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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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Tsala Dimbuene Z, Muanza Nzuzi R, Nzita Kikhela PD. Poverty, education and health insurance coverage among women of reproductive ages in the Democratic Republic of the Congo: a cross-sectional and multilevel analysis. BMJ Open 2022; 12:e064834. [PMID: 36523216 PMCID: PMC9748937 DOI: 10.1136/bmjopen-2022-064834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To investigate inequalities of health insurance coverage (outcome) at subnational level, and the effects of education and poverty on the outcome. DESIGN Secondary analysis of Demographic and Health Surveys. The outcome variable was health insurance ownership. SETTING The Democratic Republic of the Congo. SUBJECTS Women aged 15-49 years (n=18 827). RESULTS Findings indicated significant spatial variations of the health insurance ownership which ranged from 1.2% in Bandundu and Kasaï Oriental to 15.5% in Kinshasa the Capital City. Furthermore, findings showed that an additional year of women education increased by 10% the chance of health insurance ownership (adjusted OR, AOR 1.098; 95% CI 1.065 to 1.132). Finally, living in better-off households increased by 150% the chance of owing a health insurance (AOR 2.501; 95% CI 1.620 to 3.860) compared with women living in poor households. CONCLUSIONS Given the low levels of health insurance coverage, the Democratic Republic of the Congo will not reach the Sustainable Development Goal 3, aimed at improving maternal and child health unless a serious programmatic health shift is undertaken in the country to tackle inequalities among poor and uneducated women via universal health coverage.
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Affiliation(s)
- Zacharie Tsala Dimbuene
- Department of Population and Development Sciences, University of Kinshasa, Kinshasa, Congo (the Democratic Republic of the)
| | - Raphaël Muanza Nzuzi
- Department of Population and Development Sciences, University of Kinshasa, Kinshasa, Congo (the Democratic Republic of the)
| | - Paul-Denis Nzita Kikhela
- Department of Population and Development Sciences, University of Kinshasa, Kinshasa, Congo (the Democratic Republic of the)
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Conde KK, Camara AM, Jallal M, Khalis M, Zbiri S, De Brouwere V. Factors determining membership in community-based health insurance in West Africa: a scoping review. Glob Health Res Policy 2022; 7:46. [PMID: 36443890 PMCID: PMC9703663 DOI: 10.1186/s41256-022-00278-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 10/28/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND In many low-income countries, households bear most of the health care costs. Community-based health insurance (CBHI) schemes have multiplied since the 1990s in West Africa. They have significantly improved their members' access to health care. However, a large proportion of users are reluctant to subscribe to a local CBHI. Identifying the major factors affecting membership will be useful for improving CBHI coverage. The objective of this research is to obtain a general overview of existing evidence on the determinants of CBHI membership in West Africa. METHODS A review of studies reporting on the factors determining membership in CBHI schemes in West Africa was conducted using guidelines developed by the Joanna Briggs Institute. Several databases were searched (PubMed, ScienceDirect, Global Health database, Embase, EconLit, Cairn.info, BDPS, Cochrane database and Google Scholar) for relevant articles available by August 15, 2022, with no methodological or linguistic restrictions in electronic databases and grey literature. RESULTS The initial literature search resulted in 1611 studies, and 10 studies were identified by other sources. After eliminating duplicates, we reviewed the titles of the remaining 1275 studies and excluded 1080 irrelevant studies based on title and 124 studies based on abstracts. Of the 71 full texts assessed for eligibility, 32 additional papers were excluded (not relevant, outside West Africa, poorly described results) and finally 39 studies were included in the synthesis. Factors that negatively affect CBHI membership include advanced age, low education, low household income, poor quality of care, lack of trust in providers and remoteness, rules considered too strict or inappropriate, low trust in administrators and inadequate information campaign. CONCLUSIONS This study shows many lessons to be learned from a variety of countries and initiatives that could make CBHI an effective tool for increasing access to quality health care in order to achieve universal health coverage. Coverage through CBHI schemes could be improved through communication, improved education and targeted financial support.
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Affiliation(s)
- Kaba Kanko Conde
- grid.501379.90000 0004 6022 6378International School of Public Health, Mohammed VI University of Health Sciences, Bld Mohammed Taïeb Naciri, Commune Hay Hassani, 82 403 Casablanca, Morocco
| | - Aboubacar Mariama Camara
- grid.501379.90000 0004 6022 6378International School of Public Health, Mohammed VI University of Health Sciences, Bld Mohammed Taïeb Naciri, Commune Hay Hassani, 82 403 Casablanca, Morocco
| | - Manar Jallal
- grid.501379.90000 0004 6022 6378International School of Public Health, Mohammed VI University of Health Sciences, Bld Mohammed Taïeb Naciri, Commune Hay Hassani, 82 403 Casablanca, Morocco ,grid.501379.90000 0004 6022 6378Laboratory of Public Health, Health Economics and Health Management, Mohammed VI University of Health Sciences, Casablanca, Morocco
| | - Mohamed Khalis
- grid.501379.90000 0004 6022 6378International School of Public Health, Mohammed VI University of Health Sciences, Bld Mohammed Taïeb Naciri, Commune Hay Hassani, 82 403 Casablanca, Morocco ,grid.501379.90000 0004 6022 6378Laboratory of Public Health, Health Economics and Health Management, Mohammed VI University of Health Sciences, Casablanca, Morocco ,Knowledge for Health Policies Centre, Casablanca, Morocco
| | - Saad Zbiri
- grid.501379.90000 0004 6022 6378International School of Public Health, Mohammed VI University of Health Sciences, Bld Mohammed Taïeb Naciri, Commune Hay Hassani, 82 403 Casablanca, Morocco ,grid.501379.90000 0004 6022 6378Laboratory of Public Health, Health Economics and Health Management, Mohammed VI University of Health Sciences, Casablanca, Morocco ,Knowledge for Health Policies Centre, Casablanca, Morocco
| | - Vincent De Brouwere
- grid.501379.90000 0004 6022 6378International School of Public Health, Mohammed VI University of Health Sciences, Bld Mohammed Taïeb Naciri, Commune Hay Hassani, 82 403 Casablanca, Morocco ,grid.11505.300000 0001 2153 5088Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium ,grid.444715.70000 0000 8673 4005School of Tropical Medicine and Global Health, University of Nagasaki, Nagasaki, Japan
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Sheikh N, Tagoe ET, Akram R, Ali N, Howick S, Morton A. Implementation barriers and remedial strategies for community-based health insurance in Bangladesh: insights from national stakeholders. BMC Health Serv Res 2022; 22:1200. [PMID: 36153512 PMCID: PMC9508716 DOI: 10.1186/s12913-022-08561-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 09/12/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Community-based health insurance (CBHI) is a part of the health system in Bangladesh, and overcoming the obstacles of CBHI is a significant policy concern that has received little attention. The purpose of this study is to analyze the implementation barriers of voluntary CBHI schemes in Bangladesh and the strategies to overcome these barriers from the perspective of national stakeholders.
