poly Pomona. 3801 W. Temple Ave, Pomona, CA, 91768, United States.
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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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Kakama AA, Namyalo PK, Basaza RK. Feasibility and desirability of scaling up Community-based Health Insurance (CBHI) in rural communities in Uganda: lessons from Kisiizi Hospital CBHI scheme. BMC Health Serv Res 2020; 20:662. [PMID: 32680506 PMCID: PMC7367343 DOI: 10.1186/s12913-020-05525-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 07/09/2020] [Indexed: 12/03/2022] Open
Abstract
Background Community-based Health Insurance (CBHI) schemes have been implemented world over as initial steps for national health insurance schemes. The CBHI concept developed out of a need for financial protection against catastrophic health expenditures to the poor after failure of other health financing mechanisms. CBHI schemes reduce out-of-pocket payments, and improve access to healthcare services in addition to raising additional revenue for the health sector. Kisiizi Hospital CBHI scheme which was incepted in 1996, has 41,500 registered members, organised in 210 community associations known as ‘Bataka’ or ‘Engozi’ societies. Members pay annual premiums and a co-payment fee before service utilisation. This study aimed at exploring the feasibility and desirability of scaling up CBHI in Rubabo County, with specific objectives of: exploring community perceptions and determining acceptability of CBHI, identifying barriers, enablers to scaling up CBHI and documenting lessons regarding CBHI expansion in a rural community. Methods Explorative study using qualitative methods of Key informant interviews and Focus Group Discussions (FGDs). Seventeen key informant interviews, three focus group discussions for scheme members and three for non-scheme members were conducted using a topic guide. Data was analysed using thematic approach. Results Scaling up Kisiizi Hospital CBHI is desirable because: it conforms to the government social protection agenda, society values, offers a comprehensive benefits package, and is a better healthcare financing alternative for many households. Scaling up Kisiizi Hospital CBHI is largely feasible because of a strong network of community associations, trusted quality healthcare services at Kisiizi Hospital, affordable insurance fees, trusted leadership and management systems. Scheme expansion faces some obstacles that include: long distances and high transport costs to Kisiizi Hospital, low levels of knowledge about health insurance, overlapping financial priorities at household level and inability of some households to pay premiums. Conclusions CBHI implementation requires the following considerations: conformity with society values and government priorities, a comprehensive benefits package, trusted quality of healthcare services, affordable fees, trusted leadership and management systems.
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Affiliation(s)
- Alex A Kakama
- Kisiizi Hospital Community-based Health Insurance Scheme, Kisiizi Hospital, Kabale, Uganda
| | - Prossy K Namyalo
- Department of Social Sciences, Ndejje University, Kampala, Uganda
| | - Robert K Basaza
- Gudie Incubation Centre, Kira Municipality, Uganda. .,Uganda Christian University Mukono, Masters of Public Health Leadership Program, Mukono, Uganda.
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Alidu L, Grunfeld EA. 'What a dog will see and kill, a cat will see and ignore it': An exploration of health-related help-seeking among older Ghanaian men residing in Ghana and the United Kingdom. Br J Health Psychol 2020; 25:1102-1117. [PMID: 32656938 DOI: 10.1111/bjhp.12454] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 06/12/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Health care utilization rates are lower among men; however, little is known about how men's health care utilization is affected by migration. The aim of this study was to explore health-related help-seeking decisions among older Ghanaian men residing in the United Kingdom and in Ghana. METHODS Twenty-six men aged 50 years or over were recruited from community locations within two large cities in the UK and Ghana. Face-to-face semi-structured interviews were undertaken to explore the illness and help-seeking experiences of older men. RESULTS Help-seeking experiences differed among the Ghanaian men living in the UK and in Ghana. Three themes were identified that impacted on help-seeking decisions: (1) pluralistic approaches to managing health and illness and (2) perceptions of formal health services in Ghana and UK and (3) financial constraints and masculinity norms as barriers to help-seeking. CONCLUSION This is the first study to look at help-seeking decisions among older men residing in the UK and Ghana. Findings highlight how older migrant men's explanatory models of their health encompass enduring faith-based beliefs around causation of illness and approaches to management, as well as the use of pluralistic approaches to managing health. This study supports the call for culturally sensitive community-based interventions to increase engagement and facilitate improved health outcomes for migrant populations, particularly older men.
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Affiliation(s)
- Lailah Alidu
- Population Evidence and Technology, University of Warwick Medical School, Coventry, UK
| | - Elizabeth A Grunfeld
- Department of Psychological Sciences, Birkbeck, University of London, London, UK
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Suchman L, Hashim CV, Adu J, Mwachandi R. Seeking care in the context of social health insurance in Kenya and Ghana. BMC Public Health 2020; 20:614. [PMID: 32366310 PMCID: PMC7197151 DOI: 10.1186/s12889-020-08742-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 04/20/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Social Health Insurance (SHI) is widely used by countries attempting to move toward Universal Health Coverage (UHC). While evidence suggests that SHI is a promising strategy for achieving UHC, low-income countries often struggle to implement and sustain SHI systems. It is therefore important to understand how SHI enrollees use health insurance and how it affects their health-seeking behavior. This paper examines how SHI affects patient decision-making regarding when and where to seek care in Kenya and Ghana, two countries with established SHI systems in sub-Saharan Africa. METHODS This paper draws from two datasets collected under the African Health Markets for Equity (AHME) program. One dataset, collected in 2013 and 2017 as part of the AHME qualitative evaluation, consists of 106 semi-structured clinic exit interviews conducted with patients in Ghana and Kenya. This data was analyzed using an inductive, thematic approach. The second dataset was collected internally by the AHME partner organizations. It derives from a cross-sectional survey of social franchise clients at three social franchise networks supported by AHME. Data collection took place from February - May 2018 and in December 2018. RESULTS Many clients appreciated that insurance coverage made healthcare more affordable, reported seeking care more frequently when covered with SHI. Clients also noted that the coverage gave them access to a wider variety of providers, but rarely sought out SHI-accredited providers specifically. However, clients sometimes were charged for services that should have been covered by insurance. Due to a lack of understanding of SHI benefits, clients rarely knew they had been charged inappropriately. CONCLUSIONS Clients and providers would benefit from education on what is included in the SHI package. Providers should be monitored and held accountable for charging clients inappropriately; in Ghana this should be accompanied by reforms to make government financing for SHI sustainable. Since clients valued provider proximity and both Kenya and Ghana have a dearth of providers in rural areas, both countries should incentivize providers to work in these areas and prioritize accrediting rural facilities into SHI schemes to increase accessibility and reach.
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Affiliation(s)
- Lauren Suchman
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA.
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Chirwa GC, Suhrcke M, Moreno-Serra R. The Impact of Ghana's National Health Insurance on Psychological Distress. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2020; 18:249-259. [PMID: 31501998 DOI: 10.1007/s40258-019-00515-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Poor mental health is among the growing number of noncommunicable diseases in low- and middle-income countries. Despite poor mental health accounting for an already considerable and growing burden of disease in many low- and middle-income countries, policy action to confront the challenge has been limited, at both international and national levels. Recently, several low- and middle-income countries have embarked on the journey toward universal health coverage by expanding their public health insurance provision, with the ultimate objective of improving population health, in addition to other health system objectives. Mental health interventions typically may not have been specifically covered in the publicly funded benefit package, and this raises the question of whether, and if so, by how much, the expansion of public health insurance may have directly or indirectly contributed to improved mental health. OBJECTIVE We assessed the impact of Ghana's implementation of national health insurance on psychological distress. METHODS Our study used the first wave of the 2009-2010 Ghana Social Economic Panel survey, including 10,007 respondents. We employed instrumental variable and propensity score matching methods to estimate the causal impact of health insurance on psychological distress, measured by the Kessler Psychological Distress Scale (K10). Higher K10 values indicate greater psychological distress. RESULTS The median K10 score in Ghana was 16 (P < 0.001), with a minimum of 10 (P < 0.001) and a maximum of 45 (P < 0.001). The results from the instrumental variable estimations, without matching, indicated that the K10 score for the insured was 11.8% lower (P < 0.001) than that of the uninsured. After running the instrumental variable regression on the matched sample, the K10 score for the insured was 10.6% (P < 0.001) lower than that of the uninsured. Similarly, the estimates based on propensity score matching indicated that the insured had a lower K10 score (- 0.023; P < 0.05). Furthermore, the beneficial impact of health insurance on psychological distress is larger for wealthier than poorer insurance members and varies across regions in Ghana. The findings were robust to the various estimation methods. CONCLUSION This study suggests that having health insurance is associated with reduced psychological distress and hence improved mental health, even though mental illness treatment or prevention were at best only partially covered by the National Health Insurance Scheme in Ghana.
