Association of information, education, and communication with enrolment in health insurance: a case of Nepal
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ABSTRACT: Background
Many studies indicate that various health programmes have been failed because of the lack of appropriate information, education, and communication [IEC] for the target audiences. It is still unanswered which methods/means of communication could be the most powerful for changing behaviour or decision-making capacity. The paper aims to assess the effects of IEC on family enrolment in health insurance programme [HIP] in Nepal. Methods
We employed a household-based observational study with a control group. Altogether 810 household interviews were conducted in Baglung and Kailali districts of Nepal in 2018. The study used a validated structured interview schedule. Background characteristics of the family and respondents and their exposure to the means of communication were the independent variables while enrolment in health insurance [HI] was the dependent variable. Results
Data showed that 72% of the respondents heard about the HI and 66% knew the contribution amount for enrolment in HI. In the total enrolled households, 53% were household heads, 59% belonged to the age group 41–60 and 68% were above 60?years. More than half (56%) of rich compared to 46 and 49% of middle and poor (p?Conclusion Knowledge about HI and interaction with peers and neighbours about the HI scheme of the government could lead to higher participation in the HIP. It would be better to incorporate this strategy while planning interventions for increasing enrolment in the HIP. Supplementary Information
The online version contains supplementary material available at 10.1186/s13690-020-00518-8.
SUBMITTER: Acharya D
PROVIDER: S-EPMC7737309 | biostudies-literature | 2020 Jan
REPOSITORIES: biostudies-literature
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Project description:ObjectivesWe analysed predictors of health insurance enrolment in Nepal, measured wealth-related inequality and decomposed inequality into its contributing factors.DesignCross-sectional study.SettingWe used nationally representative data based on Nepal Multiple Indicator Cluster Survey 2019. Out of 10 958 households included in this study, 6.95% households were enroled in at least one health insurance scheme.Primary outcomemeasures health insurance (of any type) enrolment.ResultsHouseholds were more likely to have health insurance membership when household head have higher secondary education or above compared with households without formal education (adjusted OR 1.87; 95% CI: 1.32 to 2.64)). Households with mass media exposure were nearly three times more likely to get enroled into the schemes compared with their counterparts (adjusted OR 2.96; 95% CI 2.03 to 4.31). Hindus had greater odds of being enroled (adjusted OR 1.82; 95% CI 1.20 to 2.77) compared with non-Hindus. Dalits were less likely to get enroled compared with Brahmin, Chhetri and Madhesi (adjusted OR 0.66; 95% CI 0.47 to 0.94). Households from province 2, Bagmati and Sudurpaschim were less likely to have membership compared with households from province 1. Households from Richer and Richest wealth quintiles were more than two times more likely to have health insurance membership compared with households from the poorest wealth quintile. A positive concentration index 0.25 (95% CI 0.21 to 0.30; p<0.001) indicated disproportionately higher health insurance enrolment among wealthy households.ConclusionsEducation of household head, exposure to mass media, religious and ethnic background, geographical location (province) and wealth status were key predictors of health insurance enrolment in Nepal. There was a significant wealth-related inequality in health insurance affiliation. The study recommends regular monitoring of inequality in health insurance enrolment across demographic and socioeconomic groups to ensure progress towards Universal Health Coverage.
| S-EPMC8628343 | biostudies-literature
Project description:In 2003, Ghana implemented a National Health Insurance Scheme (NHIS) to move towards Universal Health Coverage. NHIS enrolment is mandatory for all Ghanaians, but the most recent estimates show that coverage stands under 40%. The evidence on the relationship between socio-economic characteristics and NHIS enrolment is mixed, and comes mainly from studies conducted in a few areas. Therefore, in this study we investigate the socio-economic determinants of NHIS enrolment using three recent national household surveys. We used data from the Ghanaian Demographic and Health Survey conducted in 2014, the Multiple Indicator Cluster Survey conducted in 2011 and the sixth wave of the Ghana Living Standard Survey conducted in 2012-13. Given the multilevel nature of the three databases, we use multilevel logistic regression models to estimate the probability of enrolment for women and men separately. We used three levels of analysis: geographical clusters, household and individual units. We found that education, wealth, marital status-and to some extent-age were positively associated with enrolment. Furthermore, we found that enrolment was correlated with the type of occupation. The analyses of three national household surveys highlight the challenges of understanding the complex dynamics of factors contributing to low NHIS enrolment rates. The results indicate that current policies aimed at identifying and subsidizing underprivileged population groups might insufficiently encourage health insurance enrolment.