Methods
This study is exploratory qualitative research, specifically case study design, using key informant interviews to investigate the barriers of CBHI that are faced during the implementation. Using a topic guide, we conducted thirteen semi-structured in-depth interviews with key stakeholders directly involved in the CBHI implementation process. The data were analyzed using the Framework analysis method.
Results
The implementation of CBHI schemes in Bangladesh is being constrained by several issues, including inadequate population coverage, adverse selection and moral hazard, lack of knowledge about health insurance principles, a lack of external assistance, and insufficient medical supplies. Door-to-door visits by local community-health workers, as well as regular promotional and educational campaigns involving community influencers, were suggested by stakeholders as ways to educate and encourage people to join the schemes. Stakeholders emphasized the necessity of external assistance and the design of a comprehensive benefits package to attract more people. They also recommended adopting a public–private partnership with a belief that collaboration among the government, microfinance institutions, and cooperative societies will enhance trust and population coverage in Bangladesh.
Conclusions
Our research concludes that systematically addressing implementation barriers by including key stakeholders would be a significant reform to the CBHI model, and could serve as a foundation for the planned national health protection scheme for Bangladesh leading to universal health coverage.
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Hasan MZ, Ahmed MW, Mehdi GG, Khan JAM, Islam Z, Chowdhury ME, Ahmed S. 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. BMC Health Serv Res 2022; 22:885. [PMID: 35804366 PMCID: PMC9270808 DOI: 10.1186/s12913-022-08254-1] [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: 01/19/2022] [Accepted: 06/24/2022] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Md Zahid Hasan
- Health Systems and Population Studies Division, Health Economics and Financing, icddr,b, 68 Shahid Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh. .,Leeds Institute of Health Sciences, University of Leeds, 6 Clarendon Way, Woodhouse, LS2 9NL, Leeds, UK.
| | - Mohammad Wahid Ahmed
- Health Systems and Population Studies Division, Health Economics and Financing, icddr,b, 68 Shahid Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Gazi Golam Mehdi
- Health Systems and Population Studies Division, Health Economics and Financing, icddr,b, 68 Shahid Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Jahangir A M Khan
- Health Economics and Policy Unit, School of Public Health and Community Medicine, University of Gothenburg, Medicinaregatan 18A, 405 30, Gothenburg, Sweden
| | - Ziaul Islam
- Health Systems and Population Studies Division, Health Economics and Financing, icddr,b, 68 Shahid Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Mahbub Elahi Chowdhury
- Health Systems and Population Studies Division, Health Economics and Financing, icddr,b, 68 Shahid Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Sayem Ahmed
- Health Economics and Health Technology Assessment (HEHTA), Institute of Health & Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow, G12 8RZ, UK
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A mixed-methods study on health learning materials utilization for COVID-19 risk communication and community engagement among health workers in Arsi Zone, Ethiopia: Implication for response to pandemic. PLoS One 2022; 17:e0269574. [PMID: 35671317 PMCID: PMC9173612 DOI: 10.1371/journal.pone.0269574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 05/23/2022] [Indexed: 11/19/2022] Open
Abstract
Background Risk communication and community engagement are among the key strategies used in response to pandemics. Effective risk communication and community engagement can be achieved when assisted by health learning materials. However, their utilization was not known in Ethiopia. Therefore, the present study aimed to assess the utilization of COVID-19 health learning materials (HLMs), and explore barriers and facilitating factors. Methods A sequential explanatory mixed-methods study consisting of two phases was carried out. The first phase was a cross-sectional survey to assess the utilization of COVID-19 HLMs and their predictors. In this phase, a multistage sampling technique was used to select 530 health workers. A self-administered structured questionnaire was used for data collection. Epi-data manager version 4.6.0.2 and STATA version 16 were used for data entry and analyses, respectively. Descriptive analyses were carried out as necessary. Ordinal logistic regression analyses were done to identify the predictors of COVID-19 HLMs utilization. Phase two is a qualitative study to explore enablers and barriers to COVID-19 HLMs utilization. A judgmental sampling technique was used and 14 key informants were recruited. The collected data were uploaded into Atlas ti version 7.0.71. An inductive process of thematic analysis was employed and the data were coded, categorized, and thematized. Results Findings showed that out of the total 530 respondents, 210(39.6%), 117(22.1%), and 203(38.3%) of them never use COVID-19 HLMs, use sometimes, and always, respectively. Health workers’ perceived quality of COVID-19 HLMs [AOR = 6.44 (95% CI: 4.18–9.94)], health workers’ perceived usefulness of COVID-19 HLMs [AOR = 2.82 (95% CI: 1.88–4.22)], working facility [AOR = 1.83 (95% CI: 1.07–3.14)], educational level of the respondents [AOR = 1.73 (95% CI: 1.11–2.72)] and availability of COVID-19 HLMs [AOR = 1.45(95% CI: 1.01–2.08)] had statistically significant association with the utilization status of COVID-19 HLMs. Findings from the qualitative study showed that materials-related factors, and structure and health workers-related factors had influence on HLMs utilization. Conclusions In this study, we found that only a few of the respondents were regularly utilizing COVID-19 HLMs. Perceived quality, usefulness, and availability of HLMs, and health workers’ educational status and working facility determined the level of COVID-19 HLMs utilization. There is a need for giving due attention to HLMs, evaluating their quality, availing them to health facilities, and providing training for health workers.
