Factors associated with household willingness to pay for Universal Health Coverage in Cameroon: a nationwide cross-sectional analysis

BACKGROUND

Sustained financing for Universal Health Coverage (UHC) has been a concern for the Cameroon government. Household contributions have been considered as a financing mechanism, but this raises concerns on the willingness of households to pay for UHC. The current study assessed factors associated with the willingness to pay (WTP) for UHC in Cameroon.

METHODS

Community based, cross-sectional analysis of data from households (selected via multi-stage, randomized, cluster sampling) across all ten regions of Cameroon, during July 2020. Factors associated with WTP for UHC were determined using a multinominal logistic regression model, tested at varying significance levels (1%, 5%, and 10%) to enhance its ability to detect meaningful and practical value associations.

RESULTS

Overall, 5,014 households were surveyed, 64.3% and 35.6% from rural and urban areas respectively. Household heads were 40.2 ± 10.1 years old and mostly male (60.6%). Most surveyed households (72%) were willing to contribute for UHC. Amongst these willing households, WTP varied with the sex (females opted for lower payments) and educational level (those with ≥ high school education opted for contributions ≥ US$ 165.6 annually, p < 0.01) of the household head. WTP also varied proportionally with household income and was influenced by the sector of activity (formal secondary/tertiary and informal sector workers opted for contributions > US$ 165.6 annually, p < 0.01) of the household head. Other factors affecting WTP included household size (households with ≥ 13 persons opted for contributions ≥ US$ 165.6, p < 0.01) and the age of the household head (those ≥ 55 years opted for higher contributions; US$ 33.1-82.6, p < 0.01). WTP varied positively with knowledge on UHC and affiliation to a health insurance scheme. Household who did not resort to self-medication/prayers when in need of healthcare services opted for higher contributions (US$ 82.6- 165.6, p < 0.01).

CONCLUSION

UHC implementation in Cameroon will require that factors shown here-in to influence WTP be carefully considered. Modifiable factors such as self-medication/prayers and poor knowledge on UHC, underlines the need for greater sensitization on UHC. Given the high WTP from the informal sector, characterization of the sector could go a long way to increase the financial envelope allocated for UHC.

Financing for equity for women's, children's and adolescents' health in low- and middle-income countries: A scoping review

Over the past few decades, the world has witnessed considerable progress in women's, children's and adolescents' health (WCAH) and the Sustainable Development Goals (SDGs). Yet deep inequities remain between and within countries. This scoping review aims to map financing interventions and measures to improve equity in WCAH in low- and middle-income countries (LMICs). This scoping review was conducted following Joanna Briggs Institute (JBI) guidance for conducting such reviews as well as the PRISMA Extension for Scoping Reviews (PRISMA-ScR) for reporting scoping reviews. We searched Medline, PubMed, EMBASE and the World Health Organization's (WHO) Global Index Medicus, and relevant websites. The selection process was conducted in duplicate and independently. Out of 26 355 citations identified from electronic databases, relevant website searches and stakeholders' consultations, 413 studies were included in the final review. Conditional cash transfers (CCTs) (22.3%), health insurance (21.4%), user fee exemptions (18.1%) and vouchers (16.9%) were the most reported financial interventions and measures. The majority were targeted at women (57%) and children (21%) with others targeting adolescents (2.7%) and newborns (0.7%). The findings highlighted that CCTs, voucher programs and various insurance schemes can improve the utilization of maternal and child health services for the poor and the disadvantaged, and improve mortality and morbidity rates. However, multiple implementation challenges impact the effectiveness of these programmes. Some studies suggested that financial interventions alone would not be sufficient to achieve equity in health coverage among those of a lower income and those residing in remote regions. This review provides evidence on financing interventions to address the health needs of the most vulnerable communities. It can be used to inform the design of equitable health financing policies and health system reform efforts that are essential to moving towards universal health coverage (UHC). By also unveiling the knowledge gaps, it can be used to inform future research on financing interventions and measures to improve equity when addressing WCAH in LMICs.

