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Osei Afriyie D, Loo PS, Kuwawenaruwa A, Kassimu T, Fink G, Tediosi F, Mtenga S. Understanding the role of the Tanzania national health insurance fund in improving service coverage and quality of care. Soc Sci Med 2024; 347:116714. [PMID: 38479141 DOI: 10.1016/j.socscimed.2024.116714] [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: 08/04/2023] [Revised: 01/19/2024] [Accepted: 02/20/2024] [Indexed: 04/20/2024]
Abstract
Health insurance is one of the main financing mechanisms currently being used in low and middle-income countries to improve access to quality services. Tanzania has been running its National Health Insurance Fund (NHIF) since 2001 and has recently undergone significant reforms. However, there is limited attention to the causal mechanisms through which NHIF improves service coverage and quality of care. This paper aims to use a system dynamics (qualitative) approach to understand NHIF causal pathways and feedback loops for improving service coverage and quality of care at the primary healthcare level in Tanzania. We used qualitative interviews with 32 stakeholders from national, regional, district, and health facility levels conducted between May to July 2021. Based on the main findings and themes generated from the interviews, causal mechanisms, and feedback loops were created. The majority of feedback loops in the CLDs were reinforcing cycles for improving service coverage among beneficiaries and the quality of care by providers, with different external factors affecting these two actions. Our main feedback loop shows that the NHIF plays a crucial role in providing additional financial resources to facilities to purchase essential medical commodities to deliver care. However, this cycle is often interrupted by reimbursement delays. Additionally, beneficiaries' perception that lower-level facilities have poorer quality of care has reinforced care seeking at higher-levels. This has decreased lower level facilities' ability to benefit from the insurance and improve their capacity to deliver quality care. Another key finding was that the NHIF funding has resulted in better services for insured populations compared to the uninsured. To increase quality of care, the NHIF may benefit from improving its reimbursement administrative processes, increasing the capacity of lower levels of care to benefit from the insurance and appropriately incentivizing providers for continuity of care.
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Affiliation(s)
- Doris Osei Afriyie
- Swiss Tropical and Public Health Institute, Department of Epidemiology and Public Health, Switzerland; University of Basel, Switzerland.
| | - Pei Shan Loo
- Swiss Tropical and Public Health Institute, Department of Epidemiology and Public Health, Switzerland; University of Basel, Switzerland.
| | - August Kuwawenaruwa
- Health Systems, Impact Evaluation and Policy Group, Ifakara Health Institute, Dar Es Salaam, United Republic of Tanzania.
| | - Tani Kassimu
- Swiss Tropical and Public Health Institute, Department of Epidemiology and Public Health, Switzerland; University of Basel, Switzerland; Health Systems, Impact Evaluation and Policy Group, Ifakara Health Institute, Dar Es Salaam, United Republic of Tanzania.
| | - Günther Fink
- Swiss Tropical and Public Health Institute, Department of Epidemiology and Public Health, Switzerland; University of Basel, Switzerland.
| | - Fabrizio Tediosi
- Swiss Tropical and Public Health Institute, Department of Epidemiology and Public Health, Switzerland; University of Basel, Switzerland.
| | - Sally Mtenga
- Health Systems, Impact Evaluation and Policy Group, Ifakara Health Institute, Dar Es Salaam, United Republic of Tanzania; Institute of Health and Wellbeing, University of Glasgow, Ireland, UK.
