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Boachie MK, Amporfu E. Effect of capitation payment method on health outcomes, healthcare utilization, and referrals in Ghana. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002423. [PMID: 38905260 PMCID: PMC11192346 DOI: 10.1371/journal.pgph.0002423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 05/22/2024] [Indexed: 06/23/2024]
Abstract
Different provider payment systems generate different incentives for patients, providers, and purchasers. Ghana introduced the National Health Insurance Scheme (NHIS) in 2003 and has made reforms to its provider payment methods to create incentives in providers for cost containment. Starting with the fee for service method, it shifted to the Diagnostic Related Group (DRG) method in 2008 to improve cost containment. In 2012 the NHIS began piloting capitation method of payment which has been suspended since 2017 to allow for thorough review. This study uncovers the association between capitation payment system and patient health outcomes, utilization of healthcare services and referral patterns in Ghana based on data collected between November 2012 and January 2013. Using a cross-sectional data on 500 malaria patients who were enrollees of the NHIS from the two payment plans (i.e., capitation and DRG plan), ordered logit, negative binomial and logit regression results showed that patients under capitation were 11.9% less likely to report better health and had 1.583 fewer visits relative to patients under DRG. In relation to referrals, capitated providers were more likely to refer patients than under DRG plans. In the capitated region, better health outcomes were reported by patients of private health facilities. Capitation in Ghana was associated with under-provision of care, hence decreasing any efficiency gain from the reform. Implementors of capitation need to ensure a good monitoring and evaluation system for adequate provision of quantity and quality of care. Some limitations of this study include the use of cross sectional rather that panel data which follows individuals over time and therefore may be more able to provide definite information about cause-and-effect relationships. It also does not account for events before and after the introduction of any payment method. Overall, this study provides valuable information on the implementation policy for reintroducing capitation.
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Affiliation(s)
- Micheal Kofi Boachie
- SAMRC/Wits Centre for Health Economics and Decision Science – PRICELESS SA, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Eugenia Amporfu
- Department of Economics, Kwame Nkrumah University of Science and Technology, PMB, Kumasi, Ashanti Region, Ghana
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Syafrawati S, Machmud R, Aljunid SM, Semiarty R. Incidence of moral hazards among health care providers in the implementation of social health insurance toward universal health coverage: evidence from rural province hospitals in Indonesia. Front Public Health 2023; 11:1147709. [PMID: 37663851 PMCID: PMC10473252 DOI: 10.3389/fpubh.2023.1147709] [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: 01/19/2023] [Accepted: 07/31/2023] [Indexed: 09/05/2023] Open
Abstract
Objective To identify the incidence of moral hazards among health care providers and its determinant factors in the implementation of national health insurance in Indonesia. Methods Data were derived from 360 inpatient medical records from six types C public and private hospitals in an Indonesian rural province. These data were accumulated from inpatient medical records from four major disciplines: medicine, surgery, obstetrics and gynecology, and pediatrics. The dependent variable was provider moral hazards, which included indicators of up-coding, readmission, and unnecessary admission. The independent variables are Physicians' characteristics (age, gender, and specialization), coders' characteristics (age, gender, education level, number of training, and length of service), and patients' characteristics (age, birth weight, length of stay, the discharge status, and the severity of patient's illness). We use logistic regression to investigate the determinants of moral hazard. Results We found that the incidences of possible unnecessary admissions, up-coding, and readmissions were 17.8%, 11.9%, and 2.8%, respectively. Senior physicians, medical specialists, coders with shorter lengths of service, and patients with longer lengths of stay had a significant relationship with the incidence of moral hazard. Conclusion Unnecessary admission is the most common form of a provider's moral hazard. The characteristics of physicians and coders significantly contribute to the incidence of moral hazard. Hospitals should implement reward and punishment systems for doctors and coders in order to control moral hazards among the providers.