Willingness to pay for National Health Insurance Services and Associated Factors in Africa and Asia: a systematic review and meta-analysis

Background

Universal health coverage (UHC) is crucial for public health, poverty eradication, and economic growth. However, 97% of low- and middle-income countries (LMICs), particularly Africa and Asia, lack it, relying on out-of-pocket (OOP) expenditure. National Health Insurance (NHI) guarantees equity and priorities aligned with medical needs, for which we aimed to determine the pooled willingness to pay (WTP) and its influencing factors from the available literature in Africa and Asia.

Methods

Database searches were conducted on Scopus, HINARI, PubMed, Google Scholar, and Semantic Scholar from March 31 to April 4, 2023. The Joanna Briggs Institute's (JBI's) tools and the "preferred reporting items for systematic reviews and meta-analyses (PRISMA) 2020 statement" were used to evaluate bias and frame the review, respectively. The data were analyzed using Stata 17. To assess heterogeneity, we conducted sensitivity and subgroup analyses, calculated the Luis Furuya-Kanamori (LFK) index, and used a random model to determine the effect estimates (proportions and odds ratios) with a p value less than 0.05 and a 95% CI.

Results

Nineteen studies were included in the review. The pooled WTP on the continents was 66.0% (95% CI, 54.0-77.0%) before outlier studies were not excluded, but increased to 71.0% (95% CI, 68-75%) after excluding them. The factors influencing the WTP were categorized as socio-demographic factors, income and economic issues, information level and sources, illness and illness expenditure, health service factors, factors related to financing schemes, as well as social capital and solidarity. Age has been found to be consistently and negatively related to the WTP for NHI, while income level was an almost consistent positive predictor of it.

Conclusion

The WTP for NHI was moderate, while it was slightly higher in Africa than Asia and was found to be affected by various factors, with age being reported to be consistently and negatively related to it, while an increase in income level was almost a positive determinant of it.

Association between women's household decision-making autonomy and health insurance enrollment in sub-saharan Africa

BACKGROUND

Out of pocket payment for healthcare remains a barrier to accessing health care services in sub-Saharan Africa (SSA). Women's decision-making autonomy may be a strategy for healthcare access and utilization in the region. There is a dearth of evidence on the link between women's decision-making autonomy and health insurance enrollment. We, therefore, investigated the association between married women's household decision making autonomy and health insurance enrollment in SSA.

METHODS

Demographic and Health Survey data of 29 countries in SSA conducted between 2010 and 2020 were analyzed. Both bivariate and multilevel logistic regression analyses were carried out to investigate the relationship between women's household decision-making autonomy and health insurance enrollment among married women. The results were presented as an adjusted odds ratio (AOR) and the 95% confidence interval (CI).

RESULTS

The overall coverage of health insurance among married women was 21.3% (95% CI; 19.9-22.7%), with the highest and lowest coverage in Ghana (66.7%) and Burkina Faso (0.5%), respectively. The odds of health insurance enrollment was higher among women who had household decision-making autonomy (AOR = 1.33, 95% CI; 1.03-1.72) compared to women who had no household decision-making autonomy. Other covariates such as women's age, women's educational level, husband's educational level, wealth status, employment status, media exposure, and community socioeconomic status were found to be significantly associated with health insurance enrollment among married women.

CONCLUSION

Health insurance coverage is commonly low among married women in SSA. Women's household decision-making autonomy was found to be significantly associated with health insurance enrollment. Health-related policies to improve health insurance coverage should emphasize socioeconomic empowerment of married women in SSA.