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Affiliation(s)
- Gowokani Chijere Chirwa
- Centre for Health Economics, University of York, Heslington, York, YO10 5DD, UK.
- Economics Department, Chancellor College, University of Malawi, Zomba, Malawi.
| | - Marc Suhrcke
- Centre for Health Economics, University of York, Heslington, York, YO10 5DD, UK
- Luxembourg Institute of Socio-economic Research (LISER), Maison des Sciences Humaines, 11, Porte des Sciences, 4366, Esch-sur-Alzette, Luxembourg
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Kwarteng A, Akazili J, Welaga P, Dalinjong PA, Asante KP, Sarpong D, Arthur S, Bangha M, Goudge J, Sankoh O. The state of enrollment on the National Health Insurance Scheme in rural Ghana after eight years of implementation. Int J Equity Health 2019; 19:4. [PMID: 31892331 PMCID: PMC6938612 DOI: 10.1186/s12939-019-1113-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Accepted: 12/13/2019] [Indexed: 11/10/2022] Open
Abstract
Background In 2004, Ghana implemented a national health insurance scheme (NHIS) as a step towards achieving universal health coverage. In this paper, we assessed the level of enrollment and factors associated with NHIS membership in two predominantly rural districts of northern Ghana after eight years of implementation, with focus on the poor and vulnerable populations. Methods A cross-sectional survey was conducted from July 2012 to December 2012 among 11,175 randomly sampled households with their heads as respondents. Information on NHIS status, category of membership and socio-demographic characteristics of household members was obtained using a structured questionnaire. Principal component analysis was used to compute wealth index from household assets as estimates of socio-economic status (SES). The factors associated with NHIS enrollment were assessed using logistic regression models. The reasons behind enrollment decisions of each household member were further investigated against their SES. Results Approximately half of the sampled population of 39,262 were registered with a valid NHIS card; 53.2% of these were through voluntary subscriptions by payment of premium whilst the remaining (46.8%) comprising of children below the ages of 18 years, elderly 70 years and above, pregnant women and formal sector workers were exempt from premium payment. Despite an exemption policy to ameliorate the poor and vulnerable households against catastrophic health care expenditures, only 0.5% of NHIS membership representing 1.2% of total exemptions granted on accounts of poverty and other social vulnerabilities was applied for the poor. Yet, cost of premium was the main barrier to NHIS registration (92.6%) and non-renewal (78.8%), with members of the lowest SES being worst affected. Children below the ages of 18 years, females, urban residents and those with higher education and SES were significantly more likely to be enrolled with the scheme. Conclusions Despite the introduction of policy exemptions as an equity measure, the poorest of the poor were rarely identified for exemption. The government must urgently resource the Department of Social Welfare to identify the poor for NHIS enrollment.
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Affiliation(s)
- Anthony Kwarteng
- Kintampo Health Research Center, Ghana Health Service, P. O. Box 200, Kintampo, Ghana.
| | - James Akazili
- Navrongo Health Research Center, Ghana Health Service, Navrongo, Ghana
| | - Paul Welaga
- Navrongo Health Research Center, Ghana Health Service, Navrongo, Ghana
| | | | - Kwaku Poku Asante
- Kintampo Health Research Center, Ghana Health Service, P. O. Box 200, Kintampo, Ghana
| | - Doris Sarpong
- Dodowa Health Research Center, Ghana Health Service, Dodowa, Ghana
| | | | | | - Jane Goudge
- Center for Health Policy/MRC Health Policy Research Group, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Otieno PO, Wambiya EOA, Mohamed SF, Donfouet HPP, Mutua MK. Prevalence and factors associated with health insurance coverage in resource-poor urban settings in Nairobi, Kenya: a cross-sectional study. BMJ Open 2019; 9:e031543. [PMID: 31843827 PMCID: PMC6924758 DOI: 10.1136/bmjopen-2019-031543] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 10/07/2019] [Accepted: 11/11/2019] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To determine the prevalence of health insurance and associated factors among households in urban slum settings in Nairobi, Kenya. DESIGN The data for this study are from a cross-sectional survey of adults aged 18 years or older from randomly selected households in Viwandani slums (Nairobi, Kenya). Respondents participated in the Lown scholars' study conducted between June and July 2018. SETTING The Lown scholars' survey was nested in the Nairobi Urban Health and Demographic Surveillance System in Viwandani slums in Nairobi, Kenya. PARTICIPANTS A total of 300 randomly sampled households participated in the survey. The study respondents comprised of either the household head, their spouses or credible adult household members. PRIMARY OUTCOME MEASURE The primary outcome of this study was enrolment in a health insurance programme. The households were classified into two groups: those having at least one member covered by health insurance and those without any health insurance cover. RESULTS The prevalence of health insurance in the sample was 43%. Being unemployed (adjusted OR (aOR) 0.17; p<0.05; 95% CI 0.06 to 0.47) and seeking care from a public health facility (aOR 0.50; p<0.05; 95% CI 0.28 to 0.89) was significantly associated with lower odds of having a health insurance cover. The odds of having a health insurance cover were significantly lower among respondents who perceived their health status as good (aOR 0.62; p<0.05; 95% CI 1.17 to 5.66) and those who were unsatisfied with the cost of seeking primary care (aOR 0.34; p<0.05; 95% CI 0.17 to 0.69). CONCLUSIONS Health insurance coverage in Viwandani slums in Nairobi, Kenya, is low. As universal health coverage becomes the growing focus of Kenya's 'Big Four Agenda' for socioeconomic transformation, integrating enabling and need factors in the design of the national health insurance package may scale-up social health protection.
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Affiliation(s)
- Peter O Otieno
- Health and Systems for Health, African Population and Health Research Center, Nairobi, Kenya
| | | | - Shukri F Mohamed
- Health and Systems for Health, African Population and Health Research Center, Nairobi, Kenya
- University of Warwick, Coventry, UK
| | - Hermann Pythagore Pierre Donfouet
- Health and Systems for Health, African Population and Health Research Center, Nairobi, Kenya
- Data, Measurement and Evaluation, African Population and Health Research Center, Nairobi, Kenya
| | - Martin K Mutua
- Health and Systems for Health, African Population and Health Research Center, Nairobi, Kenya
- Data, Measurement and Evaluation, African Population and Health Research Center, Nairobi, Kenya
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Salari P, Akweongo P, Aikins M, Tediosi F. Determinants of health insurance enrolment in Ghana: evidence from three national household surveys. Health Policy Plan 2019; 34:582-594. [PMID: 31435674 PMCID: PMC6794569 DOI: 10.1093/heapol/czz079] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2019] [Indexed: 11/22/2022] Open
Abstract
In 2003, Ghana implemented a National Health Insurance Scheme (NHIS) to move towards Universal Health Coverage. NHIS enrolment is mandatory for all Ghanaians, but the most recent estimates show that coverage stands under 40%. The evidence on the relationship between socio-economic characteristics and NHIS enrolment is mixed, and comes mainly from studies conducted in a few areas. Therefore, in this study we investigate the socio-economic determinants of NHIS enrolment using three recent national household surveys. We used data from the Ghanaian Demographic and Health Survey conducted in 2014, the Multiple Indicator Cluster Survey conducted in 2011 and the sixth wave of the Ghana Living Standard Survey conducted in 2012-13. Given the multilevel nature of the three databases, we use multilevel logistic regression models to estimate the probability of enrolment for women and men separately. We used three levels of analysis: geographical clusters, household and individual units. We found that education, wealth, marital status-and to some extent-age were positively associated with enrolment. Furthermore, we found that enrolment was correlated with the type of occupation. The analyses of three national household surveys highlight the challenges of understanding the complex dynamics of factors contributing to low NHIS enrolment rates. The results indicate that current policies aimed at identifying and subsidizing underprivileged population groups might insufficiently encourage health insurance enrolment.
