Health insurance and health system (un) responsiveness: a qualitative study with elderly in rural Tanzania.
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ABSTRACT: Background
Health insurance (HI) has increasingly been accepted as a mechanism to facilitate access to healthcare in low and middle-income countries. However, health insurance members, especially those in Sub-Saharan Africa, have reported a low responsiveness in health systems. This study aimed to explore the experiences and perceptions of healthcare services from the perspective of insured and uninsured elderly in rural Tanzania.Method
An explanatory qualitative study was conducted in the rural districts of Igunga and Nzega, located in western-central Tanzania. Eight focus group discussions were carried out with 78 insured and uninsured elderly men and women who were purposely selected because they were 60 years of age or older and had utilised healthcare services in the past 12 months prior to the study. The interview questions were inspired by the domains of health systems' responsiveness. Qualitative content analysis was used to analyse the data.Results
Elderly participants appreciated that HI had facilitated the access to healthcare and protected them from certain costs. But they also complained that HI had failed to provide equitable access due to limited service benefits and restricted use of services within schemes. Although elderly perspectives varied widely across the domains of responsiveness, insured individuals generally expressed dissatisfaction with their healthcare.Conclusions
The national health insurance policy should be revisited in order to improve its implementation and expand the scope of service coverage. Strategic decisions are required to improve the healthcare infrastructure, increase the number of healthcare workers, ensure the availability of medicines and testing facilities at healthcare centers, and reduce long administrative procedures related to HI. A continuous training plan for healthcare workers focused on patients´ communication skills and care rights is highly recommended.
SUBMITTER: Amani PJ
PROVIDER: S-EPMC8532322 | biostudies-literature | 2021 Oct
REPOSITORIES: biostudies-literature
Publications
Health insurance and health system (un) responsiveness: a qualitative study with elderly in rural Tanzania.
Amani Paul Joseph PJ Hurtig Anna-Karin AK Frumence Gasto G Kiwara Angwara Denis AD Goicolea Isabel I San Sebastiån Miguel M
BMC health services research 20211022 1
<h4>Background</h4>Health insurance (HI) has increasingly been accepted as a mechanism to facilitate access to healthcare in low and middle-income countries. However, health insurance members, especially those in Sub-Saharan Africa, have reported a low responsiveness in health systems. This study aimed to explore the experiences and perceptions of healthcare services from the perspective of insured and uninsured elderly in rural Tanzania.<h4>Method</h4>An explanatory qualitative study was conduc ...[more]
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Project description:BACKGROUND:Health system performance is one of the important components of the health care delivery; its achievement depends on the quality of services rendered and the health system responsiveness of its beneficiaries. Health system responsiveness is a multi-dimensional concept and is usually measured through several domains. Health system responsiveness (HSR) remains to be a key indicator for evaluation of health system performance in any settings. This study aimed at assessing the situation of health system responsiveness in primary health facilities in Tanzania prior to introduction of the Direct Health Facility Financing (DHFF) program. METHODS:This was a cross sectional study conducted between January and February in 2018. We collected data from 42 primary health facilities (14 health centers and 28 dispensaries) where a questionnaire was administered to a total of 422 participants. The questionnaire collected information on attention, respect to dignity, clear communication, autonomy, access to care, respect to confidentiality and basic amenities. Descriptive analysis was done to determine the distribution of the variables whereas ANOVA and linear regression analysis was employed to discern the association between variables. RESULTS:More than 67% of participants had visited the same health facility more than 5 times. Sixty seven percent of the patients were residing within 5kms from the public primary health care facilities. The geographical access to health care scored the lowest (43.5% for Dispensaries and 36% for Health center) mean as compared to other domains of health system responsiveness. The highest score was in respect to confidentiality (86.7%) followed by respect to dignity (81.4%). Linear regression analysis revealed no statistical association between any of the social demographic features with the overall HSR performances. However, in post hoc analysis, Pwani and Shinyanga regions didn't differ significantly in terms of their performances whereas those two regions differ from all other regions. CONCLUSION:Based on the study findings health system responsiveness domains has performed relatively poor in many regions except for respect of dignity and confidentiality scored high of all the domains. Shinyanga and Pwani regions scored relatively well in all domains this could have been due to the effect of Results Based financing (RBF) in the respective regions. All in all the Government and other stakeholders in the health sector they should deliberately invest on the access to care domain as seem to be a challenge as compared to others.
