Social Health Insurance Scheme Research Articles

Re-envisioning contributory health schemes to achieve equity in the design of financial protection mechanisms in low- and middle-income countries

Abstract Universal health coverage has emerged as a global health priority, requiring that financing strategies that ensure low-income and medically and financially at-risk individuals can access health services without the threat of financial catastrophe. Contributory financing schemes and social health insurance (SHI) schemes, in particular, predominate in low- and middle-income countries (LMICs), despite evidence that suggests the most vulnerable remain excluded from such schemes. In this commentary, we discuss the need to re-envision schemes to prioritize equity, offering 3 concrete recommendations: adopt participatory designs for the co-design of schemes with beneficiaries, establish linkages between contributory financial protection schemes with economic empowerment initiatives, and prioritize the needs and preferences of beneficiaries over political expediency. Co-design alone does not necessarily translate into more equitable schemes, underscoring the need for greater monitoring and evaluation of these schemes that consider differential impacts across contexts and subgroups. In doing so, SHI schemes can be both attractive and accessible to populations that have long been excluded from financial protections in LMICs, acting as 1 channel in a broader financing strategy to achieve universal health coverage.

Towards universal health coverage in Vietnam: a mixed-method case study of enrolling people with tuberculosis into social health insurance

BackgroundVietnam’s primary mechanism of achieving sustainable funding for universal health coverage (UHC) and financial protection has been through its social health insurance (SHI) scheme. Steady progress towards access has been made and by 2020, over 90% of the population were enrolled in SHI. In 2022, as part of a larger transition towards the increased domestic financing of healthcare, tuberculosis (TB) services were integrated into SHI. This change required people with TB to use SHI for treatment at district-level facilities or to pay out of pocket for services. This study was conducted in preparation for this transition. It aimed to understand more about uninsured people with TB, assess the feasibility of enrolling them into SHI, and identify the barriers they faced in this process.MethodsA mixed-method case study was conducted using a convergent parallel design between November 2018 and January 2022 in ten districts of Hanoi and Ho Chi Minh City, Vietnam. Quantitative data were collected through a pilot intervention that aimed to facilitate SHI enrollment for uninsured individuals with TB. Descriptive statistics were calculated. Qualitative interviews were conducted with 34 participants, who were purposively sampled for maximum variation. Qualitative data were analyzed through an inductive approach and themes were identified through framework analysis. Quantitative and qualitative data sources were triangulated.ResultsWe attempted to enroll 115 uninsured people with TB into SHI; 76.5% were able to enroll. On average, it took 34.5 days to obtain a SHI card and it cost USD 66 per household. The themes indicated that a lack of knowledge, high costs for annual premiums, and the household-based registration requirement were barriers to SHI enrollment. Participants indicated that alternative enrolment mechanisms and greater procedural flexibility, particularly for undocumented people, is required to achieve full population coverage with SHI in urban centers.ConclusionsSignificant addressable barriers to SHI enrolment for people affected by TB were identified. A quarter of individuals remained unable to enroll after receiving enhanced support due to lack of required documentation. The experience gained during this health financing transition is relevant for other middle-income countries as they address the provision of financial protection for the treatment of infectious diseases.

Morbidity Cost and Willingness to Pay for Healthcare Insurance among Wheat Farmers in Jigawa State of Nigeria

The study determined the costs of morbidity and farmers' willingness to pay for health insurance in the Jigawa State of Nigeria using a cross-sectional data collected from 284 farmers through a multi-stage sampling technique. Using an easy-route cost approach, a well-structured questionnaire coupled with interview schedule was used for data collection. Besides, the collected data was then analysed using both descriptive and inferential statistics. Empirically, the majority of farmers utilised an accumulation strategy for livelihood sustenance, alongside enterprise diversification – which acted as a catalyst in increasing their stocks and consumption outcomes, thus smoothing their income and consumption. However, financial and, at worst, physical livelihood capitals posed challenges that affected farmers' livelihood assets in the study area. Furthermore, malaria emerged as the major health issue affecting livelihoods; consequently, slightly over half of the sampled population agreed to the notion of a social health insurance scheme for a healthy livelihood. However, this inclination was largely influenced by the overlooked or nearly neglected social learning aspect of extension service delivery. Therefore, as a method to reduce public capital expenditure on healthcare for livelihoods in the study area, the study recommends that policymakers expand the healthcare scheme to include the farming community, going beyond formal organisations, thereby enhancing farm family livelihoods specifically and overall economic growth and development in general. Nonetheless, enhance institutional factors, alongside social extension, financial and infrastructural facilities are recommended.

