Achieving universal health coverage through voluntary insurance: what can we learn from the experience of Lao PDR?

Spatial distribution and geographical heterogeneity factors associated with households' enrollment level in community-based health insurance

Background

Healthcare service utilization is unequal among different subpopulations in low-income countries. For healthcare access and utilization of healthcare services with partial or full support, households are recommended to be enrolled in a community-based health insurance system (CBHIS). However, many households in low-income countries incur catastrophic health expenditure. This study aimed to assess the spatial distribution and factors associated with households' enrollment level in CBHIS in Ethiopia.

Methods

A cross-sectional study design with two-stage sampling techniques was used. The 2019 Ethiopian Mini Demographic and Health Survey (EMDHS) data were used. STATA 15 software and Microsoft Office Excel were used for data management. ArcMap 10.7 and SaTScan 9.5 software were used for geographically weighted regression analysis and mapping the results. A multilevel fixed-effect regression was used to assess the association of variables. A variable with a p < 0.05 was considered significant with a 95% confidence interval.

Results

Nearly three out of 10 (28.6%) households were enrolled in a CBHIS. The spatial distribution of households' enrollment in the health insurance system was not random, and households in the Amhara and Tigray regions had good enrollment in community-based health insurance. A total of 126 significant clusters were detected, and households in the primary clusters were more likely to be enrolled in CBHIS. Primary education (AOR: 1.21, 95% CI: 1.05, 1.31), age of the head of the household >35 years (AOR: 2.47, 95% CI: 2.04, 3.02), poor wealth status (AOR: 0.31, 95% CI: 0.21, 1.31), media exposure (AOR: 1.35, 95% CI: 1.02, 2.27), and residing in Afar (AOR: 0.01, 95% CI: 0.003, 0.03), Gambela (AOR: 0.03, 95% CI: 0.01, 0.08), Harari (AOR: 0.06, 95% CI: 0.02, 0.18), and Dire Dawa (AOR: 0.02, 95% CI: 0.01, 0.06) regions were significant factors for households' enrollment in CBHIS. The secondary education status of household heads, poor wealth status, and media exposure had stationary significant positive and negative effects on the enrollment of households in CBHIS across the geographical areas of the country.

Conclusion

The majority of households did not enroll in the CBHIS. Effective CBHIS frameworks and packages are required to improve the households' enrollment level. Financial support and subsidizing the premiums are also critical to enhancing households' enrollment in CBHIS.

Financing Comprehensive Immunization Services in Lao PDR: A Fiscal Space Analysis From a Public Policy Perspective

INTRODUCTION

A comprehensive package of immunization services is an internal component of the Essential Health Service Package (ESP) implemented by Government of Lao People's Democratic Republic (Lao PDR). Thus, the cost of delivering the immunization program and its feasibility given the fiscal space emerges as an important policy question. The present analysis was undertaken to estimate the total cost of implementing the immunization program under ESP, determinants of total cost and the program's fiscal implications from the government's perspective.

METHODOLOGY

We employed a normative costing approach for costing of immunization services under ESP. Standard treatment guidelines (STGs) from both within and outside Lao PDR were considered to identify the resource use for each vaccine delivery. Subsequently, cost per dose administered and fully immunized beneficiary were computed. We assessed the fiscal space for financing immunization services in Lao PDR by adapting the decomposition method given by Tandon et al. RESULTS: In 2019, the estimated total cost of financing immunization in Lao PDR was US$12 million, which will increase in 2025 by 1.75 times, to US$21 million. The per capita budget for immunization needs to increase from about US$2 to US$7. Introduction of newer vaccines in the immunization schedule accounts for the major share (60%) of the increased cost for financing immunization. In view of current fiscal space, the government immunization expenditure (GIE) allocations will be adequate only in a scenario where no new vaccine is introduced under ESP in future years.

CONCLUSION

The current fiscal space would fall short of meeting the aspirational goals of ESP-Immunization for the introduction of newer vaccines in Lao PDR. The present analysis of the fiscal space provides important evidence to support a greater role for the Global Alliance for Vaccine Initiative (GAVI) to continue to finance immunization in Lao PDR. A publicly financed immunization model in Lao PDR would require significant strategic amendments with low short-term viability.

Implementation barriers and remedial strategies for community-based health insurance in Bangladesh: insights from national stakeholders

Background

Community-based health insurance (CBHI) is a part of the health system in Bangladesh, and overcoming the obstacles of CBHI is a significant policy concern that has received little attention. The purpose of this study is to analyze the implementation barriers of voluntary CBHI schemes in Bangladesh and the strategies to overcome these barriers from the perspective of national stakeholders.

Methods

This study is exploratory qualitative research, specifically case study design, using key informant interviews to investigate the barriers of CBHI that are faced during the implementation. Using a topic guide, we conducted thirteen semi-structured in-depth interviews with key stakeholders directly involved in the CBHI implementation process. The data were analyzed using the Framework analysis method.