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Acharya D, Devkota B, Kreps GL. Does perceived susceptibility and severity of health problems serve as drivers for household enrolment in health insurance? A case study from Nepal. Int J Health Plann Manage 2022; 37:839-853. [PMID: 34719054 DOI: 10.1002/hpm.3377] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 03/02/2021] [Accepted: 10/21/2021] [Indexed: 12/31/2022] Open
Abstract
This study was conducted from a behaviour change perspective to assess the association between the constructs of Health Belief Model and enrolment in health insurance (HI). A cross-sectional study was conducted among 810 households in Kailali and Baglung districts. The study used personal interviews to collect data. Perceived susceptibility, severity of diseases, benefits of enrolment, causes of non-enrolment, interaction with peers/neighbours, and family member's approval to enrol were independent variables and enrolment in HI served as dependent variable. More than half (52%) of the respondents evaluated themselves as not susceptible to health problems. The severity of the health problem was perceived as an economic burden. General treatment and reduction of financial load were perceived as the main benefits of enrolment. Economic status was described as the main barrier to enrol. A vast majority of the respondents had been invited to enrol, and 73% agreed to enrol. Perceived susceptibility and severity of health problems were significantly associated with HI enrolment but were not significant predictors. However, peers' requests to register in HI, discussion with relatives, and family members' approval to enrol were the most significant predictors enrolment. These factors could be incorporated into future intervention plans for increasing enrolment in HI.
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Affiliation(s)
- Devaraj Acharya
- Bhairahawa Multiple Campus, Tribhuvan University, Siddharthanagar, Bhairahawa, Nepal
| | - Bhimsen Devkota
- Mahendra Ratna Campus, Tribhuvan University, Kathmandu, Nepal
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Osei Afriyie D, Krasniq B, Hooley B, Tediosi F, Fink G. Equity in health insurance schemes enrollment in low and middle-income countries: A systematic review and meta-analysis. Int J Equity Health 2022; 21:21. [PMID: 35151323 PMCID: PMC8841076 DOI: 10.1186/s12939-021-01608-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 12/10/2021] [Indexed: 01/11/2023] Open
Abstract
Background Ensuring access to essential quality health services and reducing financial hardship for all individuals regardless of their ability to pay are the main goals of universal health coverage. Various health insurance schemes have been recently implemented in low- and middle-income countries (LMICs) to achieve both of these objectives. We systematically reviewed all available literature to assess the extent to which current health insurance schemes truly reach the poor and underserved populations in LMICs. Methods In the systematic review, we searched on PubMed, Web of Science, EconLit and Google Scholar to identify eligible studies which captured health insurance enrollment information in LMICs from 2010 up to September 2019. Two authors independently selected studies, extracted data, and appraised included studies. The primary outcome of interest was health insurance enrollment of the most vulnerable populations relative to enrollment of the best-off subgroups. We classified households both with respect to their highest educational attainment and their relative wealth and used random-effects meta-analysis to estimate average enrollment gaps. Results 48 studies from 17 countries met the inclusion criteria. The average enrollment rate into health insurance schemes for vulnerable populations was 36% with an inter-quartile range of 26%. On average, across countries, households from the wealthiest subgroup had 61% higher odds (95% CI: 1.49 to 1.73) of insurance enrollment than households in the poorest group in the same country. Similarly, the most educated groups had 64% (95% CI: 1.32 to 1.95) higher odds of enrollment than the least educated groups. Conclusion The results of this study show that despite major efforts by governments, health insurance schemes in low-and middle-income countries are generally not reaching the targeted underserved populations and predominantly supporting better-off population groups. Current health insurance designs should be carefully scrutinized, and the extent to which health insurance can be used to support the most vulnerable populations carefully re-assessed by countries, which are aiming to use health insurance schemes as means to reach their UHC goals. Furthermore, studies exploring best practices to include vulnerable groups in health insurance schemes are needed. Registration Not available Supplementary Information The online version contains supplementary material available at 10.1186/s12939-021-01608-x.
