The impact of health insurance programs on out-of-pocket expenditures in Indonesia: an increase or a decrease?

Access to health insurance amongst people with disabilities and its association with healthcare use, health status and financial protection in low- and middle-income countries: a systematic review

BACKGROUND

People with disabilities often incur higher costs for healthcare, due to higher needs, greater indirect costs, and the need for services not offered by the public system. Yet, people with disabilities are more likely to experience poverty and so have reduced capacity to pay. Health insurance is an important social protection strategy to meet healthcare needs and avoid catastrophic expenditures for this group. This systematic review synthesized evidence on health insurance coverage and potential effects among people with disabilities in low- and middle-income countries (LMICs).

METHODS

This systematic review followed PRISMA Guidelines. We searched English peer-reviewed articles from nine databases (Medline, Embase, CINAHL, Web of Science, Scopus, Cochrane Library, PsyInfo, Global Health, and Econlit) from January 2000 to 24 January 2023. Two independent reviewers conducted the article selection, data extraction, and risk of bias assessment using NIH Guidelines. Studies were eligible for inclusion if they quantitatively assessed at least one of four key outcomes amongst people with disabilities: health insurance coverage/access, the association between health insurance and health care utilization, financial protection, or health status/outcome. Narrative synthesis was deployed due to high variety of outcome measurements.

RESULTS

Out of 8,545 records retrieved and three from hand search, 38 studies covering data from 51 countries met the eligibility criteria. Over two-thirds (68.4%) focused on access/coverage, which was generally limited amongst people with disabilities. Seventeen studies (44.7%) examined healthcare utilization, with a positive association (9/12) found between health insurance and the use of disability-related services. However, its association with general healthcare utilization (5 studies) remained inconclusive. Financial protection, explored by six studies (15.8%), similarly yielded inconclusive results. Only four studies (10.5%) reported on health status, and the findings suggest a favourable association of health insurance with self-reported health among people with disabilities (2/4), despite the limited number of high-quality studies.

CONCLUSIONS

There is considerable variability and limited evidence regarding health insurance coverage and its potential impact among individuals with disabilities in LMICs. This gap highlights the pressing need for further evaluations of health insurance, with a specific focus on people with disabilities, aligning with the broader goal of achieving Universal Health Coverage (UHC).

TRIAL REGISTRATION

PROSPERO CRD42023389533.

Utilisation, out-of-pocket payments and access before and after COVID-19: Thailand's Universal Health Coverage Scheme

The goal of Universal Health Coverage (UHC) is that everyone needing healthcare can access quality services without financial hardship. Recent research covering countries with UHC systems documents the emergence, and acceleration following the COVID-19 pandemic of unapproved informal payment systems by providers that collect under-the-table payments from patients. In 2001, Thailand extended its '30 Baht' government-financed coverage to all uninsured people with little or no cost sharing. In this paper, we update the literature on the performance of Thailand's Universal Health Coverage Scheme (UCS) with data covering 2019 (pre-COVID-19) through 2021. We find that access to care for Thailand's UCS-covered population (53 million) is similar to access provided to populations covered by the other major public health insurance schemes covering government and private sector workers, and that, unlike reports from other UHC countries, no evidence that informal side payments have emerged, even in the face of COVID-19 related pressures. However, we do find that nearly one out of eight Thailand's UCS-covered patients seek care outside the UCS delivery system where they will incur out-of-pocket payments. This finding predates the COVID-19 pandemic and suggests the need for further research into the performance of the UHC-sponsored delivery system.

Measuring the Effect of Ayushman Bharat-Pradhan Mantri Jan Aarogya Yojna (AB-PMJAY) on Health Expenditure among Poor Admitted in a Tertiary Care Hospital in the Northern State of India

Background

Ayushman Bharat-Pradhan Mantri Jan Aarogya Yojna (AB-PMJAY) as a financial risk protection scheme intends to reduce catastrophic health expenditure (CHE), especially among poor. The current study was carried out to assess the utility of AB-PMJAY in terms of reduction in CHE from before and after admission in a tertiary hospital in the northern state of India.

Methodology

It was a hospital-based cross-sectional study carried out from August 2020 to October 2021 at a public tertiary hospital of Himachal Pradesh, India. Data were collected from surgery- and medicine-allied (SA and MA) specialties. Along with socio-demographic details, information for total monthly family expenditure (TMFE), out-of-pocket expenditure (OOPE), and indirect illness-related expenditure (IIE) was recorded before and after hospital admission. CHE was considered as more than 10.0% OOPE of THFE and more than 40.0% of capacity to pay (CTP).

Results

A total of 336 participants with a mean age of 46 years were recruited (MA: 54.6%). The majority (~93.0%) of participants had illness of fewer than 6 months. The mean TMFE was observed to be INR 4213.1 (standard deviation: 2483.7) and found to be similar across specialties. The OOPE share of TMFE declined from 76.1% (before admission) to 30.0% (after admission). Before admission, CHE was found among 65.5% (10.0% of THFE) and 54.2% (40.0% of CTP) participants. It reduced to about 29.0% (based on both THE and CTP) after admission to hospital.

Conclusion

AB-PMJAY scheme found to be useful in reducing CHE in a tertiary hospital.

Barriers to accessing internationally controlled essential medicines in sub-saharan Africa: A scoping review

BACKGROUND

Access to internationally controlled essential medicines (ICEMs), medicines that are listed on both the World Health Organization's Essential Medicines List and one of three international drug control conventions, remains problematic in Sub-Saharan Africa (SSA). Previous reviews have focused only on specific ICEMs or ICEM-related healthcare fields, but none have focused on all ICEMs as a distinct class. This scoping review therefore aims to identify the barriers to accessing ICEMs across all relevant healthcare fields in SSA.

METHODS

A scoping review was conducted across indexing platforms Embase, PubMed, Scopus and Web of Science of studies published between January 1 2012 and February 1 2022. Articles were eligible if they mentioned barriers to accessing ICEMs and/or ICEM-related healthcare fields, if studies were conducted in SSA, or included data on an SSA country within a multi-country study. The review was guided by the Access to Medicines from a Health System Perspective framework.

RESULTS

The search identified 5519 articles, of which 97 met the inclusion criteria. Many barriers to access were reported and were common across the ICEMs drug class. Main barriers were: at the individual level, the lack of knowledge about ICEMs; at the health service delivery level, low availability, stockouts, affordability, long distances to health facilities, insufficient infrastructure to store and distribute ICEMs, and lack of ICEM knowledge and training among healthcare workers; at the health sector level, lack of prioritisation of ICEM-related healthcare fields by governments and subsequent insufficient budget allocation. Cross-cutting, governance-related barriers pertained to lack of proper quantification systems, cumbersome procurement processes, and strict national laws controlling ICEMs, leading to overly restrictive prescription practices.