Results

The implementation of CBHI schemes in Bangladesh is being constrained by several issues, including inadequate population coverage, adverse selection and moral hazard, lack of knowledge about health insurance principles, a lack of external assistance, and insufficient medical supplies. Door-to-door visits by local community-health workers, as well as regular promotional and educational campaigns involving community influencers, were suggested by stakeholders as ways to educate and encourage people to join the schemes. Stakeholders emphasized the necessity of external assistance and the design of a comprehensive benefits package to attract more people. They also recommended adopting a public–private partnership with a belief that collaboration among the government, microfinance institutions, and cooperative societies will enhance trust and population coverage in Bangladesh.

Conclusions

Our research concludes that systematically addressing implementation barriers by including key stakeholders would be a significant reform to the CBHI model, and could serve as a foundation for the planned national health protection scheme for Bangladesh leading to universal health coverage.

Factors Associated With Community Based Health Insurance Healthcare Service Utilization of Households in South Gondar Zone, Amhara, Ethiopia. A Community-Based Cross-Sectional Study

In Ethiopia, community-based health insurance was implemented to promote equitable access to sustainable quality health care and increase financial protection. The purpose of this study was to identify factors associated with community-based Health Insurance, Health Care Service Utilization of Households in the South Gondar Zone. A community-based cross-sectional study was employed. Data were collected among 619 randomly selected households in the south Gondar zone. Chi-square and binary logistic regression analyses with a P-Value of less than .05 were used to determine the association. Out of the total households, 511(82.6%) were using the CBHI scheme for health care service utilization. Residence, marital status, education level, occupation status, family size, presence of under-five children in the household, presence of elders in the households, nearest health institution, presence of chronic illness in the household's, time taken to reach health institution, an attitude of a household were the determinant factors of community-based health insurance scheme health care service utilization of households. It is recommended that the local, regional and national governments, policymakers on optimal actions, NGOs, and other supporting organizations shall improve or scale-up the scheme by providing awareness to the community based on these significant factors and the attitude of households.

Willingness to Pay for National Health Insurance: A Contingent Valuation Study Among Patients Visiting Public Hospitals in Melaka, Malaysia

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.

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.

Do Health Expenditures Converge Among ASEAN Countries?

This paper aims to determine the existence of convergence in health expenditures among Association for South East Asian Nations (ASEAN) countries. Based on the SPSM procedure and panel KSS unit root test results, the public health expenditures (PUHE) in Indonesia, Lao PDR, Cambodia, the Philippines, and Myanmar are converging, while that of Brunei Darussalam, Malaysia, Vietnam, Singapore, and Thailand are diverging. In addition, the sequences of private health expenditures (PRHE) in ASEAN member states are stationary, which implies convergence. This finding is in accordance with Wagner's law, that is, as nations develop, they are forced to expand public expenditure. Specifically, countries with low levels of PUHE tend to catch up with the high health spending countries. This research has policy implications with regard to the convergence of health expenditure across countries. The government in low- and lower-middle income countries should raise PUHE to provide access to health services for those who are unaffordable individuals.

Perceived Quality of Healthcare and Availability of Supplies Determine Household-Level Willingness to Join a Community-Based Health Insurance Scheme in Amhara Region, Ethiopia

Purpose

The Ethiopian health system has been challenged by a shortage of funds and is heavily reliant on foreign donation. However, voluntary community-based health insurance (CBHI) has been implemented to reach and cover the very large agricultural sector since 2010. Thus, the level of acceptability of the scheme needs to be regularly assessed through households’ willingness to join before the nationwide rollout of the scheme. This study was intended to assess the level of willingness to join in community-based health insurance and associated factors in northwest Ethiopia.

Patients and Methods

Using a pretested structured questionnaire, a cross-sectional community-based study was conducted in 2017 in Amhara Region, northwest Ethiopia. Using a multi-stage sampling method, from 15 clusters in which CBHI was implemented, 1,179 households without CBHI membership were included as a sample for the study. Bivariable and multivariable logistic regression was fitted to assess the association between predictor variables and the outcome of interest.

Results

Out of the total (1,179) participants, 60.5% (713) were willing to join the scheme. Households’ occupation (AOR=2.26; 95% CI:=1.12–5.07), perceived good (AOR=2.21; 95% CI:=1.53−3.21), and medium (AOR=1.44; 95% CI=1.22–2.0) healthcare quality and richer wealth status (AOR=1.72; 95% CI=1.08–2.73) were associated with higher odds of willingness to join the scheme.

Conclusion

As The study revealed that level of willingness to join is lower compared to other studies. Therefore, social protection activities for the low-income population and enhancement of the capacity of health facilities are crucial.

Monitoring Process Barriers and Enablers Towards Universal Health Coverage Within the Sustainable Development Goals: A Systematic Review and Content Analysis

BACKGROUND

This study builds on previous successes of using tracer indicators in tracking progress towards Universal Health Coverage (UHC) and complements them by offering a more detailed tool that would allow us to identify potential process barriers and enablers towards such progress.