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Affiliation(s)
| | | | - Syed Mohamed Aljunid
- Department of Community Medicine, School of Medicine, International Medical University, Kuala Lumpur, Malaysia
- International Center for Casemix and Clinical Coding, Faculty of Medicine, National University of Malaysia, Cheras, Malaysia
| | - Rima Semiarty
- Faculty of Medicine, Andalas University, Padang, Indonesia
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3
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Osei Afriyie D, Kwesiga B, Achungura G, Tediosi F, Fink G. Effects of Health Insurance on Quality of Care in Low-Income Countries: A Systematic Review. Public Health Rev 2023; 44:1605749. [PMID: 37635905 PMCID: PMC10447888 DOI: 10.3389/phrs.2023.1605749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 07/25/2023] [Indexed: 08/29/2023] Open
Abstract
Objectives: To evaluate the effectiveness of health insurance on quality of care in low-income countries (LICs). Methods: We conducted a systematic review following PRISMA guidelines. We searched seven databases for studies published between 2010 and August 2022. We included studies that evaluated the effects of health insurance on quality of care in LICs using randomized experiments or quasi-experimental study designs. Study outcomes were classified using the Donabedian framework. Results: We included 15 studies out of the 6,129 identified. Available evidence seems to suggest that health insurance has limited effects on structural quality, and its effects on the process of care remain mixed. At the population level, health insurance is linked to improved anthropometric measures for children and biomarkers such as blood pressure and hemoglobin levels. Conclusion: Based on the currently available evidence, it appears that health insurance in LICs has limited effects on the quality of care. Further studies are required to delve into the mechanisms that underlie the impact of health insurance on the quality of care and identify the most effective strategies to ensure quality within insurance programs. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=219984, identifier PROSPERO CRD42020219984.
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Affiliation(s)
- Doris Osei Afriyie
- Department of Epidemiology/Public Health, Swiss Tropical and Public Health Institute (Swiss TPH), Basel, Switzerland
- University of Basel, Basel, Switzerland
| | | | | | - Fabrizio Tediosi
- Department of Epidemiology/Public Health, Swiss Tropical and Public Health Institute (Swiss TPH), Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Günther Fink
- Department of Epidemiology/Public Health, Swiss Tropical and Public Health Institute (Swiss TPH), Basel, Switzerland
- University of Basel, Basel, Switzerland
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Qin Y, Liu J, Li J, Wang R, Guo P, Liu H, Kang Z, Wu Q. How do moral hazard behaviors lead to the waste of medical insurance funds? An empirical study from China. Front Public Health 2022; 10:988492. [PMID: 36388392 PMCID: PMC9643743 DOI: 10.3389/fpubh.2022.988492] [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: 07/07/2022] [Accepted: 09/28/2022] [Indexed: 01/26/2023] Open
Abstract
Objective The huge loss of health insurance funds has been a topic of concern around the world. This study aims to explore the network of moral hazard activities and the attribution mechanisms that lead to the loss of medical insurance funds. Methods Data were derived from 314 typical cases of medical insurance moral hazards reported on Chinese government official websites. Social network analysis (SNA) was utilized to visualize the network structure of the moral hazard activities, and crisp-set qualitative comparative analysis (cs/QCA) was conducted to identify conditional configurations leading to funding loss in cases. Results In the moral hazard activity network of medical insurance funds, more than 50% of immoral behaviors mainly occur in medical service institutions. Designated private hospitals (degree centrality = 33, closeness centrality = 0.851) and primary medical institutions (degree centrality = 30, closeness centrality = 0.857) are the main offenders that lead to the core problem of medical insurance fraud (degree centrality = 50, eigenvector centrality = 1). Designated public hospitals (degree centrality = 27, closeness centrality = 0.865) are main contributor to another important problem that illegal medical charges (degree centrality = 26, closeness centrality = 0.593). Non-medical insurance items swap medical insurance items (degree centrality = 28), forged medical records (degree centrality = 25), false hospitalization (degree centrality = 24), and overtreatment (degree centrality = 23) are important immoral nodes. According to the results of cs/QCA, low-economic pressure, low informatization, insufficient policy intervention, and organization such as public medical institutions, were the high-risk conditional configuration of opportunism; and high-economic pressure, insufficient policy intervention, and organizations, such as public medical institutions and high violation rates, were the high-risk conditional configuration of risky adventurism (solution coverage = 31.03%, solution consistency = 90%). Conclusion There are various types of moral hazard activities in medical insurance, which constitute a complex network of behaviors. Most moral hazard activities happen in medical institutions. Opportunism lack of regulatory technology and risky adventurism with economic pressure are two types causing high loss of funds, and the cases of high loss mainly occur before the government implemented intervention. The government should strengthen the regulatory intervention and improve the level of informatization for monitoring the moral hazard of medical insurance funds, especially in areas with low economic development and high incident rates, and focus on monitoring the behaviors of major medical services providers.