Study on the Dynamic Relationship between Chinese Residents' Individual Characteristics and Commercial Health Insurance Demand

Based on the time series data of age characteristics, household registration characteristics, gender characteristics, education characteristics, marriage characteristics and commercial health insurance density of Chinese residents from 1997 to 2020, this paper aims to explore the dynamic relationship between the individual characteristics of Chinese residents and the demand for commercial health insurance by means of impulse response and variance decomposition analysis using an SVAR model. The results show that the age characteristics, household registration characteristics, gender characteristics, education characteristics and marriage characteristics of Chinese residents have a significant impact on the demand for commercial health insurance, but there is a time lag. There is a long-term equilibrium relationship between them: In terms of age characteristics and gender characteristics, the former has a positive effect in the short term and a significant inhibition on commercial health insurance demand in the long term, while the latter has the opposite. In terms of household registration characteristics, education characteristics and marriage characteristics, there are positive effects on the whole and negative effects in a particular period.

Sex of household head and other household determinants of childhood anaemia among households in Ghana: regression analysis of the 2019 Malaria Indicator Survey

BACKGROUND

Childhood anaemia is still a major public health concern. Although the prevalence of anaemia among children under age five is reducing in Ghana, the severity level is still worsening. This study sought to examine and compare household factors affecting the anaemia status of children under age five living in male- and female-headed households in Ghana.

METHODS

The study used a weighted sample of 5,799 household heads from the 2019 Ghana Malaria Indicator Survey (GMIS). A binary logistic regression analysis was used to examine the effect of sex of household heads and other household factors on the anaemia status of children under the age of five in male- and female-headed households in Ghana. All analyses were conducted at the 95% confidence level.

RESULTS

The results showed that a higher proportion (83.0%) of children under age five are not anaemic in households in Ghana. However, the probability of a child being anaemic is higher in male-headed households (aOR = 1.28; C.I:1.08-1.51), in the poorest (aOR = 2.41; CI: 1.59-3.65), poorer (aOR = 2.04; C.I:1.41-2.94) and middle (aOR = 1.78; C.I:1.29-2.46) household wealth category. Higher likelihood of anaemia was found among children in households that used charcoal (aOR = 1.51; C.I:1.15-1.99) and fuelwood (aOR = 1.44; C.I:1.02-2.02) for cooking. Similarly, there is a high probability of childhood anaemia in households with 5-10 members (aOR = 4.49; C.I: 3.78-5.34), 11 or more members (aOR = 7.21; C.I: 4.60-11.31) and household residing in northern part of Ghana (aOR = 1.40; C.I:1.07-1.83). The lower odds of being anaemic were recorded among children whose household heads were aged 40 years and older, household using other cooking fuels (aOR = 0.49; C.I: 0.21-0.78) and household with no bednets (aOR = 0.57; C.I: 0.44-0.74).

CONCLUSIONS

The GMIS data suggest that anaemia and its severity are higher among children living in MHH than among those living in FHH. The results indicate that poverty, a higher number of household members, relatively younger male household heads and the type of cooking fuel used were factors accounting for the differences in childhood anaemia in MHH and FHH. Equal attention should be given to MHH and FHH in terms of programmes and interventions aimed towards preventing and reducing childhood anaemia in Ghana.

Equity in health insurance schemes enrollment in low and middle-income countries: A systematic review and meta-analysis

Background

Ensuring access to essential quality health services and reducing financial hardship for all individuals regardless of their ability to pay are the main goals of universal health coverage. Various health insurance schemes have been recently implemented in low- and middle-income countries (LMICs) to achieve both of these objectives. We systematically reviewed all available literature to assess the extent to which current health insurance schemes truly reach the poor and underserved populations in LMICs.

Methods

In the systematic review, we searched on PubMed, Web of Science, EconLit and Google Scholar to identify eligible studies which captured health insurance enrollment information in LMICs from 2010 up to September 2019. Two authors independently selected studies, extracted data, and appraised included studies. The primary outcome of interest was health insurance enrollment of the most vulnerable populations relative to enrollment of the best-off subgroups. We classified households both with respect to their highest educational attainment and their relative wealth and used random-effects meta-analysis to estimate average enrollment gaps.

