Dataset Information

Assessing the feasibility and appropriateness of introducing a national health insurance scheme in Malawi.

ABSTRACT:

Background

In May 2015 the Malawian Ministry of Health (MOH) contacted the German Development Cooperation to seek technical assistance from the P4H Network for Social Health Protection for an "Assessment of the appropriateness and feasibility of National Health Insurance in Malawi" against two alternative options: continuing with a tax (and donor)-funded National Health Service, and introducing a purchaser-provider split without a revenue collection function.

Methods

A health financing benchmarking matrix was agreed with MOH, with six domains corresponding to six objectives: revenue mobilisation, technical efficiency, equity, financial risk protection, policy coordination, and health outcomes. The assessment comprised key informant interviews with Malawian stakeholders, a review of the relevant literature and datasets, rapid assessments of the Malawi Revenue Authority (MRA) and the Unified Beneficiary Registry (UBR), and projections of the National Health Insurance Scheme's (NHIS) revenue collection costs and benefits.

Results

A key finding was that introducing NHIS in Malawi would increase revenues for health, but these would come predominantly from the formal sector and would be unlikely to cover the health sector funding gap. The performance of existing poverty identification and targeting mechanisms was not commensurate with the requirements of a NHIS. Incentives to enrol in NHI are insufficient to reach scale unless service fees be introduced, which would negatively affect equity and financial risk protection. The assessment identified the Purchaser Scenario as the most favourable reform model.

Conclusions

As ever more countries look towards implementing National Health Insurance, the proposed assessment framework can provide an orientation for evidence-based policy making in the area of health financing.

SUBMITTER: Gheorghe A

PROVIDER: S-EPMC6526615 | biostudies-literature | 2019

REPOSITORIES: biostudies-literature

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Publications

Assessing the feasibility and appropriateness of introducing a national health insurance scheme in Malawi.

Gheorghe Adrian A Straehler-Pohl Kai K Nkhoma Dominic D Mughandira Wathando W Garand Denis D Malema Deliwe D Murray-Zmijewski Alexandra A Kardan Andrew A Lievens Tomas T

Global health research and policy 20190520

<h4>Background</h4>In May 2015 the Malawian Ministry of Health (MOH) contacted the German Development Cooperation to seek technical assistance from the P4H Network for Social Health Protection for an "Assessment of the appropriateness and feasibility of National Health Insurance in Malawi" against two alternative options: continuing with a tax (and donor)-funded National Health Service, and introducing a purchaser-provider split without a revenue collection function.<h4>Methods</h4>A health fina ...[more]

PMID: 31139753

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Project description:BackgroundResponsiveness of health care services in low and middle income countries has been given little attention. Despite being introduced over a decade ago in many developing countries, national health insurance schemes have yet to be evaluated in terms of responsiveness of health care services. Although this responsiveness has been evaluated in many developed countries, it has rarely been done in developing countries. The concept of responsiveness is multi-dimensional and can be measured across various domains including prompt attention, dignity, communication, autonomy, choice of provider, quality of facilities, confidentiality and access to family support. This study examines the insured users' perspectives of their health care services' responsiveness.MethodsThis retrospective, cross-sectional survey took place between October 2010 and March 2011. The study used a modified out-patient questionnaire from a responsiveness survey designed by the World Health Organization (WHO). Seven hundred and ninety six (796) enrolees, insured for more than one year in Kaduna State-Nigeria, were interviewed. Generalized ordered logistic regression was used to identify factors that influenced the users' perspectives on responsiveness to health services and quantify their effects.ResultsCommunication (55.4%), dignity (54.1%), and quality of facilities (52.0%) were rated as "extremely important" responsiveness domains. Users were particularly contented with quality of facilities (42.8%), dignity (42.3%), and choice of provider (40.7%). Enrolees indicated lower contentment on all other domains. Type of facility, gender, referral, duration of enrolment, educational status, income level, and type of marital status were most related with responsiveness domains.ConclusionsAssessing the responsiveness of health care services within the NHIS is valuable in investigating the scheme's implementation. The domains of autonomy, communication and prompt attention were identified as priority areas for action to improve this responsiveness. For the Nigerian context, we suggest that health care providers in the NHIS should pay attention to these domains, and the associated characteristics of users, when delivering health care services to their clients. Policy makers, and the insurance regulatory agency, should consider the reform strategies of monitoring and quality assurance which focus on the domains of responsiveness to lessen the gap between users' expectations and their experiences with health services.

