Compulsory Health Insurance Scheme Research Articles

Market forces in healthcare insurance: The impact of healthcare reform on regulated competition revisited

AbstractThe Dutch healthcare insurance reform in 2006 replaced the dual system of public and private insurance with a single compulsory health insurance scheme, in which insurance providers compete for customers in a free market. This paper investigates whether competition among healthcare insurers has indeed increased and their efficiency has improved. We measure competition directly from either shifts in market shares, or developments in profits, using Dutch regulatory data. We find that a structural break occurs after the reform: competition is significantly higher after 2006 than before. This holds both for the analysis based on shifts in market shares and that based on profits. Several robustness tests confirm this outcome. Hence, the reform has had a significant impact. Nevertheless, we find that the health insurance sector is still less competitive than financial sectors such as banking and life insurance.

Willingness-to-pay for Health Insurance: A Comparative Study between Formal and Informal Health-Workers

_Introduction_ People in low- to middle-income countries, such as Bangladesh, have less access to healthcare than those in wealthier nations. Bangladeshi households spent approximately Tk 103.46 billion (US $1.49 billion) on out-of-pocket medical costs per year, accounting for 64.3% of total health expenditures. Bangladesh's informal sector employs 85.1% of the total workforce with limited to no health insurance. Less than 1% of Bangladesh's population, mostly those who work in the formal sector, have access to social health protection, which is 14.9% of all jobs. The current comparative study will determine the willingness-to-pay (WTP) for health insurance and associated factors between formal and informal health workers using the contingent valuation method. _Methods and analysis_ This comparative study of WTP and associated factors between formal and informal health workers using the contingent valuation method (CVM) will be conducted over a twelve-month period, from August 2022 to July 2023. A total of 250 health workers will be selected by a purposive sampling technique from various formal and informal work stations in Dhaka City. Out of 250 participants, 125 will be from the formal sector and 125 will be from the informal sector. To collect data, a semi-structured questionnaire will be used via face-to-face interviews. Data will be processed and analyzed using R (version 4.3.0), RStudio (2023.03.1 Build 446) using jmv and DCchoice packages. WTP for social health insurance will be estimated using the DCchoice package. This study will employ a logit model that will consist of a binary dependent variable with follow-up dichotomous choice. Different premium levels will be offered to each participant at different premium levels, to estimate the factors associated with joining the compulsory health insurance scheme. _Ethics and dissemination_ Ethical clearance was obtained from the Institutional Review Board (IRB) of the National Institute of Preventive and Social Medicine (NIPSOM) (Memo no: NIPSOM/IRB/2022/14 (1)) on 29 December 2022. Informed consent will be taken from each participant before data collection. Privacy and confidentiality of data will be maintained strictly. Participants will have full freedom to refuse to participate at any point in the study. The results of the study will be published in scientific, peer-reviewed journals. _Strengths and limitations of this study_ 1. The contingent valuation method is a well-established method of eliciting WTP for health insurance. 2. The current study will be among the first of its nature as it will focus on formal and informal healthcare workers. 3. Starting point bias may affect the result as this type of bias comes with the Double bounded dichotomous choice (DBDC) method used in this study.

Assessment of the design and implementation challenges of the National Health Insurance Scheme in Nigeria: a qualitative study among sub-national level actors, healthcare and insurance providers

BackgroundHealth insurance is an important mechanism to prevent financial hardship in the process of accessing health care. Since the launch of Nigeria’s National Health Insurance Scheme (NHIS) in 2005, only 5% of Nigerians have health insurance and 70% still finance their healthcare through Out-Of-Pocket (OOP) expenditure. Understanding the contextualized perspectives of stakeholders involved in NHIS is critical to advancing and implementing necessary reforms for expanding health insurance coverage at national and sub-national levels in Nigeria. This study explored the perspectives of sub-national level actors/stakeholders on the design and implementation challenges of Nigeria’s NHIS.MethodsA descriptive case study design was used in this research. Data were collected in Ibadan, Oyo State in 2016 from health insurance regulators, healthcare providers, and policymakers. Key informant interviews (KII) were conducted among purposively selected stakeholders to examine their perspectives on the design and implementation challenges of Nigeria’s National Health Insurance Scheme. Data were analysed using inductive and deductive thematic approaches with the aid of NVIVO software package version 11.ResultsImplementation challenges identified include abject poverty, low level of awareness, low interest (in the scheme), superstitious beliefs, inefficient mode of payment, drug stock-out, weak administrative and supervisory capacity. The scheme is believed to have provided more coverage for the formal sector, its voluntary nature and lack of legal framework at the subnational levels were seen as the overarching policy challenge. Only NHIS staff currently make required financial co-contribution into the scheme, as all other federal employees are been paid for by the (federal) government.ConclusionsSub-national governments should create legal frameworks establishing compulsory health insurance schemes at the subnational levels. Effective and efficient platforms to get the informal sector enrolled in the scheme is desirable. CBHI schemes and the currently approved state supported health insurance programmes may provide a more acceptable platform than NHIS especially among the rural informal sector. These other two should be promoted. Awareness and education should also be raised to enlighten citizens. Stakeholders need to address these gaps as well as poverty.