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Acharya D, Devkota B, Kreps GL. The association between media exposure and enrollment in health insurance in Nepal: Implications for health policy. WORLD MEDICAL & HEALTH POLICY 2021. [DOI: 10.1002/wmh3.437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Devaraj Acharya
- Faculty of Education Tribhuvan University Kirtipur, Kathmandu Nepal
| | | | - Gary L. Kreps
- Center for Health and Risk Communication at George Mason University Fairfax Virginia USA
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Kalolo A, Gautier L, Radermacher R, Srivastava S, Meshack M, De Allegri M. Factors influencing variation in implementation outcomes of the redesigned community health fund in the Dodoma region of Tanzania: a mixed-methods study. BMC Public Health 2021; 21:1. [PMID: 33388037 PMCID: PMC7777388 DOI: 10.1186/s12889-020-10013-y] [Citation(s) in RCA: 353] [Impact Index Per Article: 117.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 12/06/2020] [Indexed: 01/13/2023] Open
Abstract
Introduction Micro-health insurance (MHI) has been identified as a possible interim solution to foster progress towards Universal Health Coverage (UHC) in low- and middle- income countries (LMICs). Still, MHI schemes suffer from chronically low penetration rates, especially in sub-Saharan Africa. Initiatives to promote and sustain enrolment have yielded limited effect, yet little effort has been channelled towards understanding how such initiatives are implemented. We aimed to fill this gap in knowledge by examining heterogeneity in implementation outcomes and their moderating factors within the context of the Redesigned Community Health Fund in the Dodoma region in Tanzania. Methods We adopted a mixed-methods design to examine implementation outcomes, defined as adoption and fidelity of implementation (FOI) as well as their moderating factors. A survey questionnaire collected individual level data and a document review checklist and in-depth interview guide collected district level data. We relied on descriptive statistics, a chi square test and thematic analysis to analyse our data. Results A review of district level data revealed high adoption (78%) and FOI (77%) supported also by qualitative interviews. In contrast, survey participants reported relatively low adoption (55%) and FOI (58%). Heterogeneity in adoption and FOI was observed across the districts and was attributed to organisational weakness or strengths, communication and facilitation strategies, resource availability (fiscal capacity, human resources and materials), reward systems, the number of stakeholders, leadership engagement, and implementer’s skills. At an individual level, heterogeneity in adoption and FOI of scheme components was explained by the survey participant’s level of education, occupation, years of stay in the district and duration of working in the scheme. For example, the adoption of job description was statistically associated with occupation (p = 0.001) and wworking in the scheme for more than 20 months had marginal significant association with FOI (p = 0.04). Conclusion The study demonstrates that assessing the implementation processes helps to detect implementation weaknesses and therefore address such weaknesses as the interventions are implemented or rolled out to other settings. Attention to contextual and individual implementer elements should be paid in advance to adjust implementation strategies and ensure greater adoption and fidelity of implementation. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-020-10013-y.
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Affiliation(s)
- Albino Kalolo
- Department of Public Health, St. Francis University College of Health and Allied Sciences, P.O. Box 175, Ifakara, Tanzania. .,Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Heidelberg, Germany.
| | - Lara Gautier
- Department of Sociology, Faculty of Arts, McGill University, Montreal, Canada
| | - Ralf Radermacher
- Deutsche Gesellschaft für Internationale Zusammenarbeit, 10/319, Mtendere Drive, Lilongwe, Malawi
| | - Siddharth Srivastava
- Swiss Tropical and Public Health Institute, Socinstrasse 57, P.O. Box CH-4002, Basel, Switzerland.,University of Basel, Petersplatz 1, P. O. Box 4001, Basel, Switzerland
| | - Menoris Meshack
- Health Promotion and System Strengthening (HPSS) Project, P.O Box 29, Dodoma, Tanzania
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Heidelberg, Germany
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Suchman L, Hashim CV, Adu J, Mwachandi R. Seeking care in the context of social health insurance in Kenya and Ghana. BMC Public Health 2020; 20:614. [PMID: 32366310 PMCID: PMC7197151 DOI: 10.1186/s12889-020-08742-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 04/20/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Social Health Insurance (SHI) is widely used by countries attempting to move toward Universal Health Coverage (UHC). While evidence suggests that SHI is a promising strategy for achieving UHC, low-income countries often struggle to implement and sustain SHI systems. It is therefore important to understand how SHI enrollees use health insurance and how it affects their health-seeking behavior. This paper examines how SHI affects patient decision-making regarding when and where to seek care in Kenya and Ghana, two countries with established SHI systems in sub-Saharan Africa. METHODS This paper draws from two datasets collected under the African Health Markets for Equity (AHME) program. One dataset, collected in 2013 and 2017 as part of the AHME qualitative evaluation, consists of 106 semi-structured clinic exit interviews conducted with patients in Ghana and Kenya. This data was analyzed using an inductive, thematic approach. The second dataset was collected internally by the AHME partner organizations. It derives from a cross-sectional survey of social franchise clients at three social franchise networks supported by AHME. Data collection took place from February - May 2018 and in December 2018. RESULTS Many clients appreciated that insurance coverage made healthcare more affordable, reported seeking care more frequently when covered with SHI. Clients also noted that the coverage gave them access to a wider variety of providers, but rarely sought out SHI-accredited providers specifically. However, clients sometimes were charged for services that should have been covered by insurance. Due to a lack of understanding of SHI benefits, clients rarely knew they had been charged inappropriately. CONCLUSIONS Clients and providers would benefit from education on what is included in the SHI package. Providers should be monitored and held accountable for charging clients inappropriately; in Ghana this should be accompanied by reforms to make government financing for SHI sustainable. Since clients valued provider proximity and both Kenya and Ghana have a dearth of providers in rural areas, both countries should incentivize providers to work in these areas and prioritize accrediting rural facilities into SHI schemes to increase accessibility and reach.
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Affiliation(s)
- Lauren Suchman
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA.
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Ravit M, Ravalihasy A, Audibert M, Ridde V, Bonnet E, Raffalli B, Roy FA, N’Landu A, Dumont A. The impact of the obstetrical risk insurance scheme in Mauritania on maternal healthcare utilization: a propensity score matching analysis. Health Policy Plan 2020; 35:388-398. [PMID: 32003810 PMCID: PMC7195851 DOI: 10.1093/heapol/czz150] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2019] [Indexed: 01/24/2023] Open
Abstract
In Mauritania, obstetrical risk insurance (ORI) has been progressively implemented at the health district level since 2002 and was available in 25% of public healthcare facilities in 2015. The ORI scheme is based on pre-payment scheme principles and focuses on increasing the quality of and access to both maternal and perinatal healthcare. Compared with many community-based health insurance schemes, the ORI scheme is original because it is not based on risk pooling. For a pre-payment of 16-18 USD, women are covered during their pregnancy for antenatal care, skilled delivery, emergency obstetrical care [including caesarean section (C-section) and transfer] and a postnatal visit. The objective of this study is to evaluate the impact of ORI enrolment on maternal and child health services using data from the Multiple Indicator Cluster Survey (MICS) conducted in 2015. A total of 4172 women who delivered within the last 2 years before the interview were analysed. The effect of ORI enrolment on the outcomes was estimated using a propensity score matching estimation method. Fifty-eight per cent of the studied women were aware of ORI, and among these women, more than two-thirds were enrolled. ORI had a beneficial effect among the enrolled women by increasing the probability of having at least one prenatal visit by 13%, the probability of having four or more visits by 11% and the probability of giving birth at a healthcare facility by 15%. However, we found no effect on postnatal care (PNC), C-section rates or neonatal mortality. This study provides evidence that a voluntary pre-payment scheme focusing on pregnant women improves healthcare services utilization during pregnancy and delivery. However, no effect was found on PNC or neonatal mortality. Some efforts should be exerted to improve communication and accessibility to ORI.