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Project description:BackgroundOver 150 million people, mostly from low and middle-income countries (LMICs) suffer from catastrophic health expenditure (CHE) every year because of high out-of-pocket (OOP) payments. In Tanzania, OOP payments account for about a quarter of the total health expenditure. This paper compares healthcare utilization and the incidence of CHE among improved Community Health Fund (iCHF) members and non-members in central Tanzania.MethodsA survey was conducted in 722 households in Bahi and Chamwino districts in Dodoma region. CHE was defined as a household health expenditure exceeding 40% of total non-food expenditure (capacity to pay). Concentration index (CI) and logistic regression were used to assess the socioeconomic inequalities in the distribution of healthcare utilization and the association between CHE and iCHF enrollment status, respectively.Results50% of the members and 29% of the non-members utilized outpatient care in the previous month, while 19% (members) and 15% (non-members) utilized inpatient care in the previous twelve months. The degree of inequality for utilization of inpatient care was higher (insured, CI = 0.38; noninsured CI = 0.29) than for outpatient care (insured, CI = 0.09; noninsured CI = 0.16). Overall, 15% of the households experienced CHE, however, when disaggregated by enrollment status, the incidence of CHE was 13% and 15% among members and non-members, respectively. The odds of iCHF-members incurring CHE were 0.4 times less compared to non-members (OR = 0.41, 95%CI: 0.27-0.63). The key determinants of CHE were iCHF enrollment status, health status, socioeconomic status, chronic illness, and the utilization of inpatient and outpatient care.ConclusionThe utilization of healthcare services was higher while the incidence of CHE was lower among households enrolled in the iCHF insurance scheme relative to those not enrolled. More studies are needed to establish the reasons for the relatively high incidence of CHE among iCHF members and the low degree of healthcare utilization among households with low socioeconomic status.
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Project description:ObjectivesIn Tanzania, contraceptive use is limited, particularly in rural communities and even among women who would like to delay childbearing. This paper aims to present health providers' perspectives on populations seeking contraception and barriers that could be addressed to increase access to and uptake of contraception, given their interface with large portions of their communities.Study designWe conducted 18 in-depth interviews with providers stationed at health dispensaries in six rural villages in northwest Tanzania. Two investigators independently coded interviews using a stepwise process to achieve consensus on prevalent topics.ResultsThree topics emerged from our analysis: (1) nature of clients seeking contraception; (2) barriers to uptake of contraception; and (3) the role of secrecy in obtaining and using contraception. Health providers reported that married women with children were the most frequent users of contraception, alongside some single women, men, sex workers, and students. Barriers to contraception included lack of supplies and trained staff, misconceptions and fears, stigma, and unsupportive partners. Providers observed that contraception was often used secretly. They reported surreptitious visits and described clients' preferential use of discreet methods. Providers respected and supported clients' desires to keep visits confidential.ConclusionOur data suggest maintaining high stocks of discreet contraceptive methods and deploying more trained staff to dispensaries could increase availability and access to contraceptives. At the community level, more education campaigns are warranted to address barriers, especially those related to stigma.ImplicationsOur work highlights the need for additional contraceptive methods that are easy to administer and discreet for women who must maintain secrecy. Future studies of the effectiveness of interventions and new contraceptives should obtain healthcare providers' perspectives, as they can provide important insights to service provision.
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Project description:ObjectivesTo assess the responsiveness of the National Health Insurance Fund (NHIF) Supa Cover benefit package to the needs of individuals with diabetes and hypertension in Kenya.Design, setting and participantsWe carried out a qualitative study and collected data using key informant interviews (n=39) and focus group discussions (n=4) in two purposively selected counties in Western Kenya. Study participants were drawn from NHIF officials, county government officials, health facility managers, healthcare workers and individuals with hypertension and diabetes who were enrolled in NHIF. We analysed data using a thematic approach.ResultsStudy participants reported that the NHIF Supa Cover benefit package expanded access to services for people living with hypertension and diabetes. However, the NHIF members and healthcare workers had inadequate awareness of the NHIF service entitlements. The NHIF benefit package inadequately covered the range of services needed by people living with hypertension and diabetes and the benefits package did not prioritise preventive and promotive services. Sometimes patients were discriminated against by healthcare providers who preferred cash-paying patients, and some NHIF-empanelled health facilities had inadequate structural inputs essential for quality of care. Study participants felt that the NHIF premium for the general scheme was unaffordable, and NHIF members faced additional out-of-pocket costs because of additional payments for services not available or covered.ConclusionWhereas NHIF has reduced financial barriers for hypertension and diabetes patients, to enhance its responsiveness to patient needs, NHIF should implement mechanisms to increase benefit package awareness among members and providers. In addition, preventive and promotive services should be included in NHIF's benefits package and mechanisms to monitor and hold contracted providers accountable should be strengthened.