Market Forces in Healthcare Insurance: The Impact of Healthcare Reform on Regulated Competition Revisited

This paper investigates the impact of market forces on competitive behaviour and efficiency in healthcare by investigating the Dutch healthcare insurance reform in 2006. This reform replaced the dual system of public and private insurance with a single compulsory health insurance scheme, in which insurance providers compete for customers in a free market. We measure competition directly from either shifts in market shares, or developments in profits. Using formal tests we find that in each approach a structural break occurs after the reform: competition is significantly higher after 2006 than before. Several robustness tests confirm this outcome. Nevertheless, we find that the health insurance sector is still less competitive than the banking, manufacturing and service industries, and even less competitive than life insurance.

Impact of population ageing on medical consumption: compulsory health insurance in Morocco

Introductionles régimes d'assurance maladie obligatoire des salariés des secteurs public et privé connaissent, d'une part, une croissance continue des dépenses médicales, et d'autre part, une augmentation de la part de la population couverte ayant plus de 60 ans. L'objectif de cet article est d'analyser l'impact du vieillissement sur la dépense moyenne par personne bénéficiant de la couverture médicale.Méthodesnous avons effectué le test de Kruskal-Wallis afin de tester si il y a une différence significative entre les populations - de différents groupes d'âge - en matière de consommation médicale selon que la personne est touchée ou non par une affection de longue durée. Ont été effectuées également des analyses d'autres indicateurs à savoir la part de la population souffrant d'une affection de longue durée et recourant aux soins, la dépense moyenne par personne touchée par une affection de longue durée et la dépense moyenne par personne couverte non touchée par une affection de longue durée aussi bien pour les personnes ayant moins de 60 ans que celles ayant plus de 60 ans.Résultatsle test de Kruskal-Wallis a montré que l'âge est une variable explicative de la dépense moyenne par personne couverte. L'examen de l'évolution des principales composantes de la dépense moyenne a permis de mettre en évidence d'autres facteurs.Conclusionle vieillissement démographique contribuerait à la hausse de la consommation médicale et il existe d'autres facteurs dont l'impact sur l'augmentation des dépenses n'est pas moins important.

Exploring Factors That Influence the Uptake of Maternal Health Care Services by Women in Zimbabwe

The study investigated factors that influence the uptake of maternal healthcare services by women in Zimbabwe, using a logit model. Data from the Zimbabwe Demographic Health Survey (ZDHS, 2015) was used. Deteriorating maternal health indicators motivated the study. The effect of socio-economic and demographic factors on the probability of utilising maternal healthcare services was examined. Descriptive statistics and a logit model were used for data analysis. Results from the logit model show that region of residence, insurance cover, educational level, employment status, maternal age, birth order, place of residence, number of living children, maternal age and household income all influence the utilisation of maternal healthcare services by women in Zimbabwe. Basing on research findings, the study recommends that relevant authorities make more available vocational training centres and education institutions since education was found to influence the uptake of maternal healthcare services. There is need to encourage family planning so as to reduce the number of children, especially among the apostolic sect, which affects the uptake of maternal healthcare. Compulsory national health insurance schemes could be adopted to mitigate the effect of low income that discourages the use of institutional facilities for delivery. The issue of balanced regional development needs to be pursued through accelerating devolution to ensure equal access to maternal healthcare facilities in all provinces.

Factors Affecting Enrollment in Government Health Insurance Program in Kailali District.