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Affiliation(s)
- Paola Salari
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute (Swiss TPH), Socinstrasse 57, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Patricia Akweongo
- School of Public Health, College of Health Sciences, University of Ghana, Legon, Accra, Ghana
| | - Moses Aikins
- School of Public Health, College of Health Sciences, University of Ghana, Legon, Accra, Ghana
| | - Fabrizio Tediosi
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute (Swiss TPH), Socinstrasse 57, Basel, Switzerland
- University of Basel, Basel, Switzerland
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Nshakira-Rukundo E, Mussa EC, Nshakira N, Gerber N, von Braun J. Determinants of Enrolment and Renewing of Community-Based Health Insurance in Households With Under-5 Children in Rural South-Western Uganda. Int J Health Policy Manag 2019; 8:593-606. [PMID: 31657186 PMCID: PMC6819630 DOI: 10.15171/ijhpm.2019.49] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 06/09/2019] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The desire for universal health coverage in developing countries has brought attention to communitybased health insurance (CBHI) schemes in developing countries. The government of Uganda is currently debating policy for the national health insurance programme, targeting the integration of existing CBHI schemes into a larger national risk pool. However, while enrolment has been largely studied in other countries, it remains a generally under-covered issue from a Ugandan perspective. Using a large CBHI scheme, this study, therefore, aims at shedding more light on the determinants of households' decisions to enrol and renew membership in these schemes. METHODS We collected household data from 464 households in 14 villages served by a large CBHI scheme in southwestern Uganda. We then estimated logistic and zero-inflated negative binomial (ZINB) regressions to understand the determinants of enrolment and renewing membership in CBHI, respectively. RESULTS Results revealed that household's socioeconomic status, husband's employment in rural casual work (odds ratio [OR]: 2.581, CI: 1.104-6.032) and knowledge of health insurance premiums (OR: 17.072, CI: 7.027-41.477) were significant predictors of enrolment. Social capital and connectivity, assessed by the number of voluntary groups a household belonged to, was also positively associated with CBHI participation (OR: 5.664, CI: 2.927-10.963). More positive perceptions on insurance (OR: 2.991, CI: 1.273-7.029), access to information were also associated with enrolment and renewing among others. Burial group size and number of burial groups in a village, were all significantly associated with increased the likelihood of renewing CBHI. CONCLUSION While socioeconomic factors remain important predictors of participation in insurance, mechanisms to promote inclusion should be devised. Improving the participation of communities can enhance trust in insurance and eventual coverage. Moreover, for households already insured, access to correct information and strengthening their social network information pathways enhances their chances of renewing.
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Affiliation(s)
| | - Essa Chanie Mussa
- Department of Economics and Technological Change, Center for Development Research (ZEF), University of Bonn, Bonn, Germany
| | - Nathan Nshakira
- Department of Environmental and Public Health, Kabale University, Kabale, Uganda
| | - Nicolas Gerber
- Department of Economics and Technological Change, Center for Development Research (ZEF), University of Bonn, Bonn, Germany
| | - Joachim von Braun
- Department of Economics and Technological Change, Center for Development Research (ZEF), University of Bonn, Bonn, Germany
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Determinants of community-based health insurance implementation in west Gojjam zone, Northwest Ethiopia: a community based cross sectional study design. BMC Health Serv Res 2019; 19:544. [PMID: 31375108 PMCID: PMC6679527 DOI: 10.1186/s12913-019-4363-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 07/19/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In most developing countries, healthcare cost is mainly paid at the time of sickness and out-of-pocket at the point of service delivery which potentially could inhibit access. The total economic cost of illness for households is also estimated to be frequently above 10% of household income which is categorized as catastrophic. The purpose of this study was to assess factors that determine decisions to join the community based health insurance in West Gojjam zone. METHODS A community based cross sectional survey was conducted to collect data from 690 household heads using a multistage sampling technique. A binary logistic regression was used to identify the determinants of household decisions for CBHI enrollment. RESULTS Out of the participants, 58% were CBHI members. Besides, family size (AOR = 1.17; CI = 1.02-1.35), average health status (AOR = .380; CI = .179-.805), chronic disease (AOR = 3.42; CI = 1.89-6.19); scheme benefit package adequacy (AOR = 2.17; CI = 1.20-3.93), perceived health service quality (AOR = 3.69; CI = 1.77-7.69), CBHI awareness (AOR = 4.90; CI = 1.65-14.4); community solidarity (AOR = 3.77; CI = 2.05-6.92) and wealth (AOR = 3.62; CI = 1.67-7.83) were significant determinant factors for enrolment in the community based health insurance scheme. CONCLUSION CBHI awareness, family health status, community solidarity, quality of service of health institutions, and wealth were major factors that most determine the household decisions to enroll in the system. Therefore, in-depth and sustainable awareness creation programs on the scheme; stratified premium- based on economic status of households; incorporation of social capital factors, particularly building community solidarity in the scheme implementation are vital to enhance sustainable enrollment. As perceived family health status and the existence of chronic disease were also found significant determinants of enrollment, the Government might have to look for options to make the scheme mandatory.
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Antabe R, Atuoye KN, Sano Y, Kuuire VZ, Galaa SZ, Luginaah I. Health insurance enrolment in the Upper West Region of Ghana: Does food security matter? Int J Health Plann Manage 2019; 34:e1621-e1632. [PMID: 31321826 DOI: 10.1002/hpm.2857] [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: 05/04/2019] [Revised: 07/06/2019] [Accepted: 07/08/2019] [Indexed: 11/07/2022] Open
Abstract
Toward achieving universal health coverage, Ghana's national health insurance has been acclaimed as a pro-poor scheme, yet been criticized for leaving the poor behind. Arising from this is how poverty has been operationalized and how poor people are targeted for enrolment into the scheme. We examine the role of food insecurity (not currently considered) as a multidimensional vulnerability concept on enrolment into Ghana's health insurance using binary logistics regression on cross-sectional survey of household heads (n = 1438) in the Upper West Region of Ghana. Our analyses show that heads of severely food-insecure households were significantly less likely to enroll in national health insurance scheme (NHIS) relative to households who reported being food-secure (OR = 0.36, P < .05). We also found education, occupation, and religion as significant predictors of health insurance enrolment. Based on our findings, it is crucial to incorporate food security status in the identification of vulnerable people for free enrolment in Ghana's health insurance.
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Affiliation(s)
- Roger Antabe
- Department of Geography, Western University, London, Ontario, Canada
| | | | - Yujiro Sano
- Department of Sociology, Western University, London, Ontario, Canada
| | | | | | - Isaac Luginaah
- Department of Geography, Western University, London, Ontario, Canada
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Adjei KK, Kikuchi K, Owusu-Agyei S, Enuameh Y, Shibanuma A, Ansah EK, Yasuoka J, Poku-Asante K, Okawa S, Gyapong M, Tawiah C, Oduro AR, Sakeah E, Sarpong D, Nanishi K, Asare GQ, Hodgson A, Jimba M. Women's overall satisfaction with health facility delivery services in Ghana: a mixed-methods study. Trop Med Health 2019; 47:41. [PMID: 31320830 PMCID: PMC6612170 DOI: 10.1186/s41182-019-0172-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 06/26/2019] [Indexed: 11/10/2022] Open
Abstract
Background Skilled birth delivery has increased up to nearly 74% in Ghana, but its quality has been questioned over the years. As understanding women's satisfaction could be important to improving service quality, this study aimed to determine what factors were associated with women's overall satisfaction with delivery services quantitatively and qualitatively in rural Ghanaian health facilities. Results This cross-sectional, mixed methods study used an explanatory sequential design across three Ghana Health Service research areas in 2013. Participants were women who had delivered in the preceding 2 years. Two-stage random sampling was used to recruit women for the quantitative survey. Relationships between women's socio-demographic characteristics and their overall satisfaction with health facility delivery services were examined using univariate and multiple logistic regression analyses. For qualitative analyses, women who completed the quantitative survey were purposively selected to participate in focus group discussions. Data from the focus group discussions were analyzed based on predefined and emerging themes. Overall, 1130 women were included in the quantitative analyses and 136 women participated in 15 focus group discussions. Women's mean age was 29 years. Nearly all women (94%) were satisfied with the overall services received during delivery. Women with middle level/junior high school education [adjusted odds ratio (AOR) = 0.50, 95% confidence interval (CI) = (0.26-0.98)] were less likely to be satisfied with overall delivery services compared to women with no education. Qualitatively, women were not satisfied with the unconventional demands, negative attitude, and unavailability of healthcare workers, as well as the long wait time. Conclusions Although most women were satisfied with the overall service they received during delivery, they were not satisfied with specific aspects of the health services; therefore, higher quality service delivery is necessary to improve women's satisfaction. Additional sensitivity training and a reduction in work hours may also improve the experience of clients.