Results

48 studies from 17 countries met the inclusion criteria. The average enrollment rate into health insurance schemes for vulnerable populations was 36% with an inter-quartile range of 26%. On average, across countries, households from the wealthiest subgroup had 61% higher odds (95% CI: 1.49 to 1.73) of insurance enrollment than households in the poorest group in the same country. Similarly, the most educated groups had 64% (95% CI: 1.32 to 1.95) higher odds of enrollment than the least educated groups.

Conclusion

The results of this study show that despite major efforts by governments, health insurance schemes in low-and middle-income countries are generally not reaching the targeted underserved populations and predominantly supporting better-off population groups. Current health insurance designs should be carefully scrutinized, and the extent to which health insurance can be used to support the most vulnerable populations carefully re-assessed by countries, which are aiming to use health insurance schemes as means to reach their UHC goals. Furthermore, studies exploring best practices to include vulnerable groups in health insurance schemes are needed.

Registration

Not available

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-021-01608-x.

A Comparative Cross-Sectional Study of the Prevalence and Determinants of Health Insurance Coverage in Nigeria and South Africa: A Multi-Country Analysis of Demographic Health Surveys

Background: The core Universal Health Coverage (UHC) objectives are to ensure universal access to healthcare services by reducing all forms of inequalities. However, financial constraints are major barriers to accessing healthcare, especially in countries such as Nigeria and South Africa. The findings of this study may aid in informing and communicating health policy to increase financial access to healthcare and its utilization in South Africa and Nigeria. Nigeria-South Africa bilateral relations in terms of politics, economics and trade are demonstrated in the justification of the study setting selection. The objectives were to estimate the prevalence of health insurance coverage, and to explore the socio-demographic factors associated with health insurance in South Africa and Nigeria. Methods: This was a cross-sectional study using the 2018 Nigeria Demographic Health Survey and the 2016 South Africa Demographic Health Survey. The 2018 Nigeria Demographic Health Survey data on 55,132 individuals and the 2016 South Africa Demographic Health Survey on 12,142 individuals were used to investigate the prevalence of health insurance associated with socio-demographic factors. Percentages, frequencies, Chi-square and multivariate logistic regression were e mployed, with a significance level of p < 0.05. Results: About 2.8% of the Nigerian population and 13.3% of the South African population were insured (Nigeria: males-3.4%, females-2.7% vs. South Africa: males-13.9%, females-12.8%). The multivariate logistic regression analyses showed that higher education was significantly more likely to be associated with health insurance, independent of other socio-demographic factors in Nigeria (Model I: OR: 1.43; 95% CI: 0.34-1.54, p < 0.05; Model II: OR: 1.34; 95% CI: 0.28-1.42, p < 0.05) and in South Africa (Model I: OR: 1.33; 95% CI: 0.16-1.66, p < 0.05; Model II: OR: 1.76; 95% CI: 0.34-1.82, p < 0.05). Respondents with a higher wealth index and who were employed were independently associated with health insurance uptake in Nigeria and South Africa (p < 0.001). Females were more likely to be insured (p < 0.001) than males in both countries, and education had a significant impact on the likelihood of health insurance uptake in high wealth index households among both male and females in Nigeria and South Africa. Conclusion: Health insurance coverage was low in both countries and independently associated with socio-demographic factors such as education, wealth and employment. There is a need for continuous sensitization, educational health interventions and employment opportunities for citizens of both countries to participate in the uptake of wide health insurance coverage.