CONCLUSION

This review showed that there are a multitude of barriers to accessing ICEMs in SSA across all health system levels. Many of the barriers identified are applicable to all ICEMs, highlighting the importance of tackling barriers for this entire class of drugs together.

Healthcare Services Utilisation and Financial Burden among Vietnamese Older People and Their Households

BACKGROUND

This research examined differences in the utilisation of healthcare services and financial burden between and within insured and uninsured older persons and their households under the social health insurance scheme in Vietnam.

METHODS

We used nationally representative data from the Vietnam Household Living Standard Survey (VHLSS) conducted in 2014. We applied the World Health Organization (WHO)'s financial indicators in healthcare to provide cross-tabulations and comparisons for insured and uninsured older persons along with their individual and household characteristics (such as age groups, gender, ethnicity, per-capita household expenditure quintiles, and place of residence).

RESULTS

We found that social health insurance was beneficial to the insured in comparison with the uninsured in terms of utilization of healthcare services and financial burden. However, between and within these two groups, more vulnerable groups (i.e., ethnic minorities and rural persons) had lower utilization rates and higher rates of catastrophic spending than the better groups (i.e., Kinh and urban persons).

CONCLUSION

Given the rapidly ageing population under low middle-income status and the "double burden of diseases", this paper suggested that Vietnam reform the healthcare system and social health insurance so as to provide more equitable utilisation and financial protection to all older persons, including improving the quality of healthcare at the grassroots level and reducing the burden on the provincial/central health level; improving human resources for the grassroots healthcare facilities; encroaching public-private partnerships (PPPs) in the healthcare service provision; and developing a nationwide family doctor network.

Out-of-Pocket expenditure and patient experience of care under-Indonesia's national health insurance: A cross-sectional facility-based study in six provinces

BACKGROUND

Low- and middle-income countries worldwide are striving to achieve universal health coverage (UHC), frequently through expansion of statutory health insurance schemes. However, oftentimes evidence is lacking on progress towards quality patient-centred care and out-of-pocket expenditure (OOPE), particularly for poor population groups. We contribute patient-centred evidence examining patient experience and OOPE under JKN, the Indonesian social health insurance.

METHODS

Using data from 2526 patient exit interviews conducted among JKN beneficiaries in 2015, we computed a summative patient experience measure from 14 experience items. We used descriptive statistics to assess patient experience and the probability, amount and components of OOPE. We applied a two-part model to examine the relationships between socio-demographics, facility types, and OOPE and an OLS regression on patient experience determinants.

RESULTS

The mean patient experience measure was 11.7 out of 14 maximal points. Differences were observed between single items, with highest ratings on ease of understanding providers' language (97%) and lowest on waiting time (54%). OOPE were reported by 20% of patients with a mean equivalent to US$40, the most prevalent reason being medicines (61% of all OOPE). Considerable OOPE heterogeneity occurred by province and facility type. We found differentials in OOPE by gender (females paying more likely, but less) and subsidised JKN membership (same likelihood as non-subsidised, but paying less).

CONCLUSION

Our findings suggest that during its early implementation, patients under JKN reported mostly positive patient experience yet a fifth incurred OOPE, mostly on medicines. Further patient-centred research is needed to ensure JKN's progress towards UHC.

Factors affecting the healthcare utilization from Shasthyo Suroksha Karmasuchi scheme among the below-poverty-line population in one subdistrict in Bangladesh: a cross sectional study

BACKGROUND

Financing healthcare through out-of-pocket (OOP) payment is a major barrier in accessing healthcare for the poor people. The Health Economics Unit (HEU) of the Ministry of Health and Family Welfare of the government of Bangladesh has developed Shasthyo Suroksha Karmasuchi (SSK), a health protection scheme, with the aim of reducing OOP expenditure and improving access of the below-poverty-line (BPL) population to healthcare. The scheme started piloting in 2016 at Kalihati sub-district of Tangail District. Our objective was to assess healthcare utilization by the enrolled BPL population and to identify the factors those influencing their utilization of the scheme.

METHOD

A cross-sectional household survey was conducted from July to September 2018 in the piloting sub-district. A total of 806 households were surveyed using a semi-structured questionnaire. Information on illness and sources of healthcare service were captured for the last 90 days before the survey. Multiple logistic regression models were applied to determine the factors related to utilization of healthcare from the SSK scheme and other medically trained providers (MTPs) by the SSK members for both inpatient and outpatient care.

RESULT

A total of 781 (24.6%) people reported of suffering from illness of which 639 (81.8%) sought healthcare from any sources. About 8.0% (51 out of 639) of them sought healthcare from SSK scheme and 28.2% from other MTPs within 90 days preceding the survey. Households with knowledge about SSK scheme were more likely to utilize healthcare from the scheme and less likely to utilize healthcare from other MTPs. Non-BPL status and suffering from an accident/injury were significantly positively associated with utilization of healthcare from SSK scheme.

CONCLUSION

Among the BPL population, healthcare utilization from the SSK scheme was very low compared to that of other MTPs. Effective strategies should be in place for improving knowledge of BPL population on SSK scheme and the benefits package of the scheme should be updated as per the need of the target population. Such initiative can be instrumental in increasing utilization of the scheme and ultimately will reduce the barriers of OOP payment among BPL population for accessing healthcare.

How Jaminan Kesehatan Nasional (JKN) coverage influences out-of-pocket (OOP) payments by vulnerable populations in Indonesia

While Indonesia introduced a national health insurance scheme (JKN) in 2014 and coverage has grown to over 80% of the population, Indonesians still spend significant sums out-of-pocket (OOP) for their healthcare-over 30% of current health expenditure (CHE). This study aims to better understand how JKN is influencing OOP payments, especially among the poor and rural, at the range of health facilities. This study uses data from the National Socio-Economic Survey (SUSENAS) in 2018 and 2019, as these surveys started including a question on how much OOP spending a household incurs on health. The results show that households with JKN membership are far less likely than the uninsured to pay OOP for healthcare, and that if they do incur a cost, the magnitude of this cost is much lower among JKN households than uninsured ones. The results also show that JKN households in the two poorest quintiles have a higher probability to not incur any OOP (37% and 35%, respectively) compared to those in the wealthier quintiles 4 (32%) and 5 (30%). Poorer JKN households living in the eastern part of Indonesia-the less urbanized and developed regions-experienced the most cost-savings, though largely due to supply-side constraints. In fact, JKN members save more at public primary health care facilities vs. private ones (who often do not contract with JKN) and also save significantly more (over 50%) than uninsured households at both public and private hospitals. The study demonstrates the positive influence JKN has on OOP payments, especially among the poor and rural, but also highlights how the scheme needs to better engage with the growing private sector and invest in infrastructure in rural areas to help secure financial protection for its entire population.