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Affiliation(s)
- Kwame K Adjei
- 1Kintampo Health Research Centre, Kintampo, Brong-Ahafo Ghana
| | - Kimiyo Kikuchi
- 2Institute of Decision Science for a Sustainable Society, Kyushu University, Fukuoka, Japan
| | - Seth Owusu-Agyei
- 1Kintampo Health Research Centre, Kintampo, Brong-Ahafo Ghana.,3University of Health and Allied Science, Ho, Ghana
| | - Yeetey Enuameh
- 1Kintampo Health Research Centre, Kintampo, Brong-Ahafo Ghana.,4Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Akira Shibanuma
- 5Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-0033 Japan
| | - Evelyn Korkor Ansah
- 3University of Health and Allied Science, Ho, Ghana.,11Research and Development Division, Ghana Health Service, Accra, Ghana
| | - Junko Yasuoka
- 6Research and Education Center for Prevention of Global Infectious Diseases of Animals, Tokyo University of Agriculture and Technology, Tokyo, Japan
| | | | - Sumiyo Okawa
- 5Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-0033 Japan
| | | | | | | | | | - Doris Sarpong
- 8Dodowa Health Research Centre, Dodowa, Greater Accra Ghana
| | - Keiko Nanishi
- 9Office of International Academic Affairs, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | | | - Abraham Hodgson
- 11Research and Development Division, Ghana Health Service, Accra, Ghana
| | - Masamine Jimba
- 5Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-0033 Japan
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Haw NJL. Utilization of the Ghana National Health Insurance Scheme and its association with patient perceptions on healthcare quality. Int J Qual Health Care 2019; 31:485-491. [PMID: 30165414 DOI: 10.1093/intqhc/mzy185] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 07/14/2018] [Accepted: 08/03/2018] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To determine the association between the utilization of the Ghana National Health Insurance Scheme (NHIS) and patient perceptions of quality of care. METHODS Ghana Demographic and Health Survey (GDHS) 2014 had 19 questions on perceptions of quality of care received during the last reported health visit (n = 4332). These questions were summarized into an overall 100-point perception score using item response theory (IRT). Patients were divided into three utilization categories: those paying with their NHIS card fully, those paying with their card and out-of-pocket (OOP), and those paying fully OOP. A multiple linear regression model was used to measure the association between NHIS utilization and overall perception. RESULTS In general, NHIS utilization was negatively associated with overall perception, and the difference across utilization categories was higher among private facility users than public facility users. Among private facilities, those who paid fully with NHIS reported five points lower than those who paid fully OOP (P = 0.005). Among public facilities, the difference is only 1.7 (P = 0.4342). CONCLUSION NHIS utilization was a negative predictor for patient perceptions, but the differences are more nuanced according to type of facility. Future GDHS rounds should continue measuring perceptions in aid of policy to improve service delivery under the NHIS.
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Affiliation(s)
- Nel Jason L Haw
- Department of International Health, School of Nursing and Health Studies, Georgetown University, Washington, DC, USA
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Factors Contributing to Low Adherence to Community-Based Health Insurance in Rural Nyanza District, Southern Rwanda. JOURNAL OF ENVIRONMENTAL AND PUBLIC HEALTH 2018; 2018:2624591. [PMID: 30662470 PMCID: PMC6312613 DOI: 10.1155/2018/2624591] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 10/30/2018] [Accepted: 11/11/2018] [Indexed: 11/24/2022]
Abstract
Background Community-based health insurance (CBHI) schemes are an emerging mechanism for providing financial protection against health-related poverty. In Rwanda, CBHI is being implemented across the country, and it is based on four socioeconomic categories of the “Ubudehe system”: the premiums of the first category are fully subsidized by government, the second and third category members pay 3000 frw, and the fourth category members pay 7000 frw as premium. However, low adherence of community to the scheme since 2011 has not been sufficiently studied. Objective This study aimed at determining the factors contributing to low adherence to the CBHI in rural Nyanza district, southern Rwanda. Methodology A cross-sectional study was conducted in nine health centers in rural Nyanza district from May 2017 to June 2017. A sample size of 495 outpatients enrolled in CBHI or not enrolled in the CBHI scheme was calculated based on 5% margin of error and a 95% confidence interval. Logistic regression was used to identify the determinants of low adherence to CBHI. Results The study revealed that there was a significant association between long waiting time to be seen by a medical care provider and between health care service provision and low adherence to the CBHI scheme (P value < 0.019) (CI: 0.09107 to 0.80323). The estimates showed that premium not affordable (P value < 0.050) (CI: 0.94119 to 9.8788) and inconvenient model of premium payment (P value < 0.001) (CI: 0.16814 to 0.59828) are significantly associated with low adherence to the CBHI scheme. There was evidence that the socioeconomic status as measured by the category of Ubudehe (P value < 0.005) (CI: 1.4685 to 8.93406) increases low adherence to the CBHI scheme. Conclusion This study concludes that belonging to the second category of the Ubudehe system, long waiting time to be seen by a medical care provider and between services, premium not affordable, and inconvenient model of premium payment were significant predictors of low adherence to CBHI scheme.
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Fenenga CJ, Buzasi K, Arhinful DK, Duku SKO, Ogink A, Poortinga W. Health insurance and social capital in Ghana: a cluster randomised controlled trial. Glob Health Res Policy 2018; 3:35. [PMID: 30534601 PMCID: PMC6282266 DOI: 10.1186/s41256-018-0090-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 11/05/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The National Health Insurance Scheme (NHIS) was introduced in Ghana in 2003, enrolment is still far from the desired target of universal coverage. Low community engagement in the design and management of the system was identified as one of the main barriers. The aim of the current study was to explore the role of social capital in NHIS enrolment in two regions of Ghana, Western and Greater Accra. METHODS The study involved a cluster-randomised controlled trial of 3246 clients of 64 healthcare facilities who completed both a baseline and a follow-up survey. Thirty-two facilities were randomly selected to receive two types of intervention. The remaining facilities served as control. The interventions were co-designed with stakeholders. Baseline and follow up surveys included measures of different types of social capital, as well as enrolment in the health insurance scheme. RESULTS The study found that the interventions encouraged NHIS enrolment (from 40.29 to 49.39% (intervention group) versus 36.49 to 36.75% (control group)). Secondly, certain types of social capital are associated with increased enrolment (log-odds ratios (p-values) of three types of vertical social capital are 0.127 (< 0.01), 0.0952 (< 0.1) and 0.15 (< 0.01)). Effectiveness of the interventions was found dependent on initial levels of social capital: respondents with lowest measured level of interpersonal trust in the intervention group were about 25% more likely to be insured than similar respondents in the control group. Among highly trusting respondents this difference was insignificant. There was however no evidence that the interventions effect social capital. Limitations of the study are discussed. CONCLUSION We showed that the interventions helped to increase enrolment but that the positive effect was not realized by changes in social capital that we hypothesised based on result of the first phase of our study. Future research should aim to identify other community factors that are part of the enrolment process, whether other interventions to improve the quality of services could help to increase enrolment and, as a result, could provide community benefits in terms of social capital.Our findings can guide the NHIS in Ghana and other health organizations to enhance enrolment. TRIAL REGISTRATION Ethical Clearance by Ghana Health Service Ethical Committee No. GHS-ERC 08.5.11.