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Affiliation(s)
- Yinghua Qin
- Department of Social Medicine, School of Public Health, Health Management College, Harbin Medical University, Harbin, China,Department of Health Economy and Social Security, College of Humanities and Management, Guilin Medical University, Guilin, China
| | - Jingjing Liu
- Department of Social Medicine, School of Public Health, Health Management College, Harbin Medical University, Harbin, China
| | - Jiacheng Li
- Department of Social Medicine, School of Public Health, Health Management College, Harbin Medical University, Harbin, China
| | - Rizhen Wang
- Department of Social Medicine, School of Public Health, Health Management College, Harbin Medical University, Harbin, China
| | - Pengfei Guo
- Department of Social Medicine, School of Public Health, Health Management College, Harbin Medical University, Harbin, China
| | - Huan Liu
- Department of Social Medicine, School of Public Health, Health Management College, Harbin Medical University, Harbin, China
| | - Zheng Kang
- Department of Social Medicine, School of Public Health, Health Management College, Harbin Medical University, Harbin, China
| | - Qunhong Wu
- Department of Social Medicine, School of Public Health, Health Management College, Harbin Medical University, Harbin, China,*Correspondence: Qunhong Wu
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Hussien M, Azage M, Bayou NB. Financial viability of a community-based health insurance scheme in two districts of northeast Ethiopia: a mixed methods study. BMC Health Serv Res 2022; 22:1072. [PMID: 35996128 PMCID: PMC9396896 DOI: 10.1186/s12913-022-08439-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 08/10/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Community-based health insurance initiatives in low- and middle-income countries encountered a number of sustainability challenges due to their voluntary nature, small risk pools, and low revenue. In Ethiopia, the schemes' financial viability has not been well investigated so far. This study examined the scheme's financial viability and explored underlying challenges from the perspectives of various key stakeholders. METHODS This study employed a mixed methods case study in two purposively selected districts of northeast Ethiopia. By reviewing financial reports of health insurance schemes, quantitative data were collected over a seven years period from 2014 to 2020 to examine trends in financial status. Trends for each financial indicator were analyzed descriptively for the period under review. Interviews were conducted face-to-face with nine community members and 19 key informants. We used the maximum variation technique to select the study participants. Interviews were audio recorded, transcribed verbatim, and translated into English. Thematic analysis was applied with both inductive and deductive coding methods. RESULTS Both schemes experienced excess claims costs and negative net income in almost all the study period. Even after government subsidies, the scheme's net income remained negative for some reporting periods. The challenges contributing to the observed level of financial performance have been summarized under five main themes, which include adverse selection, moral hazard behaviors, stockout of medicines, delays in claims settlement for service providers, and low insurance premiums. CONCLUSIONS The health insurance scheme in both districts spent more than it received for claims settlement in almost all the period under the study, and experienced heavy losses in these periods, implying that it is not financially viable for the period in question. The scheme is also unable to fulfill its purpose of protecting members against out-of-pocket expenses at the point of health care. Interventions should target on the highlighted challenges to restore financial balance and enhance the scheme's viability.
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Affiliation(s)
- Mohammed Hussien
- Department of Health Systems Management and Health Economics, School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia.
| | - Muluken Azage
- Department of Environmental Health, School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Negalign Berhanu Bayou
- Department of Health Policy and Management, Faculty of Public Health, Institute of Health, Jimma University, Jimma, Ethiopia
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Vahidi J, Takian A, Amini-Rarani M, Moeeni M. "To enroll or not to enroll": a qualitative study on preferences for dental insurance in Iran. BMC Health Serv Res 2022; 22:901. [PMID: 35820919 PMCID: PMC9277837 DOI: 10.1186/s12913-022-08285-8] [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: 02/16/2022] [Accepted: 07/04/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Oral public health services are included in primary healthcare. Although oral diseases are preventable, improving oral health has become a concern in many countries. Evidence shows that functioning insurance coverage can significantly increase the use of dental health services, improve quality of services, and reduce financial barriers to utilization. Little evidence exists on households' preferences for dental insurance in Iran. This study seeks to identify the households' preferences for dental insurance in Tehran-Iran. METHOD This is a qualitative study. We interviewed 84 participants who visited selected public and private dental clinics in Tehran-Iran, from October 2018 until January 2019. All interviews were recorded and transcribed verbatim. We used a mixed inductive/deductive approach for thematic analysis of the interviews. RESULTS We identified two main themes and 12 sub-themes: pecuniary attributes (insurance premium, coinsurance, insurance coverage granted, discounting option, reimbursement of expenses), and non-pecuniary attributes (notification status, ethical issues, benefits package, contract providers with health insurance, quality of service centers, administrative process, and dental insurance scheme). CONCLUSION Our participants considered both pecuniary and non-pecuniary attributes for choosing a dental insurance package. Our findings could help, we envisage, policymakers understand Iranian households' preferences for a dental insurance scheme that they afford to buy.