Project description:BackgroundGhana introduced capitation payment method in 2012 but was faced with resistance from provider groups and civil society organizations for its perceived negative effects on quality care delivery. This study seeks to explore the views of providers to understand their preferred payment method for the various types of services they provide in order to inform the discussion and negotiations during this period of reform. Findings will not only aid the National Health Insurance Authority (NHIA) to improve the implementation arrangements but also provide useful inputs for other low and middle-income countries (LMICs) in their quest to reform their provider payment systems.Materials and methodsWe conducted a cross-sectional survey of 200 credentialed health care providers' in the three regions of Ghana on providers' preference for payment method. We administered closed-ended questionnaires employing 5-point Likert scales for measurement of payment method preference. Descriptive and regression analysis were performed to examine healthcare providers' background characteristics and their association with preferred payment method for primary care.ResultsIn general, health care providers prefer the Ghana-Diagnosis-Related Grouping (G-DRG) payment method to fee-for-service and capitation payment methods. Result of bivariate analyses showed that healthcare providers' preference for payment method for primary outpatient services differed significantly by their region of residence (p<0.001). The multinomial logic model showed that being a female (p = 0.013) or healthcare provider in the Volta region (p = 0.008) was significantly associated with health provider preference for G-DRG payment method relative to fee-for-service. Similarly, being a healthcare provider in the Volta region (p = 0.026) or Medical Assistant (p = 0.032) was significantly associated with capitation relative to fee-for-service payment method.ConclusionWe conclude that the most preferred payment method across all regions is the G-DRG. However, whereas providers in the Volta region are not willing to accept capitation as payment method, this was not the case in Ashanti and Central regions. Capitation payment method as an option for primary care services in Ghana should, therefore, not be ruled out of the discussion.

Project description:ObjectiveThe debate surrounding access to medicines in Nigeria has become increasingly necessary due to the high cost of essential medicine drugs and the prevalence of counterfeit medicines in the country. The Nigerian government has proposed the implementation of the National Health Insurance Scheme (NHIS) to address these issues and guarantee universal access to essential medicines. Access was investigated using the 3 A's (accessibility, affordability, and availability). This paper investigates whether the NHIS is a viable pathway to sustained access to medicines in Nigeria.DesignThis was a cross-sectional study using a mixed-methods design. Both qualitative and quantitative methods were utilized for the study.SettingThis study was conducted at NHIS-accredited public and private facilities in Enugu State.Participants296 randomly selected enrollees took part in the quantitative component, while, 6 participants were purposively selected for the qualitative component, where in-depth interviews (IDIs) were conducted face-to-face with NHIS desk officers in selected public and private health facilities.ResultsThe quantitative findings showed that 94.9% of respondents sought medical help. Our data shows that 78.4% of the respondents indicated that the scheme improved their access to care (accessibility, affordability, and availability). The qualitative results from the NHIS desk officers showed that respondents across all the socio-economic groups reported that the NHIS had marginally improved access to medicine over the years. It was also observed that most of the staff in NHIS-accredited facilities were not adequately trained on the scheme's requirements and that most times, essential drugs were not readily available at the accredited facilities.ConclusionThe study findings revealed that although the NHIS has successfully expanded access to medicines, there remain several challenges to its effective implementation and sustainability. Additionally, the scheme's coverage of essential medicines is could be improved even more, leading to reduced access to needed drugs for many Nigerians. A focus on the 3As for the scheme means that all facility categories (private and public) and their interests (where necessary) must be considered in further planning of the scheme to ensure that things work out well.

Project description:Implementation of a National Health Insurance (NHI) in South Africa requires a reliable, standardized health information system that supports Diagnosis-Related Groupers for reimbursements and resource management. We assessed the quality of inpatient health records, the availability of standard discharge summaries and coded clinical data and the congruence between inpatient health records and discharge summaries in public-sector hospitals to support the NHI implementation in terms of reimbursement and resource management. We undertook a cross-sectional health-records review from 45 representative public hospitals consisting of seven tertiary, 10 regional and 28 district hospitals in 10 NHI pilot districts representing all nine provinces. Data were abstracted from a randomly selected sample of 5795 inpatient health records from the surgical, medical, obstetrics and gynaecology, paediatrics and psychiatry departments. Quality was assessed for 10 pre-defined data elements relevant to NHI reimbursements, by comparing information in source registers, patient folders and discharge summaries for patients admitted in March and July 2015. Cohen's/Fleiss' kappa coefficients (κ) were used to measure agreements between the sources. While 3768 (65%) of the 5795 inpatient-level records contained a discharge summary, less than 835 (15%) of diagnoses were coded using ICD-10 codes. Despite most of the records having correct patient identifiers [κ: 0.92; 95% confidence interval (CI) 0.91-0.93], significant inconsistencies were observed between the registers, patient folders and discharge summaries for some data elements: attending physician's signature (κ: 0.71; 95% CI 0.67-0.75); results of the investigation (κ: 0.71; 95% CI 0.69-0.74); patient's age (κ: 0.72; 95% CI 0.70-0.74); and discharge diagnosis (κ: 0.92; 95% CI 0.90-0.94). The strength of agreement for all elements was statistically significant (P-value ≤ 0.001). The absence of coded inpatient diagnoses and identified data inaccuracies indicates that existing routine health information systems in public-sector hospitals in the NHI pilot districts are not yet able to sufficiently support reimbursements and resource management. Institutional capacity is needed to undertake diagnostic coding, improve data quality and ensure that a standard discharge summary is completed for every inpatient.