| S-EPMC6794569 | biostudies-literature
Project description:BackgroundSeveral countries including Tanzania, have established voluntary non-profit insurance schemes, commonly known as community-based health insurance schemes (CBHIs), that typically target rural populations and the informal sector. This paper considers the importance of household perceptions towards CBHIs in Tanzania and their role in explaining the enrolment decision of households.MethodsThis was a cross-sectional household survey that involved 722 households located in Bahi and Chamwino districts in the Dodoma region. A three-stage sampling procedure was used, and the data were analyzed using both factor analysis (FA) and principal component analysis (PCA). Statistical tests such as Bartlett's test of sphericity, Kaiser-Meyer-Olkin (KMO) for sampling adequacy, and Cronbach's alpha test for internal consistency and scale reliability were performed to examine the suitability of the data for PCA and FA. Finally, multivariate logistic regressions were run to determine the associations between the identified factors and the insurance enrolment status.ResultsThe PCA identified seven perception factors while FA identified four factors. The quality of healthcare services, preferences (social beliefs), and accessibility to insurance scheme administration (convenience) were the most important factors identified by the two methods. Multivariate logistic regressions showed that the factors identified from the two methods differed somewhat in importance when considered as independent predictors of the enrollment status. The most important perception factors in terms of strength of association (odds ratio) and statistical significance were accessibility to insurance scheme administration (convenience), preferences (beliefs), and the quality of health care services. However, age and income were the only socio-demographic characteristics that were statistically significant.ConclusionHousehold perceptions were found to influence households' decisions to enroll in CBHIs. Policymakers should recognize and consider these perceptions when designing policies and programs that aim to increase the enrolment into CBHIs.
| S-EPMC7893739 | biostudies-literature
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.
| S-EPMC7609471 | biostudies-literature
Project description:BackgroundEarlier studies have found significant associations between sociodemographic factors and enrolment in the National Health Insurance Scheme (NHIS) in Ghana. These studies were mainly household surveys in relatively rural areas with high incidence of poverty. To expand the scope of existing evidence, this paper examines policy design factors associated with enrolment and dropout of the scheme in an urban poor district using routine secondary data.MethodsThis study is a cross-sectional quantitative analysis of 2014-2016 NHIS enrolment data of the Ashiedu Keteke district office. Descriptive and multivariate logistic regression analyses were performed to examine sociodemographic factors associated with NHIS enrolment and dropout.ResultsA total of 215,724 individuals enrolled in the NHIS over the period under study, of which 98,232 (46%) were new members. About 41% of existing members in 2014 dropped out of the NHIS in 2015 and 53% of those in 2015 dropped out in 2016. The indigents (core poor) are significantly more likely to enrol and to drop out of the NHIS. However, the males, informal sector employees, social security and national insurance trust (SSNIT) contributors, and the aged (70+ years) are significantly less likely to enrol in the NHIS but more likely to retain coverage.ConclusionsA considerable number of members are dropping out of the NHIS. The indigents in particular, are increasingly enrolling in and dropping out of the NHIS whilst the males, informal sector employees, SSNIT contributors and the aged are not enrolling as expected but increasingly retaining coverage. Policy reforms to ensuring continued growth towards realization of universal health coverage should take these factors into consideration.
