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Inequalities in the benefits of national health insurance on financial protection from out-of-pocket payments and access to health services: cross-sectional evidence from Ghana.

ABSTRACT: A central pillar of universal health coverage (UHC) is to achieve financial protection from catastrophic health expenditure. There are concerns, however, that national health insurance programmes with premiums may not benefit impoverished groups. In 2003, Ghana became the first sub-Saharan African country to introduce a National Health Insurance Scheme (NHIS) with progressively structured premium charges. In this study, we test the impact of being insured on utilization and financial risk protection compared with no enrolment, using the 2012-13 Ghana Living Standards Survey (n?=?72 372). Consistent with previous studies, we observed that participating in health insurance significantly decreased the probability of unmet medical needs by 15 percentage points (p.p.) and that of incurring catastrophic out-of-pocket (OOP) health payments by 7 p.p. relative to no enrolment in the NHIS. Households living outside a 1-h radius to the nearest hospital had lower reductions in financial risk from excess OOP medical spending relative to households living closer (-5 p.p. vs -9 p.p.). We also find evidence that in Ghana, the scheme was highly pro-poor. Once insured, the poorest 40% of households experienced significantly larger improvements in medical utilization (18 p.p. vs. 8 p.p.) and substantively larger reductions in catastrophic OOP health expenditure (-10 p.p. vs. -6 p.p.) compared with that of the richest households. However, health insurance did not benefit vulnerable persons equally from financial risk. Once insured, poor, low-educated and self-employed households living far from hospitals had significantly lower reductions in catastrophic OOP medical spending compared with their counterparts living closer. Taken together, we show that enrolment in the NHIS is associated with improved financial protection but less so among geographically remote vulnerable groups. Efforts to boost not just insurance uptake but also health service delivery may be needed as a supplement for insurance schemes to accelerate progress towards UHC.

SUBMITTER: Fiestas Navarrete L

PROVIDER: S-EPMC6880330 | biostudies-literature | 2019 Nov

REPOSITORIES: biostudies-literature

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Inequalities in the benefits of national health insurance on financial protection from out-of-pocket payments and access to health services: cross-sectional evidence from Ghana.

Fiestas Navarrete Lucia L Ghislandi Simone S Stuckler David D Tediosi Fabrizio F

Health policy and planning 20191101 9

A central pillar of universal health coverage (UHC) is to achieve financial protection from catastrophic health expenditure. There are concerns, however, that national health insurance programmes with premiums may not benefit impoverished groups. In 2003, Ghana became the first sub-Saharan African country to introduce a National Health Insurance Scheme (NHIS) with progressively structured premium charges. In this study, we test the impact of being insured on utilization and financial risk protec ...[more]

PMID: 31539034

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Project description:IntroductionThe free maternal health policy was implemented in Ghana in 2008 under the National Health Insurance Scheme (NHIS). The policy sought to eliminate out of pocket (OOP) payments and enhance the utilisation of maternal health services. It is unclear whether the policy had altered OOP payments for services. The study explored views on costs and actual OOP payments during pregnancy. The source of funding for payments was also explored.MethodsA convergent parallel mixed methods design, involving quantitative and qualitative data collection approaches. The study was set in the Kassena-Nankana municipality, a rural area in Ghana. Women (n = 406) who utilised services during pregnancy were surveyed. Also, 10 focus groups discussions (FGDs) were held with women who used services during pregnancy as well as 28 in-depth interviews (IDIs) with midwives/nurses (n = 25) and insurance managers/directors (n = 3). The survey was analysed using descriptive statistics, focussing on costs from the women's perspective. Qualitative data were audio recorded, transcribed and translated verbatim into English where necessary. The transcripts were read and coded into themes and sub-themes.ResultsThe NHIS did not cover all expenses in relation to maternal health services. The overall mean for OOP cost during pregnancy was GH¢17.50 (US$8.60). Both FGDs and IDIs showed that women especially paid for drugs and ultrasound scan services. Sixty-five percent of the women used savings, whilst twenty-two percent sold assets to meet the OOP cost. Some women were unable to afford payments due to poverty and had to forgo treatment. Participants called for payments to be eliminated and for the NHIS to absorb the cost of emergency referrals. All participants admitted the benefits of the policy.ConclusionWomen needed to make payments despite the policy. Measures should be put in place to eliminate payments to enable all women to receive services and promote universal health coverage.