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Project description:One of the main challenges facing the expansion of universal health coverage (UHC) in developing countries like Indonesia is the high prevalence of those working in the informal sector who must voluntarily register in the National Health Insurance System (NHIS). This condition hinders some from being covered by the NHIS. Following Bourdieu's concepts of field, capital and habitus, this research aims to analyse some aspects that influence the decision of informal sector workers to join the NHIS in Indonesia. We conducted qualitative methods, including in-depth interviews of 29 informants and Focus Group Discussion (FGD) in the three selected regions of Deli Serdang (North Sumatera), Pandeglang (Banten) and Kupang (East Nusa Tenggara). Using thematic content analysis and several triangulation processes, this study found that three main factors influence the decisions of those working in the informal sector to join the NHIS: health conditions, family and peers, and existing knowledge and experience. The stories provided by the informants regarding their decision-making processes in joining NHIS also reveal the necessary and sufficient conditions that enable informal sector workers to join the NHIS, which are individual-specific and which may differ between people, depending on individual characteristics, regional socioeconomic and demographic characteristics and belief systems. These three factors are all necessary conditions to support the joining of informal sector workers into the NHIS. This study suggests that one possible route for expanding the UHC coverage of informal sector workers is through maximising the word-of-mouth effect by engaging local or influential leaders.
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Project description:As many low- and middle-income countries scale up community health worker (CHW) programmes to achieve universal health coverage, ensuring quality as well as access is critical. Health system responsiveness (HSR) is a core domain of quality patient-centred care but has not been widely measured in CHW-delivered care. We report results from a household survey measuring HSR and health systems' quality of CHW-delivered care in two Liberian counties where the national CHW programme of Community Health Assistants (CHAs) for communities ≥5 km from a health centre has been implemented. We conducted a cross-sectional population-based household survey in 2019 in Rivercess (RC) and Grand Gedeh (GG) counties, using a two-stage cross-sectional cluster sampling approach. We included validated HSR questions on six responsiveness domains and patient-reported health system outcomes, such as satisfaction and trust in the CHA's skills and abilities. The HSR questions were administered to women aged 18-49 years who reported seeking care from a CHA in the 3 months prior to the survey. A composite responsiveness score was calculated and divided into tertiles. Multivariable analysis using Poisson regression with log link and adjusting for respondent characteristics was used to determine the association between responsiveness and patient-reported health system outcomes. The proportion of individuals rating responsiveness as very good or excellent was similar across all domains within a district, with ratings being lower in RC (23-29%) than in GG (52-59%). High ratings in both counties were seen for high trust in the CHA's skills and abilities (GG 84%, RC 75%) and high confidence in the CHA (GG 58%, RC 60%). Compared with women in the lowest responsiveness tertile (score ≤3), women in the highest tertile (score $ \ge $4.25) were significantly more likely to report high quality of CHA-delivered care (prevalence ratio, PR = 14.1), very good/excellent at meeting health needs (PR = 8.0), high confidence in the CHA to provide future care (PR = 2.4), and a high level of trust in CHA's skills and abilities (PR = 1.4). Controlling for respondent characteristics, the composite responsiveness score was significantly associated with all patient-reported health system outcomes (P < 0.001). We found that HSR was associated with important patient-reported health system quality outcomes, including satisfaction, trust, and confidence in the CHA. Measuring patients' experience and outcomes of care is important to complement more common measures of technical quality for CHW-delivered care to ensure that this domain of quality is central to the community health programme design and delivery.
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Project description:BackgroundIn 2016, the Chinese government introduced an integration reform of the health insurance system with the aim to enhance equity in healthcare coverage and reduce disparities between urban and rural sectors. The gradual introduction of the policy integrating urban and rural medical insurance in pilot cities provides an opportunity to evaluate the policy impact. This study attempts to assess the policy impact of urban-rural health insurance integration on the chronic poverty of rural residents and to analyze the mechanisms.MethodBased on the four waves of data from the China Health and Retirement Longitudinal Study (CHARLS) conducted in 2011, 2013, 2015, and 2018, we employed a staggered difference-in-differences (staggered DID) model to assess the impact of integrating urban-rural health insurance on poverty vulnerability among rural inhabitants and a mediation model to analyze the mechanism channel of the policy impact.Results(1) Baseline regression analysis revealed that the urban-rural health insurance integration significantly reduced the poverty vulnerability of rural residents by 6.32% (p < 0.01). The one health insurance system with one unified scheme of contributions and benefits package (OSOS, 6.27%, p < 0.01) is more effective than the transitional one health insurance system with multiple schemes (OSMS, 3.25%, p < 0.01). (2) The heterogeneity analysis results showed that the urban-rural health insurance integration had a more significant impact on vulnerable groups with relatively poor health (7.84%, p < 0.1) than those with fairly good health (6.07%, p < 0.01), and it also significantly reduced the poverty vulnerability of the group with chronic diseases by 9.59% (p < 0.01). The integration policy can significantly reduce the poverty vulnerability of the low consumption and low medical expenditure groups by 8.6% (p < 0.01) and 7.64% (p < 0.01), respectively, compared to their counterparts. (3) The mechanism analysis results showed that the urban-rural health insurance integration can partially enhance labor supply (14.23%, p < 0.01) and physical examinations (6.28%, p < 0.01). The indirect effects of labor supply and physical examination in reducing poverty vulnerability are 0.14%, 0.13% respectively.ConclusionThe urban-rural health insurance integration policy significantly reduced poverty vulnerability, and the OSOS is more effective than the OSMS. The urban-rural health insurance integration policy can significantly reduce poverty vulnerability for low consumption and poor health groups. Labor supply and physical examination are indirect channels of the impact. Both channels potentially increase rural household income and expectations of investment in human health capital to achieve the policy objective of eliminating chronic poverty.