PURPOSE

This tool was designed accounting for possibly available data in low- and middle-income counties.

METHODOLOGY

A systematic review of relevant studies was carried out using PubMed, ISI Web of Science, Embase, Scopus, and ProQuest databases with no time restriction. The search was complemented by a scoping review of grey literature, using the World Bank and the World Health Organization (WHO) official reports depositories. Next, an inductive content analysis identified determinants influencing the progress towards UHC and its relevant indicators. The conceptual proximity between indicators and categorized themes was explored through three focus group discussion with 18 experts in UHC. Finally, a comprehensive list of indicators was converted into an assessment tool and refined following three consecutive expert panel discussions and two rounds of email surveys.

RESULTS

A total of 416 themes (including indicators and determinants factors) were extracted from 166 eligible articles and documents. Based on conceptual proximity, the number of factors was reduced to 119. These were grouped into eight domains: social infrastructure and social sustainability, financial and economic infrastructures, population health status, service delivery, coverage, stewardship/governance, and global movements. The final assessment tool included 20 identified subcategories and 88 relevant indicators.

CONCLUSION

Identified factors in progress towards UHC are interrelated. The developed tool can be adapted and used in whole or in part in any country. Periodical use of the tool is recommended to understand potential factors that impede or advance progress towards UHC.

Factors associated with patient payments exceeding National Health Insurance fees and out-of-pocket payments in Lao PDR

BACKGROUND

Attaining universal health coverage is a target in the Sustainable Development Goals. In Lao PDR, to achieve universal health coverage, the government is implementing a national insurance scheme, initially targeting the informal sector.

OBJECTIVE

The purpose was to assess: i) the percentage of NHI patients who paid above the scheduled amount, based on individual billing payment; and ii) the factors related to overpayment.

METHODS

Descriptive cross-sectional study based on a structured questionnaire administered at health facilities in face-to-face interviews with 1,850 patients in six provinces.

RESULTS

All 1,850 participants worked in the informal sector. Of these, 78.8% of respondents (77.9% of in-patients; 79.5% of out-patients) made co-payments or were exempted from. Factors associated with in-patients paying above the scheduled fee were living in the province and district (OR = 2.8; 95%CI 1.2 to 6.3); not having documents with them (OR = 21.2; 95%CI 5.6 to 80.3); or not having documents (OR: 7.8; 95% CI 2.1 to 28.6). Significant factors associated with additional costs for out-patients were level of facility used at the provincial hospital (OR:1.4; 95% CI 1.1 to 1.9); older age (OR = 2.2; 95%CI 1.5 to 3.1); living in the province and district (OR = 2.3; 95%CI 1.5 to 3.7); living more than 5 km from the facility (OR = 1.4; 95%CI 1.1 to 1.9); buying medicine or supplies outside of the health facility (OR: 5.6; 95% CI 3.1 to 10.2); not bringing documents (OR:9.1; 95% CI 6.1 to 13.5), not having the right documents (OR: 8.9; 95% CI 5.4 to 14.8).

CONCLUSIONS

A number of patients paid above scheduled fee rates, which may deter people from utilising services when needing them. There is a need for increased understanding of the benefits of the national insurance scheme among patients and healthcare staff.

Enrollment in community based health insurance program and the associated factors among households in Boricha district, Sidama Zone, Southern Ethiopia; a cross-sectional study

Background

In absence of any form of health insurance, out-of-pocket payments for health care lead to decreased use of health services and catastrophic health expenditures. Community-based health insurances has been promised financial model for informal sectors to reduce these problems in many countries. When this comes down to Ethiopia, in the South Nation Nationality People’s Region of the country established 52 schemes including Boricha district, the study area However, there has been little evidence about the enrollment status and the associated factors in the study area in particular elsewhere in general.

Objective

The study aims to assess the current enrollment status of households in community based health insurance and the associated factors in Boricha district of Sidama Zone, Southern Ethiopia.

Methods and materials

A community based cross-sectional study design was employed from February 01, 2019 to March 31, 2019, using a sample of 632 households. Data were collected using interviewer-administered pre-tested questionnaire and entered into EPI-Info 7and transported to SPSSversion20 for analysis. Multi-variable logistic regression analysis along with odds ratio and the corresponding 95% CI was conducted and significance was declared at P-value <0.05.

Results

Current enrollment status of households in community based health insurance was found to be 81 (12.8%). According to this study, educational status; secondary school& above[AOR = 2.749, 95%CI(1.142, 6.618)], timing of collecting premium [AOR = 0.433; 95% CI (0.196, 0.958)], family size ≥5, [AOR = 4.16;95%CI (1.337, 12.944)], no trust on scheme management[AOR = 0.272; 95%CI (0.140, 0.528)], lack of information [AOR = 0.086; 95%CI (0.026, 0.288)], dissatisfaction with health care service received[AOR = 0.303; 95%CI (0.171, 0.537)], no chronic illness in the family[AOR = 0.259; 95%C.I.(0.137, 0.488)] were factors significantly associated with current enrollment status in CBHI.

