Assessment of Willingness to pay for Community-Based Health Insurance among Artisans in a selected Community of Ekiti State, Southwest Nigeria

Background: Community-based health insurance (CBHI) has emerged as a more efficient and equitable approach to healthcare financing. It was designed to ensure that sufficient resources are made available for members to access effective healthcare. This study assessed the willingness to pay (WTP) for CBHI among artisans in a town in Ekiti State, South West Nigeria. Methods: This was a cross-sectional survey conducted among 416 artisans in a town in Ekiti State. A semi-structured interviewer-administered questionnaire was designed and used for data collection on sociodemographic data and WTP for CBHIS. Data entry and analysis was done using IBM SPSS software version 25.0. Results: The mean age and standard deviation of the respondents was 29.7±10.9 years with male to female ratio of 1:1.4. Most of the respondents were willing to pay (86.3%) and willing to enroll other household members (73.6%) in the CBHI. A large percentage (44.3%) of those willing to pay were ready to pay between ₦1,000-₦5,000 (US$2.63­US$13.16) per year while 39.6% preferred frequency of payment to be annually. Positive predictors of WTP for CBHI were age groups ≥50 years and 40-49 years than <20 years (AOR:13.270, 95%CI: 1.597-110.267; AOR:142.996, 95%CI: 10.689-1913.009). Females than males (AOR:9.155, 95%CI: 3.680-22.775), tertiary level of education than no formal of education (AOR:23.420, 95%CI: 1.648-850.921), no children than ≥5 children (AOR:20.099, 95%CI: 2.705-149.364), earn ≥₦30,000 (US$78.95) than <₦30,000 (AOR:2.248, 95%CI: 1.278-6.499). often and somethings fall ill than seldom fall ill (AOR:6.505, 95%CI: 1.623-26.065; AOR:4.889, 95%CI: 1.674-14.279) Conclusion: WTP for CBHI was high among the artisans, however, there is a variation across the amount and frequency of payment. Therefore, policy that is flexible enough to allow artisans enroll and pay a premium that is affordable, at an acceptable frequency, should be formulated by the Government.

Is South Africa Advancing towards National Health Insurance? The Perspectives of General Practitioners in One Pilot Site

Background. The launch of the National Health Insurance (NHI) White Paper in December 2015 heralded a new stage in South Africa's advancement towards universal health coverage. The 'contracting in' of private sector general practitioners (GPs); though only one component of the overall reformed system; is nevertheless crucial to address staff shortages and capacity; and also to realise the broader vision of a single unified; integrated system.Objective. To report on the views and experiences of GP providers tasked with implementing the reforms at one pilot site; Tshwane District in Gauteng Province; providing an insight into the practical challenges the NHI scheme faces in implementation.Methods. The study was qualitative in nature; using a combination of convenience and purposeful sampling to recruit participants. A thematic analysis of the data was conducted using Nvivo 10 software.Results. The overall experiences of the GPs exposed a number of problems with the pilot.These included frustration with lack of appropriate infrastructure and equipment in NHI facilities; difficulties integrating into the facilities and lack of professional autonomy; as well as unhappiness with contracting arrangements. Despite strong support for the idea of NHI; there was general scepticism that private doctors would embrace the scheme on the scale required.Conclusion. The study suggests that the current pilots are still a long way from the vision of a single; integrated health system. While it may be argued that the pilots are not themselves the completed NHI; the findings suggest that it will take much longer to establish than the timeline envisaged by government

Operationalizing Universal Health Coverage in Nigeria through Social Health Insurance

Nigeria faces challenges that delay progress toward the attainment of the national government's declared goal of universal health coverage (UHC). One such challenge is system-wide inequities resulting from lack of financial protection for the health care needs of the vast majority of Nigerians. Only a small proportion of Nigerians have prepaid health care. In this paper; we draw on existing evidence to suggest steps toward reforming health care financing in Nigeria to achieve UHC through social health insurance. This article sets out to demonstrate that a viable path to UHC through expanding social health insurance exists in Nigeria. We argue that encouraging the states which are semi-autonomous federating units to setup and manage their own insurance schemes presents a unique opportunity for rapidly scaling up prepaid coverage for Nigerians. We show that Nigeria's federal structure which prescribes a sharing of responsibilities for health care among the three tiers of government presents serious challenges for significantly extending social insurance to uncovered groups. We recommend that rather than allowing this governance structure to impair progress toward UHC; it should be leveraged to accelerate the process by supporting the states to establish and manage their own insurance funds while encouraging integration with the National Health Insurance Scheme