Project description:BackgroundThe low-and middle-income countries, including Nepal, aim to address the financial hardship against healthcare out-of-pocket (OOP) payments through various health financing reforms, for example, risk-pooling arrangements that cover different occupations. World Health Organization (WHO) has recommended member states to establish pooling arrangements so that the financial risks owing to health uncertainty can be spread across population. This study aims to analyse the situation of financial protection across occupations and geography using nationally representative annual household survey (AHS) in Nepal.MethodsWe measured catastrophic health expenditure (CHE) due to OOP using two popular approaches-budget share and capacity-to-pay, and impoverishment impact at absolute and relative poverty lines. This study is the first of its kind from south-east Asia to analyse disaggregated estimates of financial protection across occupations and geography. The inequality in financial risk protection was measured using concentration index. Data were extracted from AHS 2014-15 -a cross-sectional survey that used standard consumption measurement tool (COICOP) and International Standard Classification of Occupations (ISCO).ResultsWe found a CHE of 10.7% at 10% threshold and 5.2% at 40% threshold among households belonging to agricultural workers. The corresponding figures were 10% and 4.8% among 'plant operators and craft workers'. Impoverishment impact was also higher among these households at all poverty lines. In addition, CHE was higher among unemployed households. A negative concentration index was observed for CHE and impoverishment impact among agricultural workers and 'plant operators and craft workers'. In rural areas, we found a CHE of 11.5% at 10% threshold and a high impoverishment impact. Across provinces, CHE was 12% in Madhesh and 14.3% in Lumbini at 10% threshold, and impoverishment impact was 1.9% in Madhesh, Karnali and Sudurpachim at US $1.90 a day poverty line.ConclusionHouseholds belonging to informal occupations were more prone to CHE and impoverishment impact due to healthcare OOP payments. Impoverishment impact was disproportionately higher among elementary occupations, agricultural workers, and 'plant operators and craft workers'. Similarly, the study found a wide urban/rural and provincial gap in financial protection. The results can be useful to policymakers engaged in designing health-financing reforms to make progress toward UHC.

Project description:ObjectiveThe financial burden from noncommunicable diseases (NCDs) is a threat worldwide, alleviated only when good social protection schemes are in place. Albeit the Government in Albania has committed to Universal Healthcare Coverage (UHC), Out-of-Pockets (OOPs) persist. Through this study, we aimed to assess the OOPs related to consultations, diagnostic tests, and medicine prescriptions as self-reported by people suffering from NCDs.MethodsA household survey was conducted in two regions of Albania. The present analysis includes respondents who suffered from chronic health conditions and consulted a health care provider within the last 8 weeks (n = 898). Mixed logistic regression models with random intercepts at the level of communities were employed in order to assess the association of OOPs with age, gender, urban vs. rural residency, health insurance, marital status, barriers experienced, type of chronic condition(s) and region.ResultsOf those who consulted a provider, 95% also received a drug prescription. Among them, 94% were able to obtain all the drugs prescribed. Out-of-pocket payments occurred throughout the NCD treatment process; specifically, for consultation (36%), diagnostic tests (33%), and drugs purchased (88%). Drug expenditures accounted for 62% of all household expenditures. Respondents with health insurance were less likely to pay for consultation and drugs. The elderly (patients above 60 years old) were less likely to pay for consultations and tests. Those who lived in urban areas were less likely to pay for drugs and consultations. Patients encountering any form of barrier when seeking care had increased odds of OOPs for consultations (OR; 2.25 95%-CI; 1.57; 3.23) and tests (OR; 1.71 95%-CI; 1.19; 2.45).ConclusionOut-of-pocket payments by NCD patients principally made up through the purchase of prescribed drugs, remain important. Tackling the high costs of drugs will be important to accelerate the UHC agenda. Here, it is important to raise the population's awareness on patients' knowledge of their entitlements to health insurance, and on the current health reforms.

Project description:BackgroundGhana introduced a national health insurance program in 2005 with the goal of removing user fees, popularly called "cash and carry", along with their associated catastrophic and impoverishment effects on the population and ensuring access to equitable health care. However, after a decade of implementation, the impact of this program on user fees and out-of-pocket payment (OOP) is not properly documented. This paper contributes to understanding the impact of Ghana's health insurance program on out-of-pocket healthcare payments and the factors associated with the level of out-of-pocket payments for primary healthcare in a predominantly rural region of Ghana.MethodsUsing a five-year panel data of revenues accruing to public primary health facilities in seven districts, We employed mean comparison tests (t-test) to examine the trend in revenues accruing from out-of-pocket payments vis-à-vis health insurance claims for health services, medication, and obstetric care. Furthermore, generalized estimation equation regression models were used to assess the relationship between explanatory variables and the level of out-of-pocket payments and health insurance claims.ResultsOut-of-pocket payment for health services and medications declined by 63% and 62% respectively between 2010 and 2014. Insurance claims however increased by 16% within the same period. There was statistically a significant mean reduction in out-of-pocket payment over the period. Factors significantly associated with out-of-pocket payments in a given district are the number of community health facilities, availability of a district hospital and the year of observation.ConclusionThe study provides evidence that Ghana's national health insurance program is significantly contributing to a reduction in out-of-pocket payment for primary healthcare in public health facilities. Efforts should therefore be put in place to ensure the sustainability of this policy as a major pathway for achieving universal health coverage in Ghana.