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Nabanoba C, Zakumumpa H. Experiences of membership in munno mubulwadde (your friend indeed) - a novel community-based health insurance scheme in Luwero district in rural central Uganda. BMC Health Serv Res 2024; 24:89. [PMID: 38233909 PMCID: PMC10792776 DOI: 10.1186/s12913-023-10517-4] [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: 04/03/2023] [Accepted: 12/21/2023] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND Community-Based Health Insurance (CBHI) schemes are recognized as an important health financing pathway to achieving universal health coverage (UHC). Although previous studies have documented CBHIs in low-income countries, the majority of these have been provider-based. Non-provider based schemes have received comparatively less empirical attention. We sought to describe a novel non-provider based CBHI munno mubulwadde (your friend indeed) comprising informal sector members in rural central Uganda to understand the structure of the scheme, the experiences of scheme members in terms of the perceived benefits and barriers to retention in the scheme. METHODS We report qualitative findings from a larger mixed-methods study. We conducted in-depth interviews with insured members (n = 18) and scheme administrators (n = 12). Four focus groups were conducted with insured members (38 participants). Data were inductively analyzed by thematic approach. RESULTS Munno mubulwadde is a union of ten CBHI schemes coordinated by one administrative structure. Members were predominantly low-income rural informal sector households who pay annual premiums ranging from $17 and $50 annually and received medical care at 13 scheme-contracted private health facilities in Luwero District in Central Uganda. Insured members reported that scheme membership protected them from catastrophic health expenditure during episodes of sickness among household members, and especially so among households with children under-five who were reported to fall sick frequently, the scheme enabled members to receive perceived better quality health care at private providers in the study district relative to the nearest public facilities. The identified barriers to retention in the scheme include inconvenient dates for premium payment that are misaligned with harvest periods for cash crops (e.g. maize corn) on which members depended for their agrarian livelihoods, long distances to insurance-contracted private providers, falling prices of cash crops which diminished real incomes and affordability of insurance premiums in successive years after initial enrolment. CONCLUSION Munno mubulwadde was perceived by as a valuable financial cushion during episodes of illness by rural informal sector households. Policy interventions for promoting price stability of cash crops in central Uganda could enhance retention of members in this non-provider CBHI which is worthy of further research as an additional funding pathway for realizing UHC in Uganda and other low-income settings.
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Affiliation(s)
- Christine Nabanoba
- Department of Social Work and Social Administration, Makerere University, Kampala, Uganda
| | - Henry Zakumumpa
- School of Public Health, Makerere University, Kampala, Uganda.
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Ngo Bebe D, Kwilu FN, Mavila A, Mafuta EM, Mangalu JM, Jessani NS, Criel B. Making health insurance responsive to citizens: the management of members' complaints by mutual health organisations in Kinshasa, Democratic Republic of Congo. BMJ Glob Health 2023; 7:e011438. [PMID: 37666577 PMCID: PMC10514665 DOI: 10.1136/bmjgh-2022-011438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 08/06/2023] [Indexed: 09/06/2023] Open
Abstract
INTRODUCTION In moving towards universal health coverage, a number of low-income and middle-income countries have adopted community-based health insurance (CBHI) as a means to reduce both the inequity in healthcare access and the burden of catastrophic health expenditures linked to user fees. However, organisations managing CBHIs face many challenges, including a poor relationship with their members. In the Democratic Republic of the Congo, CBHI schemes are managed by mutual health organisations (MHOs) and are in the process of enhancing their accountability and responsiveness to members' needs and expectations. This study assessed how MHOs have managed member complaints and their performance in grievance redressal. METHODS Using a sequential mixed-methods approach, we drew insights from four types of sources: review of approximately 50 relevant documents, 25 in-depth interviews (IDIs) with CBHI managers, 9 IDIs with health facility managers, 1063 surveys of MHO members and 15 focus group discussions (FGDs) comprising an additional 153 MHO members. MHO members in this study belonged to three different MHOs (Lisanga, La Borne and Mutuelle de santé des Enseignants de l'Enseignement Primaire, Secondaire et Professionnel) in the capital, Kinshasa. RESULTS The document review showed that there were no clear administrative processes for the implementation of the grievance redressal arrangement measures resulting in low member awareness of these measures. These results were confirmed by the IDIs. Of 1044 members surveyed, only 240 (23%) were aware of the complaint measures, and 201 (84%) of these declared they had used the measures at some point in time, 181/201 (90%) users who had used the measures declared being satisfied with the response provided. The FGDs confirmed that most members lack knowledge on the grievance redressal procedures, but those who were aware had made use of them and were often satisfied with the response provided. CONCLUSION MHOs should urgently improve communication with their members on the range of redressal measures put in place to address grievances. Attention should be given to properly monitor existing arrangements, and possibly adapt them with well-documented and communicated standard operating procedures.