Healthcare workers' perspectives on access to sexual and reproductive health services in the public, private and private not-for-profit sectors: insights from Kenya, Tanzania, Uganda and Zambia

Background

Access to sexual and reproductive health services remains a challenge for many in Kenya, Tanzania, Uganda and Zambia. Health service delivery in the four countries is decentralised and provided by the public, private and private not-for-profit sectors. When accessing sexual and reproductive health services, clients encounter numerous challenges, which might differ per sector. Healthcare workers have first-hand insight into what impediments to access exist at their health facility. The aim of this study was to identify differences and commonalities in barriers to access to sexual and reproductive health services across the public, private and private not-for-profit sectors.

Methods

A cross-sectional survey was conducted among healthcare workers working in health facilities offering sexual and reproductive health services in Kenya (n = 212), Tanzania (n = 371), Uganda (n = 145) and Zambia (n = 243). Data were collected in July 2019. Descriptive statistics were used to describe the data, while binary logistic regression analyses were used to test for significant differences in access barriers and recommendations between sectors.

Results

According to healthcare workers, the most common barrier to accessing sexual and reproductive health services was poor patient knowledge (37.1%). Following, issues with supply of commodities (42.5%) and frequent stockouts (36.0%) were most often raised in the public sector; in the other sectors these were also raised as an issue. Patient costs were a more significant barrier in the private (33.3%) and private not-for-profit sectors (21.1%) compared to the public sector (4.6%), and religious beliefs were a significant barrier in the private not-for-profit sector compared to the public sector (odds ratio = 2.46, 95% confidence interval = 1.69–3.56). In all sectors delays in the delivery of supplies (37.4-63.9%) was given as main stockout cause. Healthcare workers further believed that it was common that clients were reluctant to access sexual and reproductive health services, due to fear of stigmatisation, their lack of knowledge, myths/superstitions, religious beliefs, and fear of side effects. Healthcare workers recommended client education to tackle this.

Conclusions

Demand and supply side barriers were manifold across the public, private and private not-for-profit sectors, with some sector-specific, but mostly cross-cutting barriers. To improve access to sexual and reproductive health services, a multi-pronged approach is needed, targeting client knowledge, the weak supply chain system, high costs in the private and private not-for-profit sectors, and religious beliefs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08249-y.

Potential Impact of the Insurance on Catastrophic Health Expenditures Among the Urban Poor Population in India

Background:

Urban poor face a disproportionate burden of ill health and high out-of-pocket expenditure (OOPE), creating a severe unmet need for affordable and quality health care. This article highlights the impact of health insurance on OOPE and catastrophic healthcare expenditure among the urban poor of India.

Methods:

The study uses randomly collected household data from a baseline survey conducted in the states of Rajasthan and Uttar Pradesh. Separate Insurance impact models have been generated for the analysis.

Results:

Mean out-of-pocket health expenses is higher in the private health facility for the inpatient care but in case of outpatient care, the expenditure was more in public. Expenditure on medicine constitutes the largest part of the total OOPE. Insurance impact model shows that coverage on medicine alone can reduce medical impoverishment by 85% in the case of Outpatient Deparment (OPD) and 71% in the case of Inpatient Department (IPD). The urban poor preferred private facility for treatment in case of illness, albeit when it comes to delivery, they prefer public facility

Conclusions:

Study findings indicate overt reliance on private health care must be regulated, to reduce OOPE among the urban poor. Also, effective universal health insurance can go a long way in reducing the OOPE with availability of free medicines and diagnostics in the public health facilities.

Strengths and Weaknesses of Strategic Health Purchasing for Universal Health Coverage in Rwanda

In the context of scarce resources and increasing health care costs, strategic purchasing is viewed as a key mechanism to spur countries' progress toward universal health coverage (UHC), by using limited resources more effectively. We applied the Strategic Health Purchasing Progress Tracking Framework to examine the health purchasing arrangements in three health financing schemes in Rwanda-the Community Based Health Insurance (CBHI) scheme, the Rwanda Social Security Board (RSSB) medical scheme, and performance-based financing (PBF). Data were collected from secondary and primary sources between September 2020 and March 2021.The objective of the study was to identify areas of progress in strategic purchasing that can be built on, and to identify areas of overlap, duplication, or conflict that limit progress in strategic purchasing to advance UHC goals. This study found that Rwanda has made progress in many areas of strategic purchasing and has a strong foundation for building further. However, some overlaps and duplication of functions weaken the power of purchasers to improve resource allocation, incentives for providers, and accountability. In addition, some of the policies within the purchasing functions could be made more strategic. In particular, open-ended fee-for-service payment in the CBHI scheme not only threatens the scheme's financial sustainability but also imposes a high administrative burden. Better alignment and integration of contracting, incentives, and information system design to provide timely and relevant information for purchasing decisions would contribute to more strategic health purchasing and ensure that Rwanda's health sector achievements are sustained and expanded.

A STUDY OF CATASTROPHIC HEALTH EXPENDITURES IN INDIA - EVIDENCE FROM NATIONALLY REPRESENTATIVE SURVEY DATA: 2014-2018

Abstract

Background: India is taking steps to provide Universal Health Coverage (UHC). Out-of-pocket (OOP) health care payment is the most important mechanism for health care payment in India. This study aims to investigate the effect of OOP health care payments on catastrophic health expenditures (CHE).

Methods: Data from the National Sample Survey Organization, Social Consumption in Health 2014 and 2018 are used to investigate the effect of OOP health expenditure on household welfare in India. Three aspects of catastrophic expenditure were analyzed in this paper: (i) incidence and intensity of ‘catastrophic’ health expenditure, (ii) socioeconomic inequality in catastrophic health expenditures, and (iii) factors affecting catastrophic health expenditures.

Results: The odds of incidence and intensity of CHE were higher for the poorer households. Using the logistic regression model, it was observed that the odds of incidence of CHE was higher among the households with at least one child aged less than 5 years, one elderly person, one secondary educated female member, and if at least one member in the household used a private healthcare facility for treatment. The multiple regression model showed that the intensity of CHE was higher among households with members having chronic illness, and if members had higher duration of stay in the hospital. Subsidizing healthcare to the households having elderly members and children is necessary to reduce CHE.

Conclusion: Expanding health insurance coverage, increasing coverage limits, and inclusion of coverage for outpatient and preventive services are vital to protect households. Strengthening public primary health infrastructure and setting up a regulatory organization to establish policies and conduct regular audits to ensure that private hospitals do not increase hospitalizations and the duration of stay is necessary.