Conclusions

Households head’s education status, timing of premium collection, family size, no trust on scheme management, lack of information, services dissatisfaction and chronic illness in the family member were the identified factors associated with enrollment in CBHI in the study area. Therefore, to enhance the enrollment and sustainability of CBHI in the study area awareness creation, improving timing of premium collection, strengthening scheme management, improving quality of service are the areas that decision makers needs to intervene.

Factors Associated with Enrolment of Households in Nepal's National Health Insurance Program

BACKGROUND

Nepal has made remarkable efforts towards social health protection over the past several years. In 2016, the Government of Nepal introduced a National Health Insurance Program (NHIP) with an aim to ensure equitable and universal access to healthcare by all Nepalese citizens. Following the first year of operation, the scheme has covered 5 percent of its target population. There are wider concerns regarding the capacity of NHIP to achieve adequate population coverage and remain viable. In this context, this study aimed to identify the factors associated with enrolment of households in the NHIP.

METHODS

A cross-sectional household survey using face to face interview was carried out in 2 Palikas (municipalities) of Ilam district. 570 households were studied by recruiting equal number of NHIP enrolled and non-enrolled households. We used Pearson's chi-square test and binary logistic regression to identify the factors associated with household's enrolment in NHIP. All statistical analyses were performed using IBM SPSS version 23 software.

RESULTS

Enrolment of households in NHIP was found to be associated with ethnicity, socio-economic status, past experience of acute illness in family and presence of chronic illness. The households that belonged to higher socio-economic status were about 4 times more likely to enrol in the scheme. It was also observed that households from privileged ethnic groups such as Brahmin, Chhetri, Gurung, and Newar were 1.7 times more likely to enrol in NHIP compared to those from underprivileged ethnic groups such as janajatis (indigenous people) and dalits (the oppressed). The households with illness experience in 3 months preceding the survey were about 1.5 times more likely to enrol in NHIP compared to households that did not have such experience. Similarly, households in which at least one of the members was chronically ill were 1.8 times more likely to enrol compared to households with no chronic illness.

CONCLUSION

Belonging to the privileged ethnic group, having a higher socio-economic status, experiencing an acute illness and presence of chronically ill member in the family are the factors associated with enrolment of households in NHIP. This study revealed gaps in enrolment between rich-poor households and privileged-underprivileged ethnic groups. Extension of health insurance coverage to poor and marginalized households is therefore needed to increase equity and accelerate the pace towards achieving universal health coverage.

Treatment-seeking behaviour for febrile illnesses and its implications for malaria control and elimination in Savannakhet Province, Lao PDR (Laos): a mixed method study

Background

How people respond to febrile illness is critical to malaria prevention, control, and ultimately elimination. This article explores factors affecting treatment-seeking behaviour for febrile illnesses in a remote area of Lao PDR.

Methods

Household heads or their representatives (n = 281) were interviewed using a structured questionnaire. A total of twelve focus group discussions (FGDs) each with eight to ten participants were conducted in four villages. In addition, observations were recorded as field notes (n = 130) and were used to collect information on the local context, including the treatment seeking behaviour and the health services.

Results

Almost three-quarters (201/281) of respondents reported fever in past two months. Most (92%, 185/201) sought treatment of which 80% (149/185) sought treatment at a health centre. Geographic proximity to a health centre (AOR = 6.5; CI = 1.74–24.25; for those < 3.5 km versus those > 3.6 km) and previous experience of attending a health centre (AOR = 4.7; CI = 1.2–19.1) were strong predictors of visiting a health centre for febrile symptoms. During FGDs, respondents described seeking treatment from traditional healers and at health centre for mild to moderate illnesses. Respondents also explained how if symptoms, including fever, were severe or persisted after receiving treatment elsewhere, they sought assistance at health centres. Access to local health centres/hospitals was often constrained by a lack of transportation and an ability to meet the direct and indirect costs of a visit.

Conclusion

In Nong District, a rural area bordering Vietnam, people seek care from health centres offering allopathic medicine and from spiritual healers. Decisions about where and when to attend health care depended on their economic status, mobility (distance to the health centre, road conditions, availability of transport), symptoms severity and illness recognition. Current and future malaria control/elimination programmes could benefit from greater collaboration with the locally accessible sources of treatments, such as health volunteers and traditional healers.

Potential demand for voluntary community-based health insurance improvement in rural Lao People's Democratic Republic: A randomized conjoint experiment

INTRODUCTION

In Lao People's Democratic Republic (PDR), community-based health insurance (CBHI) is the only voluntary insurance scheme; it typically targets self-employed people, most of whom reside in rural areas and are dependent on agricultural activities for subsistence. However, until very recently, the enrollment rate has fallen short and failed to reach a large percentage of the target group. To promote the CBHI scheme and increase demand, some supporting components should be considered for inclusion together with the health infrastructure component.