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Affiliation(s)
- Marion Ravit
- Centre Population et Développement (CEPED), IRD (French Institute for Research on Sustainable Development), IRD-Université Paris Descartes, Universités Paris Sorbonne Cités, ERL INSERM SAGESUD, 45 rue des Saints-Pères, 75006 Paris, France
| | - Andrainolo Ravalihasy
- Centre Population et Développement (CEPED), IRD (French Institute for Research on Sustainable Development), IRD-Université Paris Descartes, Universités Paris Sorbonne Cités, ERL INSERM SAGESUD, 45 rue des Saints-Pères, 75006 Paris, France
| | - Martine Audibert
- Université Clermont Auvergne, CNRS, CERDI, 63000 Clermont-Ferrand, France
| | - Valéry Ridde
- Centre Population et Développement (CEPED), IRD (French Institute for Research on Sustainable Development), IRD-Université Paris Descartes, Universités Paris Sorbonne Cités, ERL INSERM SAGESUD, 45 rue des Saints-Pères, 75006 Paris, France
- Institut de Recherche en Santé Publique de Montréal (IRSPUM), Canada/Ecole de Santé Publique de Montréal (ESPUM), H3N 1X9, Montreal, Canada
| | - Emmanuel Bonnet
- UMR IDEES CNRS 6266, Université de Normandie/IRD RESILIENCE 236, 14000 Caen, France
| | - Bertille Raffalli
- Centre Population et Développement (CEPED), IRD (French Institute for Research on Sustainable Development), IRD-Université Paris Descartes, Universités Paris Sorbonne Cités, ERL INSERM SAGESUD, 45 rue des Saints-Pères, 75006 Paris, France
| | - Flore-Apolline Roy
- UMR IDEES CNRS 6266, Université de Normandie/IRD RESILIENCE 236, 14000 Caen, France
| | - Anais N’Landu
- Université Clermont Auvergne, CNRS, CERDI, 63000 Clermont-Ferrand, France
| | - Alexandre Dumont
- Centre Population et Développement (CEPED), IRD (French Institute for Research on Sustainable Development), IRD-Université Paris Descartes, Universités Paris Sorbonne Cités, ERL INSERM SAGESUD, 45 rue des Saints-Pères, 75006 Paris, France
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Examining purchasing reforms towards universal health coverage by the National Hospital Insurance Fund in Kenya. Int J Equity Health 2020. [PMID: 32013955 DOI: 10.1186/s12939‐019‐1116‐x] [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 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.
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Mbau R, Kabia E, Honda A, Hanson K, Barasa E. Examining purchasing reforms towards universal health coverage by the National Hospital Insurance Fund in Kenya. Int J Equity Health 2020; 19:19. [PMID: 32013955 PMCID: PMC6998279 DOI: 10.1186/s12939-019-1116-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 12/23/2019] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Rahab Mbau
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, P.O. BOX 43640-00100, Nairobi, Kenya
| | - Evelyn Kabia
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, P.O. BOX 43640-00100, Nairobi, Kenya
| | | | - Kara Hanson
- London School of Hygiene and Tropical Medicine, London, UK
| | - Edwine Barasa
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, P.O. BOX 43640-00100, Nairobi, Kenya
- Nuffield department of medicine, Oxford University, Oxford, UK
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Garedew MG, Sinkie SO, Handalo DM, Salgedo WB, Yitebarek Kehali K, Kebene FG, Waldemarium TD, Mengesha MA. Willingness to Join and Pay for Community-Based Health Insurance Among Rural Households of Selected Districts of Jimma Zone, Southwest Ethiopia. CLINICOECONOMICS AND OUTCOMES RESEARCH 2020; 12:45-55. [PMID: 32021339 PMCID: PMC6980847 DOI: 10.2147/ceor.s227934] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 01/03/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Globally, millions of people suffer and die because they do not have the money to pay for health care. A voluntary health insurance scheme is a prepayment mechanism to overcome the financial hardship of poor households. There is a high demand to determine the enrolment rate and ability to pay before scale-up of the scheme by the government to be sure of its feasibility and sustainability. OBJECTIVE To determine willingness to join and pay for a community-based health insurance scheme and associated factors among rural households of selected districts in Jimma Zone, 2018. METHODS A community-based cross-sectional study design was employed in selected districts of Jimma Zone, Ethiopia. Multistage simple random sampling was used to select 422 households. Data were collected using a semi-structured interviewer-administered questionnaire. A double bounded contingent valuation method was applied to elicit households' willingness to pay for the scheme. Data were entered into Epi-Data 3.1 and analyzed with SPSS V.23. A binary logistic regression model was fitted to determine the presence of statistically significant associations between the dependent and independent variables at p-value <0.05 and AOR values with 95% CI. RESULTS Of 422 sampled respondents, 389 participated in this study with a response rate of 92%. Of these, 305 (78%) were willing to join and 274 (90%) of them were willing to pay. The average amount of money the households were willing to pay per household per annum was 228 ETB (8.27 USD), with a range of 100-500 ETB. The older age groups, poor households, and experience of local risk-sharing schemes were found to be determinants for willingness to join the community-based health insurance. Similarly, having a large family size, and low economic and education status of households were significant predictors of willingness to pay for this scheme. CONCLUSION A high proportion of households were willing to join and pay for the CBHI scheme. The average amount of money they were willing to pay for the scheme was very slightly lower than what is planned by the government. Thus, the government of Ethiopia should strengthen efforts to scale up this scheme in the rural areas of the country specifically to districts not yet enrolled, to reduce direct out-of-pocket payment at service delivery points. This will also contribute to guaranteeing dwellers of rural areas access to quality health services without facing financial hardship, to achieve universal health coverage for all by the end of 2035.