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Affiliation(s)
- Dosithee Ngo Bebe
- School of Public Health, University of Kinshasa, Kinshasa, Congo (the Democratic Republic of the)
| | - Fulbert Nappa Kwilu
- School of Public Health, University of Kinshasa, Kinshasa, Congo (the Democratic Republic of the)
| | - Arlette Mavila
- School of Public Health, University of Kinshasa, Kinshasa, Congo (the Democratic Republic of the)
| | - Eric Musalu Mafuta
- School of Public Health, University of Kinshasa, Kinshasa, Congo (the Democratic Republic of the)
| | - José Mobhe Mangalu
- Department of Population Sciences and Development, University of Kinshasa, Kinshasa, Congo (the Democratic Republic of the)
| | - Nasreen S Jessani
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
- Department of GlobalHealth, Stellenbosch University, Stellenbosch, South Africa
| | - Bart Criel
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
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Deresse T, Eshete A, Mulatu H, Dessalegn M. Community-Based Health Insurance Utilization and Its Determinants among Informal Workers: Cross-Sectional Study. Ethiop J Health Sci 2023; 33:781-794. [PMID: 38784508 PMCID: PMC11111200 DOI: 10.4314/ejhs.v33i5.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 07/11/2023] [Indexed: 05/25/2024] Open
Abstract
Background Ethiopia has implemented a community-based health insurance (CBHI) program to provide coverage to 80% of the population and shield underprivileged individuals from the detrimental effects of exorbitant medical expenses. However, there is a paucity of data regarding its utilization and pertinent concerns. This study aimed to evaluate the utilization of CBHI and its associated factors among informal workers in Berek District. Methods This community-based cross-sectional study was conducted between June 15 and July 15, 2022. The sample population comprised 538 households selected using a multistage sampling approach. Data analysis was done using SPSS Version 26. Variables with P-values of less than 0.25 during the bivariate analysis were selected for multivariate analysis using binary logistic regression. The statistical significance threshold was set at a p-value of 0.05. Results The utilization of Community-Based Health Insurance (CBHI) was 49.8%. Age between 30 and 39 years, monthly earnings of less than 1500 Ethiopian Birr, presence of chronic illness, membership in social organization, and possessing adequate knowledge were found to have a statistically significant association with the use of CBHI. Conclusion The utilization of CBHI was low within the confines of this district Age, income, social group membership, and chronic illnesses were significantly associated with CBHI utilization.
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Affiliation(s)
- Tilahun Deresse
- Department of Surgery, School of Medicine, Debre Berhan University, Debre Berhan, Ethiopia
| | - Akine Eshete
- Department of Public Health, Debre Berhan University, Debre Berhan, Ethiopia
| | - Hailu Mulatu
- Department of Public Health, Debre Berhan University, Debre Berhan, Ethiopia
| | - Megbar Dessalegn
- Department of Surgery, School of Medicine, Debre Markos University, Debre Markos, Ethiopia
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Shah A, Lemma S, Tao C, Wong J. The Role of Health Policy and Systems in the Uptake of Community-Based Health Insurance Schemes in Low- and Middle-Income Countries: A Narrative Review. Health Serv Insights 2023; 16:11786329231172675. [PMID: 37153878 PMCID: PMC10155025 DOI: 10.1177/11786329231172675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 03/15/2023] [Indexed: 05/10/2023] Open
Abstract
This study explores how health policies and systems can affect voluntary uptake of community-based health insurance (CBHI) schemes in low- and middle-income countries (LMICs). A narrative review was conducted involving searches of 10 databases (Medline, Global Index Medicus, Cumulative Index to Nursing, and Allied Health Literature, Health Systems Evidence, Worldwide Political Science Abstracts, PsycINFO, International Bibliography of the Social Sciences, EconLit, Bibliography of Asian Studies, and Africa Wide Information) across the social sciences, economics, and medical sciences. A total of 8107 articles were identified through the database searches, 12 of which were retained for analysis and narrative synthesis after 2 stages of screening. Our findings suggest that in the absence of directly subsidizing CBHI schemes by governments in LMICs, government policies can nonetheless promote voluntary uptake of CBHIs through intentional actions in 3 key areas: (a) improving quality of care, (b) providing a regulatory framework that integrates CBHIs into the national health system and its goals, and (c) leveraging administrative and managerial capacity to facilitate enrollment. The findings of this study highlight several considerations for CBHI planners and governments in LMICs to promote voluntary enrollment in CBHIs. Governments can effectively extend their outreach toward marginalized and vulnerable populations that are excluded from social protection by formulating supportive regulatory, policy, and administrative provisions that enhance voluntary uptake of CBHI schemes.