OBJECTIVES

This paper provides empirical evidence that the benefit package components of hypothetical CBHI schemes have causal effects on enrollment probabilities. Furthermore, we examine the distribution of willingness to pay (WTP) in response to policy changes based on a sample of 5,800 observations.

METHODS

A randomized conjoint experiment is conducted in rural villages in Savannakhet Province, Lao PDR, to elicit stated preference data. Each respondent ranks three options-two hypothetical alternatives and the CBHI status quo scheme. The levels of seven attributes-insurance coverage for medical consultations, hospitalizations, traffic accidents, pharmaceuticals and transportation; premiums; and prepaid discounts-are randomly and simultaneously assigned to the two alternatives.

RESULTS

The findings suggest that the average WTP is at least as large as 10.9% of the per capita income of those who live in rural areas, which is higher than the WTP for health insurance averaged across low- and middle-income countries (LMICs) in the literature. The component of round-trip transportation insurance coverage has a significant effect on WTP distribution, particularly increasing the share of the highest bin.

CONCLUSION

Therefore, the low CBHI scheme enrollment rate in Lao PDR does not necessarily imply low demand among the targeted population, as the finding from the WTP analysis illustrates potential demand for the CBHI scheme. Specifically, if transportation is addressed, enrollment is likely to significantly increase.

Kenya National Hospital Insurance Fund Reforms: Implications and Lessons for Universal Health Coverage

This article identifies and describes the reforms undertaken by the National Hospital Insurance Fund (NHIF) and examines their implications for Kenya’s quest to achieve universal health coverage (UHC). We undertook a review of published and grey literature to identify key reforms that had been implemented by the NHIF since 2010. We examined the reforms undertaken by the NHIF using a health financing evaluation framework that considers the feasibility, equity, efficiency, and sustainability of health financing mechanisms. We found the following NHIF reforms: (1) the introduction of the Civil Servants Scheme (CSS), (2) the introduction of a stepwise quality improvement system, (3) the health insurance subsidy for the poor (HISP), (4) revision of monthly contribution rates and expansion of the benefit package, and (5) the upward revision of provider reimbursement rates. Though there are improvements in several areas, these reforms raise equity, efficiency, feasibility, and sustainability concerns. The article concludes that though NHIF reforms in Kenya are well intentioned and there has been improvement in several areas, design attributes could compromise the extent to which they achieve their intended goal of providing universal financing risk protection to the Kenyan population.

Clients' Experience and Satisfaction of Utilizing Healthcare Services in a Community Based Health Insurance Program in Bangladesh

Background: Community-based health insurance is recognized as a promising tool for health system improvement for low-income people that improves the health status of enrolees and enhances productivity and labor supply. The experience and opinion of the clients who utilized health services through the insurance scheme are important for improving healthcare services, shaping health policies and providing feedback on the quality, availability, and responsiveness of healthcare services. However, studies focusing on clients' satisfaction provided by the health insurance scheme are still limited globally. Objective: To address this knowledge gap, this current study attempted to measure the degree of clients' satisfaction towards healthcare services and insurance scheme, based on their experience of health care which will serve the future reference point to implement potential quality improvement initiatives of community-based health insurance program. Methods: A cross-sectional household survey was conducted within the catchment area of a community-based health insurance pilot program named Labor Association for Social Protection (LASP) during April⁻June 2014 to compare the evaluation of healthcare services provided by LASP scheme. In the descriptive analyses, the characteristics of the study participants were presented regarding frequency and the percentages with 95% confidence interval. Spearman correlation analysis was conducted between the satisfaction score of each indicator and overall satisfaction score; multivariate linear regression analysis was used to identify the factors associated with overall health scheme satisfaction. Results: The overall satisfaction mean score was 4.17 ± 0.04 (95% CI: 4.08⁻4.26) out of 5.00. The most satisfied domains were related to the diagnostic services (4.46 ± 0.98), explanation about the prescribed medicine (4.23 ± 0.81), the surrounding environment of healthcare facility (4.21 ± 0.70) and the behavior of health personnel toward clients (4.18 ± 0.73). Conclusions: Our study observed that the overall satisfaction level towards health services is quite favorable, but satisfaction scores can still be improved. These findings could contribute towards developing and designing the healthcare services packages of community-based health scheme which is in line with the health care financing strategy of Bangladesh as well as the recommendation of the World Health Organization for developing social health insurance as part of path to Universal Health Coverage.

A Comparative Study on the Constitutional Right to Health in the Western Pacific Region Countries

We examined the constitutional provisions on the right to health in the Western Pacific region countries and compared universal health coverage (UHC) achievement. In 9 of the 11 countries, the constitution had provisions related to health rights, of which 7 countries also included details related to the health care system. Additionally, 5 countries also had provisions for the vulnerable. The countries with weak state obligation and no clear provisions on health rights (China and Laos) all recorded low UHC achievement scores. Australia and Malaysia, which do not have constitutional provisions regarding health, have achieved high UHC achievement scores. Constitution is the supreme law of a country and the basis for developing and implementing health and medical laws and policies. In addition, laws or constitutions that regulate the rights to health can help gain access to health care. Follow-up research related to the constitutional right to health will be needed.