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Project description:BackgroundIt is essential to involve service users in efforts to expand access to mental health care in integrated primary care settings in low- and middle-income countries (LMICs). However, there is little evidence from LMICs to guide this process. The aim of this study was to explore barriers to, and facilitators of, service user/caregiver involvement in rural Ethiopia to inform the development of a scalable approach.MethodsThirty nine semi-structured interviews were carried out with purposively selected mental health service users (n = 13), caregivers (n = 10), heads of primary care facilities (n = 8) and policy makers/planners/service developers (n = 8). The interviews were audio-recorded and transcribed in Amharic, and translated into English. Thematic analysis was applied.ResultsAll groups of participants supported service user and caregiver involvement in mental health system strengthening. Potential benefits were identified as (i) improved appropriateness and quality of services, and (ii) greater protection against mistreatment and promotion of respect for service users. However, hardly any respondents had prior experience of service user involvement. Stigma was considered to be a pervasive barrier, operating within the health system, the local community and individuals. Competing priorities of service users included the need to obtain adequate individual care and to work for survival. Low recognition of the potential contribution of service users seemed linked to limited empowerment and mobilization of service users. Potential health system facilitators included a culture of community oversight of primary care services. All groups of respondents identified a need for awareness-raising and training to equip service users, caregivers, service providers and local community for involvement. Empowerment at the level of individual service users (information about mental health conditions, care and rights) and the group level (for advocacy and representation) were considered essential, alongside improved, accessible mental health care and livelihood interventions.ConclusionAs Ethiopia increases access to mental health care, a fundamental barrier to service user involvement is beginning to be addressed. Our study identified further barriers that need to be tackled, including a supportive political climate, and receptiveness amongst stakeholders. The findings will inform the development of a model of service user involvement, which will be piloted and evaluated.
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Project description:BACKGROUND:Insurance organizations are essential stakeholders in health care ecosystems. For addressing future health care needs, insurance companies require access to health data to deliver preventative and proactive digital health services to customers. However, extant research is limited in examining the conditions that incentivize health data sharing. OBJECTIVE:This study aimed to (1) identify the expectations of insurance customers when sharing health data, (2) determine the perceived intrinsic value of health data, and (3) explore the conditions that aid in incentivizing health data sharing in the relationship between an insurance organization and its customer. METHODS:A Web-based survey was distributed to randomly selected customers from a Finnish insurance organization through email. A single open-text answer was used for a qualitative data analysis through inductive coding, followed by a thematic analysis. Furthermore, the 4 constructs of commitment, power, reciprocity, and trust from the social exchange theory (SET) were applied as a framework. RESULTS:From the 5000 customers invited to participate, we received 452 surveys (response rate: 9.0%). Customer characteristics were found to reflect customer demographics. Of the 452 surveys, 48 (10.6%) open-text responses were skipped by the customer, 57 (12.6%) customers had no expectations from sharing health data, and 44 (9.7%) customers preferred to abstain from a data sharing relationship. Using the SET framework, we found that customers expected different conditions to be fulfilled by their insurance provider based on the commitment, power, reciprocity, and trust constructs. Of the 452 customers who completed the surveys, 64 (14.2%) customers required that the insurance organization meets their data treatment expectations (commitment). Overall, 4.9% (22/452) of customers were concerned about their health data being used against them to profile their health, to increase insurance prices, or to deny health insurance claims (power). A total of 28.5% (129/452) of customers expected some form of benefit, such as personalized digital health services, and 29.9% (135/452) of customers expected finance-related compensation (reciprocity). Furthermore, 7.5% (34/452) of customers expected some form of empathy from the insurance organization through enhanced transparency or an emotional connection (trust). CONCLUSIONS:To aid in the design and development of digital health services, insurance organizations need to address the customers' expectations when sharing their health data. We established the expectations of customers in the social exchange of health data and explored the perceived values of data as intangible goods. Actions by the insurance organization should aim to increase trust through a culture of transparency, commitment to treat health data in a prescribed manner, provide reciprocal benefits through digital health services that customers deem valuable, and assuage fears of health data being used to prevent providing insurance coverage or increase costs.
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