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Affiliation(s)
- Amika Shah
- The Reach Alliance, Munk School of
Global Affairs & Public Policy, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management,
and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Samrawit Lemma
- The Reach Alliance, Munk School of
Global Affairs & Public Policy, University of Toronto, Toronto, ON, Canada
| | - Chelsea Tao
- The Reach Alliance, Munk School of
Global Affairs & Public Policy, University of Toronto, Toronto, ON, Canada
- Munk School of Global Affairs &
Public Policy, University of Toronto, Toronto, ON, Canada
| | - Joseph Wong
- The Reach Alliance, Munk School of
Global Affairs & Public Policy, University of Toronto, Toronto, ON, Canada
- Munk School of Global Affairs &
Public Policy, University of Toronto, Toronto, ON, Canada
- Department of Political Science,
University of Toronto, Toronto, ON, Canada
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Tazinya RMA, Hajjar JM, Yaya S. Strengthening integrated sexual reproductive health and rights and HIV services programs to achieve sustainable development goals 3 and 5 in Africa. Reprod Health 2022; 19:223. [PMID: 36494750 PMCID: PMC9734483 DOI: 10.1186/s12978-022-01535-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Each year, over 200 million women globally cannot prevent pregnancy through modern contraceptive methods, with 70-80% of these women residing in sub-Saharan Africa. Consequently, almost 50% of pregnancies are unintended and 35 million unsafe abortions occur annually in the region. Further, sub-Saharan Africa has the highest burden globally of Human Immune-Deficiency Virus (HIV) infection, and over 57% of those affected are women. Women with a positive HIV status in sub-Saharan Africa experience higher rates of unintended pregnancy and unsafe abortion practices. In this commentary, we propose strategies to strengthen integrated sexual and reproductive health and rights (SRHR) and HIV services programs to improve the sexual and reproductive health of girls and women and to work towards achieving SDGs 3 and 5 in sub-Saharan Africa. We suggest a focus on capacity building, strengthening intersectoral collaborations, and improving governance and financial investment.
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Affiliation(s)
- Rose-Mary Asong Tazinya
- grid.28046.380000 0001 2182 2255Interdisciplinary School of Health Sciences, University of Ottawa, Ottawa, Canada
| | - Julia Marie Hajjar
- grid.28046.380000 0001 2182 2255Interdisciplinary School of Health Sciences, University of Ottawa, Ottawa, Canada
| | - Sanni Yaya
- grid.28046.380000 0001 2182 2255School of International Development and Global Studies, Faculty of Social Sciences, University of Ottawa, 120 University Private, Ottawa, ON K1N 6N5 Canada ,grid.7445.20000 0001 2113 8111The George Institute for Global Health, Imperial College London, London, UK
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Moyehodie YA, Mulugeta SS, Amare Yilema S. The effects of individual and community-level factors on community-based health insurance enrollment of households in Ethiopia. PLoS One 2022; 17:e0275896. [PMID: 36215271 PMCID: PMC9550060 DOI: 10.1371/journal.pone.0275896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 09/26/2022] [Indexed: 11/06/2022] Open
Abstract
Introduction Community-based health insurance (CBHI) is a type of volunteer health insurance that has been adopted all over the world in which people of the community pool funds to protect themselves from the high costs of seeking medical care and treatment for the disease. In Ethiopia, healthcare services are underutilized due to a lack of resources in the healthcare system. The study aims to identify the individual and community level factors associated with community-based health insurance enrollment of households in Ethiopia. Methods Data from the Ethiopian mini demographic and health survey 2019 were used to identify factors associated with community-based health insurance enrollment of households in Ethiopia. Multilevel logistic regression analysis was used on a nationally representative sample of 8,663 households nested within 305 communities, considering the data’s layered structure. We used a p-value<0.05 with a 95% confidence interval for the results. Result The prevalence of community-based health insurance enrollment in Ethiopia was 20.2%. The enrollment rate of households in the scheme was high in both Amhara (57.9), and Tigray (57.9%) regions and low (3.0%) in the Afar region. At the individual level; the age of household heads, number of children 5 and under, number of household members, has land for agriculture, has a mobile telephone, receiving cash of food from the safety Net Program, Owning livestock, and herds of farm animals, wealth index, and at the community level; the region had a significant association with community-based health insurance enrollment. Conclusion Both individual and community-level characteristics were significant predictors of community-based health insurance enrollment in households. Furthermore, the ministry of health, health bureaus, and other concerning bodies prioritize clusters with low health insurance coverage to strengthen health system financing and intervene in factors that negatively affect the CBHI enrollment of households.
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Moyehodie YA, Fenta SM, Mulugeta SS, Agegn SB, Yismaw E, Biresaw HB, Muluneh MW, Masresha BM, Dagnaw FT. Factors Associated With Community Based Health Insurance Healthcare Service Utilization of Households in South Gondar Zone, Amhara, Ethiopia. A Community-Based Cross-Sectional Study. Health Serv Insights 2022; 15:11786329221096065. [PMID: 35571582 PMCID: PMC9092581 DOI: 10.1177/11786329221096065] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 04/04/2022] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | - Embet Yismaw
- Department of Statistics, Debre Tabor
University, Debre Tabor, Ethiopia
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