Adverse selection and supply-side factors in the enrollment in community-based health insurance in Northwest Ethiopia: A mixed methodology

BACKGROUND

Since 2010, the Ethiopian government introduced different measures to implement community-based health insurance (CBHI) schemes to improve access to health service and reduce the catastrophic effect of health care costs.

OBJECTIVES

The aim of this study was to examine the determinants of enrollment in CBHI in Northwest Ethiopia.

METHODS

In this study, we utilized a mix of quantitative (multivariate logistic regression applied to population survey linked with health facility survey) and qualitative (focus group discussion and in-depth interview) methods to better understand the factors that affect CBHI enrollment.

RESULTS

The study revealed important factors, such as household, informal association, and health facility, as barriers to CBHI enrollment. Age and educational status, self-rated health status, perceived quality of health services, knowledge, and information (awareness) about CBHI were among the characteristics of individual household head, affecting enrollment. Household size and participation in an informal association, such as local credit associations, were also positively associated with CBHI enrollment. Additionally, health facility factors like unavailability of laboratory tests were the main factor that hinders CBHI enrollment.

CONCLUSIONS

This study showed a possibility of adverse selection in CBHI enrollment. Additionally, perceived quality of health services, knowledge, and information (awareness) are positively associated with CBHI enrollment. Therefore, policy interventions to mitigate adverse selection as well as provision of social marketing activities are crucial to increase enrollment in CBHI. Furthermore, policy interventions that enhance the capacity of health facilities and schemes to provide the promised services are necessary.

Barriers and facilitators to implementation, uptake and sustainability of community-based health insurance schemes in low- and middle-income countries: a systematic review

BACKGROUND

Community-based health insurance (CBHI) has evolved as an alternative health financing mechanism to out of pocket payments in low- and middle-income countries (LMICs), particularly in areas where government or employer-based health insurance is minimal. This systematic review aimed to assess the barriers and facilitators to implementation, uptake and sustainability of CHBI schemes in LMICs.

METHODS

We searched six electronic databases and grey literature. We included both quantitative and qualitative studies written in English language and published after year 1992. Two reviewers worked in duplicate and independently to complete study selection, data abstraction, and assessment of methodological features. We synthesized the findings based on thematic analysis and categorized according to the ecological model into individual, interpersonal, community and systems levels.

RESULTS

Of 15,510 citations, 51 met the eligibility criteria. Individual factors included awareness and understanding of the concept of CBHI, trust in scheme and scheme managers, perceived service quality, and demographic characteristics, which influenced enrollment and sustainability. Interpersonal factors such as household dynamics, other family members enrolled in the scheme, and social solidarity influenced enrollment and renewal of membership. Community-level factors such as culture and community involvement in scheme development influenced enrollment and sustainability of scheme. Systems-level factors encompassed governance, financial and delivery arrangement. Government involvement, accountability of scheme management, and strong policymaker-implementer relation facilitated implementation and sustainability of scheme. Packages that covered outpatient and inpatient care and those tailored to community needs contributed to increased enrollment. Amount and timing of premium collection was reported to negatively influence enrollment while factors reported as threats to sustainability included facility bankruptcy, operating on small budgets, rising healthcare costs, small risk pool, irregular contributions, and overutilization of services. At the delivery level, accessibility of facilities, facility environment, and health personnel influenced enrollment, service utilization and dropout rates.

CONCLUSION

There are a multitude of interrelated factors at the individual, interpersonal, community and systems levels that drive the implementation, uptake and sustainability of CBHI schemes. We discuss the implications of the findings at the policy and research level.

TRIAL REGISTRATION

The review protocol is registered in PROSPERO International prospective register of systematic reviews (ID =  CRD42015019812 ).

Extending voluntary health insurance to the informal sector: experiences and expectations of the informal sector in Kenya

Background: Kenya has made a policy decision to use contributory health insurance as one of its key pre-payment health financing mechanisms. The National Hospital Insurance Fund (NHIF) is the main health insurer in Kenya. While the NHIF has hitherto focused its efforts on providing health insurance coverage to individuals in the formal sector, it has recently broadened its focus to include individuals in the informal sector. This paper provides an analysis of the perceptions, and experiences of informal sector individuals in Kenya with regard to enrolment with the NHIF. Methods: We collected data through key informant interviews (39) in two purposefully selected counties. Study participants were drawn from healthcare facilities contracted by the NHIF, and current, former, and prospective informal sector members. We analyzed data using a grounded approach. Results: Participants felt that the NHIF provided inadequate information about the registration and membership processes as well as benefit entitlements. There was variable and inconsistent communication by the NHIF. There was also variance between the official benefit package and the actual benefits received by members. The NHIF registration requirements and processes presented an administrative barrier to obtaining membership. The NHIF premium level and contribution mechanism presents a financial barrier to current and prospective members. Healthcare providers discriminated against NHIF members compared to cash-payers or private insurance holders. Conclusions: The NHIF could improve enrolment and retention of informal sector individuals by; 1) using communication strategies that are effective at reaching the informal sector, 2) improving the affordability of the premium rates, 3) simplifying the enrolment requirements and process, and 4) strengthening accountability mechanisms between itself and healthcare facilities to ensure that enrolled members receive the benefits that they are entitled to, and that client experience at healthcare facilities are satisfactory.