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Affiliation(s)
- Jamileh Vahidi
- School of Management & Medical Information Sciences, Isfahan University of Medical Sciences, Isfahan, Iran.,Baharloo Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Amirhossein Takian
- Department of Health Management, Policy and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.,Department of Global Health & Public Policy, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.,Health Equity Research Center (HERC), Tehran University of Medical Sciences, Tehran, Iran
| | - Mostafa Amini-Rarani
- Health Management and Economics Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Maryam Moeeni
- Social Determinants of Health Research Center, Isfahan University of Medical Sciences, Isfahan, Iran.
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Sinjela KM, Simangolwa WMW, Hehman L, Kamanga M, Mwambazi WK, Sundewall J. Exploring for-profit healthcare providers' perceptions of inclusion in the Zambia National Health Insurance Scheme: A qualitative content analysis. PLoS One 2022; 17:e0268940. [PMID: 35622836 PMCID: PMC9140276 DOI: 10.1371/journal.pone.0268940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 05/08/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND In 2019, Zambia introduced the national health insurance (NHI) as a healthcare financing strategy to increase universal access to health care services. The private health sector can complement public sector providers as service providers under the NHI. As such, the NHI Management Authority seeks to accredit for-profit private healthcare facilities in the NHI. Ascertaining factors that influence private-for-profit health providers to participate in the NHI is essential, but the evidence is lacking. In this study, we aimed to explore and characterize perceptions and experiences of for-profit private hospitals, dental clinics, eye clinics, diagnostic centres, and pharmacies regarding their inclusion in the NHI. METHODS We conducted in-depth interviews with owners or management officers of purposively sampled private health care providers in Lusaka, Zambia (n = 22) between May and June 2020. Qualitative content analysis was used to analyse data. RESULTS The findings highlight low awareness of the NHI among providers and a need to understand the NHI. Providers revealed their positions and views on the accreditation process and payment arrangements and stated that their participation would complement the NHI. They also cited conditions to participate in the NHI, highlighted opportunities and challenges of engaging in the NHI, and expressed a need for sustainable ways of governing the scheme. CONCLUSION The assessment of health providers' inclusion in the NHI scheme is multifaceted. The results of this study surfaced factors such as raising awareness on the NHI among providers and how their concerns on aspects such as payments can be considered as inputs to enlighten consensual agreements between the NHI authority and health providers in leveraging the private health sector. Private providers' concerns must be further understood and considered as the NHI strives to include this group as health care providers in the scheme.
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Affiliation(s)
| | | | | | - Mpuma Kamanga
- National Health Insurance Management Authority (NHIMA), Lusaka, Zambia
| | | | - Jesper Sundewall
- Division of Social Medicine and Global Health, Lund University, Malmö, Sweden
- University of KwaZulu-Natal, Durban, South Africa
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Siregar AYM, Habibie I, Sihotang RB, Allo RP, Kusumawardana R, Sunjaya DK, Remi SS. Costs of providing hospital-based psychotic disorder treatment in Indonesia. J Ment Health 2022; 32:443-451. [PMID: 34983298 DOI: 10.1080/09638237.2021.2022609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Mental illness prevalence is increasing globally and has caused a significant economic burden. However, information from developing countries regarding this issue is still limited. AIMS To estimate the cost of treating psychotic disorders in outpatient and inpatient wards in a provincial referral mental health hospital in West Java province, Indonesia. METHODS We collected data on the direct cost of treating psychotic disorders within 2014-2015. Billing data from 1565 patients were used to calculate inpatient cost, while micro-costing was used to estimate outpatient cost. One hundred and five patients visiting the hospital were interviewed to estimate indirect costs, for example, patients' and caretakers' travel, meal, and opportunity costs. RESULTS For inpatient care, the average direct and indirect cost/patient/episode are USD328.84 and USD213.22, respectively. For outpatient care, the direct and indirect costs are USD148,484.83/year (USD25.38/visit) and USD88,503.70/year (USD15.13/visit), respectively. The total societal cost of treating patients in the hospital is USD1,085,310.21/year (39% is an indirect cost, dominated by productivity loss). CONCLUSION The societal cost of treating psychotic disorders is large and potentially catastrophic to the patients. Early treatment for mental illness may avoid the high costs and lead to better productivity. Potential access barriers such as financial factors and stigma should be addressed.