Estimating heterogeneous policy impacts using causal machine learning: a case study of health insurance reform in Indonesia

Policymakers seeking to target health policies efficiently towards specific population groups need to know which individuals stand to benefit the most from each of these policies. While traditional approaches for subgroup analyses are constrained to only consider a small number of pre-defined subgroups, recently proposed causal machine learning (CML) approaches help explore treatment-effect heterogeneity in a more flexible yet principled way. Causal forests use a generalisation of the random forest algorithm to estimate heterogenous treatment effects both at the individual and the subgroup level. Our paper aims to explore this approach in the setting of health policy evaluation with strong observed confounding, applied specifically to the context of mothers’ health insurance enrolment in Indonesia. Comparing two health insurance schemes (subsidised and contributory) against no insurance, we find beneficial average impacts of enrolment in contributory health insurance on maternal health care utilisation and infant mortality, but no impact of subsidised health insurance. The causal forest algorithm identified significant heterogeneity in the impacts of contributory insurance, not just along socioeconomic variables that we pre-specified (indicating higher benefits for poorer, less educated, and rural women), but also according to some other characteristics not foreseen prior to the analysis, suggesting in particular important geographical impact heterogeneity. Our study demonstrates the power of CML approaches to uncover unexpected heterogeneity in policy impacts. The findings from our evaluation of past health insurance expansions can potentially guide the re-design of the eligibility criteria for subsidised health insurance in Indonesia.

Is Indonesia achieving universal health coverage? Secondary analysis of national data on insurance coverage, health spending and service availability

OBJECTIVES

To analyse the relationship between health need, insurance coverage, health service availability, service use, insurance claims and out-of-pocket spending on health across Indonesia.

DESIGN

Secondary analysis of nationally representative quantitative data. We merged four national data sets: the National Socioeconomic Survey 2018, National Census of Villages 2018, Population Health Development Index 2018 and National Insurance Records to end 2017. Descriptive analysis and linear regression were performed.

SETTING

Indonesia has one of the world's largest single-payer national health insurance schemes. Data are individual and district level; all are representative for each of the country's 514 districts.

PARTICIPANTS

Anonymised secondary data from 1 131 825 individual records in the National Socioeconomic Survey and 83 931 village records in the village census. Aggregate data for 220 million insured citizens.

PRIMARY OUTCOME MEASURES

Health service use and out-of-pocket payments, by health need, insurance status and service availability. Secondary outcome: insurance claims.

RESULTS

Self-reported national health insurance registration (60.6%) is about 10% lower compared with the insurer's report (71.1%). Insurance coverage is highest in poorer areas, where service provision, and thus service use and health spending, are lowest. Inpatient use is higher among the insured than the uninsured (OR 2.35, 95% CI 2.27 to 2.42), controlling for health need and access), and poorer patients are most likely to report free inpatient care (53% in wealth quintile 1 vs 41% in Q5). Insured patients spend US$ 3.14 more on hospitalisation than the uninsured (95% CI 1.98 to 4.31), but the difference disappears when controlled for wealth. Lack of services is a major constraint on service use, insurance claims and out-of-pocket spending.

CONCLUSIONS

The Indonesian public insurance system protects many inpatients, especially the poorest, from excessive spending. However, others, especially in Eastern Indonesia cannot benefit because few services are available. To achieve health equity, the Indonesian government needs to address supply side constraints and reduce structural underfunding.

Strategies for reducing out of pocket payments in the health system: a scoping review

BACKGROUND

Direct out-of-pocket payments (OOP) are among the most important financing mechanisms in many health systems, especially in developing countries, adversely affecting equality and leading vulnerable groups to poverty. Therefore, this scoping review study was conducted to identify the strategies involving OOP reduction in health systems.

METHODS

Articles published in English on strategies related to out-of-pocket payments were Searched and retrieved in the Web of Science, Scopus, PubMed, and Embase databases between January 2000 and November 2020, following PRISMA guidelines. As a result, 3710 papers were retrieved initially, and 40 were selected for full-text assessment.

RESULTS

Out of 40 papers included, 22 (55%) and 18 (45%) of the study were conducted in developing and developed countries, respectively. The strategies were divided into four categories based on health system functions: health system stewardship, creating resources, health financing mechanisms, and delivering health services.As well, developing and developed countries applied different types of strategies to reduce OOP.

CONCLUSION

The present review identified some strategies that affect the OOP payments According to the health system functions framework. Considering the importance of stewardship, creating resources, the health financing mechanisms, and delivering health services in reducing OOP, this study could help policymakers make better decisions for reducing OOP expenditures.

Economic burden of cardiovascular diseases before and after Iran's health transformation plan: evidence from a referral hospital of Iran

Background

Different countries have set different policies to control and decrease the costs of cardiovascular diseases (CVDs). Iran was aiming to reduce the economic burden of different disease by a recent reform from named as health transformation plan (HTP). This study aimed to examine the economic burden of CVDs before and after of HTP.

Methods

This cross-sectional study was conducted on 600 patients with CVDs, who were randomly selected from a specialized cardiovascular hospital in the north-west of Iran. Direct and indirect costs of CVDs were calculated using the cost of illness and human capital approaches. Data were collected using a researcher-made checklist obtained from several sources including structured interviews, the Statistical Center of Iran, Iran’s Ministry of Cooperatives, Labor, and Social Welfare, the central bank of Iran, and the data of global burden of disease obtained from the Institute for Health Metrics and Evaluation to estimate direct and mortality costs. All costs were calculated in Iranian Rials (IRR).

Results

Total costs of CVDs were about 5571 and 6700 billion IRR before and after the HTP, respectively. More than 62% of the total costs of CVDs accounted for premature death before (64.89%) and after (62.01%) the HTP. The total hospitalization costs of CVDs was significantly increased after the HTP (p = 0.038). In both times, surgical services and visiting had the highest and lowest share of hospitalization costs, respectively. The OOP expenditure decreased significantly and reached from 54.2 to 36.7%. All hospitalization costs, except patients’ OOP expenditure, were significantly increased after the HTP about 1.3 times. Direct non-medical costs reached from 2.4 to 3.3 billion before and after the HTP, respectively.

Conclusion

Economic burden of CVDs increased in the north-west of Iran after the HTP due to the increase of all direct and indirect costs, except the OOP expenditure. Non-allocation of defined resources, which coincided with the international and national political and economic challenges in Iran, led to unsustainable resources of the HTP. So, no results of this study can be attributed solely to the HTP. Therefore, more detailed studies should be carried out on the reasons for the significant increase in CVDs costs in the region.