An in-depth investigation of the causes of persistent low membership of community-based health insurance: a case study of the mutual health organisation of Dar Naïm, Mauritania

BACKGROUND

Persistent low membership is observed in many community-based health insurance (CBHI) schemes in Africa. Causes for low membership have been identified and solutions suggested, but this did not result in increased membership. In this case study of the mutual health organisation of Dar Naïm in Mauritania we explore the underlying drivers that may explain why membership continued to stagnate although several plans for change had been designed.

METHODS

We used a systems approach focussed on processes, underlying dynamics and complex interactions that produce the outcomes, to delve into 10 years of data collected between 2003 and 2012. We used qualitative research methods to analyse the data and interpret patterns.

RESULTS

Direct causes of stagnation and possible solutions had been identified in the early years of operations, but most of the possible solutions were not implemented. A combination of reasons explains why consecutive action plans were not put into practice, showing the complexity of implementation and the considerable management capacity required, as well as the challenges of integrating a novel organisational structure into exiting social structures.

CONCLUSIONS

For any CBHI project aiming at high membership, skilled professional management seems essential, with capacity to question and adapt routine procedures and interpret interactions within the wider society. Countries that include community-based health insurance in their strategic plan towards universal coverage will have to pay more attention to management capacity and the minutiae of implementation.

Community-based health insurance and communities' scheme requirement compliance in Thehuldere district, northeast Ethiopia: cross-sectional community-based study

BACKGROUND

Community-based health insurance (CBHI) is becoming a prominent and promising concept in tackling financial health care issues confronting the poor rural communities in developing countries. Ethiopia endorsed and constituted CBHI schemes in 13 pilot "woredas" in 2010/11. This study aimed to assess the compliance of the community to CBHI scheme requirements in Thehuledere district, northeast Ethiopia.

METHODS

A community-based cross-sectional study was conducted among 530 respondents between April and June 2015 in Thehuledere District, South Wollo Zone, northeast Ethiopia. A systematic random sampling technique was deployed to select the study participants. A self-administered, structured, pre-tested questionnaire was used to collect the data. Bivariate and multivariate logistic regression analyses were used to identify factors associated with CBHI compliance.

RESULTS

A total of 511 study participants were included in the study. Approximately 77.9% of the study population complied with CBHI requirements: members' age (AOR = 0.74, 95% CI: 0.62-0.8), premium fee affordability (AOR: 2.66, 95% CI: [1.13-4.42]), members' occupation (AOR = 0.14, 95% CI: 0.04-0.45), members' attitude toward CBHI management (AOR = 2.11 [1.14-3.90]), and CBHI members' knowledge (AOR = 0.24, 95% CI: [0.13-0.42]) were found to be major predictors of community compliance to CBHI requirements.

CONCLUSION

CBHI requirement compliance at the early stage was relatively high. We observed that members' age, premium fee affordability, occupation, attitude, and knowledge were significant predictors. CBHI management's involvement in awareness creation and training on requirements of the CBHI scheme would contribute to better outcomes and success.

Informal workers and access to healthcare: a qualitative study of facilitators and barriers to accessing healthcare for beer promoters in the Lao People's Democratic Republic

Background

Informal workers often face considerable risks and vulnerabilities as a consequence of their work and employment conditions. The purpose of this study was to examine the interplay between the experience of informal work and access to health, using as an example, female beer promoters employed in the informal economy, in the Lao People’s Democratic Republic.

Methods

In-depth interviews were undertaken with 24 female beer promoters working in beer shops, restaurants and entertainment venues in Vientiane City. The recruitment strategy of snowball sampling was used. Interviews explored the beer promoter’s experience of the organization of work, perceived healthcare needs, access to healthcare and insurance, and health seeking practices. The data was analysed thematically and subsequently using Bourdieu’s concepts of habitus, capital and field.

Results

Most of the beer promoters included in the study were 18 years of age, single, had worked as beer promoters for more than one year and just over half were working to support their higher education. The beer promoters demonstrated a holistic view of health, also viewing good health as contributing to being beautiful – an important attribute in their work. Many reported that their work conditions, including the noisy environment, exposure to second-hand tobacco smoke, long hours on their feet and sexual harassment negatively affected their physical and mental health. Only four participants had any form of health insurance with access to healthcare constrained by individual characteristics, health system factors and the conditions of their informal employment.