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Affiliation(s)
- Muluneh Getachew Garedew
- Department of Health Policy and Management, Faculty of Public Health, Institute of Health, Jimma University, Jimma, Ethiopia
| | - Shimeles Ololo Sinkie
- Department of Health Policy and Management, Faculty of Public Health, Institute of Health, Jimma University, Jimma, Ethiopia
| | - Dejene Melese Handalo
- Department of Health Policy and Management, Faculty of Public Health, Institute of Health, Jimma University, Jimma, Ethiopia
| | - Waju Beyene Salgedo
- Department of Health Policy and Management, Faculty of Public Health, Institute of Health, Jimma University, Jimma, Ethiopia
| | - Kidus Yitebarek Kehali
- Department of Health Policy and Management, Faculty of Public Health, Institute of Health, Jimma University, Jimma, Ethiopia
| | - Feyera Gebissa Kebene
- Department of Health Policy and Management, Faculty of Public Health, Institute of Health, Jimma University, Jimma, Ethiopia
| | - Tesfaye Dagne Waldemarium
- Department of Health Policy and Management, Faculty of Public Health, Institute of Health, Jimma University, Jimma, Ethiopia
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Sanogo NA, Yaya S. Wealth Status, Health Insurance, and Maternal Health Care Utilization in Africa: Evidence from Gabon. BIOMED RESEARCH INTERNATIONAL 2020; 2020:4036830. [PMID: 32461984 PMCID: PMC7212326 DOI: 10.1155/2020/4036830] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 11/18/2019] [Accepted: 12/18/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND To achieve the universal health coverage among other Sustainable Development Goals, African countries have shown the commitment by implementing strategies to improve access and coverage of health care services whose access is still very low. The achievement of universal health care requires the provision and availability of an adequate financing system. This study explored the wealth-related association of compulsory health insurance on maternal health care utilization in Gabon. METHODS The study used the 6th round of Gabon Demographic and Health Surveys (GDHSs)-2012 data to explore three outcome measures of maternal health care utilization extracted on number of antenatal care (ANC) visits during pregnancy, place of birth delivery, and postnatal health care. The dependent variable was women with health insurance coverage against those without. Logistic regression and propensity scoring matching analysed associations of health insurance coverage on women's utilization of health care. RESULTS Mean (+/- SD) age of women respondents of reproductive age was 29 years (9.9). The proportion of at least 4 antenatal care visits was 69.2%, facility-based delivery was 84.7%, and postnatal care utilization was 67.9%. The analysis of data showed disparities in maternal health care services utilization. The GDHS showed maternal age, and geographical region was significantly associated with maternal health care service utilization. A high proportion of urban dwellers and Christian women used maternal health care services. According to the wealth index, maternal health services utilization was higher in women from wealthy households compared to lower households wealth index (ANC (Conc. Index = 0.117; p ≤ 0.001), facility-based delivery (Conc. Index = 0.069; p ≤ 0.001), and postnatal care (Conc. Index = 0.075; p ≤ 0.001), respectively). With regard to health care insurance coverage, women with health insurance were more likely to use ANC and facility-based delivery services than those without (concentration indices for ANC and facility-based delivery were statistically significant; ANC: z-stat = 2.69; p=0.007; Conc. Index: 0.125 vs. 0.096 and facility-based delivery: z-stat = 3.38; p=0.001; Conc. Index: 0.076 vs. 0.053, respectively). CONCLUSION Women enrollment in health insurance and improved household's financial status can improve key maternal health services utilization.
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Nshakira-Rukundo E, Mussa EC, Nshakira N, Gerber N, von Braun J. Determinants of Enrolment and Renewing of Community-Based Health Insurance in Households With Under-5 Children in Rural South-Western Uganda. Int J Health Policy Manag 2019; 8:593-606. [PMID: 31657186 PMCID: PMC6819630 DOI: 10.15171/ijhpm.2019.49] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 06/09/2019] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The desire for universal health coverage in developing countries has brought attention to communitybased health insurance (CBHI) schemes in developing countries. The government of Uganda is currently debating policy for the national health insurance programme, targeting the integration of existing CBHI schemes into a larger national risk pool. However, while enrolment has been largely studied in other countries, it remains a generally under-covered issue from a Ugandan perspective. Using a large CBHI scheme, this study, therefore, aims at shedding more light on the determinants of households' decisions to enrol and renew membership in these schemes. METHODS We collected household data from 464 households in 14 villages served by a large CBHI scheme in southwestern Uganda. We then estimated logistic and zero-inflated negative binomial (ZINB) regressions to understand the determinants of enrolment and renewing membership in CBHI, respectively. RESULTS Results revealed that household's socioeconomic status, husband's employment in rural casual work (odds ratio [OR]: 2.581, CI: 1.104-6.032) and knowledge of health insurance premiums (OR: 17.072, CI: 7.027-41.477) were significant predictors of enrolment. Social capital and connectivity, assessed by the number of voluntary groups a household belonged to, was also positively associated with CBHI participation (OR: 5.664, CI: 2.927-10.963). More positive perceptions on insurance (OR: 2.991, CI: 1.273-7.029), access to information were also associated with enrolment and renewing among others. Burial group size and number of burial groups in a village, were all significantly associated with increased the likelihood of renewing CBHI. CONCLUSION While socioeconomic factors remain important predictors of participation in insurance, mechanisms to promote inclusion should be devised. Improving the participation of communities can enhance trust in insurance and eventual coverage. Moreover, for households already insured, access to correct information and strengthening their social network information pathways enhances their chances of renewing.