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Affiliation(s)
- Adiatma Yudistira Manogar Siregar
- Center for Economics and Development Studies, Department of Economics, Faculty of Economics and Business, Universitas Padjadjaran, Bandung, Indonesia.,Center for Health Technology Assessment (CHTA), Universitas Padjadjaran, Bandung, Indonesia.,West Java Development Institute (INJABAR), Universitas Padjadjaran, Bandung, Indonesia
| | - Ibnu Habibie
- Center for Economics and Development Studies, Department of Economics, Faculty of Economics and Business, Universitas Padjadjaran, Bandung, Indonesia
| | - Rykaard Baressi Sihotang
- Center for Economics and Development Studies, Department of Economics, Faculty of Economics and Business, Universitas Padjadjaran, Bandung, Indonesia
| | - Rika Permatasari Allo
- Center for Economics and Development Studies, Department of Economics, Faculty of Economics and Business, Universitas Padjadjaran, Bandung, Indonesia
| | - Rangga Kusumawardana
- Center for Economics and Development Studies, Department of Economics, Faculty of Economics and Business, Universitas Padjadjaran, Bandung, Indonesia
| | - Deni Kurniadi Sunjaya
- Department of Public Health, Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia
| | - Sutyastie Soemitro Remi
- Center for Economics and Development Studies, Department of Economics, Faculty of Economics and Business, Universitas Padjadjaran, Bandung, Indonesia
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Wang Y, Dong J, Wang X, Liu Q, Li X. Grounded theory research on the factors that lead to doctor moral hazard. SAUDE E SOCIEDADE 2021. [DOI: 10.1590/s0104-12902021190995] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Abstract Moral hazard clearly exists among doctors, and it has a dramatic impact on doctor-patient relationships, medical costs and medical risks. This study explored the factors that lead to doctor moral hazard, as well as the interrelationships and internal regularity of these factors. This study takes doctor moral hazard as the research content and the inducing factors as the core theme, conducting grounded theory research on the causes of doctor moral hazard. Scientific understanding of doctor behavior would facilitate the prevention and control of doctor moral hazard behavior. This study used the principles and methodology of Glaser and Strauss’s grounded theory. Theoretical and snowball samplings were used to identify 24 subjects. Semi-structured in-depth interviews were conducted with each subject. Themes were identified through substantial (open) coding and theoretical coding. The factors that lead to doctor moral hazard were categorized into five dimensions, i.e. motivation, opportunity, self-rationalization, exposure and punishment. These five factors influence each other, forming the inducing mechanism of doctor moral hazard. This will provide useful theoretical support and method guidance for the follow-up prevention and control of moral hazard for doctors.