Public expenditure on health care and the incidence of non-communicable diseases (NCDs) in China from 2008 to 2018

ObjectivesThis study investigates whether differences in individual-level and provincial-level health funding could explain or mitigate health inequalities among older people in terms of non-communicable diseases within a population served by fragmented health insurance schemes. Study designA national repeated cross-sectional analysis was done of the 2008, 2011, 2014, and 2018 Chinese Longitudinal Healthy Longevity Surveys. These provided a total of 44,623 persons aged 60 and over. Main outcome measuresRespondents were asked whether they had been diagnosed with any types of non-communicable diseases by doctors. A dichotomous outcome variable was constructed to indicate whether older people had any diagnosed non-communicable diseases. ResultsCompared with uninsured older persons, those who were enrolled in social health insurance schemes designed for civil servants as cadres, urban employees and urban residents were more likely to report a higher incidence of non-communicable diseases. There were no significant differences in the prevalence of non-communicable diseases between uninsured older people and those in the New Rural Cooperative Medical Scheme. Although the incidence of non-communicable diseases among older persons increased over the study period, greater health expenditure was significantly associated with a lower risk of non-communicable diseases. The interaction results between individual social health insurance schemes and public health expenditure indicate that disparities in the incidence of non-communicable diseases among different health insurance schemes diminish as public health expenditure increases. Older individuals with Public Free Medical Services benefited the most in provinces with higher public health expenditure compared with other health insurance schemes. ConclusionsGiven the evidence of the beneficial effects of universal health coverage on non-communicable diseases among older persons, these results should encourage policy makers to increase public health funding and to raise the overall benefit packages for social health insurance schemes.

Willingness to pay for Social Health Insurance and associated factors among Public Civil Servants in Ethiopia: A systematic review and meta-analysis.

The provision of equitable and accessible healthcare is one of the goals of universal health coverage. However, due to high out-of-pocket payments, people in the world lack sufficient health services, especially in developing countries. Thus, many low and middle-income countries introduced different prepayment mechanisms to reduce large out-of-pocket payments and overcome financial barriers to accessing health care. Though many studies were conducted on willingness to pay for social health insurance in Ethiopia, there is no aggregated data at the national level. Therefore, this systematic review and meta-analysis aimed to estimate the pooled magnitude of willingness to pay for social health insurance and its associated factors among public servants in Ethiopia. Studies conducted before June 1, 2022, were retrieved from electronic databases (PubMed/Medline, Science Direct, African Journals Online, Google Scholar, and Web of Science) as well as from Universities' digital repositories. Data were extracted using a data extraction format prepared in Microsoft Excel and the analysis was performed using STATA 16 statistical software. The quality of the included studies was assessed using the Newcastle-Ottawa Scale for cross-sectional studies. To evaluate publication bias, a funnel plot, and Egger's regression test were utilized. The study's heterogeneity was determined using Cochrane Q test statistics and the I2 test. To determine the pooled effect size, odds ratio, and 95% confidence intervals across studies, the DerSimonian and Laird random-effects model was used. Subgroup analysis was conducted by region, sample size, and publication year. The influence of a single study on the whole estimate was determined via sensitivity analysis. To estimate the pooled magnitude of willingness to pay for the Social Health insurance scheme in Ethiopia, twenty articles with a total of 8744 participants were included in the review. The pooled magnitude of willingness to pay for Social Health Insurance in Ethiopia was 49.62% (95% CI: 36.41-62.82). Monthly salary (OR = 6.52; 95% CI:3.67,11.58), having the degree and above educational status (OR = 5.52; 95%CI:4.42,7.17), large family size(OR = 3.69; 95% CI:1.10,12.36), having the difficulty of paying the bill(OR = 3.24; 95%CI: 1.51, 6.96), good quality of services(OR = 4.20; 95%CI:1.97, 8.95), having favourable attitude (OR = 5.28; 95%CI:1.45, 19.18) and awareness of social health insurance scheme (OR = 3.09;95% CI:2.12,4.48) were statistically associated with willingness to pay for Social health insurance scheme. In this review, the magnitude of willingness to pay for Social Health insurance was low among public Civil servants in Ethiopia. Willingness to pay for Social Health Insurance was significantly associated with monthly salary, educational status, family size, the difficulty of paying medical bills, quality of healthcare services, awareness, and attitude towards the Social Health Insurance program. Hence, it's recommended to conduct awareness creation through on-the-job training about Social Health Insurance benefit packages and principles to improve the willingness to pay among public servants.