Impact of Health Insurance on Health Care Utilisation and Out-of-Pocket Health Expenditure in Vietnam

Background

In recent years, health insurance (HI) has been chosen by many low- and middle-income countries to obtain an important health policy target—universal health coverage. Vietnam has recently introduced the Revised Health Insurance Law, and the effects of the voluntary health insurance (VHI) and heavily subsidised health insurance (HSHI) programmes have not yet been analysed. Therefore, this study is aimed at examining the impact of these HI programmes on the utilisation of health care services and out-of-pocket health expenditure (OOP) in general and across different health care providers in particular.

Methods

Using the two waves of Vietnam Household Living Standard Surveys 2014 and 2016 and the difference-in-difference method, the impacts of VHI and HSHI on health care utilisation and OOP in Vietnam were estimated.

Results

For both the VHI and HSHI groups, we found that HI increased the probability of seeking outpatient care, the mean number of outpatient visits, the total number of visits, and the mean number of visits at the district level of health care providers in the last 12 months. However, there was no evidence that the HSHI programmes increased the mean number of inpatient visits and the number of visits at the provincial hospital. We also found that while the VHI programme reduced OOP for both outpatient and inpatient care, the HSHI scheme did not result in a reduction in OOP for hospitalisation, although HI lowered the total OOP. Similarly, we found that for both groups, HI reduced OOP when the insured visited district and provincial hospitals. However, the statistically significant impact was not demonstrated when the enrolees of HSHI programmes visited provincial hospitals.

Conclusion

The study offers evidence that the Vietnamese HI scheme increased health care service utilisation and decreased OOP for the participants of the VHI and HSHI programmes. Therefore, the government should continue to consider improving the HI system as a strategy to achieve universal health coverage.

Effect of health insurance program for the poor on out-of-pocket inpatient care cost in India: evidence from a nationally representative cross-sectional survey

BACKGROUND

In India, Out-of-pocket expenses accounts for about 62.6% of total health expenditure - one of the highest in the world. Lack of health insurance coverage and inadequate coverage are important reasons for high out-of-pocket health expenditures. There are many Public Health Insurance Programs offered by the Government that cover the cost of hospitalization for the people below poverty line (BPL), but their coverage is still not complete. The objective of this research is to examine the effect of Public Health Insurance Programs for the Poor on hospitalizations and inpatient Out-of-Pocket costs.

METHODS

Data from the recent national survey by the National Sample Survey Organization, Social Consumption in Health 2014 are used. Propensity score matching was used to identify comparable non-enrolled individuals for individuals enrolled in health insurance programs. Binary logistic regression model, Tobit model, and a Two-part model were used to study the effects of enrolment under Public Health Insurance Programs for the Poor on the incidence of hospitalizations, length of hospitalization, and Out-of- Pocket payments for inpatient care.

RESULTS

There were 64,270 BPL people in the sample. Individuals enrolled in health insurance for the poor have 1.21 higher odds of incidence of hospitalization compared to matched poor individuals without the health insurance coverage. Enrollment under the poor people health insurance program did not have any effect on length of hospitalization and inpatient Out-of-Pocket health expenditures. Logistic regression model showed that chronic illness, household size, and age of the individual had significant effects on hospitalization incidence. Tobit model results showed that individuals who had chronic illnesses and belonging to other backward social group had significant effects on hospital length of stay. Tobit model showed that days of hospital stay, education and age of patient, using a private hospital for treatment, admission in a paying ward, and having some specific comorbidities had significant positive effect on out-of-pocket costs.

CONCLUSIONS

Enrolment in the public health insurance programs for the poor increased the utilization of inpatient health care. Health insurance coverage should be expanded to cover outpatient services to discourage overutilization of inpatient services. To reduce out-of-pocket costs, insurance needs to cover all family members rather than restricting coverage to a specific maximum defined.

The effect of a community-based health insurance on the out-of-pocket payments for utilizing medically trained providers in Bangladesh

BACKGROUND

We aimed to estimate the effect of the community-based health insurance (CBHI) scheme on the magnitude of out-of-pocket (OOP) payments for the healthcare of the informal workers and their dependents. The CBHI scheme was piloted through a cooperative of informal workers, which covered seven unions in Chandpur Sadar Upazila, Bangladesh.

METHODS

A quasi-experimental study was conducted using a case-comparison design. In total 1292 (646 insured and 646 uninsured) households were surveyed. Propensity score matching was done to minimize the observed baseline differences in the characteristics between the insured and uninsured groups. A two-part regression model was applied using both the probability of OOP spending and magnitude of such spending for healthcare in assessing the association with enrolment status in the CBHI scheme while controlling for other covariates.

RESULTS

The OOP payment was 6.4% (p < 0.001) lower for medically trained provider (MTP) utilization among the insured compared with the uninsured. However, no significant difference was found in the OOP payments for healthcare utilization from all kind of providers, including the non-trained ones.

CONCLUSIONS

The CBHI scheme could reduce OOP payments while providing better quality healthcare through the increased use of MTPs, which consequently could push the country towards universal health coverage.

Examining purchasing reforms towards universal health coverage by the National Hospital Insurance Fund in Kenya

BACKGROUND

Kenya has prioritized the attainment of universal health coverage (UHC) through the expansion of health insurance coverage by the National Hospital Insurance Fund (NHIF). In 2015, the NHIF introduced reforms in premium contribution rates, benefit packages, and provider payment methods. We examined the influence of these reforms on NHIF's purchasing practices and their implications for strategic purchasing and health system goals of equity, efficiency and quality.

METHODS

We conducted an embedded case study with the NHIF as the case and the reforms as embedded units of analysis. We collected data at the national level and in two purposively selected counties through 41 in-depth interviews with health financing stakeholders, facility managers and frontline providers; 4 focus group discussions with 51 NHIF members; and, document reviews. We analysed the data using a Framework approach.

RESULTS

The new NHIF reforms were characterized by weak purchasing actions. Firstly, the new premium contribution rates were inadequately communicated and unaffordable for certain citizen groups. Secondly, while the new benefit packages were reported to be based on service needs, preferences and values of the population, they were inadequately communicated and unequally distributed across different citizen groups. In addition, the presence of service delivery infrastructure gaps in public healthcare facilities and the pro-urban and pro-private distribution of contracted health facilities compromised delivery of, and access to, these new services. Lastly, the new provider payment methods and rates were considered inadequate, with delayed payments and weak links to financial accountability mechanisms which compromised their ability to incentivize equity, efficiency and quality of healthcare delivery.