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Affiliation(s)
- Yaohui Wang
- China University of Mining & Technology, China; Zhejiang University, China
| | | | - Xifeng Wang
- Taizhou Hospital of Zhejiang Province, China
| | | | - Xinchun Li
- China University of Mining & Technology, China
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Ranabhat CL, Subedi R, Karn S. Status and determinants of enrollment and dropout of health insurance in Nepal: an explorative study. Cost Eff Resour Alloc 2020. [PMID: 33013204 DOI: 10.1186/s12962‐020‐00227‐7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background Compared to other countries in the South Asia Nepal has seen a slow progress in the coverage of health insurance. Despite of a long history of the introduction of health insurance (HI) and a high priority of the government of Nepal it has not been able to push rapidly its social health insurance to its majority of the population. There are many challenges while to achieve universal health insurance in Nepal ranging from existing policy paralysis to program operation. This study aims to identify the enrollment and dropout rates of health insurance and its determinants in selected districts of Nepal. Methods The study was conducted while using a mixed method including both quantitative and qualitative approaches. Numerical data related to enrollment and dropout rates were taken from Health Insurance Board (HIB) of Nepal. For the qualitative data, three districts, Bardiya, Chitwan, and Gorkha of Nepal were selected purposively. Enrollment assistants (EA) of social health insurance program were taken as the participants of study. Focus group discussions (FGD) were arranged with the selected EAs using specific guidelines along with unstructured questions. The results from numerical data and focus group discussions are synthesized and presented accordingly. Results The findings of the study suggested variation in enrollment and dropout of health insurance in the districts. Enrollment coverage was 13,545 (1%), 249,104 (5%), 1,159,477 (9%) and 1,676,505 (11%) from 2016 to 2019 among total population and dropout rates were 9121(67%), 110,885 (44%) and 444,967 (38%) among total enrollment from 2016 to 2018 respectively. Of total coverage, more than one-third proportion was subsidy enrollment-free enrollment for vulnerable groups. The population characteristics of unwilling and dropout in social health insurance came from relatively well-off families, government employees, businessman, migrants' people, some local political leaders as well as the poor class families. The major determinants of poor enrollment and dropout were mainly due to unavailability of enough drugs, unfriendly behavior of health workers, and indifferent behavior of the care personnel to the insured patients in health care facilities and prefer to take health service in private clinic for their own benefits. The long maturation time to activate health service, limited health package and lack of copayment in different types of health care were the factors related to inefficient program and policy implementation. Conclusion There is a high proportion of dropout and subsidy enrollment, the key challenge for sustainability of health insurance program in Nepal. Revisiting of existing HI policy on health care packages, more choices on copayment, capacity building of enrollment assistants and better coordination between health insurance board and health care facilities can increase the enrollment and minimize the dropout.
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Affiliation(s)
- Chhabi Lal Ranabhat
- Policy Research Institute, Sanogaucharan, Kathmandu, Nepal.,Manmohan Memorial Institute of Health Sciences, Solteemod, Kathmandu, Nepal.,Global Center for Research and Development, Kathmandu, Nepal
| | - Radha Subedi
- Policy Research Institute, Sanogaucharan, Kathmandu, Nepal
| | - Sujeet Karn
- Policy Research Institute, Sanogaucharan, Kathmandu, Nepal.,Global Center for Research and Development, Kathmandu, Nepal
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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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12
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Ranabhat CL, Subedi R, Karn S. Status and determinants of enrollment and dropout of health insurance in Nepal: an explorative study. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2020; 18:40. [PMID: 33013204 PMCID: PMC7528465 DOI: 10.1186/s12962-020-00227-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 08/21/2020] [Indexed: 11/10/2022] Open
Abstract
Background Compared to other countries in the South Asia Nepal has seen a slow progress in the coverage of health insurance. Despite of a long history of the introduction of health insurance (HI) and a high priority of the government of Nepal it has not been able to push rapidly its social health insurance to its majority of the population. There are many challenges while to achieve universal health insurance in Nepal ranging from existing policy paralysis to program operation. This study aims to identify the enrollment and dropout rates of health insurance and its determinants in selected districts of Nepal. Methods The study was conducted while using a mixed method including both quantitative and qualitative approaches. Numerical data related to enrollment and dropout rates were taken from Health Insurance Board (HIB) of Nepal. For the qualitative data, three districts, Bardiya, Chitwan, and Gorkha of Nepal were selected purposively. Enrollment assistants (EA) of social health insurance program were taken as the participants of study. Focus group discussions (FGD) were arranged with the selected EAs using specific guidelines along with unstructured questions. The results from numerical data and focus group discussions are synthesized and presented accordingly. Results The findings of the study suggested variation in enrollment and dropout of health insurance in the districts. Enrollment coverage was 13,545 (1%), 249,104 (5%), 1,159,477 (9%) and 1,676,505 (11%) from 2016 to 2019 among total population and dropout rates were 9121(67%), 110,885 (44%) and 444,967 (38%) among total enrollment from 2016 to 2018 respectively. Of total coverage, more than one-third proportion was subsidy enrollment-free enrollment for vulnerable groups. The population characteristics of unwilling and dropout in social health insurance came from relatively well-off families, government employees, businessman, migrants' people, some local political leaders as well as the poor class families. The major determinants of poor enrollment and dropout were mainly due to unavailability of enough drugs, unfriendly behavior of health workers, and indifferent behavior of the care personnel to the insured patients in health care facilities and prefer to take health service in private clinic for their own benefits. The long maturation time to activate health service, limited health package and lack of copayment in different types of health care were the factors related to inefficient program and policy implementation. Conclusion There is a high proportion of dropout and subsidy enrollment, the key challenge for sustainability of health insurance program in Nepal. Revisiting of existing HI policy on health care packages, more choices on copayment, capacity building of enrollment assistants and better coordination between health insurance board and health care facilities can increase the enrollment and minimize the dropout.