A qualitative assessment on the acceptability of providing cash transfers and social health insurance for tuberculosis-affected families in Ho Chi Minh City, Vietnam.

To achieve the Sustainable Development Goal's targets of universal health coverage (UHC) and poverty reduction, interventions are required that strengthen and harmonize both UHC and social protection. Vietnam is committed to achieving financial protection and over 90% of the general population has enrolled in its social health insurance (SHI) scheme. However, an estimated 63% of tuberculosis (TB)-affected households in Vietnam still face catastrophic costs and little is known about the optimal strategies to mitigate the costs of TB care for vulnerable families. This study assessed the acceptability of a social protection package containing cash transfers and SHI using individual interviews (n = 19) and focus group discussions (n = 3 groups). Interviews were analyzed through framework analysis. The study's main finding indicated that both conditional and unconditional cash transfers paired with SHI were acceptable, across six dimensions of acceptability. Cash transfers were considered beneficial for mitigating out-of-pocket expenditure, increasing TB treatment adherence, and improving mental health and general well-being, but the value provided was inadequate to fully alleviate the economic burden of the illness. The conditionality of the cash transfers was not viewed by participants as inappropriate, but it increased the workload of the TB program, which brought into question the feasibility of scale-up. SHI was viewed as a necessity by almost all participants, but people with TB questioned the quality of care received when utilizing it for auxiliary TB services. Access to multiple sources of social protection was deemed necessary to fully offset the costs of TB care. Additional research is needed to assess the impact of cash transfer interventions on health and economic outcomes in order to create an enabling policy environment for scale-up.

Enrollees’ satisfaction with health service provision under the formal sector Social Health Insurance Scheme in South Eastern Nigeria

Introduction : Healthcare financing is a critical global issue, particularly in low and middle-income countries (LMICs) grappling with underfunded health systems. Various financing approaches, such as fee-for-service, private insurance, general taxation, social insurance, community financing, loans, and grants, have been explored to bridge the funding gap. Health insurance, a mechanism involving resource pooling and risk sharing, plays a pivotal role in achieving Universal Health Coverage (UHC) and delivering quality healthcare. This study aimed to assess enrollees' satisfaction with the Formal Sector Social Health Insurance Scheme (FSSHIS) at the University of Nigeria Teaching Hospital (UNTH), with a focus on the registration process, waiting time, drug availability, and willingness to continue using the scheme.
 Methods : A descriptive cross-sectional study was conducted at UNTH, Enugu, involving 470 enrollees. Data were collected using a pretested Patient Satisfaction Survey Questionnaire and analyzed using descriptive statistics. Enrollees' satisfaction was assessed on a 5-point Likert scale, a score of ≥ 3 signified enrollees’ satisfaction.
 Results : Respondents were satisfied with the processes of registration (4.10±0.95), getting an identity card (3.50±0.72) and interest shown by the providers (3.80±0.83). They were dissatisfied with the referral process (2.7±0.41), level of their involvement in decision making (2.8±0.44), long waiting time (2.5±0.45), non-availability of drugs (1.8±0.24) and diagnostic facilities (1.5±0.22). The overall satisfaction was poor (43%) while 59% would not recommend a health insurance scheme in the facility for family or friends.
 Conclusions : Enrollees' dissatisfaction with the FSSHIS suggests a need for immediate intervention and improvement in healthcare service delivery. Addressing these concerns can foster increased utilization of health services and contribute to the scheme's success in achieving its objectives.

