Prepayment Schemes Research Articles

Health Care Financing in Asia

This article examines the major elements of health care financing such as financial risk protection, resource generation, resource pooling, and purchasing and payment; provides key lessons; and discusses the challenges for health care financing systems of Asian countries. With the exception of Japan, Korea, Taiwan, and Thailand, most health care systems of Asia provide very limited financial risk protection. The role of public prepaid schemes such as tax and social health insurance is minimal, and out-of-pocket payment is a major source of financing. The large informal sector is a major challenge to the extension of population coverage in many low-income countries of Asia, which must seek the optimal mix of tax subsidy and health insurance for universal coverage. Implementation of effective payment systems to control the behavior of health care providers is also a key factor in the success of health care financing reform in Asia.

The determinants of the willingness-to-pay for community-based prepayment scheme in rural Cameroon

In rural Cameroon, many people have no access to quality healthcare services. This is largely attributed to lack of private out-of-pocket payment to finance healthcare services. A community-based prepayment health insurance scheme may be implemented to improve healthcare access in rural areas. This study examines the determinants of willingness-to-pay for a community-based prepayment healthcare system using a contingent valuation method conducted in rural Cameroon. To mitigate potential hypothetical bias, a consequential script is introduced in the questionnaire. The results indicate age, religion, profession, knowledge of community-based health insurance, awareness of usual practice in rural areas, involvement in association and disposable income are the key determinants of willingness to pay for a prepayment health scheme. On average, willingness to pay for the scheme by rural households is 1011 CFA francs/person/month (2.15 US dollars). The results underlie two important implications: first, there is substantial demand for a community healthcare prepayment scheme by rural poor households in Cameroon; second, rural households are averse to health shocks and hence they are willing to sacrifice monthly premium payments to protect themselves (and their households) from unforeseen health-related risks. If government could engage in social marketing strategies such as mass media campaigns and awareness, this could prove vital for encouraging participation by the rural poor in healthcare prepayment scheme in Cameroon.

Expert trio take on Africa’s health care problems – one step at a time

Africa’s debilitating quarter share of the world’s disease burden, with just 3% of the globe’s health workers and 1% of its finances, is to be tackled through a unique international partnership involving a top South African NGO. Aimed at improving quality, access and affordability and beginning with sub-Saharan Africa, the partnership will upgrade health care facilities by offering a quality improvement framework and incentivised performance-based loan mechanisms. At the same time the majority low-income patients will be offered pragmatic subsidised voluntary private health insurance via a pre-payment scheme.

Financial Protection for the Poor in Colombia: The Effects of a Subsidized Health Insurance Scheme

Financial protection is one of the objectives of health systems, which protects poor households from falling into poverty as a result of health care related expenses. Expanding prepayment schemes to the poor is difficult in developing countries because labor is largely informal. Providing health care free-at-point-of-service does not adequately target spending on the poorest, but occupation- or community-based schemes have also inherent limitations to achieve universal coverage. Colombia adopted a government-subsidized health insurance scheme (SHI) strategy. The political debate about increasing SHI enrollment needs evidence about the effectiveness of this scheme regarding financial protection. This study runs a four-part model to estimate the effect of SHI on out-of-pocket expenses by the poor that are currently uninsured, if they were enrolled in the SHI. The results show a 43% and 50% reduction in expenses at Bogota and national level respectively, which confirms the effectiveness of SHI as a financial protection tool.

Will private health insurance schemes subscriptions continue after the introduction of National Health Insurance in Uganda?

Uganda is currently designing a National Health Insurance (NHI) scheme, with the aim of raising additional resources for the health sector. Very little was known about the health insurance market in Uganda before this study, so one of our main objectives was to investigate the nature of the private health insurance market in Uganda and the opinions of various stakeholders on NHI, with the view to establish the impact of NHI implementation on the existing PHI. Specifically, we aimed to gather the opinions of employees and employers on the likely impact of NHI on their PHI schemes. We conducted interviews with health insurance providers, and a sample of employers and employees in Kampala, using structured questionnaires and analysed quantitative data using STATA. Qualitative data was analysed through grouping of emerging themes. Community-based health insurances were excluded from the study. Health insurance and/or prepayment schemes are offered by a handful of organisations or private health providers, mainly in Kampala and cover a relatively small percentage of Uganda's population. The premiums charged and the benefit packages offered by the different agencies vary widely. There are 2 health insurance agencies, 2 HMOs and about 5 or more private providers offering pre-payment schemes to their patients. Responses from a significant proportion of employers and employees show that PHI schemes may be abandoned once the mandatory NHI scheme is implemented. A few respondents argued that they would maintain their PHI subscriptions because of their perceptions of the quality of services likely to be provided under the NHI scheme. If successfully introduced, the NHI scheme may displace existing private health insurance and/or pre-payment schemes in Uganda. The extent to which PHI schemes are displaced depends on whether NHI is successfully implemented and the quality of services being offered under the NHI scheme.