Are children in female-headed households at a disadvantage? An analysis of immunization coverage and stunting prevalence: in 95 low- and middle-income countries

Studies of inequalities in child health have given limited attention to household structure and headship. The few existing reports on child outcomes in male and female-headed households have produced inconsistent results. The aim of our analyses was to provide a global view of the influence of sex of the household head on child health in cross-sectional surveys from up to 95 LMICs. Studied outcomes were full immunization coverage in children aged 12-23 months and stunting prevalence in under-five children. We analyzed the most recent nationally-representative surveys for each country (since 2010) with available data. After initial exploratory analyses, we focused on three types of households: a) male-headed household (MHH) comprised 73.1% of all households in the pooled analyses; b) female Headed Household (FHH) with at least one adult male represented 9.8% of households; and c) FHH without an adult male accounted for 15.0% of households. Our analyses also included the following covariates: wealth index, education of the child's mother and urban/rural residence. Meta-analytic approaches were used to calculate pooled effects across the countries with MHH as the reference category. Regarding full immunization, the pooled prevalence ratio for FHH (any male) was 0.99 (0.97; 1.01) and that for FHH (no male) was 0.99 (0.97; 1.02). For stunting prevalence, the pooled prevalence ratio for FHH (any male) was 1.00 (0.98; 1.02) and for FHH (no male) was 1.00 (0.98; 1.02). Adjustment for covariates did not lead to any noteworthy change in the results. No particular patterns were found among different world regions. A few countries presented significant inequalities with different directions of association, indicating the diversity of FHH and how complex the meaning and measurement of household headship may be. Further research is warranted to understand context, examine mediating factors, and exploring alternative definitions of household headship in countries with some association.

Who will drop out of voluntary social health insurance? Evidence from the New Cooperative Medical Scheme in China

Although public voluntary health insurance (VHI) has been adopted in many low- and middle-income countries to improve access to care for the population, a common issue with VHI is its high dropout rate. Using the New Cooperative Medical Scheme (NCMS)-a public VHI in China-as a case study, this article employs a fixed-effects negative binomial regression model combining the difference-in-difference-in-differences approach and multivariate distance matching to examine the factors associated with dropping out and the impact of dropout on outpatient care utilization among middle-aged and older people in rural China. Drawing data from the China Health and Retirement Longitudinal Study, our results showed that healthy people, vulnerable people and people who use less healthcare tended to drop out. Dropout had a significant negative impact on outpatient care utilization, especially for those with worse health statuses and those living in poorer provinces. We also found that the impact of dropout on outpatient utilization was more pronounced at secondary and tertiary hospitals than at primary care clinics. We urge policymakers to rethink the design of the NCMS by waiving premiums for the most vulnerable people.

Changing men or changing health systems? A scoping review of interventions, services and programmes targeting men's health in sub-Saharan Africa

BACKGROUND

Sex and gender have been shown to influence health literacy, health seeking behaviour, and health outcomes. However, research examining the links between gender and health has mainly focused on women's health, which is a long-standing global health priority. We examine literature focused on the 'missing men' in global health research, in particular empirical studies that document interventions, programmes, and services targeting men's health issues in Sub-Saharan Africa. Within these studies, we identify dominant conceptualisations of men and men's health and how these have influenced the design of men's health interventions and services.

METHODS

This is a scoping review of published and grey literature. Following comprehensive searches, we included 56 studies in the review. We conducted a bibliographic analysis of all studies and used inductive methods to analyse textual excerpts referring to conceptualizations of men and service design. An existing framework to categorise services, interventions, or programs according to their gender-responsiveness was adapted and used for the latter analysis.

RESULTS

From the included studies, we distinguished four principal ways in which men were conceptualized in programs and interventions: men are variously depicted as 'gatekeepers'; 'masculine' men, 'marginal' men and as 'clients. Additionally, we classified the gender-responsiveness of interventions, services or programmes described in the studies within the following categories: gender-neutral, -partnering, -sensitive and -transformative. Interventions described are predominantly gender-neutral or gender-partnering, with limited data available on transformative interventions. Health systems design features - focused mainly on achieving women's access to, and uptake of services - may contribute to the latter gap leading to poor access and engagement of men with health services.

CONCLUSION

This review highlights the need for transformation in sub-Saharan African health systems towards greater consideration of men's health issues and health-seeking patterns.