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Affiliation(s)
- Christine J. Fenenga
- Amsterdam Institute for Global Health and Development, Paasheuvelweg 24, 1105 BP Amsterdam, The Netherlands
- University of Groningen, Broerstraat 5, 9712 CP Groningen, The Netherlands
| | - Katalin Buzasi
- Amsterdam Institute for Global Health and Development, Paasheuvelweg 24, 1105 BP Amsterdam, The Netherlands
- Vrije Universiteit Amsterdam, De Boelelaan 1105, 1081 HV Amsterdam, The Netherlands
| | - Daniel K. Arhinful
- Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, Legon, Accra, Ghana
| | - Stephen K. O. Duku
- Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, Legon, Accra, Ghana
- Vrije Universiteit Amsterdam, De Boelelaan 1105, 1081 HV Amsterdam, The Netherlands
- Tinbergen Institute, Gustav Mahlerplein 117, 1082 MS Amsterdam, The Netherlands
| | - Alice Ogink
- Amsterdam Institute for Global Health and Development, Paasheuvelweg 24, 1105 BP Amsterdam, The Netherlands
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Suchman L. Accrediting private providers with National Health Insurance to better serve low-income populations in Kenya and Ghana: a qualitative study. Int J Equity Health 2018. [PMID: 30518378 DOI: 10.1186/s12939‐018‐0893‐y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Small private providers in low- and middle-income countries (LMICs) are well positioned to fill gaps in services to low-income populations using Social Health Insurance (SHI) schemes. However, we know little about the practical challenges both private providers and patients face in the context of SHI that may ultimately limit access to quality services for low-income populations. In this paper, we pull together data collected from private providers, patients, and SHI officials in Kenya and Ghana to answer the question: does participation in an SHI scheme affect private providers' ability to serve poorer patient populations with quality health services? METHODS In-depth interviews were held with 204 providers over three rounds of data collection (2013, 2015, 2017) in Kenya and Ghana. We also conducted client exit interviews in 2013 and 2017 for a total of 106 patient interviews. Ten focus group discussions (FGDs) were conducted in Kenya and Ghana respectively in 2013 for a total of 171 FGD participants. A total of 13 in-depth interviews also were conducted with officials from the Ghana National Health Insurance Agency (NHIA) and the Kenya National Hospital Insurance Fund (NHIF) across four rounds of data collection (2013, 2014, 2016, 2017). Provider interviews covered reasons for (non) enrollment in the health insurance system, experiences with the accreditation process, and benefits and challenges with the system. Client exit interviews covered provider choice, clinic experience, and SHI experience. FGDs covered the local healthcare landscape. Interviews with SHI officials covered officials' experiences working with private providers, and the opportunities and challenges they faced both accrediting providers and enrolling members. Transcripts were coded in Atlas.ti using an open coding approach and analyzed thematically. RESULTS Private providers and patients agreed that SHI schemes are beneficial for reducing out-of-pocket costs to patients and many providers felt they had to become SHI-accredited in order to keep their facilities open. The SHI officials in both countries corroborated these sentiments. However, due to misunderstanding of the system providers tended to charge clients for services they felt were above and beyond reimbursable expenses. Services were sometimes limited as well. Significant delays in SHI reimbursement in Ghana exacerbated these problems and compromised providers' abilities to cover basic expenses without charging patients. While patients recognized the potential benefits of SHI coverage and many sought it out, a number of patients reported allowing their enrollment to lapse for cost reasons or because they felt the coverage was useless when they were still asked to pay for services out-of-pocket at the health facility. CONCLUSIONS Our data point to several major barriers to SHI access and effectiveness for low-income populations in Ghana and in Kenya, in addition to opportunities to better engage private providers to serve these populations. We recommend using fee-for-service payments based on Diagnosis Related Group rather than a capitation payment system, as well as building more monitoring and accountability mechanisms into the SHI systems in order to reduce requests for informal out-of-pocket payments from patients while also ensuring quality of care. However, particularly in Ghana, these reforms should be accompanied by financial reform within the SHI system so that small private providers can be adequately funded through government financing.
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Affiliation(s)
- Lauren Suchman
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, USA.
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Suchman L. Accrediting private providers with National Health Insurance to better serve low-income populations in Kenya and Ghana: a qualitative study. Int J Equity Health 2018; 17:179. [PMID: 30518378 PMCID: PMC6282320 DOI: 10.1186/s12939-018-0893-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 11/19/2018] [Indexed: 12/16/2022] Open
Abstract
Background Small private providers in low- and middle-income countries (LMICs) are well positioned to fill gaps in services to low-income populations using Social Health Insurance (SHI) schemes. However, we know little about the practical challenges both private providers and patients face in the context of SHI that may ultimately limit access to quality services for low-income populations. In this paper, we pull together data collected from private providers, patients, and SHI officials in Kenya and Ghana to answer the question: does participation in an SHI scheme affect private providers’ ability to serve poorer patient populations with quality health services? Methods In-depth interviews were held with 204 providers over three rounds of data collection (2013, 2015, 2017) in Kenya and Ghana. We also conducted client exit interviews in 2013 and 2017 for a total of 106 patient interviews. Ten focus group discussions (FGDs) were conducted in Kenya and Ghana respectively in 2013 for a total of 171 FGD participants. A total of 13 in-depth interviews also were conducted with officials from the Ghana National Health Insurance Agency (NHIA) and the Kenya National Hospital Insurance Fund (NHIF) across four rounds of data collection (2013, 2014, 2016, 2017). Provider interviews covered reasons for (non) enrollment in the health insurance system, experiences with the accreditation process, and benefits and challenges with the system. Client exit interviews covered provider choice, clinic experience, and SHI experience. FGDs covered the local healthcare landscape. Interviews with SHI officials covered officials’ experiences working with private providers, and the opportunities and challenges they faced both accrediting providers and enrolling members. Transcripts were coded in Atlas.ti using an open coding approach and analyzed thematically. Results Private providers and patients agreed that SHI schemes are beneficial for reducing out-of-pocket costs to patients and many providers felt they had to become SHI-accredited in order to keep their facilities open. The SHI officials in both countries corroborated these sentiments. However, due to misunderstanding of the system providers tended to charge clients for services they felt were above and beyond reimbursable expenses. Services were sometimes limited as well. Significant delays in SHI reimbursement in Ghana exacerbated these problems and compromised providers’ abilities to cover basic expenses without charging patients. While patients recognized the potential benefits of SHI coverage and many sought it out, a number of patients reported allowing their enrollment to lapse for cost reasons or because they felt the coverage was useless when they were still asked to pay for services out-of-pocket at the health facility. Conclusions Our data point to several major barriers to SHI access and effectiveness for low-income populations in Ghana and in Kenya, in addition to opportunities to better engage private providers to serve these populations. We recommend using fee-for-service payments based on Diagnosis Related Group rather than a capitation payment system, as well as building more monitoring and accountability mechanisms into the SHI systems in order to reduce requests for informal out-of-pocket payments from patients while also ensuring quality of care. However, particularly in Ghana, these reforms should be accompanied by financial reform within the SHI system so that small private providers can be adequately funded through government financing.
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Affiliation(s)
- Lauren Suchman
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, USA.
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Ghaddar S, Byun J, Krishnaswami J. Health insurance literacy and awareness of the Affordable Care Act in a vulnerable Hispanic population. PATIENT EDUCATION AND COUNSELING 2018; 101:2233-2240. [PMID: 30220598 DOI: 10.1016/j.pec.2018.08.033] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 08/25/2018] [Accepted: 08/29/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE The Patient Protection and Affordable Care Act (ACA) has allowed millions of Americans to obtain coverage. However, many, especially minorities, remain uninsured. With mounting evidence supporting the importance of health insurance literacy (HIL), the purpose of this cross-sectional study is to examine the association between HIL and ACA knowledge. METHODS We conducted 681 in-person interviews with participants at a community health event along the Texas-Mexico border in 2015, after the conclusion of the ACA's second enrollment period. To assess HIL, we used the Health Insurance Literacy Measure, reflecting consumers' confidence to choose, compare, and use health insurance. We assessed ACA knowledge through the following question: "How much would you say you know about this health reform law?" Logistic regression was used to examine the association between HIL and ACA knowledge after controlling for several covariates. RESULTS Almost 70% of participants knew nothing/very little about the ACA. Multivariate analyses revealed that no/very little ACA knowledge was associated with low levels of confidence "choosing health insurance plans" (OR:0.55; 95%CI:0.40-0.75) (full sample) and "comparing plans" (OR:0.56; 95%CI:0.32-0.96) (U.S.-born sub-sample). CONCLUSION No/little ACA knowledge is associated with lower levels of HIL. PRACTICE IMPLICATIONS Promoting HIL is an essential step towards improving healthcare access.
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Affiliation(s)
- Suad Ghaddar
- Department of Health and Biomedical Sciences, The University of Texas Rio Grande Valley, Edinburg, USA.
| | - Jihyun Byun
- School of Human Ecology, The University of Texas at Austin, Austin, USA.
| | - Janani Krishnaswami
- Department of Pediatrics and Preventive Medicine, The University of Texas Rio Grande Valley, Edinburg, USA.
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Badu E, Agyei-Baffour P, Ofori Acheampong I, Opoku MP, Addai-Donkor K. Perceived satisfaction with health services under National Health Insurance Scheme: Clients' perspectives. Int J Health Plann Manage 2018; 34:e964-e975. [PMID: 30468521 DOI: 10.1002/hpm.2711] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 10/23/2018] [Accepted: 10/23/2018] [Indexed: 11/12/2022] Open
Abstract
The study aims to explore the perceived satisfaction of insured clients in financing health services through National Health Insurance in Ghana. A quantitative method was used to recruit 380 respondents, selected by multistage cluster sampling. Data were collected through the administration of questionnaires. More than half, 57.9%, of respondents were males, and the average age was 34 years. Most respondents, 74.3%, were insured. Overall, 53.12% of insured clients were dissatisfied with the services of providers. Factors, such as benefit package of insurance, willingness to pay higher premium, and perceived discrimination were significantly associated with poor satisfaction with health services. The current advocacy for and awareness about the use of health insurance as a prepayment plan should be prioritised in policy initiatives. The benefit package for the insurance should be increased in order to cover all disease conditions that afflict the Ghanaian population.