Laos’ Social Health Insurance (SHI) program’s impact on older people’s accessibility and financial security against catastrophic health expense

Laos has introduced various SHI schemes for multiple groups of the population, such as government officials and other population groups under the NHI schemes. There is no specific health insurance policy for this group of people who need special health services and may have a higher possibility of entering financial catastrophe. This study aims to assess the impact of SHI schemes on accessibility and financial catastrophe against catastrophic health expenditures for older people in Laos. A structured questionnaire has been used to retrieve information from 400 older people across 39 villages in Kaysone Phomvihane District, Savannakhet province, the largest province in Laos. In the analytical process, this study used a cross-sectional study design and binary logistic regression models to predict the likelihood of accessing health facilities and experiencing financial catastrophe. The study outcome shows that the increase in age, occupation, number of older people within a household, and presence of chronic conditions increase the likelihood of using health services. Despite the existence of various SHI schemes, this study found that 74 out of 165 households reported using health services experienced catastrophic health expenditure. Several characteristics are associated with catastrophic health expenditure: age, income level, and gender are prone to suffer from catastrophic health expenditure. The difficult problems stem from the absence of comprehensive legislation regarding the older population. Recommendations for policymakers in various timeframes have been made, which cover short- and long-term policy proposals, including providing a specialized lane or fast-track for an older population, building health facilities exclusively for older people, and providing transportation services for older individuals living alone.

Health Financing Options for Sri Lanka: What, and Why?

The purpose of this paper is to renew and stimulate the national discourse on how to further Sri Lanka's aspirational goal of achieving Universal Health Coverage (UHC [1]) in line with the global sustainable development goals (SDG) to which Sri Lanka is a signatory. After a brief status update about UHC in Sri Lanka, the paper focuses on the financing function, justified on the basis of its central role in addressing the problems confronting the health system, in terms of its inherent inefficiencies as well as the specific context of the economic crisis which the country is currently facing. The paper argues for a well-managed prepaid, pooled health financing mechanism (such as the current tax-based system or social health insurance schemes), incorporating strategic purchasing approaches, leveraging the private sector (both for-profit and non-profit), in order to increase efficiency, equity and accountability by separating the financing and purchasing functions from service delivery.

Health financing options for Sri Lanka

The purpose of this paper is to renew and stimulate the national discourse on how to further Sri Lanka’s aspirational goal of achieving Universal Health Coverage(UHC [1]) in line with the global sustainable development goals (SDG) to which Sri Lanka is a signatory. After a brief status update about UHC in Sri Lanka, the paper focuses on the financing function, justified on the basis of its central role in addressing the problems confronting the health system, in terms of its inherent inefficiencies as well as the specific context of the economic crisis which the country is currently facing. The paper argues for a well-managed prepaid, pooled health financing mechanism (such as the current tax-based system or social health insurance schemes), incorporating strategic purchasing approaches, leveraging the private sector (both for-profit and non-profit), in order to increase efficiency, equity and accountability by separating the financing and purchasing functions from service delivery.

The impact of health insurance enrollment on health outcomes in Kenya

BackgroundThe achievement of the global agenda on universal health coverage (UHC) is pivotal in ensuring healthy lives and promoting the well-being of all. However, achieving healthy lives and wellbeing of all has been hampered by the challenge of health care financing. As such, healthcare financing, through health insurance is gaining popularity in developing countries such as Kenya, in their pursuit to achieve universal health coverage. The primary purpose of health insurance and delivery is to improve health. However, there is a paucity of evidence on the effectiveness of health insurance in improving the health outcomes and health status of the Kenyan population. Therefore, this study aimed to analyze the impact of health insurance on health outcomes in Kenya.MethodsThe study utilized the most recent nationally representative Kenya Integrated Household Budget Survey (KIHBS) 2015/16 dataset in order to analyze the impact of health insurance on health outcomes. The instrumental variable 2-stage least squares (IV 2SLS) and control function approach (CFA) estimation techniques were used to cater for potential endogeneity and heterogeneity biases present in ordinary least squares (OLS) estimators.ResultsHealth insurance enrolment leads to a reduction in mortality, thereby improving the health status of the Kenyan population, despite low levels of insurance uptake. However, the insured population experienced higher chronic illnesses and out-of-pocket (OOP) expenditures raising concerns about financial risk protection. The fact that health insurance is linked to chronic illnesses not only reinforces the reverse causality of health insurance and health status, but also that the effects of potential adverse selection strongly drive the strength and direction of this impact.ConclusionsWe conclude that health insurance enrolment reduces mortality and hence has a beneficial impact in promoting health. Health insurance coverage therefore, should be promoted through the restructuring of the National Hospital Insurance Fund (NHIF) fragmented schemes and by consolidating the different insurance schemes to serve different population groups more effectively and equitably. The government should revisit the implementation of a universal social health insurance scheme, as a necessary step towards UHC, while continuing to offer subsidies in the form of health insurance to the marginalized, vulnerable and poor populations.