Is health care financing in Uganda equitable?

Health care financing provides the resources and economic incentives for operating health systems and is a key determinant of health system performance. Equitable financing is based on: financial protection, progressive financing and cross-subsidies. This paper describes Uganda's health care financing landscape and documents the key equity issues associated with the current financing mechanisms. We extensively reviewed government documents and relevant literature and conducted key informant interviews, with the aim of assessing whether Uganda's health care financing mechanisms exhibited the key principles of fair financing. Uganda's health sector remains significantly under-funded, mainly relying on private sources of financing, especially out-of-pocket spending. At 9.6 % of total government expenditure, public spending on health is far below the Abuja target of 15% that GoU committed to. Prepayments form a small proportion of funding for Uganda's health sector. There is limited cross-subsidisation and high fragmentation within and between health financing mechanisms, mainly due to high reliance on out-of-pocket payments and limited prepayment mechanisms. Without compulsory health insurance and low coverage of private health insurance, Uganda has limited pooling of resources, and hence minimal cross-subsidisation. Although tax revenue is equitable, the remaining financing mechanisms for Uganda are inequitable due to their regressive nature, their lack of financial protection and limited cross-subsidisation. Overall, Uganda's current health financing is inequitable and fragmented. The government should take explicit action to promote equitable health care financing by establishing pre-payment schemes, enhancing cross-subsidisation mechanisms and through appropriate integration of financing mechanisms.

Effect of Removing Direct Payment for Health Care on Utilisation and Health Outcomes in Ghanaian Children: A Randomised Controlled Trial

BackgroundDelays in accessing care for malaria and other diseases can lead to disease progression, and user fees are a known barrier to accessing health care. Governments are introducing free health care to improve health outcomes. Free health care affects treatment seeking, and it is therefore assumed to lead to improved health outcomes, but there is no direct trial evidence of the impact of removing out-of-pocket payments on health outcomes in developing countries. This trial was designed to test the impact of free health care on health outcomes directly.Methods and Findings2,194 households containing 2,592 Ghanaian children under 5 y old were randomised into a prepayment scheme allowing free primary care including drugs, or to a control group whose families paid user fees for health care (normal practice); 165 children whose families had previously paid to enrol in the prepayment scheme formed an observational arm. The primary outcome was moderate anaemia (haemoglobin [Hb] < 8 g/dl); major secondary outcomes were health care utilisation, severe anaemia, and mortality. At baseline the randomised groups were similar. Introducing free primary health care altered the health care seeking behaviour of households; those randomised to the intervention arm used formal health care more and nonformal care less than the control group. Introducing free primary health care did not lead to any measurable difference in any health outcome. The primary outcome of moderate anaemia was detected in 37 (3.1%) children in the control and 36 children (3.2%) in the intervention arm (adjusted odds ratio 1.05, 95% confidence interval 0.66–1.67). There were four deaths in the control and five in the intervention group. Mean Hb concentration, severe anaemia, parasite prevalence, and anthropometric measurements were similar in each group. Families who previously self-enrolled in the prepayment scheme were significantly less poor, had better health measures, and used services more frequently than those in the randomised group.ConclusionsIn the study setting, removing out-of-pocket payments for health care had an impact on health care-seeking behaviour but not on the health outcomes measured.Trial registration: ClinicalTrials.gov (#NCT00146692).

Abolishing User Fees in Africa

Valery Ridde and Slim Haddad discuss a new trial in Ghana in which households were randomized into a pre-payment scheme allowing free primary care or to a control group who paid user fees for health care.

Exploring the features of universal coverage

Exploring the features of universal coverage

Coping with out-of-pocket health payments: empirical evidence from 15 African countries

To explore factors associated with household coping behaviours in the face of health expenditures in 15 African countries and provide evidence for policy-makers in designing financial health protection mechanisms. A series of logit regressions were performed to explore factors correlating with a greater likelihood of selling assets, borrowing or both to finance health care. The average partial effects for different levels of spending on inpatient care were derived by computing the partial effects for each observation and taking the average across the sample. Data used in the analysis were from the 2002-2003 World Health Survey, which asked how households had financed out-of-pocket payments over the previous year. Households selling assets or borrowing money were compared to those that financed health care from income or savings. Those that used insurance were excluded. For the analysis, a value of 1 was assigned to selling assets or borrowing money and a value of 0 to other coping mechanisms. Coping through borrowing and selling assets ranged from 23% of households in Zambia to 68% in Burkina Faso. In general, the highest income groups were less likely to borrow and sell assets, but coping mechanisms did not differ strongly among lower income quintiles. Households with higher inpatient expenses were significantly more likely to borrow and deplete assets compared to those financing outpatient care or routine medical expenses, except in Burkina Faso, Namibia and Swaziland. In eight countries, the coefficient on the highest quintile of inpatient spending had a P-value below 0.01. In most African countries, the health financing system is too weak to protect households from health shocks. Borrowing and selling assets to finance health care are common. Formal prepayment schemes could benefit many households, and an overall social protection network could help to mitigate the long-term effects of ill health on household well-being and support poverty reduction.