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Affiliation(s)
- Chhabi Lal Ranabhat
- Policy Research Institute, Sanogaucharan, Kathmandu, Nepal.,Manmohan Memorial Institute of Health Sciences, Solteemod, Kathmandu, Nepal.,Global Center for Research and Development, Kathmandu, Nepal
| | - Radha Subedi
- Policy Research Institute, Sanogaucharan, Kathmandu, Nepal
| | - Sujeet Karn
- Policy Research Institute, Sanogaucharan, Kathmandu, Nepal.,Global Center for Research and Development, Kathmandu, Nepal
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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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Sackey FG, Amponsah PN. Willingness to accept capitation payment system under the Ghana National Health Insurance Policy: do income levels matter? HEALTH ECONOMICS REVIEW 2017; 7:38. [PMID: 29101723 PMCID: PMC5670093 DOI: 10.1186/s13561-017-0175-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 10/20/2017] [Indexed: 06/07/2023]
Abstract
This research was set to examine the factors influencing the willingness and the likelihood of Ghanaians to accept the capitation payment system under the National Health Insurance Scheme. Data was collected through the random sampling method in all the ten regions of Ghana. A probit estimation with marginal effects was adopted to examine the factors influencing the willingness and the likelihood while the generalized Blinder-Oaxaca decomposition was used to examine the extent to which individual characteristics influence the acceptance gap between high income and low-income earners. Our results indicated that, at the individual level, high income, being employed, awareness and smaller household size were the significant factors influencing the willingness and the likelihood to accept capitation. We also observed that the acceptance gap between high income and low-income earners was largely influenced by unexplained factors other than individual characteristics of high income earners. Since the willingness and the likelihood to accept capitation are mixed across regions and largely dependent on high incomes, the intention to roll out and implement the capitation system should be as a complementary payment system to the already existing one, being the diagnosis related grouping. We recommend that the current payment system, the diagnosis-related-grouping be maintained and complemented with capitation while measures to reduce, if not eliminate, the abuse associated with it be put in place.
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Fusheini A, Marnoch G, Gray AM. Stakeholders Perspectives on the Success Drivers in Ghana's National Health Insurance Scheme - Identifying Policy Translation Issues. Int J Health Policy Manag 2017; 6:273-283. [PMID: 28812815 PMCID: PMC5417149 DOI: 10.15171/ijhpm.2016.133] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 09/25/2016] [Indexed: 11/29/2022] Open
Abstract
Background: Ghana’s National Health Insurance Scheme (NHIS), established by an Act of Parliament (Act 650), in 2003 and since replaced by Act 852 of 2012 remains, in African terms, unprecedented in terms of growth and coverage. As a result, the scheme has received praise for its associated legal reforms, clinical audit mechanisms and for serving as a hub for knowledge sharing and learning within the context of South-South cooperation. The scheme continues to shape national health insurance thinking in Africa. While the success, especially in coverage and financial access has been highlighted by many authors, insufficient attention has been paid to critical and context-specific factors. This paper seeks to fill that gap.
Methods: Based on an empirical qualitative case study of stakeholders’ views on challenges and success factors in four mutual schemes (district offices) located in two regions of Ghana, the study uses the concept of policy translation to assess whether the Ghana scheme could provide useful lessons to other African and developing countries in their quest to implement social/NHISs.