Health care financial burden on households is high in Nepal. High health care expenditure is a major obstacle in achieving universal health coverage. The health insurance is expected to reduce healthcare expenditure. However, only small segments of the population are covered by health insurance in Nepal.This study assessed the factors affecting enrollment in government health insurance program in the first piloted district, Kailali, Nepal. A cross-sectional survey was conducted among 1048 households located in 26 wards of Kailali district after 21 months of the implementation of social health insurance program, Nepal. The sample was selected in two stages, first stage being the selection of wards and second, being the households. The higher level of household economic status was associated with increased odds of enrollment in health insurance program (ORs=4.99, 5.04, 5.13, 8.05, for second, third, fourth, and the highest quintile of households, respectively). A higher level of head's education was associated with increased odds of health insurance enrollment (ORs = 1.58, 1.78, 2.36, for primary, secondary, tertiary education, respectively). Presence of chronic illness in the household was positively associated with increased odds of health insurance enrollment (OR= 1.29). The poor and low educated groups were less benefited by social health insurance program in Kailali district, Nepal. Hence, policymakers should focus to implement income-based premium scheme for ensuring equal access to healthcare.Since household with chronic illness leads to high odds of being enrolled, a compulsory health insurance scheme can make the program financially sustainable.

Diabetic and cardiovascular patients\u2019 willingness to pay for upcoming national health insurance scheme in C\xf4te d\u2019Ivoire

BackgroundCôte d’Ivoire’s current health care financing system results from successive reforms undertaken with government funding and international support. The country is moving towards a national compulsory health insurance scheme. This context offered an opportunity to study additional features of health insurance’s potential market in Sub-Sahara Africa developing economy. This study examined patients’ willingness to pay in order to get access to health care when it is needed.MethodsA cross-sectional study was carried out in four tertiary level teaching hospitals from October to December 2017. These hospitals are located in Bouake (service of cardiology) and in Abidjan (two services of Endocrinology-Diabetology and Institute of Cardiology). Monthly willingness to pay was elicited using the contingent valuation method through a bidding game pre-tested interviewer-administered questionnaire. Multinomial logistic regression analysis was performed to predict participants’ willingness to pay.ResultsOut of 450 participants included in the analysis, 22.2% were not willing to pay at least 4.5 euros per month while 7.6%, 26.9%, 29.6%, 5.3% and 8.4% stated to be willing to pay 4.5, 7.5, 15, 30, and 45 euros per month, respectively. Males were 2.3 and 2.5 times more likely to be willing to pay 4.5 or 7.5 and 30 or 45 euros, respectively. However, there was no statistically significant difference between males and females who stated being willing to pay a premium of 15 euros per month as compared to the participants in the reference modality, below 4.5 euros.ConclusionsThe findings indicated that the amount that participants were willing to pay is consistent with other previously elicited. The association of sex with the willingness to pay suggested what might influence the acceptability of and the contribution to the upcoming compulsory health insurance scheme. These pointed out that some market features have to be understood for a successful implementation of this social health insurance scheme.

Competition and Scale Economy Effects of the Dutch 2006 Health-Care Insurance Reform

This paper investigates competitive behaviour and scale economies of the health-care insurance market in the Netherlands over the period 1995–2012. We focus on the impact on the market structure of the 2006 health-care reform, which replaced the dual system of public and private insurance with a single compulsory health insurance scheme in which insurance providers compete for customers in a free market. We start with estimating unused scale economies and find that, after the health-care reform in 2006, unused scale economies at around 20 per cent are much higher than before the reform (4 per cent), pointing to a relative increase of fixed costs. Our interpretation of this change is that fixed costs increased after the reform, as insurers now have to monitor care providers and negotiate with them about lower prices or higher quality. To measure competition directly, we apply a novel approach that estimates the impact of marginal costs as an indicator of inefficiency on either market shares or net profits. Over time, competition in health insurance has increased significantly, but reform-induced market turbulences in 2006 caused a fall in the average level of competitive pressure. After the reform, competition continued to improve.

Health Care Insurance System in the Republic of Albania and Development Perspective

Health is a critical component of sustainable human development. It is an important part of people’s physical, mental and social well being, and at the same time it has a long-term impact on social and economic development. In the framework of the government's strategy regarding the improvement and strengthening of health services is establish a mandatory health care insurance scheme in Albania. The right to health care is a fundamental right of a social – economic character and aims respect of human rights, equality and social justice. Albanian model of health insurance has realized this right preferring to keep in harmony legislation and institutions responsible for the organization and implementation of the right to health insurance. The compulsory health insurance scheme intends coverage of the population with health care services and specifies the main principles on which the health insurance scheme is set up, that is contributions and the principle of solidarity.In this paper, we analyze the recent developments and current situation related to legal and institutional bases for health care insurance system development in the Republic of Albanian, as well as to reach recommendations for its improvement in the near future. DOI: 10.5901/jesr.2015.v5n1p49

Informal patient payments in publicly financed healthcare facilities in Lithuania.

