Abstract
BackgroundSocial 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.MethodsThis 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.ResultsMany 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.ConclusionsClients 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.
Highlights
Social Health Insurance (SHI) is widely used by countries attempting to move toward Universal Health Coverage (UHC)
The participating franchise networks included the Amua and BlueStar franchises operated by Marie Stopes Kenya; NHIF: National hospital insurance scheme (Kenya) (MSK) and Marie Stopes Ghana (MSIG) respectively, and the Tunza franchise operated by Population Services Kenya (PS Kenya)
During the final round of Qualitative Evaluation (QE) interviews (2017), some clients in Kenya were especially grateful for the access their SHI coverage afforded them while the country’s public health doctors went on strike
Summary
Social Health Insurance (SHI) is widely used by countries attempting to move toward Universal Health Coverage (UHC). Social health insurance (SHI), which involves fund and risk pooling, is widely accepted. Suchman et al BMC Public Health (2020) 20:614 location is a common determinant of provider choice and frequency of visits [8,9,10] Despite their promise, SHI schemes often have difficulties achieving UHC. While evidence indicates that the introduction of an SHI scheme can significantly increase equity in financing and access to healthcare services [6, 11], factors such as mistrust in the public health system [12], a lack of transparency in government [13], low reenrollment rates [14], and a lack of sustainable funding [15] can hinder countries’ progress toward UHC. The question remains whether SHI schemes can continue to reasonably offer a large package of services to members within their limited risk pools without depleting funds [16]
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