CONCLUSION

While NHIF sought to expand population and service coverage and reduce out-of-pocket payments with the new reforms, weaknesses in the reforms' design and implementation limited NHIF's purchasing actions with negative implications for the health system goals of equity, efficiency and quality. For the reforms to accelerate the country's progress towards UHC, policy makers at the NHIF and, national and county government should make deliberate efforts to align the design and implementation of such reforms with strategic purchasing actions that are aimed at improving health system goals.

Examining purchasing reforms towards universal health coverage by the National Hospital Insurance Fund in Kenya

BACKGROUND

Kenya has prioritized the attainment of universal health coverage (UHC) through the expansion of health insurance coverage by the National Hospital Insurance Fund (NHIF). In 2015, the NHIF introduced reforms in premium contribution rates, benefit packages, and provider payment methods. We examined the influence of these reforms on NHIF's purchasing practices and their implications for strategic purchasing and health system goals of equity, efficiency and quality.

METHODS

We conducted an embedded case study with the NHIF as the case and the reforms as embedded units of analysis. We collected data at the national level and in two purposively selected counties through 41 in-depth interviews with health financing stakeholders, facility managers and frontline providers; 4 focus group discussions with 51 NHIF members; and, document reviews. We analysed the data using a Framework approach.

RESULTS

The new NHIF reforms were characterized by weak purchasing actions. Firstly, the new premium contribution rates were inadequately communicated and unaffordable for certain citizen groups. Secondly, while the new benefit packages were reported to be based on service needs, preferences and values of the population, they were inadequately communicated and unequally distributed across different citizen groups. In addition, the presence of service delivery infrastructure gaps in public healthcare facilities and the pro-urban and pro-private distribution of contracted health facilities compromised delivery of, and access to, these new services. Lastly, the new provider payment methods and rates were considered inadequate, with delayed payments and weak links to financial accountability mechanisms which compromised their ability to incentivize equity, efficiency and quality of healthcare delivery.

CONCLUSION

While NHIF sought to expand population and service coverage and reduce out-of-pocket payments with the new reforms, weaknesses in the reforms' design and implementation limited NHIF's purchasing actions with negative implications for the health system goals of equity, efficiency and quality. For the reforms to accelerate the country's progress towards UHC, policy makers at the NHIF and, national and county government should make deliberate efforts to align the design and implementation of such reforms with strategic purchasing actions that are aimed at improving health system goals.

Achieving financial risk protection through a national Social Health Insurance Programme in Nigeria: Perspectives of enrollees and healthcare providers

INTRODUCTION

Out-of-pocket (OOP) payment adversely affects universal financial risk protection (UFRP) and the achievement of Universal Health Coverage (UHC). Since the introduction of a Formal Sector Social Health Insurance Programme (FSSHIP) in Nigeria, the extent to which it has provided UFRP is still largely unknown. This study therefore assessed this from the perspectives of both enrollees and healthcare providers.

METHODS

The study was undertaken in Enugu state, Nigeria. The subjects were randomly selected primary enrollees and health care providers. An interviewer-administered questionnaire was used for data collection on service utilization under the FSSHIP, as well as out-of-pocket payment of healthcare expenditure.

RESULTS

Out of 333 formal sector workers interviewed, 283 (85%) were registered in the FSSHIP and 61.1% of them utilized FSSHIP. Among these, 89.8% of them used OOP to pay for about 95.2% of the healthcare expenditure. From the perspectives of the providers, 97.6%, patients still paid using OOP.

CONCLUSION

The FSSHIP is not providing UFRP as expected. This weakens the effectiveness of the FSSHIP to ensure UFRP and ultimately UHC. The NHIS should modify the FSSHIP to provide UFRP and eliminate both the high level of OOP and the proportion of expenditure it covers.

Associations Between Schemes of Social Insurance and Self-Rated Health Comparison: Evidence From the Employed Migrants in Urban China

Background: Little was known about the relationship between social insurance without health insurance and self-rated health comparison (SRHC). The present study aimed to investigate how social insurance schemes improved SRHC among employed migrants in urban China.

Methods: The employed migrants aged 18 and above were selected from the 2009 Rural-Urban Migration in China project. Multiple probit regression models were adopted to identify the determinants of participation of social insurance. Multiple logistic regression models were used to analyze the relationship between unemployment insurance, pension insurance, and work injury insurance and SRHC.

Results: In the sample, most of the participants were middle-aged, male, and uninsured persons. However, over 80% of them reported better SRHC. Health insurance contributed to the participation of social insurance. The social insurance schemes were associated with financial risk. Regarding the confounding effects of health insurance, the three schemes of social insurance were associated with SRHC.

Conclusions: The result indicated that not all three, but two schemes of social insurance, could improve SRHC among the employed migrants.

The impact of public health insurance on health care utilisation, financial protection and health status in low- and middle-income countries: A systematic review

BACKGROUND

Expanding public health insurance seeks to attain several desirable objectives, including increasing access to healthcare services, reducing the risk of catastrophic healthcare expenditures, and improving health outcomes. The extent to which these objectives are met in a real-world policy context remains an empirical question of increasing research and policy interest in recent years.

METHODS

We reviewed systematically empirical studies published from July 2010 to September 2016 using Medline, Embase, Econlit, CINAHL Plus via EBSCO, and Web of Science and grey literature databases. No language restrictions were applied. Our focus was on both randomised and observational studies, particularly those including explicitly attempts to tackle selection bias in estimating the treatment effect of health insurance. The main outcomes are: (1) utilisation of health services, (2) financial protection for the target population, and (3) changes in health status.

FINDINGS

8755 abstracts and 118 full-text articles were assessed. Sixty-eight studies met the inclusion criteria including six randomised studies, reflecting a substantial increase in the quantity and quality of research output compared to the time period before 2010. Overall, health insurance schemes in low- and middle-income countries (LMICs) have been found to improve access to health care as measured by increased utilisation of health care facilities (32 out of 40 studies). There also appeared to be a favourable effect on financial protection (26 out of 46 studies), although several studies indicated otherwise. There is moderate evidence that health insurance schemes improve the health of the insured (9 out of 12 studies).

INTERPRETATION

Increased health insurance coverage generally appears to increase access to health care facilities, improve financial protection and improve health status, although findings are not totally consistent. Understanding the drivers of differences in the outcomes of insurance reforms is critical to inform future implementations of publicly funded health insurance to achieve the broader goal of universal health coverage.