SOURCES OF HEALTH CARE FINANCING AMONG SURGICAL PATIENTS SEEN AT THE DALHATU ARAF SPECIALIST HOSPITAL LAFIA NASARAWA STATE NIGERIA

Sources of healthcare financing especially among surgical patients in Nasarawa state is presently unknown. Sub-Saharan African countries have introduced a number of methods to funding healthcare system. The Nigerian government commenced implementation of a social health insurance scheme (National Health Insurance Scheme; NHIS) so as to improve on healthcare funding for its citizens. This study determined the sources of financing surgical cases, type of surgeries and compared the cost of treatment among patients attending the Dalhatu Araf Specialist Hospital and other Health Centers in Nasarawa State. It was a hospital based cross-sectional descriptive study among 420 adults aged 18 years to 75 years in a study that lasted for two years. The data collected was analyzed using Statistical package for the Social Science (SPSS) version 20.0. Significant p was < 0.05. The average age of patient was 28.6 ± 11.9 years. There were more females (75.5%) with most (73.8) of our participants living in rural areas. Majority (60.0%) had Caesarean Section and one-sixth had exploratory laparotomy respectively. Most spending for healthcare needs was Out-Of-Pocket (OOP) with only a handful (6.7%) enjoying insurance coverage. The average cost of surgery was 41,337.73 Naira and 28,426.47 Naira among the low and high socio-economic class respectively. Most of the participants in this study were on Out-Of[1]Pocket healthcare financing with only one out of fifteen having health insurance coverage of the NHIS. Most of the surgical patients are from the rural areas, are females, do not attend tertiary level of education and are of low socio-economic status. Caesarean section and exploratory laparatomy were the predominant indications for surgeries. Those from the lower socio-economic status pay more for surgeries even though they earn less. We recommended that the state consider State health insurance agency and this should cater for people in both the formal ana the non-formal sectors. In addition, rural dwellers and surgeries such as caesarean section and emergency laparatomies should not be left out.

Willingness to Pay for Social Health Insurance Among Health Care Professionals in North Wollo Zone, Amhara Region, Ethiopia: Mixed Method Study.

Ethiopia introduced a social health insurance (SHI) scheme for the formal sector that will cost 3% of the monthly salary as a premium and provide universal health coverage. Since health care professionals (HCP) are the primary front-line service providers, their willingness to pay (WTP) for SHI may have a direct or indirect impact on how the programme is implemented. However, little is known about WTP for SHI among HCP. To assess WTP for SHI and associated factors among government employee HCP in the North Wollo Zone, Northeast Ethiopia. Using the contingent valuation method, a mixed approach and cross-sectional study design were applied. For the qualitative study design, in-depth interviews were performed with focal persons and officers of health insurance. Multistage systematic random sampling was used to select 636 healthcare professionals. Logistic regression analysis was used to determine independent predictors of WTP for SHI. Qualitative data were analyzed using thematic analysis. A response rate of 92.45% was achieved among the 636 participants, with 588 healthcare professionals completing the interview. The majority (61.7%) of participants were willing to joinand pay the suggested SHI premium. Participants' WTP was significantly positively associated with the presence of under five years of children but their willingness to pay was significantly negatively associated with the female gender and increasing monthly salary. On the other hand, on the qualitative side, the amount of premium contribution, benefits package, and quality of service were the major factors affecting their WTP. The majority of healthcare professionals were willing to pay for the SHI scheme, almost as much as the premium set by the government. This suggests proof that healthcare financing reform is feasible, particularly for the implementation of the SHI system.