O regime regulatório e o mercado de planos de saúde no Brasil

O artigo analisa o regime de regulação do mercado de planos privados de assistência à saúde o Brasil. Identifica a origem da Agência Nacional de Saúde Suplementar (ANS) e descreve os instrumentos de regulação que detém para intervir na indústria de planos e seguro saúde brasileira. Estabelece a associação do modelo organizacional da agência independente aplicado à ANS aos processos de privatização e desenvolvimento da regulação dos serviços públicos de monopólio natural no Brasil. O artigo demonstra que o regime de regulação afeta fortemente as condições de entrada e saída do mercado de planos de saúde.

Estimating the Willingness to Pay for Community Healthcare Insurance in Rural Nigeria

Health care financing in Nigeria is dominated by private out-of-pocket payment that is not affordable to the poor. This has greatly reduced access to quality health care for the predominantly rural poor. Insurance schemes as options for increasing access to health care services have not received considerable attention in Nigeria. In this regard, a community health prepayment scheme is proposed, and the Contingent Valuation Method is used to investigate the willingness of rural households to pay for this scheme. Contributing through agricultural commodities produced statistically higher estimates than through direct cash. Also, by incorporating uncertainty in responses using the Random Valuation Model, higher contribution amounts were obtained. This provides an option for its use in healthcare contingent valuation studies where respondents are uncertain about their true responses. The groups that are willing to pay lesser amounts into the scheme as compared with their counterparts are women, the less educated, and the less wealthy households.

Estimating the Willingness to Pay for Community Healthcare Insurance in Rural Nigeria

Health care financing in Nigeria is dominated by private out-of-pocket payment that is not affordable to the poor. This has greatly reduced access to quality health care for the predominantly rural poor. Insurance schemes as options for increasing access to health care services have not received considerable attention in Nigeria. In this regard, a community health prepayment scheme is proposed, and the Contingent Valuation Method is used to investigate the willingness of rural households to pay for this scheme. Contributing through agricultural commodities produced statistically higher estimates than through direct cash. Also, by incorporating uncertainty in responses using the Random Valuation Model, higher contribution amounts were obtained. This provides an option for its use in healthcare contingent valuation studies where respondents are uncertain about their true responses. The groups that are willing to pay lesser amounts into the scheme as compared with their counterparts are women, the less educated, and the less wealthy households.

Making choices between prepayment and user charges in Zambia. What are the results for equity?

In many low-income countries, user charges were introduced in the 1990s. As problems emerged of equity of access, interest grew in developing prepayment mechanisms to protect users from risk of out-of-pocket payments. In Zambia, a prepayment scheme did not generate sufficient revenue, due to abuses of its terms. An alternative scheme using discount cards (a set of coupons to cover episodes of care at discount) was devised. We aimed to understand the equity implications of prepayment and discount cards relative to user charges. We proposed models predicting roles of income, perceived health status, perceived quality of care and time preference in choice of payment mechanism and use of health services. We tested these models using three data sets that could be accessed or collected. It is concluded that relative to user charges, prepayment may facilitate access without incurring income-related equity losses. Evidence concerning discount cards was weaker. We concluded that they facilitate access to a lesser extent. Discount cards offer a credible intermediate solution between user charges and prepayment that avoid some problems associated with prepayment. However, since prepayment seems to be associated with the most positive outcomes, finding other solutions to their problems would be preferred.

Factors influencing implementation of the Community Health Fund in Tanzania

Although prepayment schemes are being hailed internationally as part of a solution to health care financing problems in low-income countries, literature has raised problems with such schemes. This paper reports the findings of a study that examined the factors influencing low enrollment in Tanzania's health prepayment schemes (Community Health Fund). The paper argues that district managers had a direct influence over the factors explaining low enrollment and identified in other studies (inability to pay membership contributions, low quality of care, lack of trust in scheme managers and failure to see the rationale to insure). District managers' actions appeared, in turn, to be at least partly a response to the manner of this policy's implementation. In order better to achieve the objectives of prepayment schemes, it is important to focus attention on policy implementers, who are capable of re-shaping policy during its implementation, with consequences for policy outcomes.