Project description:BackgroundApproximately 150 million people suffer from financial catastrophe annually because of out-of-pocket expenditures (OOPEs) on health. Although the National Health Insurance Scheme (NHIS) of Ghana was designed to promote universal health coverage, OOPEs as a proportion of total health expenditures remains elevated at 26%, exceeding the WHO's recommendations of less than 15-20%. To determine whether enrollment in the NHIS reduces the likelihood of OOPEs and catastrophic health expenditures (CHEs) in Ghana, we undertook a systematic review of the published literature.MethodsWe searched for quantitative articles published in English between January 1, 2003 and August 22, 2017 in PubMed, Google Scholar, Economic Literature, Global Health, PAIS International, and African Index Medicus. Two independent authors (J.S.O. & S.E.) reviewed the articles for inclusion, extracted the data, and conducted a quality assessment of the studies. We accepted the World Health Organization definition of catastrophic health expenditures which is out of pocket payments for health care which exceeds 20% of annual house hold income, 10% of household expenditures, or 40% of subsistence expenditures (total household expenditures net food expenditures).ResultsOf the 1094 articles initially identified, 7 were eligible for inclusion. These were cross-sectional household studies published between 2008 and 2016 in Ghana. They demonstrated that the uninsured paid 1.4 to 10 times more in out-of-pocket payments (OOPs) and were more likely to incur CHEs than the insured. Yet, 6 to 18% of insured households made catastrophic payments for healthcare and all studies reported insured members making OOPs for medicines.ConclusionEvidence suggests that the national health insurance scheme of Ghana over the last 14 years has made some impact on reducing OOPEs, and yet healthcare costs remain catastrophic for a large proportion of insured households in Ghana. Future studies need to explore reasons for the persistence of OOPs for medicines and services that are covered under the scheme.

Project description:BackgroundHaving to pay out-of-pocket for health care can be prohibitive and even cause financial catastrophe for patients, especially those with low and irregular incomes. Health services at Government-owned hospitals in Malawi are provided free of charge but patients do incur costs when they access facilities and some of them forego income. This research paper presents findings on the direct and indirect expenditure incurred by patients who underwent hernia surgery at district and central hospitals in Malawi. It reports the main cost drivers, how costs relate to patients' household incomes, the financial burden of undergoing surgery and the extent to which hernia patients had recovered and restored their capacity to work and earn an income.Materials and methodsUsing a cross-sectional study design, surveys were held with patients who had undergone hernia surgery in four district and two central hospitals in Malawi. Interviews were conducted by surgically trained clinical officers, trained in survey administration, and included, inter alia, questions about patients' hospital stay, the direct and indirect cost they incurred in accessing surgery, and how they financed the expenditure. Follow-up interviews by telephone were held 8-10 weeks after discharge.ResultsThe sample included 137 patients from district and 86 patients from central hospitals. The main direct cost drivers were transport and food & groceries. More than three quarters of patients who had their surgery at a district hospital incurred indirect costs, because of income lost due to hospital admission, compared with just over a third among central hospital patients. Median reported income losses were US$ 90 and US$ 71, respectively. Catastrophic expenditure for surgery occurred in 94% of district and 87% of central hospital patients. When indirect costs are added to the out-of-pocket expenditure, it constituted more than 10% of the monthly per capita income for 97% and 90% of the district and central hospital patients, respectively.ConclusionOut-of-pocket household expenditure associated with essential surgery in Malawi is high and in many instances catastrophic, putting households, especially those who are already poor, at risk of further impoverishment. The much needed scaling-up of surgical services in rural areas of Malawi needs to be accompanied by financial risk protection measures.

Dataset Information

Inequalities in the benefits of national health insurance on financial protection from out-of-pocket payments and access to health services: cross-sectional evidence from Ghana.

Publications

Inequalities in the benefits of national health insurance on financial protection from out-of-pocket payments and access to health services: cross-sectional evidence from Ghana.

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