Since the late 1990s Lithuania has had a mixed, solidary based healthcare system, predominantly funded from the National Health Insurance Fund through a compulsory health insurance scheme. The cultural tradition of informal payments in healthcare in Lithuania was inherited from the Soviet past and is still alive. This study reveals the extent and nature of informal patient payments, and identifies the motivation behind those payments occurring in publicly financed healthcare facilities in Lithuania. The quantitative household survey design was chosen for this study. The randomly selected sample was comprised of inhabitants aged 18 years and older, representing the entire population of Lithuania by county, place of residence (urban and rural), age and sex. The study sample consisted of 1067 participants interviewed in 2009 and 2010, and 1068 in 2011 (response rate ranged from 66.6% to 68.2%). Users of healthcare services usually made informal payments for the visit to, and consultation with, a general practitioner or physician specialist and for diagnostic services. Females and older citizens, the disabled, public/private sector employees, retirees, those with higher education and those in the highest household monthly income group were more prone to pay informally for health services. The majority of respondents were against formalization of informal patient payment. National health insurance payments for healthcare services from the formal public fund for healthcare are further augmented by informal payments from service consumers, used routinely for better access to and higher quality of healthcare service.

The policy of free healthcare for children under the age of 6 years in Vietnam: assessment of the uptake for children hospitalised with acute diarrhoea in Ho Chi Minh City

ObjectiveTo assess the proportion of, and reasons for, households not utilising the policy of free healthcare for children under 6 years of age (FCCU6) for hospitalisation with diarrhoea, and assess the risk of catastrophic expenditure for households that forgo FCCU6 and pay out of pocket.MethodsInvoices detailing insurance information and charges incurred from 472 hospitalised diarrhoeal cases in one paediatric hospital in Ho Chi Minh City were retrieved. Hospital charges and the utilisation of elective services were analysed for patients utilising and not utilising FCCU6. Associations between socio-economic factors with non-utilisation of FCCU6 were evaluated.ResultsOverall, 29% of patients were FCCU6 non-users. The FCCU6 non-users paid a median hospital charge of $29.13 (interquartile range, IQR: $18.57–46.24), consuming no more than 1.4% of a medium-income household's annual income. Seventy per cent of low-income FCCU6 non-users utilised less-expensive elective services, whereas only 43% of medium income patients and 21% of high-income patients did (P = 0.036). Patients from larger households and those with a parent working in government were more likely to use FCCU6.ConclusionsThe rate of FCCU6 non-usage in this study population was 29%. A significant proportion of those that did not use FCCU6 was from lower income households and may perceive a justifiable cost–benefit ratio when forgoing FCCU6. Although a single diarrhoeal hospitalisation is unlikely to induce a catastrophic expenditure, FCCU6 non-usage may disproportionately increase the risk of catastrophic expenditure for lower income households over multiple illnesses.

Changing Origins of Inequalities in Access to Health Care Services in Turkey: From Occupational Status to Income

AbstractHealth care reforms have always been critical political arenas within which the parameters of citizens' access to health care services and thus the new terms of social bargain that backs social policies are negotiated. Despite the relative success of Turkey in establishing public health insurance schemes and developing a public capacity for health care service delivery since the late 1940s, Turkey's health care system has largely failed to institute equality of access to health care services. With the promise of abolishing the inequalities, the ruling Justice and Development Party (AKP) launched Turkey's Health Transformation Program in 2003. Since then, Turkey's health care system has been undergoing a significant transformation. On the one hand, with the unification of all public health insurance schemes under a compulsory universal health insurance scheme and the equalization of benefit packages for all publicly insured, the program has succeeded in abolishing the occupational status-based inequalities in access to health care services. On the other, this article suggests that the program has changed the main origin of inequalities in service access from occupational status to income. As the country suffers from an uneven distribution of income, it is argued that these incomebased inequalities in access pose a significant threat to the realization of the social citizenship ideal in Turkey.

Risk equalisation and voluntary health insurance markets: The case of Australia

In April 2007, Australia introduced a risk equalisation (RE) scheme (de facto a claims equalisation scheme), which replaced an extant reinsurance scheme that had operated since 1976. This scheme is one of a number of policy measures that the Australian Government has instituted to support the voluntary private health insurance (PHI) market which is subject to mandatory community rating and the attendant problem of selection. The latter has been a persistent concern in the Australian PHI market since the introduction of Australia's universal, compulsory national health insurance scheme Medicare. This paper presents a brief overview of Australia's health care financing arrangements and, in particular, focuses on the history, structure and functioning of the RE scheme. It provides an exposition of the operation of the scheme and empirical evidence of the scheme's effects in its first full year of operation, 2007-08. The paper makes three contributions: first, it provides the only detailed overview of the functioning of the Australian RE scheme published to date; second, it presents the first empirical measures of the scheme's operation at the level of the 38 individual PHI funds; and third, it describes the systematic differences in the scheme's operation with respect to large and small funds. Thus, this paper provides a number of insights into the operation and outcomes of the Australian RE scheme following its first year of operation.