| S-EPMC6734452 | biostudies-literature
Project description:OBJECTIVES:This article examines equity in enrolment in the Ghana National Health Insurance Scheme (NHIS) to inform policy decisions on progress towards realisation of universal health coverage (UHC). DESIGN:Secondary analysis of data from the sixth round of the Ghana Living Standards Survey (GLSS 6). SETTING:Household based. PARTICIPANTS:A total of 16 774 household heads participated in the GLSS 6 which was conducted between 18 October 2012 and 17 October 2013. ANALYSIS:Equity in enrolment was assessed using concentration curves and bivariate and multivariate analyses to determine associated factors. MAIN OUTCOME MEASURE:Equity in NHIS enrolment. RESULTS:Survey participants had a mean age of 46 years and mean household size of four persons. About 71% of households interviewed had at least one person enrolled in the NHIS. Households in the poorest wealth quintile (73%) had enrolled significantly (p<0.001) more than those in the richest quintile (67%). The concentration curves further showed that enrolment was slightly disproportionally concentrated among poor households, particularly those headed by males. However, multivariate logistic analyses showed that the likelihood of NHIS enrolment increased from poorer to richest quintile, low to high level of education and young adults to older adults. Other factors including sex, household size, household setting and geographic region were significantly associated with enrolment. CONCLUSIONS:From 2012 to 2013, enrolment in the NHIS was higher among poor households, particularly male-headed households, although multivariate analyses demonstrated that the likelihood of NHIS enrolment increased from poorer to richest quintile and from low to high level of education. Policy-makers need to ensure equity within and across gender as they strive to achieve UHC.
| S-EPMC6609063 | biostudies-literature
Project description:OBJECTIVES:The study aimed to understand the impact of integrating a fee waiver for the National Health Insurance Scheme (NHIS) with Ghana's Livelihood Empowerment Against Poverty (LEAP) 1000 cash transfer programme on health insurance enrolment. SETTING:The study was conducted in five districts implementing Ghana's LEAP 1000 programme in Northern and Upper East Regions. PARTICIPANTS:Women, from LEAP households, who were pregnant or had a child under 1 year and who participated in baseline and 24-month surveys (2497) participated in the study. INTERVENTION:LEAP provides bimonthly cash payments combined with a premium waiver for enrolment in NHIS to extremely poor households with orphans and vulnerable children, elderly with no productive capacity and persons with severe disability. LEAP 1000, the focus of the current evaluation, expanded eligibility in 2015 to those households with a pregnant woman or child under the age of 12 months. Over the course of the study, households received 13 payments. PRIMARY AND SECONDARY OUTCOME MEASURES:Primary outcomes included current and ever enrolment in NHIS. Secondary outcomes include reasons for not enrolling in NHIS. We conducted a mixed-methods impact evaluation using a quasi-experimental design and estimated intent-to-treat impacts on health insurance enrolment among children and adults. Longitudinal qualitative interviews were conducted with an embedded cohort of 20 women and analysed using systematic thematic coding. RESULTS:Current enrolment increased among the treatment group from 37.4% to 46.6% (n=5523) and decreased among the comparison group from 37.3% to 33.3% (n=4804), resulting in programme impacts of 14 (95% CI 7.8 to 20.5) to 15 (95% CI 10.6 to 18.5) percentage points for current NHIS enrolment. Common reasons for not enrolling were fees and travel. CONCLUSION:While impacts on NHIS enrolment were significant, gaps remain to maximise the potential of integrated programming. NHIS and LEAP could be better streamlined to ensure poor households fully benefit from both services, in a further step towards integrated social protection. TRIAL REGISTRATION NUMBER:RIDIE-STUDY-ID-55942496d53af.
| S-EPMC6858157 | biostudies-literature
Project description:Background:In 2004, Ghana started experimenting a National Health Insurance Scheme (NHIS) to reduce out-of-pocket payment for healthcare. Like many other social health insurance schemes in Africa, the NHIS is striving for universal health coverage (UHC). This paper examines trends and characteristics of enrolment in the scheme to inform policy decisions on attainment of UHC. Methods:We conducted trend analysis of longitudinal enrolment data of the NHIS for the period, 2010-2017. Descriptive statistics were used to examine trends and characteristics of enrolment by geographical region and member groups. Results:Over the 8-year period, the population enrolled in the scheme increased from 33% (8.2 million) to 41% (11.3 million) between 2010 and 2015 and dropped to 35% (10.3 million) in 2017. Members who renewed their membership increased from 44% to 75.4% between 2010 and 2013 and then dropped to 73% in 2017. On average, the urban regions had significantly higher number of new enrolments than the rural ones. Similarly, the urban and peri-urban regions recorded significantly higher number of renewals than the other regions. In addition, persons below the age of 18 years and the informal sector workers had significantly higher number of enrolment than any other member group. Conclusions:Enrolment in the NHIS is declining and there are significant differences among geographical regions and member groups. Managers of the NHIS need to enforce the mandatory enrolment provision in the Act governing the scheme, employ innovative strategies such as mobile phone application for registration and renewals and address delays in healthcare provider claims to improve enrolment.