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

Project description:Ghana's National Health Insurance Scheme (NHIS), established by an Act of Parliament (Act 650), in 2003 and since replaced by Act 852 of 2012 remains, in African terms, unprecedented in terms of growth and coverage. As a result, the scheme has received praise for its associated legal reforms, clinical audit mechanisms and for serving as a hub for knowledge sharing and learning within the context of South-South cooperation. The scheme continues to shape national health insurance thinking in Africa. While the success, especially in coverage and financial access has been highlighted by many authors, insufficient attention has been paid to critical and context-specific factors. This paper seeks to fill that gap.Based on an empirical qualitative case study of stakeholders' views on challenges and success factors in four mutual schemes (district offices) located in two regions of Ghana, the study uses the concept of policy translation to assess whether the Ghana scheme could provide useful lessons to other African and developing countries in their quest to implement social/NHISs.In the study, interviewees referred to both 'hard and soft' elements as driving the "success" of the Ghana scheme. The main 'hard elements' include bureaucratic and legal enforcement capacities; IT; financing; governance, administration and management; regulating membership of the scheme; and service provision and coverage capabilities. The 'soft' elements identified relate to: the background/context of the health insurance scheme; innovative ways of funding the NHIS, the hybrid nature of the Ghana scheme; political will, commitment by government, stakeholders and public cooperation; social structure of Ghana (solidarity); and ownership and participation.Other developing countries can expect to translate rather than re-assemble a national health insurance programme in an incomplete and highly modified form over a period of years, amounting to a process best conceived as germination as opposed to emulation. The Ghana experience illustrates that in adopting health financing systems that function well, countries need to customise systems (policy customisation) to suit their socio-economic, political and administrative settings. Home-grown health financing systems that resonate with social values will also need to be found in the process of translation.

Project description:BackgroundThe introduction of the national health insurance scheme (NHIS) in Ghana in 2003 significantly contributed to improved health services utilization and health outcomes. However, stagnating active membership, reports of poor quality health care rendered to NHIS-insured clients and cost escalations have raised concerns on the operational and financial sustainability of the scheme. This paper reviewed peer reviewed articles and grey literature on the sustainability challenges and prospects of the NHIS in Ghana.MethodsElectronic search was done for literature published between 2003-2016 on the NHIS and its sustainability in Ghana. A total of 66 publications relevant to health insurance in Ghana and other developing countries were retrieved from Cochrane, PubMed, ScienceDirect and Googlescholar for initial screening. Out of this number, 31 eligible peer reviewed articles were selected for final review based on specific relevance to the Ghanaian context.ResultsAbility of the NHIS to continue its operations in Ghana is threatened financially and operationally by factors such as: cost escalation, possible political interference, inadequate technical capacity, spatial distribution of health facilities and health workers, inadequate monitoring mechanisms, broad benefits package, large exemption groups, inadequate client education, and limited community engagement. Moreover, poor quality care in NHIS-accredited health facilities potentially reduces clients' trust in the scheme and consequently decreases (re)enrolment rates. These sustainability challenges were reviewed and discussed in this paper.ConclusionsThe NHIS continues to play a critical role towards attaining universal health coverage in Ghana albeit confronted by challenges that could potentially collapse the scheme. Averting this possible predicament will largely depend on concerted efforts of key stakeholders such as health insurance managers, service providers, insurance subscribers, policy makers and political actors.

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

Dataset Information

Assessing the feasibility and appropriateness of introducing a national health insurance scheme in Malawi.

Background

Methods

Results

Conclusions

Publications

Assessing the feasibility and appropriateness of introducing a national health insurance scheme in Malawi.

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