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Affiliation(s)
- Eric Badu
- School of Nursing and Midwifery, Faculty of Medicine and Public Health, The University of Newcastle, Australia/Centre for Disability and Rehabilitation Studies/Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Peter Agyei-Baffour
- Department of Health Policy, Management and Economics/School of Public Health, Kwame Nkrumah University of Science and Technology (KNUST), Kumasi, Ghana
| | - Isaac Ofori Acheampong
- Department of Health Education and Promotion/School of Public Health, Kwame Nkrumah University of Science and Technology (KNUST), Kumasi, Ghana
| | - Maxwell Preprah Opoku
- University of Tasmania, Australia, Faculty of Education, Locked Bag 1340, Launceston, TAS, 7250, Australia
| | - Kwasi Addai-Donkor
- Department of Health Policy, Management and Economics/School of Public Health, Kwame Nkrumah University of Science and Technology (KNUST), Kumasi, Ghana
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Oraro T, Wyss K. How does membership in local savings groups influence the determinants of national health insurance demand? A cross-sectional study in Kisumu, Kenya. Int J Equity Health 2018; 17:170. [PMID: 30458792 PMCID: PMC6247627 DOI: 10.1186/s12939-018-0889-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 11/09/2018] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Rotating savings and credit associations (ROSCAs) are highly active in many sub-Saharan African countries, serving as an important gateway for coping with financial risk. In light of the Kenya's National Hospital Insurance Fund's (NHIF's) strategy of targeting ROSCAs for membership enrolment, this study sought to estimate how ROSCA membership influences the determinants of voluntary health insurance enrolment. METHODS A cross-sectional survey of 444 households was carried out in Kisumu City between July and August 2016. A structured questionnaire was administered on health insurance membership, household attributes, headship characteristics and health-seeking behaviour. We assessed the influence of ROSCA membership on the associations between NHIF enrolment and the explanatory variables using univariate logistic regression. RESULTS The study found that education was associated with NHIF demand regardless of ROSCA membership. Both ROSCA and non-ROSCA households with high socioeconomic status showed stronger health insurance demand compared with poorer households; there was, however, no evidence that the strength of this association was influenced by ROSCA status (p-value = 0.47). Participants who were self-employed were significantly less likely to enrol into the NHIF if they did not belong to a ROSCA (interaction test p-value = 0.03). NHIF enrolment was found to be lower among female-headed households. There was a borderline effect of ROSCA membership on this association, with a lower odds ratio amongst non-ROSCA members (p-value = 0.09): the low treatment numbers amongst the insured infers that ROSCA membership may play a role on the association between gender and NHIF demand. CONCLUSIONS Our findings suggest that ROSCA membership may play a role in increasing health insurance demand amongst some traditionally under-represented groups such as women and the self-employed. However, the strategy of targeting ROSCAs to increase national health insurance enrolment may yield exiguous results, given that ROSCA membership is itself influenced by several non-observable factors - such as time-availability and self-selection. It is therefore important to anchor outreach to ROSCAs within a broader, multi-pronged approach that targets households within their social, economic and political realities.
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Affiliation(s)
- Tessa Oraro
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Department of Epidemiology and Public Health, Health Systems Support Unit, Swiss Tropical and Public Health Institute, P.O. Box 4002, Basel, Switzerland
| | - Kaspar Wyss
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
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Nsiah-Boateng E, Aikins M. Trends and characteristics of enrolment in the National Health Insurance Scheme in Ghana: a quantitative analysis of longitudinal data. Glob Health Res Policy 2018; 3:32. [PMID: 30460332 PMCID: PMC6233555 DOI: 10.1186/s41256-018-0087-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 10/22/2018] [Indexed: 11/10/2022] Open
Abstract
Background In 2004, Ghana started experimenting a National Health Insurance Scheme (NHIS) to reduce out-of-pocket payment for healthcare. Like many other social health insurance schemes in Africa, the NHIS is striving for universal health coverage (UHC). This paper examines trends and characteristics of enrolment in the scheme to inform policy decisions on attainment of UHC. Methods We conducted trend analysis of longitudinal enrolment data of the NHIS for the period, 2010-2017. Descriptive statistics were used to examine trends and characteristics of enrolment by geographical region and member groups. Results Over the 8-year period, the population enrolled in the scheme increased from 33% (8.2 million) to 41% (11.3 million) between 2010 and 2015 and dropped to 35% (10.3 million) in 2017. Members who renewed their membership increased from 44% to 75.4% between 2010 and 2013 and then dropped to 73% in 2017. On average, the urban regions had significantly higher number of new enrolments than the rural ones. Similarly, the urban and peri-urban regions recorded significantly higher number of renewals than the other regions. In addition, persons below the age of 18 years and the informal sector workers had significantly higher number of enrolment than any other member group. Conclusions Enrolment in the NHIS is declining and there are significant differences among geographical regions and member groups. Managers of the NHIS need to enforce the mandatory enrolment provision in the Act governing the scheme, employ innovative strategies such as mobile phone application for registration and renewals and address delays in healthcare provider claims to improve enrolment.
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Affiliation(s)
- Eric Nsiah-Boateng
- School of Public Health, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Moses Aikins
- School of Public Health, College of Health Sciences, University of Ghana, Accra, Ghana
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Lattof SR. Health insurance and care-seeking behaviours of female migrants in Accra, Ghana. Health Policy Plan 2018; 33:505-515. [PMID: 29462305 PMCID: PMC5894076 DOI: 10.1093/heapol/czy012] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2018] [Indexed: 11/14/2022] Open
Abstract
People working in Ghana’s informal sector have low rates of enrolment in the publicly funded National Health Insurance Scheme. Informal sector workers, including migrant girls and women from northern Ghana working as head porters (kayayei), report challenges obtaining insurance and seeking formal health care. This article analyses how health insurance status affects kayayei migrants’ care-seeking behaviours. This mixed-methods study involved surveying 625 migrants using respondent-driven sampling and conducting in-depth interviews with a sub-sample of 48 migrants. Analyses explore health status and health seeking behaviours for recent illness/injury. Binary logistic regression modelled the effects of selected independent variables on whether or not a recently ill/injured participant (n = 239) sought health care. Although recently ill/injured participants (38.4%) desired health care, less than half (43.5%) sought care. Financial barriers overwhelmingly limit kayayei migrants from seeking health care, preventing them from registering with the National Health Insurance Scheme, renewing their expired health insurance policies, or taking time away from work. Both insured and uninsured migrants did not seek formal health services due to the unpredictable nature of out-of-pocket expenses. Catastrophic and impoverishing medical expenses also drove participants’ migration in search of work to repay loans and hospital bills. Health insurance can help minimize these expenditures, but only 17.4% of currently insured participants (58.2%) reported holding a valid health insurance card in Accra. The others lost their cards or forgot them when migrating. Access to formal health care in Accra remains largely inaccessible to kayayei migrants who suffer from greater illness/injury than the general female population in Accra and who are hindered in their ability to receive insurance exemptions. With internal migration on the rise in many settings, health systems must recognize the varied needs of populations in multi-ethnic and multilingual countries to ensure that internal migrants can access affordable, quality health services across domestic borders.