The impact of health insurance on out-of-pocket expenditure on delivery in Indonesia

In this study, we estimate the effects of health insurance on the out-of-pocket expenditure on health care for maternal delivery in Indonesia. Distinguishing between the types of health insurance, we explore heterogeneity in the size of the impact of noncontributory insurance for poor households vis-à-vis contributory insurance for nonpoor households. We find that noncontributory insurance and contributory insurance reduce the average out-of-pocket expenditure by 1,136,966 IDR ([Formula: see text]) and 676,402 IDR ([Formula: see text]), respectively. Also, larger impacts of noncontributory insurance and contributory insurance are found at the right tail of the distribution.

Analysis on the implementation of a health improvement project (Garbage Clinical Insurance) in Indonesia: a literature review

OBJECTIVE

Indonesia Medika has established "Garbage Clinical Insurance" (GCI), which enables the population below the poverty line (BPL) to obtain health insurance by donating their garbage to pay the premium. The objective of this paper was to critically examine the implementation of GCI in Indonesia by reviewing the background, effects, and sustainability of this program.

METHOD

A literature search of studies related to GCI, other types of micro health insurance, and their applications in developing countries was conducted. Recent news (post 2014) related with the implementation of GCI was also consulted.

RESULTS

The literature revealed that the foundation of GCI was informed by the Declaration of Alma Ata with the ideal of making health care services accessible to everyone. Unlike most health insurance, the mechanisms of GCI seem less likely to trigger moral hazard among its beneficiaries. However, as a micro insurance program, the sustainability of GCI continues to be called into question.

CONCLUSIONS

The critical analysis of the present study has highlighted the application of GCI, a micro health insurance initiative, and its relevance to Indonesia. GCI tended to work well as it was able to utilise Indonesia's social capital. However, GCI should aim to increase the benefits package available to its members in order to maintain the sustainability of the program.

[The process of health sector reform in PeruProcesso de reforma da saúde no Peru]

Objetivos

Caracterizar el proceso de la Reforma del Sector Salud (RSS) en Perú expresada públicamente en 2013, identificando los principales avances en su implementación y los desafíos pendientes desde la perspectiva de los actores participantes.

Métodos

Se trata de un estudio de sistematización de la experiencia en el cual se realizaron entrevistas semiestructuradas a 21 informantes clave, incluyendo a tres exministros de salud, y empleando como marco temporal el decenio 2005–2015. Se analizaron bases de datos oficiales para comprobar las variaciones de los indicadores de salud.

Resultados

La propuesta se basa en la expansión del aseguramiento con predominio de un seguro público en salud bajo el modelo del pluralismo estructurado, con una clara separación entre las funciones de prestación, intermediación financiera, regulación y gobierno. Los principales avances de la RSS identificados son: haber trascendido el criterio de pobreza para el aseguramiento público, el refuerzo de la inversión física y de recursos humanos, el fortalecimiento de una superintendencia orientada a los derechos del usuario, y el del papel del Ministerio de Salud en la salud pública. Y los principales desafíos, la cobertura poblacional del aseguramiento no vinculada con la pobreza, la dotación de recursos humanos especializados y la reducción de gasto de bolsillo.

Conclusiones

La RSS en el decenio examinado es un proceso que se construye sobre avances de años precedentes al periodo analizado, que consolida en el país un modelo de aseguramiento encaminado a la cobertura poblacional universal sobre la base de un seguro público de salud, y que se expresa en un incremento demostrable del gasto público y de la cobertura, aunque sus avances se ven limitados principalmente en la dotación de recursos humanos especializados y en el gasto de bolsillo, que todavía es muy elevado.

Determinants of immunisation coverage of children aged 12-59 months in Indonesia: a cross-sectional study

OBJECTIVES

Despite the adoption of WHO's Expanded Programme on Immunisation in Indonesia since 1977, a large proportion of children are still completely unimmunised or only partly immunised. This study aimed to assess factors associated with low immunisation coverage of children in Indonesia.

SETTING

Children aged 12-59 months in Indonesia.

PARTICIPANT

The socioeconomic characteristics and immunisation status of the children were obtained from the most recent Demographic and Health Survey, the 2012 Indonesia Demographic and Health Survey. Participants were randomly selected through a two-stage stratified sampling design. Data from 14 401 children aged 12-59 months nested within 1832 census blocks were included in the analysis. Multilevel logistic regression models were constructed to account for hierarchical structure of the data.

RESULTS

The mean age of the children was 30 months and they were equally divided by sex. According to the analysis, 32% of the children were fully immunised in 2012. Coverage was significantly lower among children who lived in Maluku and Papua region (adjusted OR: 1.94; 95% CI 1.42 to 2.64), were 36-47 months old (1.39; 1.20 to 1.60), had higher birth order (1.68; 1.28 to 2.19), had greater family size (1.47; 1.11 to 1.93), whose mother had no education (2.13; 1.22 to 3.72) and from the poorest households (1.58; 1.26 to 1.99). The likelihood of being unimmunised was also higher among children without health insurance (1.16; 1.04 to 1.30) and those who received no antenatal (3.28; 2.09 to 5.15) and postnatal care (1.50; 1.34 to 1.69).

CONCLUSIONS

Socioeconomic factors were strongly associated with the likelihood of being unimmunised in Indonesia. Unimmunised children were geographically clustered and lived among the most deprived population. To achieve WHO target of protective coverage, public health interventions must be designed to meet the needs of these high-risk groups.

The impact of health insurance on maternal health care utilization: evidence from Ghana, Indonesia and Rwanda

While research has assessed the impact of health insurance on health care utilization, few studies have focused on the effects of health insurance on use of maternal health care. Analyzing nationally representative data from the Demographic and Health Surveys (DHS), this study estimates the impact of health insurance status on the use of maternal health services in three countries with relatively high levels of health insurance coverage-Ghana, Indonesia and Rwanda. The analysis uses propensity score matching to adjust for selection bias in health insurance uptake and to assess the effect of health insurance on four measurements of maternal health care utilization: making at least one antenatal care visit; making four or more antenatal care visits; initiating antenatal care within the first trimester and giving birth in a health facility. Although health insurance schemes in these three countries are mostly designed to focus on the poor, coverage has been highly skewed toward the rich, especially in Ghana and Rwanda. Indonesia shows less variation in coverage by wealth status. The analysis found significant positive effects of health insurance coverage on at least two of the four measures of maternal health care utilization in each of the three countries. Indonesia stands out for the most systematic effect of health insurance across all four measures. The positive impact of health insurance appears more consistent on use of facility-based delivery than use of antenatal care. The analysis suggests that broadening health insurance to include income-sensitive premiums or exemptions for the poor and low or no copayments can increase use of maternal health care.