Conclusions

Drawing on the work of Bourdieu, the study shows how both employment and illness are linked to habitus embodied in everyday practices, access to capital and the position the female beer promoters hold in the social hierarchy in the field of employment.

Evasion of "mandatory" social health insurance for the formal sector: evidence from Lao PDR

BACKGROUND

In the last decade, almost every low- or middle-income country in the world has expressed support for universal health coverage (UHC). While at the beginning of the UHC movement, country strategies focused on increasing access to the formal sector as the first step of UHC, there is now consensus that countries should cover the entire population, with particular attention to covering the poor. However, it is often assumed that mandatory schemes will automatically cover their target populations, and consequently little is known about why firms comply or do not comply with enrolment requirements. Using the experience of Lao PDR, where the enrolment rate in the mandatory social security scheme is low and the capacity for regulation is weak, we conducted this study to better understand the determinants of enrolment of private sector firms in mandatory social security.

METHODS

We used a cross-sectional case-comparison design, surveying 130 firms. We applied a structured questionnaire to explore determinants of enrolment, specifically looking at firm characteristics (e.g., industry category, ownership); sociodemographic characteristics of company heads; firms' risk perceptions; details of employment contracts; employee benefits; and exposure to social security. Closed ended questions were analysed quantitatively, while content analysis was applied to open-ended questions. Logistic regression was used to examine the determinants of enrolment.

RESULTS

Smaller privately owned firms in the services industry were the least likely to enrol in social security, while firms in the trade industry were more likely to enrol than firms in manufacturing, construction, or services. The main reason for not enrolling was that firms offered a better package of benefits to their employees, although further investigation of company benefits showed that this was not the case in practice. Additional reasons for non-compliance were lack of knowledge and poor quality of care at government hospitals.

CONCLUSIONS

The study contributes to the dialogue on how best to increase coverage in the formal sector, which is an important element of achieving UHC. It also provides much needed information about the motivation of private sector firms to comply with mandatory schemes.

Health policy evolution in Lao People's Democratic Republic: context, processes and agency

During the last 20 years Lao People's Democratic Republic has successfully developed and adopted some 30 health policies, strategies, decrees and laws in the field of health. Still, the implementation process remains arduous. This article aims at discussing challenges of health policy development and effective implementation by contextualizing the policy evolution over time and by focusing particularly on the National Drug Policy and the Health Care Law. Special attention is given to the role of research in policymaking. The analysis was guided by the conceptual framework of policy context, process, content and actors, combined with an institutional perspective, and showed that effective implementation of a health policy is highly dependent on both structures and agency of those involved in the policy process. The National Drug Policy was formulated and adopted in a short period of time in a resource-scarce setting, but with dedicated policy entrepreneurs and support of concerned international collaborators. Timely introduction of operational health systems research played a crucial role to support the implementation, as well as the subsequent revision of the policy. The development of the Health Care Law took several years and once adopted, the implementation was delayed by institutional legacies and issues concerning the choice of institutional design and financing, despite strong support of the law among the policymakers. Among many factors, timing of the implementation appeared to be of crucial importance, in combination with strong leadership. These two examples show that more research, that problematizes the complex policy environment in combination with improved communication between researchers and policymakers, is necessary to inform about measures for effective implementation. A way forward can be to strengthen the domestic research capacity and the international research collaboration regionally as well as globally.

Determinants of community health fund membership in Tanzania: a mixed methods analysis

Background

In many developing countries, initiatives are underway to strengthen voluntary community based health insurance as a means of expanding access to affordable care among the informal sector. However, increasing coverage with voluntary health insurance in low income settings can prove challenging. There are limited studies on determinants of enrolling in these schemes using mixed methods. This study aims to shed light on the characteristics of those joining a community health fund, a type of community based health insurance, in Tanzania and the reasons for their membership and subsequent drop out using mixed methods.

Methods

A cross sectional survey of households in four rural districts was conducted in 2008, covering a total of 1,225 (524 members of CHF and 701 non-insured) households and 7,959 individuals. In addition, 12 focus group discussions were carried out with CHF members, non-scheme members and members of health facility governing committees in two rural districts. Logistic regression was used to assess the determinants of CHF membership while thematic analysis was done to analyse qualitative data.

Results

The quantitative analysis revealed that the three middle income quintiles were more likely to enrol in the CHF than the poorest and the richest. CHF member households were more likely to be large, and headed by a male than uninsured households from the same areas. The qualitative data supported the finding that the poor rather than the poorest were more likely to join as were large families and of greater risk of illness, with disabilities or persons with chronic diseases. Households with elderly members or children under-five years were also more likely to enrol. Poor understanding of risk pooling deterred people from joining the scheme and was the main reason for not renewing membership. On the supply side, poor quality of public care services, the limited benefit package and a lack of provider choice were the main factors for low enrolment.

Conclusions

Determinants of CHF membership are diverse and improving the quality of health services and expanding the benefit package should be prioritised to expand voluntary health insurance coverage.