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Affiliation(s)
- Samantha R Lattof
- Department of Social Policy, London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK
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Booysen F, Hongoro C. Perceptions of and support for national health insurance in South Africa's public and private healthcare sectors. Pan Afr Med J 2018; 30:277. [PMID: 30637062 PMCID: PMC6317390 DOI: 10.11604/pamj.2018.30.277.14147] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 11/06/2017] [Indexed: 11/11/2022] Open
Abstract
Introduction For the purpose of effective implementation of a National Health Insurance (NHI) policy it is necessary to have an understanding of the awareness and perceptions of and support for such policy among clients using the healthcare system. Methods The South African National Health and Nutrition Examination Survey asked household heads a series of questions on healthcare utilisation and access and collected information on knowledge and perceptions of and support for national health insurance. Comparisons are drawn between private sector healthcare users with medical aid and public sector healthcare users without medical aid, using descriptive and regression analysis. Results Inequalities in access to quality healthcare remain stark. Only 8.5% of private users had postponed seeking healthcare compared to 23.9% of public users (p < 0.001). Only 11.9% of public users were very satisfied with the quality of healthcare services compared to 50.2% of private users (p < 0.001). More than eighty percent of healthcare users however were of the opinion that NHI is a top priority. However, for healthcare users to sacrifice choice required a national health insurance that provides better quality healthcare, increasing the probability of support for an NHI with lower cost and full coverage by 10.1%. Conclusion It is imperative to provide better quality healthcare services in the public sector for private sector users to be supportive of national health insurance. Concerted efforts are also required to develop a proper communication strategy to disseminate information on and garner support for national health insurance, both in the public and private healthcare sectors.
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Affiliation(s)
- Frederik Booysen
- Population Health, Health Systems and Innovation (PHHSI) Research Programme, Human Sciences Research Council (HSRC), Pretoria, South Africa.,Department of Economics, University of the Free State (UFS), Bloemfontein, South Africa
| | - Charles Hongoro
- Population Health, Health Systems and Innovation (PHHSI) Research Programme, Human Sciences Research Council (HSRC), Pretoria, South Africa.,Faculty of Health Sciences, Fort Hare University, East London, South Africa
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Okoroh J, Essoun S, Seddoh A, Harris H, Weissman JS, Dsane-Selby L, Riviello R. Evaluating the impact of the national health insurance scheme of Ghana on out of pocket expenditures: a systematic review. BMC Health Serv Res 2018; 18:426. [PMID: 29879978 PMCID: PMC5992790 DOI: 10.1186/s12913-018-3249-9] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 05/29/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Approximately 150 million people suffer from financial catastrophe annually because of out-of-pocket expenditures (OOPEs) on health. Although the National Health Insurance Scheme (NHIS) of Ghana was designed to promote universal health coverage, OOPEs as a proportion of total health expenditures remains elevated at 26%, exceeding the WHO's recommendations of less than 15-20%. To determine whether enrollment in the NHIS reduces the likelihood of OOPEs and catastrophic health expenditures (CHEs) in Ghana, we undertook a systematic review of the published literature. METHODS We searched for quantitative articles published in English between January 1, 2003 and August 22, 2017 in PubMed, Google Scholar, Economic Literature, Global Health, PAIS International, and African Index Medicus. Two independent authors (J.S.O. & S.E.) reviewed the articles for inclusion, extracted the data, and conducted a quality assessment of the studies. We accepted the World Health Organization definition of catastrophic health expenditures which is out of pocket payments for health care which exceeds 20% of annual house hold income, 10% of household expenditures, or 40% of subsistence expenditures (total household expenditures net food expenditures). RESULTS Of the 1094 articles initially identified, 7 were eligible for inclusion. These were cross-sectional household studies published between 2008 and 2016 in Ghana. They demonstrated that the uninsured paid 1.4 to 10 times more in out-of-pocket payments (OOPs) and were more likely to incur CHEs than the insured. Yet, 6 to 18% of insured households made catastrophic payments for healthcare and all studies reported insured members making OOPs for medicines. CONCLUSION Evidence suggests that the national health insurance scheme of Ghana over the last 14 years has made some impact on reducing OOPEs, and yet healthcare costs remain catastrophic for a large proportion of insured households in Ghana. Future studies need to explore reasons for the persistence of OOPs for medicines and services that are covered under the scheme.
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Affiliation(s)
- Juliet Okoroh
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA USA
- Department of Surgery, Korle-Bu Teaching Hospital, Accra, Ghana
- Department of Surgery, University of California San Francisco, 513 Parnassus Ave S-321, San Francisco, CA 94143 USA
- Fogarty International Center, National Institute of Health, GloCal Consortium, Bethesda, USA
| | - Samuel Essoun
- Department of Surgery, Korle-Bu Teaching Hospital, Accra, Ghana
| | | | - Hobart Harris
- Department of Surgery, University of California San Francisco, 513 Parnassus Ave S-321, San Francisco, CA 94143 USA
| | - Joel S. Weissman
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA USA
| | | | - Robert Riviello
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA USA
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Ogben C, Ilesanmi O. Community based health insurance scheme: Preferences of rural dwellers of the federal capital territory Abuja, Nigeria. J Public Health Afr 2018; 9:540. [PMID: 30079158 PMCID: PMC6057720 DOI: 10.4081/jphia.2018.540] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 10/15/2017] [Indexed: 11/23/2022] Open
Abstract
In 2010, community based health insurance scheme (CBHIS) was launched in the Federal Capital Territory (FCT) of Nigeria. Little is known about the preferences and perception of the rural dwellers of the FCT about the scheme. This study aimed to determine the preferences of healthcare consumers towards CBHIS in FCT. A descriptive cross sectional study of 287 household heads was done. Systematic random sampling was used. Information was collected using a semi-structured, interviewer administered questionnaire. Data was analysed with SPSS version 21. Male respondents were 175 (61%), 242 (84.3%) were aware of the existence of CBHIS, 126 (82%) also enrolled their dependents. Annual payment of health insurance premium was preferred by 91 (59.9%) of enrolled respondents, 92 (60.1%) enrolled in the scheme because they perceived it to be a cheap way to access healthcare. No proper understanding was the reason why 33 (28.4%) of those aware of the scheme did not enroll themselves or their dependents. Only 124 (55.1%) were satisfied with the overall services provided to them by their health care provider (HCP). More community enlightenment on CBHIS is required. There is a need to factor in the preferences of the community members into the FCTCBHIS to determine what community members are willing to pay for their healthcare premium and how making contributions will be convenient for them.
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Affiliation(s)
| | - Olayinka Ilesanmi
- Department of Community Health, Federal Medical Centre, Owo, Ondo State, Nigeria
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Amoah PA, Phillips DR. Health literacy and health: rethinking the strategies for universal health coverage in Ghana. Public Health 2018; 159:40-49. [PMID: 29729490 DOI: 10.1016/j.puhe.2018.03.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 02/26/2018] [Accepted: 03/01/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVES Health literacy (HL) is generally thought to be associated with positive health behaviour, appropriate health service utilisation and acceptance of interventions to maximise health outcomes. It is, therefore, increasingly suggested that evidence-based research should investigate how HL may operate in the context of universal health coverage (UHC). However, the role of HL in the relationships between elements of UHC such as access to health care and health insurance has not been widely explored. This applies in particular in Sub-Saharan Africa, although service coverage and health outcomes vary hugely between and within many countries. This article addresses this lacuna in Ghana, today one of the Africa's most promising health systems. STUDY DESIGN It is a cross-sectional study. METHODS The study used structured interviews to gather data from 779 rural and urban adults using a multistage cluster sampling approach. RESULTS In a three-step multiple hierarchical linear regression model, HL (B = -.09, standard error [SE] = .04) and health insurance subscription (B = -.15, SE = .04) were found to be inversely associated with poor health-related quality of life (HRQoL). Access to health care did not predict HRQoL (B = -.02, SE = .02). However, the interaction between access to health care and HL produced a negative effect on poor HRQoL (B = -.08, SE = .03). The interaction between HL and health insurance subscription also showed a similar effect on HRQoL (B = -.10, SE = .03). Further analysis depicted that access to health care (β = -.09, P = .05) and health insurance subscription (β = -.24, P = .00) related positively to HRQoL only when HL was high. CONCLUSION The article argues that where HL is low, even favourable policies for UHC are likely to miss set targets. While not losing sight of relevant sociocultural elements, enhancing HL should be a central strategy for policies aimed at bridging health inequalities and improving UHC.
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Affiliation(s)
- Padmore Adusei Amoah
- Division of Graduate Studies and Asia Pacific Institute of Ageing Studies, Lingnan University, 8 Castle Peak Rd., Tuen Mun, Hong Kong.
| | - David R Phillips
- Department of Sociology and Social Policy, Lingnan University, 8 Castle Peak Rd., Tuen Mun, Hong Kong.
