Dataset Information

Private healthcare provider experiences with social health insurance schemes: Findings from a qualitative study in Ghana and Kenya.

ABSTRACT:

Background

Incorporating private healthcare providers into social health insurance schemes is an important means towards achieving universal health coverage in low and middle income countries. However, little research has been conducted about why private providers choose to participate in social health insurance systems in such contexts, or their experiences with these systems. We explored private providers' perceptions of and experiences with participation in two different social health insurance schemes in Sub-Saharan Africa-the National Health Insurance Scheme (NHIS) in Ghana and the National Hospital Insurance Fund (NHIF) in Kenya.

Methods

In-depth interviews were held with providers working at 79 facilities of varying sizes in three regions of Kenya (N = 52) and three regions of Ghana (N = 27). Most providers were members of a social franchise network. Interviews covered providers' reasons for (non) enrollment in the health insurance system, their experiences with the accreditation process, and benefits and challenges with the system. Interviews were coded in Atlas.ti using an open coding approach and analyzed thematically.

Results

Most providers in Ghana were NHIS-accredited and perceived accreditation to be essential to their businesses, despite challenges they encountered due to long delays in claims reimbursement. In Kenya, fewer than half of providers were NHIF-accredited and several said that their clientele were not NHIF enrolled. Understanding of how the NHIF functioned was generally low. The lengthy and cumbersome accreditation process also emerged as a major barrier to providers' participation in the NHIF in Kenya, but the NHIS accreditation process was not a major concern for providers in Ghana.

Conclusions

In expanding social health insurance, coordinated efforts are needed to increase coverage rates among underserved populations while also accrediting the private providers who serve those populations. Market pressure was a key force driving providers to gain and maintain accreditation in both countries. Developing mechanisms to engage private providers as stakeholders in social health insurance schemes is important to incentivizing their participation and addressing their concerns.

SUBMITTER: Sieverding M

PROVIDER: S-EPMC5823407 | biostudies-literature | 2018

REPOSITORIES: biostudies-literature

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Publications

Private healthcare provider experiences with social health insurance schemes: Findings from a qualitative study in Ghana and Kenya.

Sieverding Maia M Onyango Cynthia C Suchman Lauren L

PloS one 20180222 2

<h4>Background</h4>Incorporating private healthcare providers into social health insurance schemes is an important means towards achieving universal health coverage in low and middle income countries. However, little research has been conducted about why private providers choose to participate in social health insurance systems in such contexts, or their experiences with these systems. We explored private providers' perceptions of and experiences with participation in two different social health ...[more]

PMID: 29470545

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Project description:ObjectivesCommunity-based health insurance (CBI) is a common mechanism to generate financial resources for health care in developing countries. We review for the first time provider payment methods used in CBI in developing countries and their impact on CBI performance.MethodsWe conducted a systematic review of the literature on provider payment methods used by CBI in developing countries published up to January 2010.ResultsInformation on provider payment was available for a total of 32 CBI schemes in 34 reviewed publications: 17 schemes in South Asia, 10 in sub-Saharan Africa, 4 in East Asia and 1 in Latin America. Various types of provider payment were applied by the CBI schemes: 17 used fee-for-service, 12 used salaries, 9 applied a coverage ceiling, 7 used capitation and 6 applied a co-insurance. The evidence suggests that provider payment impacts CBI performance through provider participation and support for CBI, population enrolment and patient satisfaction with CBI, quantity and quality of services provided and provider and patient retention. Lack of provider participation in designing and choosing a CBI payment method can lead to reduced provider support for the scheme.ConclusionCBI schemes in developing countries have used a wide range of provider payment methods. The existing evidence suggests that payment methods are a key determinant of CBI performance and sustainability, but the strength of this evidence is limited since it is largely based on observational studies rather than on trials or on quasi-experimental research. According to the evidence, provider payment can affect provider participation, satisfaction and retention in CBI; the quantity and quality of services provided to CBI patients; patient demand of CBI services; and population enrollment, risk pooling and financial sustainability of CBI. CBI schemes should carefully consider how their current payment methods influence their performance, how changes in the methods could improve performance, and how such effects could be assessed with scientific rigour to increase the strength of evidence on this topic.

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Project description:BackgroundSickle cell disease (SCD) is a major public health concern in sub-Saharan Africa, accounting for nearly 75% of the global disease burden. The current analysis evaluated patient characteristics, treatment patterns, healthcare resource utilization (HCRU) and associated costs in patients with SCD based on a Private Medical Insurance Database in Ghana.MethodsThis retrospective longitudinal cohort study was conducted using an e-claims database from Ghana (01 January 2015 to 31 March 2021). Patients were stratified by age (0 month to < 2 years, ≥ 2 years to ˂6 years, ≥ 6 years to < 12 years, ≥ 12 years to < 16 years; ≥16 years), vaso-occlusive crisis (VOC) (< 1, ≥ 1 to < 3, and ≥ 3 per year), and continuous enrolment. Study outcomes related to patient characteristics, comorbidities, treatment pattern, HCRU were evaluated for pre- and post-index period (index period was between July 2015 to March 2020). Descriptive analysis was used to analyse different study variables.ResultsThe study included 2,863 patients (mean age: 20.1 years; Min age: 0; Max age: 83; females 56.1%). Overall, 52.2% (n = 1,495) of SCD patients were ≥ 16 years and 17.0% (n = 486) were in the ≥ 2 to ˂6-years age group. The majority of patients aged ≥ 16 years (62.5%) in the database did not have reported VOC episodes, 35.9% of patients had 1 to 3 VOCs per year and 1.5% had ≥ 3 VOCs per year during the follow-up period. Consultation-based prevalence of SCD was 0.5% [95% confidence interval (CI): 0-1.3%] - 1.4% [CI: 0.6-2.2%]. Malaria, upper respiratory tract infection (URTI) and sepsis were the common complications of SCD. Analgesics were the most frequently prescribed medications followed by anti-infectives, hematinics, and antimalarials. Hydroxyurea, a routine standard of care for SCD was under-utilized. SCD patients had median cost incurred for consultation/hospital services of $11.3 (Interquartile range [IQR] $6.2 - $27.2). For patients with VOC, maximum median cost was incurred for medications ($10.9 [IQR $5.0-$32.6]). Overall median healthcare cost was highest for individuals with ≥ 3 VOCs per year during the follow-up period ($166.8 [IQR $70.3-$223.5]).ConclusionIn this retrospective private insurance claims database analysis, SCD imposes a significant healthcare burden, especially in patients with VOC. There is a need for reimbursed treatment options that could reduce the long-term burden associated with SCD and VOC.

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Dataset Information

Private healthcare provider experiences with social health insurance schemes: Findings from a qualitative study in Ghana and Kenya.

Background

Methods

Results

Conclusions

Publications

Private healthcare provider experiences with social health insurance schemes: Findings from a qualitative study in Ghana and Kenya.

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