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

Background: This research examined differences in the utilisation of healthcare services and financial burden between and within insured and uninsured older persons and their households under the social health insurance scheme in Vietnam. Methods: We used nationally representative data from the Vietnam Household Living Standard Survey (VHLSS) conducted in 2014. We applied the World Health Organization (WHO)’s financial indicators in healthcare to provide cross-tabulations and comparisons for insured and uninsured older persons along with their individual and household characteristics (such as age groups, gender, ethnicity, per-capita household expenditure quintiles, and place of residence). Results: We found that social health insurance was beneficial to the insured in comparison with the uninsured in terms of utilization of healthcare services and financial burden. However, between and within these two groups, more vulnerable groups (i.e., ethnic minorities and rural persons) had lower utilization rates and higher rates of catastrophic spending than the better groups (i.e., Kinh and urban persons). Conclusion: Given the rapidly ageing population under low middle-income status and the “double burden of diseases”, this paper suggested that Vietnam reform the healthcare system and social health insurance so as to provide more equitable utilisation and financial protection to all older persons, including improving the quality of healthcare at the grassroots level and reducing the burden on the provincial/central health level; improving human resources for the grassroots healthcare facilities; encroaching public–private partnerships (PPPs) in the healthcare service provision; and developing a nationwide family doctor network.

Avoidable hospital admissions depend on the primary healthcare governance model? A global health perspective from Europe countries

AbstractPrimary healthcare (PHC) governance model, namely its financing scheme, might impact the health outcomes, particularly in chronic conditions, through avoidable hospital admissions (AvH). Therefore, the study aims to assess how the PHC financial governance model determines AvH, as well as how this interacts with the health system financing (HSF) scheme. An observational study comparing the GP employment type (publicly and self/privately) with asthma and COPD, and Diabetes AvH per 100,000 habitants in 26 countries of the European Region, was performed. It considered 4 regression models with structural determinants, service delivery and HSF schemes. GP self/privately employed group associated with social health insurance scheme was significantly associated with higher total AvH (OR = 28.27 [CI 95% 2.34–77.54]), and for asthma and COPD AvH (OR = 21.88 [CI 95% 6.69–180.18]). Diabetes AvH were significantly associated with increasing GP outpatient coverage (model 1) and GP availability (model 2) under a GP self/privately employed group (respectively, OR = 17.01 [CI 95% 3.67–20.63] and OR = 17.80 [CI 95% 8.12–130.35]). The study evidenced that publicly employed GPs working in a tax‐based HSF scheme ensure better health outcomes for the population. Although some limitations of equity and categorisation, the results show that the governance model might influence population health outcomes.

Awareness, Willingness to Join, and Affordability of Social Health Insurance among Public Employees in Arba Minch Town, South Ethiopia

Background. As part of the efforts being made to achieve universal health coverage, Ethiopia plans to introduce a social health insurance scheme for the formal sector. Although the contribution will be collected as 3% of an employee’s gross salary from both the employee and employer, there is a concern that the premium may not be affordable for the majority of civil servants and that there could be limited interest in joining the scheme. As a result, the purpose of this study was to assess public servants’ awareness, willingness to join, and affordability of social health insurance in Arba Minch, south Ethiopia. Methods and Materials. A cross-sectional study design was used with 713 randomly chosen public employees from Arba Minch town from January 1 to 30, 2019. The survey participants were selected based on a multistage stratified random sampling method. Descriptive statistics were used to summarize awareness and affordability of the scheme, and both bivariate and multivariable logistic regressions were used to examine factors driving the outcome variables. Variables that had a p value of less than 0.25 in bivariate analysis were changed to multivariate analysis, and a p value of less than 0.05 was cutoff point for multivariate analysis. The odds ratio and 95% CI were used to report the findings. Result. In this study, 692 people voluntarily participated, which corresponds to a response rate of 97%. As the results revealed, 347 (50.1%) respondents had never heard of SHI before, 607 (87.7%) were able to afford the 3% of gross salary per month as a scheme premium, and 254 (36.7%) were willing to join the scheme. Working sector, regularly listening for health information through mass media, and social network participation were significantly associated with awareness of the SHI scheme. Also, educational status, family size, and net income were found to be significant factors associated with the affordability of the SHI scheme. On the other hand, awareness of SHI, family size, regularly listening for health information, and participation in social networks were significantly associated with willingness to join SHI during multivariate analysis. Conclusion. Half of the participants were unaware of social health insurance, suggesting that the program is not well known. Although only one-third of respondents were willing to join and pay for the program, the majority were able to afford the proposed contribution of 3% of gross wages per month.