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Affiliation(s)
| | - Essa Chanie Mussa
- Department of Economics and Technological Change, Center for Development Research (ZEF), University of Bonn, Bonn, Germany
| | - Nathan Nshakira
- Department of Environmental and Public Health, Kabale University, Kabale, Uganda
| | - Nicolas Gerber
- Department of Economics and Technological Change, Center for Development Research (ZEF), University of Bonn, Bonn, Germany
| | - Joachim von Braun
- Department of Economics and Technological Change, Center for Development Research (ZEF), University of Bonn, Bonn, Germany
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Diop M, Kanouté A, Diouf M, Ndiaye AD, Lo CMM, Faye D, Cissé D. The role of health insurance in the coverage of oral health care in Senegal. J Public Health Afr 2018; 9:772. [PMID: 30854174 PMCID: PMC6379686 DOI: 10.4081/jphia.2018.772] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Accepted: 02/19/2018] [Indexed: 12/03/2022] Open
Abstract
Oral diseases costs are among the most expensive health care benefits. In Senegal, households contribute up to 37.6% of the national health spending through direct payments. The aim of this work was to study the role of health insurance in the coverage of oral health care in Senegal. The study was based on health insurance agents and policyholders. The study reveals that oral health care coverage through health insurance still does not meet requirements for treatment of oral infections. In financial terms, oral health care costs health insurance too much. As a result, carriers cover them partially. On top of that, the majority of the population's lack of knowledge about mutual, because they have a little background on oral health care, the latter weighs heavily on health insurance leading to the use of self-medication, traditional medicine and handicraft prosthetists. The analysis reveals an unequal access to oral health care through the health insurance system. To bring under control the expenditure for oral health care, carriers and dental surgeons must work together to raise the populations' awareness on community solidarity.
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Affiliation(s)
| | - Aida Kanouté
- Department of Odontology, Faculty of Medicine, Pharmacy and Odonto-Stomatology, University Cheikh Anta Diop of Dakar, Senegal
| | | | | | | | - Daouda Faye
- Department of Public Health Faculty of Medicine
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Fadlallah R, El-Jardali F, Hemadi N, Morsi RZ, Abou Samra CA, Ahmad A, Arif K, Hishi L, Honein-AbouHaidar G, Akl EA. Barriers and facilitators to implementation, uptake and sustainability of community-based health insurance schemes in low- and middle-income countries: a systematic review. Int J Equity Health 2018; 17:13. [PMID: 29378585 PMCID: PMC5789675 DOI: 10.1186/s12939-018-0721-4] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 01/08/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Community-based health insurance (CBHI) has evolved as an alternative health financing mechanism to out of pocket payments in low- and middle-income countries (LMICs), particularly in areas where government or employer-based health insurance is minimal. This systematic review aimed to assess the barriers and facilitators to implementation, uptake and sustainability of CHBI schemes in LMICs. METHODS We searched six electronic databases and grey literature. We included both quantitative and qualitative studies written in English language and published after year 1992. Two reviewers worked in duplicate and independently to complete study selection, data abstraction, and assessment of methodological features. We synthesized the findings based on thematic analysis and categorized according to the ecological model into individual, interpersonal, community and systems levels. RESULTS Of 15,510 citations, 51 met the eligibility criteria. Individual factors included awareness and understanding of the concept of CBHI, trust in scheme and scheme managers, perceived service quality, and demographic characteristics, which influenced enrollment and sustainability. Interpersonal factors such as household dynamics, other family members enrolled in the scheme, and social solidarity influenced enrollment and renewal of membership. Community-level factors such as culture and community involvement in scheme development influenced enrollment and sustainability of scheme. Systems-level factors encompassed governance, financial and delivery arrangement. Government involvement, accountability of scheme management, and strong policymaker-implementer relation facilitated implementation and sustainability of scheme. Packages that covered outpatient and inpatient care and those tailored to community needs contributed to increased enrollment. Amount and timing of premium collection was reported to negatively influence enrollment while factors reported as threats to sustainability included facility bankruptcy, operating on small budgets, rising healthcare costs, small risk pool, irregular contributions, and overutilization of services. At the delivery level, accessibility of facilities, facility environment, and health personnel influenced enrollment, service utilization and dropout rates. CONCLUSION There are a multitude of interrelated factors at the individual, interpersonal, community and systems levels that drive the implementation, uptake and sustainability of CBHI schemes. We discuss the implications of the findings at the policy and research level. TRIAL REGISTRATION The review protocol is registered in PROSPERO International prospective register of systematic reviews (ID = CRD42015019812 ).