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Dalaba MA, Welaga P, Oduro A, Danchaka LL, Matsubara C. Cost of malaria treatment and health seeking behaviour of children under-five years in the Upper West Region of Ghana. PLoS One 2018; 13:e0195533. [PMID: 29652938 PMCID: PMC5898715 DOI: 10.1371/journal.pone.0195533] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 03/23/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND There is limited knowledge on cost of treating malaria in children under-five years in northern Ghana which poses a challenge in determining whether interventions such as the National Health Insurance Scheme (NHIS) and Community-based Health Planning and Services (CHPS) have reduced the economic burden of malaria to households or not. This study examined the malaria care seeking and cost of treatment in children under-five years in the Upper West Region of Ghana. METHODS The study used a cross-sectional, quantitative design and data were collected between July and August 2016 in three districts in the Upper West Region of Ghana. A total of 574 women who had under-five children were interviewed. Socio-demographic characteristics of respondents, malaria seeking patterns for under-five children with malaria as well as direct medical and non-medical costs associated with treating under-five children with malaria were collected from the patient perspective. Analysis was performed using STATA 12. RESULTS Out of 574 women visited, about 63% (360) had children who had malaria and sought treatment. Most treatment was done at formal health facilities such as the health centres (37%) and the CHPS (35%) while 3% had self-treatment at home. The main reason for choice of place of treatment outside home was nearness to home (53%). The average direct medical and non-medical costs associated with treating an under-five child with malaria were US$4.13 and US$3.04 respectively. The average cost on transportation alone was US$2.64. Overall, the average direct medical and non-medical cost associated with treating an under-five child with malaria was US$4.91(range: minimum = US$0.13 -maximum = US$46.75). Children who were enrolled into the NHIS paid an average amount of US$4.76 compared with US$5.88 for those not enrolled, though the difference was not statistically significant (p-value = 0.15). CONCLUSIONS The average cost to households in treating an under-five child with malaria was US$4.91. This amount is considerably high given the poverty level in the area. Children not insured paid a little over one US dollar for malaria treatment compared to those insured. Efforts to improve enrolment into the NHIS may be needed to reduce the cost of malaria treatment to households. Construction of more health facilities near to community members and at hard to reach areas will improve access to health care and reduce direct non-medical cost such as transportation costs.
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Affiliation(s)
| | - Paul Welaga
- Navrongo Health Research Centre, Navrongo, Ghana
| | | | | | - Chieko Matsubara
- Bureau of International Medical Cooperation, National Centre for Global Health and Medicine, Tokyo, Japan
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Mathur T, Das G, Gupta H. Examining the influence of health insurance literacy and perception on the people preference to purchase private voluntary health insurance. Health Serv Manage Res 2018. [PMID: 29542342 DOI: 10.1177/0951484818760529] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Most studies have associated “un-affordability” as a plausible cause for the lower take-up of private voluntary health insurance plans. However, others refuted this claim on the pretext that when people can afford “inpatient-care” from pocket then insurance premium cost is far less than those payments. Thus, economic factors remain insufficient in clearly explaining the reason for poor private voluntary health insurance take-up. An attempt is being made by shifting the focus towards non-economic factors and understanding the role of perception and health insurance literacy in transforming people preferences to invest in private voluntary health insurance plans. The study findings will conspicuously support decision-makers in developing strategy to increase the private voluntary health insurance take-up.
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Affiliation(s)
- Tanuj Mathur
- Marketing Department, Amity Business School, Amity University, Malhour, Lucknow, Uttar Pradesh, India
| | - Gurudas Das
- Department of Humanities and Social Sciences, National Institute of Technology, Silchar, Assam, India
| | - Hemendra Gupta
- Finance Department, Jaipuria Institute of Management, Gomti Nagar, Lucknow, Uttar Pradesh, India
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Private healthcare provider experiences with social health insurance schemes: Findings from a qualitative study in Ghana and Kenya. PLoS One 2018; 13:e0192973. [PMID: 29470545 PMCID: PMC5823407 DOI: 10.1371/journal.pone.0192973] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 01/15/2018] [Indexed: 11/22/2022] Open
Abstract
Background Incorporating private healthcare providers into social health insurance schemes is an important means towards achieving universal health coverage in low and middle income countries. However, little research has been conducted about why private providers choose to participate in social health insurance systems in such contexts, or their experiences with these systems. We explored private providers’ perceptions of and experiences with participation in two different social health insurance schemes in Sub-Saharan Africa—the National Health Insurance Scheme (NHIS) in Ghana and the National Hospital Insurance Fund (NHIF) in Kenya. Methods In-depth interviews were held with providers working at 79 facilities of varying sizes in three regions of Kenya (N = 52) and three regions of Ghana (N = 27). Most providers were members of a social franchise network. Interviews covered providers’ reasons for (non) enrollment in the health insurance system, their experiences with the accreditation process, and benefits and challenges with the system. Interviews were coded in Atlas.ti using an open coding approach and analyzed thematically. Results Most providers in Ghana were NHIS-accredited and perceived accreditation to be essential to their businesses, despite challenges they encountered due to long delays in claims reimbursement. In Kenya, fewer than half of providers were NHIF-accredited and several said that their clientele were not NHIF enrolled. Understanding of how the NHIF functioned was generally low. The lengthy and cumbersome accreditation process also emerged as a major barrier to providers’ participation in the NHIF in Kenya, but the NHIS accreditation process was not a major concern for providers in Ghana. Conclusions In expanding social health insurance, coordinated efforts are needed to increase coverage rates among underserved populations while also accrediting the private providers who serve those populations. Market pressure was a key force driving providers to gain and maintain accreditation in both countries. Developing mechanisms to engage private providers as stakeholders in social health insurance schemes is important to incentivizing their participation and addressing their concerns.
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Andoh-Adjei FX, van der Wal R, Nsiah-Boateng E, Asante FA, van der Velden K, Spaan E. Does a provider payment method affect membership retention in a health insurance scheme? a mixed method study of Ghana's capitation payment for primary care. BMC Health Serv Res 2018; 18:52. [PMID: 29378567 PMCID: PMC5789689 DOI: 10.1186/s12913-018-2859-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Accepted: 01/18/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ghana introduced a National Health Insurance Scheme (NHIS) in 2003 applying fee-for-service method for paying NHIS-credentialed health care providers. The National Health Insurance Authority (NHIA) later introduced diagnosis-related-grouping (DRG) payment to contain cost without much success. The NHIA then introduced capitation payment, a decision that attracted complaints of falling enrolment and renewal rates from stakeholders. This study was done to provide evidence on this trend to guide policy debate on the issue. METHODS We applied mixed method design to the study. We did a trend analysis of NHIS membership data in Ashanti, Volta and Central regions to assess growth rate; performed independent-sample t-test to compare sample means of the three regions and analysed data from individual in-depth interviews to determine any relationship between capitation payment and subscribers' renewal decision. RESULTS Results of new enrolment data analysis showed differences in mean growth rates between Ashanti (M = 30.15, SE 3.03) and Volta (M = 40.72, SE 3.10), p = 0.041; r = 0. 15; and between Ashanti and Central (M = 47.38, SE6.49) p = 0.043; r = 0. 42. Analysis of membership renewal data, however, showed no significant differences in mean growth rates between Ashanti (M = 65.47, SE 6.67) and Volta (M = 69.29, SE 5.04), p = 0.660; r = 0.03; and between Ashanti and Central (M = 50.51, SE 9.49), p = 0.233. Analysis of both new enrolment and renewal data also showed no significant differences in mean growth rates between Ashanti (M = - 13.76, SE 17.68) and Volta (M = 5.48, SE 5.50), p = 0.329; and between Ashanti and Central (M = - 6.47, SE 12.68), p = 0.746. However, capitation payment had some effect in Ashanti compared with Volta (r = 0. 12) and Central (r = 0. 14); but could not be sustained beyond 2012. Responses from the in-depth interviews did not also show that capitation payment is a key factor in subscribers' renewal decision. CONCLUSION Capitation payment had a small but unsustainable effect on membership growth rate in the Ashanti region. Factors other than capitation payment may have played a more significant role in subscribers' enrolment and renewal decisions in the Ashanti region of Ghana.
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Affiliation(s)
| | - Renske van der Wal
- Radboud Institute for Health Sciences, Department for Health Evidence, Radboud University Medical Centre-Netherlands, Nijmegen, Netherlands
| | | | - Felix Ankomah Asante
- Institute of Statistical, Social and Economic Research (ISSER) University of Ghana, Legon-, Accra, Ghana
| | - Koos van der Velden
- Radboud Institute for Health Science, Department for Primary and Community Health, Radboud University Medical Centre-Netherlands, Nijmegen, Netherlands
| | - Ernst Spaan
- Radboud Institute for Health Sciences, Department for Health Evidence, Radboud University Medical Centre-Netherlands, Nijmegen, Netherlands
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