Public health insurance in Uganda still only a dream

Three months ago, Uganda planned to launch a compulsory public health insurance scheme, the first in the country. It didn't happen. The plan was to initially cover about 2 million employed Ugandans (6% of the population), including 300 000 government workers. Employees would have contributed about

THE GROSS PRICES OF PRIVATE FEE‐FOR‐SERVICE PSYCHIATRIC SERVICES UNDER MEDICARE IN SIX AUSTRALIAN REGIONS 1984–2001

The subsidies available for medical services under Australia's national compulsory and universal health insurance scheme (Medicare) exist to improve ‘equality of access’. This study empirically analyses the gross prices in one medical industry, private fee‐for‐service (FFS) psychiatry, across six Australian regions. Quarterly time‐series data on the average gross prices are examined to determine statistically the extent to which these prices have been constant through time, and spatially uniform. The gross price outcomes of the market(s) in which uniform subsidies apply provide, in part, an indication of whether uniform spatial ‘access’ to psychiatric services is achieved under Medicare.

Financial incentives and psychiatric services in Australia: an empirical analysis of three policy changes

Australia has a national, compulsory and universal health insurance scheme, called Medicare. In 1996 the Government changed the Medicare Benefit Schedule Book in such a way as to create different financial incentives for consumers or producers of out-of-hospital private psychiatric services, once an individual consumer had received 50 such services in a 12-month period. The Australian Government introduced a new Item (319) to cover some special cases that were affected by the policy change. At the same time, the Commonwealth introduced a 'fee-freeze' for all medical services. The purpose of this study is two-fold. First, it is necessary to describe the three policy interventions (the constraints on utilization, the operation of the new Item and the general 'fee-freeze'.) The new Item policy was essentially a mechanism to 'dampen' the effect of the 'constraint' policy, and these two policy changes will be consequently analysed as a single intervention. The second objective is to evaluate the policy intervention in terms of the (stated) Australian purpose of reducing utilization of psychiatric services, and thus reducing financial outlays. Thus, it is important to separate out the different effects of the three policies that were introduced at much the same time in November 1996 and January 1997. The econometric results indicate that the composite policy change (constraining services and the new 319 Item) had a statistically significant effect. The analysis of the Medicare Benefit (in constant prices) indicates that the 'fee-freeze' policy also had a statistically significant effect. This enables separate determination of the several policy changes. In fact, the empirical results indicate that the Commonwealth Government underestimated the 'savings' that would arise from the 'constraint' policy.

Reports from Taiwan

Taiwan is a small island of 36 000 km2 with a total population of 21 million. On 1 March 1995, the Taiwan government inaugurated a universal compulsory national health insurance...

Taiwan's 1995 health care reform

Under considerable domestic political pressure, the Taiwan government inaugurated a compulsory universal health insurance scheme on 1 March 1995. This new scheme is financed mainly by payroll tax and provides comprehensive health care benefits with a moderate cost sharing. In order to gain efficiency in delivering health services, the scheme enters contracts with health care providers and has been developing a prospective payment system. Mean-while, the scheme uses a uniform fee schedule and makes all payments through a public single-payer system to control health care costs. By the end of the inaugural year, the scheme covered 92% of the population and the utilization pattern of the newly insured became close to that of the previously insured. However, there is the beginning of a financial crisis because the payments of the scheme are rapidly increasing and expect to exceed the premiums in the coming year. Besides, the scheme did not bring in the efficient use of health care resources and probably caused it to worsen. Taiwan's health care reform has an unfinished agenda.

Employer's willingness to pay: the case for compulsory health insurance in Tanzania.

This article documents employers' expenditure on the arrangements for the health care of their employees in one of the least developed countries; Tanzania. The case for compulsory health insurance is considered in the light of the fact that only 3% of the population is employed in the formal sector and could be covered at first. It is shown from a survey of larger employers, outside government, that they were spending on average 11% of payroll on health care for their employees. This demonstrated their lack of satisfaction with the government health services. Nevertheless, those who could readily be covered by insurance were making considerable use of the more expensive government hospital services. It is argued that a compulsory health insurance scheme could be introduced for the formal sector of employment which would cover a wider range of health services at lower cost. The scheme would also have the desirable economic effect of lowering employers' labour costs while making it possible to improve the standards of the government health services.