Strategic Health Purchasing Progress Mapping in Cameroon: A Scoping Review

Many low- and middle-income countries are adopting far-reaching health financing policies using strategic health purchasing (SHP) approaches to address their health sector challenges. However, limited efforts have been directed toward analyzing the SHP activities nationwide. Our objective was to explore the scope and development of SHP in Cameroon. We conducted a scoping review applying the framework developed by Arksey and O'Malley and modified by Levac et al. to identify and extract data from relevant SHP studies and documents published between 2000 and 2019, which focused on Cameroon. Among the existing 30 health financing schemes, 5 present the elements of SHP: (1) national health insurance (NHI), (2) performance-based financing (PBF), (3) voucher system, (4) private health insurance, and (5) mutual health organizations. The findings suggest that the governance function of purchasing is very challenging due to the multiple purchaser markets and the resulting fragmentation of the health financing system. In addition, the misalignment of the different benefit packages across schemes leads to considerable gaps and overlaps in the population coverage. The issue of multiple highly fragmented payment systems also remains a big concern across the different schemes, with tentative harmonization observed with NHI and PBF. Achieving the full potential of SHP in Cameroon will require (1) a defragmentation of the multiple schemes, (2) an effective oversight arrangement, and (3) an alignment of provider payment method to a coherent set of incentives across the system, with the ultimate aim of promoting equity, efficiency and quality.

Healthcare Financing in Rural Cameroon

In the global South, low-income populations are faced with frequent health shocks. Formal mechanisms to protect them against these shocks are absent or limited. Thus, what are the mechanisms used by low-income rural populations to finance healthcare? This paper draws on a qualitative study to examine the healthcare financing mechanisms of low-income rural populations in Cameroon. The findings suggest that low-income populations use 13 mechanisms to finance healthcare. Depending on several factors, people may use more than one of these mechanisms. In addition, social factors shape people’s patterns of usage of these mechanisms. Patterns of usage of these mechanisms are embedded in the principle of reciprocity. The notion of reciprocity does seem to discourage people from enrolling in the limited voluntary health insurance programmes which exist in various communities. Newly insured people were more likely to drop out if they did not receive a payout.

Leaving no one behind? Social inclusion of health insurance in low- and middle-income countries: a systematic review

BACKGROUND

One way to achieve universal health coverage (UHC) in low- and middle-income countries (LMIC) is the implementation of health insurance schemes. A robust and up to date overview of empirical evidence assessing and substantiating health equity impact of health insurance schemes among specific vulnerable populations in LMICs beyond the more common parameters, such as income level, is lacking. We fill this gap by conducting a systematic review of how social inclusion affects access to equitable health financing arrangements in LMIC.

METHODS

We searched 11 databases to identify peer-reviewed studies published in English between January 1995 and January 2018 that addressed the enrolment and impact of health insurance in LMIC for the following vulnerable groups: female-headed households, children with special needs, older adults, youth, ethnic minorities, migrants, and those with a disability or chronic illness. We assessed health insurance enrolment patterns of these population groups and its impact on health care utilization, financial protection, health outcomes and quality of care.

RESULTS

The comprehensive database search resulted in 44 studies, in which chronically ill were mostly reported (67%), followed by older adults (33%). Scarce and inconsistent evidence is available for individuals with disabilities, female-headed households, ethnic minorities and displaced populations, and no studies were yielded reporting on youth or children with special needs. Enrolment rates seemed higher among chronically ill and mixed or insufficient results are observed for the other groups. Most studies reporting on health care utilization found an increase in health care utilization for insured individuals with a disability or chronic illness and older adults. In general, health insurance schemes seemed to prevent catastrophic health expenditures to a certain extent. However, reimbursements rates were very low and vulnerable individuals had increased out of pocket payments.

CONCLUSION

Despite a sizeable literature published on health insurance, there is a dearth of good quality evidence, especially on equity and the inclusion of specific vulnerable groups in LMIC. Evidence should be strengthened within health care reform to achieve UHC, by redefining and assessing vulnerability as a multidimensional process and the investigation of mechanisms that are more context specific.