System, institutional, and client-level factors associated with formal healthcare utilisation among older adults with low income under a social protection scheme in Ghana

BackgroundIn sub-Saharan African context, effect of system, institutional and client-level factors on formal healthcare utilisation among older adults with low income, especially those under a social protection scheme (called Livelihood Empowerment against Poverty [LEAP] programme) is least explored in the literature. However, an adequate understanding of how these factors contribute to formal healthcare utilisation among older adults who are classified as poor (in terms of low income) is important to inform health policy decisions. The aim of this study, therefore, was to examine the contributions of system, institutional and client-level factors in formal healthcare utilisation among older adults with low income under the LEAP programme in Ghana.MethodsData associated with this study were obtained from an Ageing, Health, Lifestyle and Health Services survey conducted between 1 and 20 June 2018 (N = 200) in the Atwima Nwabiagya Municipal and Atwima Nwabiagya North District of Ghana. Multivariable logistic regressions were used to determine system, institutional and client-level factors associated with formal healthcare utilisation among older adults with low income under the LEAP programme in Ghana. The significance of the test was set at a probability value of 0.05 or below.ResultsThe study revealed that participants who relied on the LEAP programme and/or health insurance subscription to cater for their healthcare expenses (AOR: 11.934, CI: 1.151-123.777), those whose family/caregivers decided on when and where to use formal healthcare (AOR:12.409; CI: 2.198–70.076) and those who did not encounter communication problem with healthcare providers (AOR: 1.358; CI: 1.074–3.737) were significantly more likely to utilise formal healthcare services compared with their counterparts. The study further found that participants who perceived the attitude of healthcare providers as poor (AOR: 0.889; CI: 0.24–0.931) and those who spent 20–40 minutes at the healthcare facility were significantly less likely to utilise formal healthcare services compared with their counterparts (AOR: 0.070; CI: 0.006–0.195).ConclusionOur findings suggest that reducing waiting time at healthcare facilities, improving social protection and/or health insurance schemes, improving patient-doctor communication and promoting attitudinal change programmes (such as orientations and supportive supervision) for healthcare providers may help to facilitate the use of needed formal healthcare services by older adults with low income in Ghana.

Stakeholders' Perspectives on the Financial Sustainability of the HIV Response in Nigeria: A Qualitative Study.

Countries in sub-Saharan Africa, including Nigeria, continue to depend on donor funding to achieve their national HIV response goals. The Government of Nigeria has made limited progress in translating political commitment to reduce donor dependency into increased domestic investment to ensure the sustainable impact of the HIV response. We explored the context-specific factors affecting the financial sustainability of the HIV response in Nigeria. Between November 2021 and March 2022, we conducted document reviews (n=13) and semistructured interviews with purposively selected national and subnational stakeholders (n=35). Data were analyzed thematically using the framework of health financing functions comprising revenue generation, pooling, and purchasing. Stakeholders reported that there is a low level of government funding for the HIV response, which has been compounded by the weak engagement of Ministry of Finance officials and the unpredictable and untimely release of budgeted funds. Opportunities for domestic funding include philanthropy and an HIV Trust Fund led by the private sector. Integration of HIV treatment services into social health insurance schemes has been slow. Commodity purchasing has been inefficient due to ineffective coordination. Government stakeholders have been reluctant to support one-stop-shop facilities that target key and priority populations. Opportunities exist in the government and private sectors for improving domestic health financing to support transitioning from donor support and ensuring the financial sustainability of the HIV response in Nigeria. To ensure that domestic financing for the HIV response is stable and predictable, the amount of domestic funding needs to increase and a framework that incorporates donor transition milestones must be developed, implemented, and monitored.