Complementary health insurance, out- of- pocket expenditures, and health services utilization: A population- based survey

Background: Studies have shown that people using complementary health insurances have more access to health services than others. In the present study, we aimed at finding the differences between out- of- pocket payments and health service utilizations in complementary health insurances (CHIs) users and nonusers. Methods: Propensity score matching was used to compare the 2 groups. First, confounder variables were identified, and then propensity score matching was used to compare out- of- pocket expenditures with dental, general physician, hospital inpatient, emergency services, nursing, midwifery, laboratory services, specialists and rehabilitation services utilization. Results: Our results revealed no significant differences between the 2 groups in out- of- pocket health expenditures. Also, the specialist visits, inpatient services at the hospital, and dental services were higher in people who used CHIs compared to nonusers. Conclusion: People did not change their budget share for health care services after using CHIs. The payments were equal for people who were not CHIs users due to the increase in the quantity of the services.

The Dynamics of Catastrophic and Impoverishing Health Spending in Indonesia: How Well Does the Indonesian Health Care Financing System Perform?

Our study examines the incidence and intensity of catastrophic and impoverishing health spending in Indonesia. A panel data set was used from 4 waves of the Indonesian Family Life Surveys 1993, 1997, 2000, and 2007. Catastrophic health expenditure was measured by calculating the ratio of out-of-pocket payments to household income. Then, we calculated poverty indicators as a measure of impoverishing spending in the health care financing system. Head count, overshoot, and mean positive overshoot for each given threshold in 2000 were lower than other surveyed periods; otherwise, fraction headcount in 2007 of households were the higher. Between 1993 and 2007, the percentage of households in poverty decreased, both in gross and net of health payments. However, in each year, the percentages of households in poverty using net health payments were higher than the gross. The estimates of poverty gap, normalized poverty gap, and normalized mean positive gap decreased across the survey periods. The health care financing system performance has shown positive evidence for financial protection offerings. A sound relationship between improvements of health care financing performance and the existing health reform demonstrated a mutual reinforcement, which should be maintained to promote equity and fairness in health care financing in Indonesia.

Voluntary Health Insurance expenditure in low- and middle-income countries: Exploring trends during 1995-2012 and policy implications for progress towards universal health coverage

BACKGROUND

Most low- and middle-income countries (LMIC) rely significantly on private health expenditure in the form of out-of-pocket payments (OOP) and voluntary health insurance (VHI). This paper assesses VHI expenditure trends in LMIC and explores possible explanations. This illuminates challenges deriving from changes in VHI expenditure as countries aim to progress equitably towards universal health coverage (UHC).

METHODS

Health expenditure data was retrieved from the WHO Global Health Expenditure Database to calculate VHI, OOP and general government health (GGHE) expenditure as a share of total health expenditure (THE) for the period of 1995-2012. A literature analysis offered potential reasons for trends in countries and regions.

RESULTS

In 2012, VHI as a percentage of THE (abbreviated as VHI%) was below 1 % in 49 out of 138 LMIC. Twenty-seven countries had no or more than five years of data missing. VHI% ranged from 1 to 5 % in 39 LMIC and was above 5 % in 23 LMIC. There is an upwards average trend in VHI% across all regions. However, increases in VHI% cannot be consistently linked with OOP falling or being redirected into private prepayment. There are various countries which exhibit rising VHI alongside a rise in OOP and fall in GGHE, which is a less desirable path in order to equitably progress towards UHC.

DISCUSSION AND CONCLUSION

Reasons for the VHI expenditure trends across LMIC include: external influences; government policies on the role of VHI and its regulation; and willingness and ability of the population to enrol in VHI schemes. Many countries have paid insufficient attention to the potentially risky role of VHI for equitable progress towards UHC. Expanding VHI markets bear the risk of increasing fragmentation and inequities. To avoid this, health financing strategies need to be clear regarding the role given to VHI on the path towards UHC.

An exploration of moral hazard behaviors under the national health insurance scheme in Northern Ghana: a qualitative study

Background

The government of Ghana introduced the National Health Insurance Scheme (NHIS) in 2003 through an Act of Parliament (Act 650) as a strategy to improve financial access to quality basic health care services. Although attendance at health facilities has increased since the introduction of the NHIS, there have been media reports of widespread abuse of the NHIS by scheme operators, service providers and insured persons. The aim of the study was to document behaviors and practices of service providers and clients of the NHIS in the Kassena-Nankana District (KND) of Ghana that constitute moral hazards (abuse of the scheme) and identify strategies to minimize such behaviors.

Methods

Qualitative methods through 14 Focused Group Discussions (FGDs) and 5 individual in-depth interviews were conducted between December 2009 and January 2010. Thematic analysis was performed with the aid of QSR NVivo 8 software.

Results

Analysis of FGDs and in-depth interviews showed that community members, health providers and NHIS officers are aware of various behaviors and practices that constitute abuse of the scheme. Behaviors such as frequent and ‘frivolous’ visits to health facilities, impersonation, feigning sickness to collect drugs for non-insured persons, over charging for services provided to clients, charging clients for services not provided and over prescription were identified. Suggestions on how to minimize abuse of the NHIS offered by respondents included: reduction of premiums and registration fees, premium payments by installment, improvement in the picture quality of the membership cards, critical examination and verification of membership cards at health facilities, some ceiling on the number of times one can seek health care within a specified time period, and general education to change behaviors that abuse the scheme.

Conclusion

Attention should be focused on addressing the identified moral hazard behaviors and pursue cost containment strategies to ensure the smooth operation of the scheme and enhance its sustainability.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-1133-4) contains supplementary material, which is available to authorized users.

Unmet needs for cardiovascular care in Indonesia

BACKGROUND

In the past twenty years the heaviest burden of cardiovascular diseases has begun to shift from developed to developing countries. However, little is known about the real needs for cardiovascular care in these countries and how well those needs are being met. This study aims to investigate the prevalence and determinants of unmet needs for cardiovascular care based on objective assessment.

METHODS AND FINDINGS

Multilevel analysis is used to analyse the determinants of met needs and multilevel multiple imputation is applied to manage missing data. The 2008 Indonesian Family Life Survey (IFLS4) survey is the source of the household data used in this study, while district data is sourced from the Ministry of Health and Ministry of Finance. The data shows that nearly 70% of respondents with moderate to high cardiovascular risk failed to receive cardiovascular care. Higher income, possession of health insurance and residence in urban areas are significantly associated with met needs for cardiovascular care, while health facility density and physician density show no association with them.

CONCLUSIONS

The prevalence of unmet needs for cardiovascular care is considerable in Indonesia. Inequality persists as a factor in meeting needs for cardiovascular care as the needs of people with higher incomes and those living in urban areas are more likely to be met. Alleviation of poverty, provision of health care insurance for the poor, and improvement in the quality of healthcare providers are recommended in order to meet this ever-increasing need.