| S-EPMC6233555 | biostudies-other
Project description:BackgroundPhysicians who hold medical disability assessment interviews (social insurance physicians) are probably influenced by stereotypes of claimants, especially because they have limited time available and they have to make complicated decisions. Because little is known about the influences of stereotyping on assessment interviews, the objectives of this paper were to qualitatively investigate: (1) the content of stereotypes used to classify claimants with regard to the way in which they communicate; (2) the origins of such stereotypes; (3) the advantages and disadvantages of stereotyping in assessment interviews; and (4) how social insurance physicians minimise the undesirable influences of negative stereotyping.MethodsData were collected during three focus group meetings with social insurance physicians who hold medical disability assessment interviews with sick-listed employees (i.e. claimants). The participants also completed a questionnaire about demographic characteristics. The data were qualitatively analysed in Atlas.ti in four steps, according to the grounded theory and the principle of constant comparison.ResultsA total of 22 social insurance physicians participated. Based on their responses, a claimant's communication was classified with regard to the degree of respect and acceptance in the physician-claimant relationship, and the degree of dominance. Most of the social insurance physicians reported that they classify claimants in general groups, and use these classifications to adapt their own communication behaviour. Moreover, the social insurance physicians revealed that their stereotypes originate from information in the claimants' files and first impressions. The main advantages of stereotyping were that this provides a framework for the assessment interview, it can save time, and it is interesting to check whether the stereotype is correct. Disadvantages of stereotyping were that the stereotypes often prove incorrect, they do not give the complete picture, and the claimant's behaviour changes constantly. Social insurance physicians try to minimise the undesirable influences of stereotypes by being aware of counter transference, making formal assessments, staying neutral to the best of their ability, and being compassionate.ConclusionsWe concluded that social insurance physicians adapt their communication style to the degree of respect and dominance of claimants in the physician-claimant relationship, but they try to minimise the undesirable influences of stereotypes in assessment interviews. It is recommended that this issue should be addressed in communication skills training.
| S-EPMC2989961 | biostudies-literature
Project description:BACKGROUND:The desire for universal health coverage in developing countries has brought attention to communitybased health insurance (CBHI) schemes in developing countries. The government of Uganda is currently debating policy for the national health insurance programme, targeting the integration of existing CBHI schemes into a larger national risk pool. However, while enrolment has been largely studied in other countries, it remains a generally under-covered issue from a Ugandan perspective. Using a large CBHI scheme, this study, therefore, aims at shedding more light on the determinants of households' decisions to enrol and renew membership in these schemes. METHODS:We collected household data from 464 households in 14 villages served by a large CBHI scheme in southwestern Uganda. We then estimated logistic and zero-inflated negative binomial (ZINB) regressions to understand the determinants of enrolment and renewing membership in CBHI, respectively. RESULTS:Results revealed that household's socioeconomic status, husband's employment in rural casual work (odds ratio [OR]: 2.581, CI: 1.104-6.032) and knowledge of health insurance premiums (OR: 17.072, CI: 7.027-41.477) were significant predictors of enrolment. Social capital and connectivity, assessed by the number of voluntary groups a household belonged to, was also positively associated with CBHI participation (OR: 5.664, CI: 2.927-10.963). More positive perceptions on insurance (OR: 2.991, CI: 1.273-7.029), access to information were also associated with enrolment and renewing among others. Burial group size and number of burial groups in a village, were all significantly associated with increased the likelihood of renewing CBHI. CONCLUSION:While socioeconomic factors remain important predictors of participation in insurance, mechanisms to promote inclusion should be devised. Improving the participation of communities can enhance trust in insurance and eventual coverage. Moreover, for households already insured, access to correct information and strengthening their social network information pathways enhances their chances of renewing.
| S-EPMC6819630 | biostudies-literature