Results: In the study, interviewees referred to both ‘hard and soft’ elements as driving the "success" of the Ghana scheme. The main ‘hard elements’ include bureaucratic and legal enforcement capacities; IT; financing; governance, administration and management; regulating membership of the scheme; and service provision and coverage capabilities. The ‘soft’ elements identified relate to: the background/context of the health insurance scheme; innovative ways of funding the NHIS, the hybrid nature of the Ghana scheme; political will, commitment by government, stakeholders and public cooperation; social structure of Ghana (solidarity); and ownership and participation.
Conclusion: Other developing countries can expect to translate rather than re-assemble a national health insurance programme in an incomplete and highly modified form over a period of years, amounting to a process best conceived as germination as opposed to emulation. The Ghana experience illustrates that in adopting health financing systems that function well, countries need to customise systems (policy customisation) to suit their socio-economic, political and administrative settings. Home-grown health financing systems that resonate with social values will also need to be found in the process of translation
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Affiliation(s)
- Adam Fusheini
- Centre for Health Policy/MRC Health Policy Research Group, and School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Department of Health Policy, Planning and Management, School of Public Health, University of Health and Allied Sciences, Ho, Ghana
| | - Gordon Marnoch
- School of Criminology, Politics and Social Policy, Faculty of Social Sciences, University of Ulster, Jordanstown, UK
| | - Ann Marie Gray
- School of Criminology, Politics and Social Policy, Faculty of Social Sciences, University of Ulster, Jordanstown, UK
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Andoh-Adjei FX, Cornelissen D, Asante FA, Spaan E, van der Velden K. Does capitation payment under national health insurance affect subscribers' trust in their primary care provider? a cross-sectional survey of insurance subscribers in Ghana. BMC Health Serv Res 2016; 16:437. [PMID: 27557551 PMCID: PMC4997684 DOI: 10.1186/s12913-016-1622-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 08/02/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ghana introduced capitation payment for primary care in 2012 with the view to containing escalating claims expenditure. This shift in provider payment method raised issues about its potential impact on patient-provider trust relationship and insured-patients' trust in the Ghana National Health Insurance Scheme. This paper presents findings of a study that explored insured-patients' perception about, and attitude towards capitation payment in Ghana; and determined whether capitation payment affect insured-patients' trust in their preferred primary care provider and the National Health Insurance Scheme in general. METHODS We adopted a survey design for the study. We administered closed-ended questionnaires to collect data from insurance card-bearing members aged 18 years and above. We performed both descriptive statistics to determine proportions of observations relating to the variables of interest and chi-square test statistics to determine differences within gender and setting. RESULTS Sixty-nine per cent (69 %) out of 344 of respondents selected hospital level of care as their primary care provider. The two most important motivations for the choice of a provider were proximity in terms of geographical access (40 %) and perceived quality of care (38 %). Eighty-eight per cent (88 %) rated their trust in their provider as (very) high. Eighty-two per cent (82 %) actively selected their providers. Eighty-eight per cent (88 %) had no intention to switch provider. A majority (91 %) would renew their membership when it expires. Female respondents (91 %; n = 281) were more likely to renew their membership than males (87 %; n = 63). Notwithstanding capitation payment experience, 81 % of respondents would recommend to their peers to enrol with the NHIS with rural dwellers (87 %; n = 156) being more likely to do so than urban dwellers (76 %; n = 188). Almost all respondents (92 %) rated the NHIS as (very) good. CONCLUSION Health Insurance subscribers in Ghana have high trust in their primary care provider giving them quality care under capitation payment despite their negative attitude towards capitation payment. They are guided by proximity and quality of care considerations in their choice of provider. The NHIA would, however, have to address itself to the negative perceptions about the capitation payment policy.
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Affiliation(s)
| | - Dennis Cornelissen
- GROW-School of Oncology and Developmental Biology, Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Centre-The Netherlands, Maastricht, Netherlands
| | - Felix Ankomah Asante
- Institute of Statistical, Social and Economic Research (ISSER) University of Ghana, Legon-Accra, Ghana
| | - Ernst Spaan
- Radboud Institute for Health Science, Department for Health Evidence, Radboud University Medical Center-Netherlands, Nijmegen, Netherlands
| | - Koos van der Velden
- Radboud Institute for Health Science, Department for Primary and Community Health, Radboud University Medical Centre-Netherlands, Nijmegen, Netherlands
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