D- cash: A flexible pre-paid e-cash scheme for date-attachment

The electronic payment system is one of the most important success factors in electronic commerce. In this paper, we propose D- Cash, a practical and flexible date-attachment pre-paid e-cash scheme. Briefly speaking, there are three important dates, including the withdrawal date, the effective date and the deposit date, in an e-coin lifetime before it is deposited in the bank. In pre-paid systems, the withdrawal date and the effective date are important to customers and merchants if the interest of e-cash is considered. Although several pre-paid schemes for date-attachment have been proposed, the interest of e-cash during the withdrawal date and the effective date is ignored. In D- Cash, the interest of e-cash during the withdrawal date and the effective date is addressed for attracting customers to use the pre-paid e-cash schemes, the attachment and management of dates are more simple and flexible than other date-attachment e-cash schemes, and the untraceability property is also preserved.

Fair Micropayment System Based on Hash Chains

Micropayment schemes usually do not provide fairness, which means that either the customer or the merchant, or both, can cheat each other and gain a financial advantage by misusing the protocols. This paper proposes an efficient hash chain-based micropayment scheme, which is an offline, prepaid scheme that supports simpler divisibility of digital coins. In the execution of payment protocol, the customer's disbursement and the merchant's submittal are performed step by step, whoever cannot gain addition profits even if he breaks off the transaction. The hash chain can also be used for transactions with different merchants. Unlike other micropayment schemes, e.g., PayWord, no public-key operation is required, which improves the efficiency. The scheme also provides restricted anonymity.

Reducing vulnerability: the supply of health microinsurance in East Africa

Reducing vulnerability: the supply of health microinsurance in East Africa

Intervening to address constraints through health sector reforms in Tanzania: some gains and the unfinished business

AbstractThis paper describes two projects designed to address health sector constraints. The Community Health Fund attempts to create a community‐owned and community‐managed prepayment scheme. Although membership growth has been disappointing, substantial funds have been mobilized and the scheme replicated in nine additional districts. The Dar Urban Health Project aimed to improve various dimensions of health service quality, and provides a model which can be replicated elsewhere. The two cases concentrated largely on relaxing constraints related to the availability of inputs, while leaving unresolved macro‐level general infrastructural and policy‐related constraints. This omission partly explains the limited gains in relaxing constraints at the input level. Copyright © 2003 John Wiley &amp; Sons, Ltd.

District health systems in a neoliberal world: a review of five key policy areas.

District health systems, comprising primary health care and first referral hospitals, are key to the delivery of basic health services in developing countries. They should be prioritized in resource allocation and in the building of management and service capacity. The relegation in the World Health Report 2000 of primary health care to a 'second generation' reform--to be superseded by third generation reforms with a market orientation--flows from an analysis that is historically flawed and ideologically biased. Primary health care has struggled against economic crisis and adjustment and a neoliberal ideology often averse to its principles. To ascribe failures of primary health care to a weakness in policy design, when the political economy has starved it of resources, is to blame the victim. Improvement in the working and living conditions of health workers is a precondition for the effective delivery of public health services. A multidimensional programme of health worker rehabilitation should be developed as the foundation for health service recovery. District health systems can and should be financed (at least mainly) from public funds. Although in certain situations user fees have improved the quality and increased the utilization of primary care services, direct charges deter health care use by the poor and can result in further impoverishment. Direct user fees should be replaced progressively by increased public finance and, where possible, by prepayment schemes based on principles of social health insurance with public subsidization. Priority setting should be driven mainly by the objective to achieve equity in health and wellbeing outcomes. Cost effectiveness should enter into the selection of treatments for people (productive efficiency), but not into the selection of people for treatment (allocative efficiency). Decentralization is likely to be advantageous in most health systems, although the exact form(s) should be selected with care and implementation should be phased in after adequate preparation. The public health service should usually play the lead provider role in district health systems, but non-government providers can be contracted if needed. There is little or no evidence to support proactive privatization, marketization or provider competition. Democratization of political and popular involvement in health enhances the benefits of decentralization and community participation. Integrated district health systems are the means by which specific health programmes can best be delivered in the context of overall health care needs. International assistance should address communicable disease control priorities in ways that strengthen local health systems and do not undermine them. The Global Fund to Fight AIDS, Tuberculosis and Malaria should not repeat the mistakes of the mass campaigns of past decades. In particular, it should not set programme targets that are driven by an international agenda and which are achievable only at the cost of an adverse impact on sustainable health systems. Above all the targets must not retard the development of the district health systems so badly needed by the rural poor.