Pattern of population coverage of a social health insurance scheme in a Southwest Nigeria State: A 3-year post implementation evaluation

Aims: Social health insurance scheme is capable of minimizing inequity of access to health services, and thereby enhance an improvement in population health outcomes. Recently the National Health Insurance Scheme (NHIS) of Nigeria decentralized its management to the sub-national levels, thus the emergence of State Health Insurance Schemes (SHIS).  The SHIS of Oyo State Nigeria started operations about three years ago (June 2017). There is limited/sparse evidence on the performance of the scheme since its inception. Therefore, the aim of this study was to assess the scheme’s level of population coverage in the first three years of implementation. The findings will also provide an evidence base to inform the repositioning of the scheme for improved performance and enable it achieve the purpose of its establishment. 
 Methods: Service data from the server of Oyo SHIS were downloaded, collated and analyzed with excel software. Data extraction, cleaning and analysis covered a period of three months (September – October, 2020). Descriptive statistics were used to summarise the data. Population coverage distributions were expressed as frequency and percentages. Frequency tables and graphs were generated to disaggregate the findings.
 Conclusion: Stakeholders in the Oyo State SHIS need to re-strategize to reposition the scheme for an accelerated population coverage as a proxy for performance assessment.
 Acknowledgements:
 Authors wish to acknowledge Oyo State Health Insurance Agency for the permission to make use of the data and to submit the manuscript for publication. We authors would like to sincerely acknowledge the contributions of Prof. Charles Wiysonge and that of Dr. Chukwudi Nnaji for the comprehensive review and suggestions made on this manuscript. Many thanks.
  
 Authors' contributions:
 David Adewole conceived and designed the study. Wuraola Ladepo and Temitope Ilori did data collection and analysis.  Adewole, Owolabi and Akande contributed equally to the manuscript write up. All authors read through the manuscript draft the second time. All authors agreed to the final manuscript.
  
 Conflict of interests: None declared.

Willingness to Pay for Social Health Insurance and its Determinants Among Public School Teachers in Akaki Kality Sub-City of Addis Ababa City Administration: Ethiopia. Institution-Based Cross-Sectional Study

Background: Ethiopia is one of the countries with high out-of-pocket payments leading to catastrophic health expenditure. The government of Ethiopia introduced social health insurance scheme to reduce the out-of-pocket payments. However, there is limited evidence on willingness to pay for social health insurance among formal sector employees in the country. This study aimed to assess the willingness to pay for social health insurance and its associated factors among teachers in public school of Addis Ababa. Methods: An institution-based cross-sectional study was conducted from 10th January to 15th April 2022 on 280 teachers. Systematic sampling technique was used; data were collected using pretested self-administered structured questionnaire. The collected data were analyzed using SPSS version 23. Binary logistic regression analysis was performed to estimate crude odds ratios. In the multivariate model, a significant level at p-value of < 0.05 and adjusted odds ratio with 95%CI was used to determine the statistical association between the willingness to pay and explanatory variables. Result: Two hundred eight 74.3%were willing pay for social health insurance. Higher educational status [AOR=5.48; 95%CI (1.80, 16.73)], difficulties associated with healthcare cost [AOR=2.39; 95%CI (1.35, 4.24)], awareness about social health insurance [AOR=5.59; 95%CI (2.98, 10.48)], and knowledge of social health insurance’s benefit package [AOR=5.56; 95%CI (3.07, 10.04)] showed significant positive association with willingness to pay for social health insurance. Perception for poor quality of public health facility and trust on a health insurance agency showed significant negative association and teachers lost interest for social health insurance scheme. Conclusions: Three – fourth of the public-school teachers were willing to pay the premium proposed by the government. Higher educational status, difficulties associated with healthcare cost and awareness about social health insurance were the factors that affect positively the willingness to pay for social health insurance among public school teachers. This can pave the way to start the scheme but attention should focus on improving the quality of public health facilities and the trustfulness on health insurance agency.