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Affiliation(s)
- Racha Fadlallah
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
- Center for Systematic Review in Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon
| | - Fadi El-Jardali
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
- Center for Systematic Review in Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON Canada
| | - Nour Hemadi
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
- Center for Systematic Review in Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon
| | - Rami Z. Morsi
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Clara Abou Abou Samra
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Ali Ahmad
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Khurram Arif
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | - Lama Hishi
- Department of Health Management and Policy, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
| | | | - Elie A. Akl
- Center for Systematic Review in Health Policy and Systems Research (SPARK), American University of Beirut, Beirut, Lebanon
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON Canada
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
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Wang W, Temsah G, Mallick L. The impact of health insurance on maternal health care utilization: evidence from Ghana, Indonesia and Rwanda. Health Policy Plan 2017; 32:366-375. [PMID: 28365754 PMCID: PMC5400062 DOI: 10.1093/heapol/czw135] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2016] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Wenjuan Wang
- International Health and Development Division, ICF International, Rockville, MD, USA
| | - Gheda Temsah
- International Health and Development Division, ICF International, Rockville, MD, USA
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Kalolo A, Radermacher R, Stoermer M, Meshack M, De Allegri M. Factors affecting adoption, implementation fidelity, and sustainability of the Redesigned Community Health Fund in Tanzania: a mixed methods protocol for process evaluation in the Dodoma region. Glob Health Action 2015; 8:29648. [PMID: 26679408 PMCID: PMC4683988 DOI: 10.3402/gha.v8.29648] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Revised: 11/19/2015] [Accepted: 11/19/2015] [Indexed: 12/23/2022] Open
Abstract
Background Despite the implementation of various initiatives to address low enrollment in voluntary micro health insurance (MHI) schemes in sub-Saharan Africa, the problem of low enrollment remains unresolved. The lack of process evaluations of such interventions makes it difficult to ascertain whether their poor results are because of design failures or implementation weaknesses. Objective In this paper, we describe a process evaluation protocol aimed at opening the ‘black box’ to evaluate the implementation processes of the Redesigned Community Health Fund (CHF) program in the Dodoma region of Tanzania. Design The study employs a cross-sectional mixed methods design and is being carried out 3 years after the launch of the Redesigned CHF program. The study is grounded in a conceptual framework which rests on the Diffusion of Innovation Theory and the Implementation Fidelity Framework. The study utilizes a mixture of quantitative and qualitative data collection tools (questionnaires, focus group discussions, in-depth interviews, and document review), and aligns the evaluation to the Theory of Intervention developed by our team. Quantitative data will be used to measure program adoption, implementation fidelity, and their moderating factors. Qualitative data will be used to explore the responses of stakeholders to the intervention, contextual factors, and moderators of adoption, implementation fidelity, and sustainability. Discussion This protocol describes a systematic process evaluation in relation to the implementation of a reformed MHI. We trust that the theoretical approaches and methodologies described in our protocol may be useful to inform the design of future process evaluations focused on the assessment of complex interventions, such as MHI schemes.
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Affiliation(s)
- Albino Kalolo
- Institute of Public Health, Medical Faculty, University of Heidelberg, Heidelberg, Germany.,Department of Community Health, St. Francis University College of Health and Allied Sciences, Ifakara, Tanzania;
| | - Ralf Radermacher
- Deutsche Gesellschaft für Internationale Zusammenarbeit, Lilongwe, Malawi
| | | | - Menoris Meshack
- Health Promotion and System Strengthening (HPSS) project, Dodoma, Tanzania
| | - Manuela De Allegri
- Institute of Public Health, Medical Faculty, University of Heidelberg, Heidelberg, Germany
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Macha J, Kuwawenaruwa A, Makawia S, Mtei G, Borghi J. Determinants of community health fund membership in Tanzania: a mixed methods analysis. BMC Health Serv Res 2014; 14:538. [PMID: 25411021 PMCID: PMC4246628 DOI: 10.1186/s12913-014-0538-9] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Accepted: 10/20/2014] [Indexed: 11/29/2022] Open
Abstract
Background In many developing countries, initiatives are underway to strengthen voluntary community based health insurance as a means of expanding access to affordable care among the informal sector. However, increasing coverage with voluntary health insurance in low income settings can prove challenging. There are limited studies on determinants of enrolling in these schemes using mixed methods. This study aims to shed light on the characteristics of those joining a community health fund, a type of community based health insurance, in Tanzania and the reasons for their membership and subsequent drop out using mixed methods. Methods A cross sectional survey of households in four rural districts was conducted in 2008, covering a total of 1,225 (524 members of CHF and 701 non-insured) households and 7,959 individuals. In addition, 12 focus group discussions were carried out with CHF members, non-scheme members and members of health facility governing committees in two rural districts. Logistic regression was used to assess the determinants of CHF membership while thematic analysis was done to analyse qualitative data. Results The quantitative analysis revealed that the three middle income quintiles were more likely to enrol in the CHF than the poorest and the richest. CHF member households were more likely to be large, and headed by a male than uninsured households from the same areas. The qualitative data supported the finding that the poor rather than the poorest were more likely to join as were large families and of greater risk of illness, with disabilities or persons with chronic diseases. Households with elderly members or children under-five years were also more likely to enrol. Poor understanding of risk pooling deterred people from joining the scheme and was the main reason for not renewing membership. On the supply side, poor quality of public care services, the limited benefit package and a lack of provider choice were the main factors for low enrolment. Conclusions Determinants of CHF membership are diverse and improving the quality of health services and expanding the benefit package should be prioritised to expand voluntary health insurance coverage.
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Affiliation(s)
- Jane Macha
- Ifakara Health Institute, P.O BOX 78373, Plot 463, Kiko Ave., Mikocheni, Dar es Salaam, Tanzania.
| | - August Kuwawenaruwa
- Ifakara Health Institute, P.O BOX 78373, Plot 463, Kiko Ave., Mikocheni, Dar es Salaam, Tanzania.
| | - Suzan Makawia
- Ifakara Health Institute, P.O BOX 78373, Plot 463, Kiko Ave., Mikocheni, Dar es Salaam, Tanzania.
| | - Gemini Mtei
- Ifakara Health Institute, P.O BOX 78373, Plot 463, Kiko Ave., Mikocheni, Dar es Salaam, Tanzania.
| | - Josephine Borghi
- Ifakara Health Institute, P.O BOX 78373, Plot 463, Kiko Ave., Mikocheni, Dar es Salaam, Tanzania. .,London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.
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