Access to Health Care: the Role of a Community Based Health Insurance in Kenya

Background: Out-of-pocket payments create financial barriers to health care access. There is an increasing interest in the role of community based health insurance schemes in improving equity and access of the poor to essential health care. The aim of this study was to assess the impact of Jamii Bora Health Insurance on access to health care among the urban poor. Methods: Data was obtained from the household health interview survey in Kibera and Mathare slums; which consisted of 420 respondents; aged 18 and above who were registered as members of Jamii Bora Trust. The members of Jamii Bora Trust were divided into two groups the insured and the non-insured. Results: In total; 17.9 respondents were hospitalized and women (19.6 respondents were hospitalized and women (19.6) were more likely to be admitted than men (14.7). Those in the poorest quintile had the highest probability of admission (18.1). Those with secondary school education; large household size; and aged 50 and above also had slightly greater probability of admission (p0.25). 86 of admissions among the insured respondents were covered JBHI and those in the poorest quintile were more likely to use the JBHI benefit. Results from the logistic regression revealed that the probability of being admitted; whether overall admission or admission covered by the JBHI benefit was determined by the presence of chronic condition (p0.01). Conclusion: Utilization and take up of the JBHI benefits was high. Overall; JBHI favoured the members in the lower income quintiles who were more likely to use health care services covered by the JBHI scheme

Health Insurance Education Strategies for Increasing the Insured among Older Population : a Quasi Experimental Study in Rural Kenya

Introduction :The older population in most developing countries are uninsured and lack access to health services. This study assessed the extent to which a multi-strategy health insurance education intervention would increase the number of insured among the older population in rural Kenya.METHODS:The quasi-experimental study prospectively followed 1;104 unpaired older persons (60 years or more) in a 10-month health insurance education and enrollment intervention. The adjusted odds ratios computed at 95confidence interval using a binary logistic regression tested the association between being insured and the multi-strategies.Results :At baseline; the lack of adequate knowledge on health insurance (52.9) and high premiums (38.1) were the main reasons for being uninsured. The insured older persons increased three-fold (from 7.7 to 23.8) in the experimental site but remained almost unchanged (from 4.0 to 4.6) in the control. The computed adjusted odds ratio for variables with significance (p 0.05) show that the older people who obtained health insurance education through the chief's public meeting; an adult daughter; an adult son; a relative-sister/brother; an agent of the National Hospital Insurance Fund; and a health insurance beneficiary were 2.6; 4.2; 2.8; 2.3; 2.5 and 2.5 times respectively more likely to be insured. Access to health insurance education using a combination of 1-3 strategies and 3 strategies predisposed the older people 14.3 times and 52.2 times respectively to being insured. Conclusion: Health insurance education through multiple strategies and their intensity and frequency were pivotal in increasing being insured among the older population in rural Kenya

A qualitative Exploration of Resilience in Pre-Adolescent AIDS Orphans Living in a Residential Care Facility

This article presents the findings of a study among a small group of South African AIDS orphans living in a residential care facility; Lebone Land. The research was conducted between June and September 2006. A qualitative; exploratory study consisting of in-depth; semistructured interviews with eight children and seven key informants aimed to identify and investigate developmental assets operating in the children's lives to help them cope amid exposure to adversities. The findings indicate that the developmental assets that facilitate coping and foster resilience in these children relate to four main components: external stressors and challenges; external supports; inner strengths and interpersonal and problem-solving skills. Emerging key themes relate to the experience of illness; death; poverty and violence; as well as the important roles of morality; social values; resistance skills; religion and faith in assisting these children in defining their purpose in life. To this end; constructive use of time; commitment to learning; goal-setting; problem-solving ability and self-efficacy are fundamental in the children's attainment of their future projections. Therefore; qualities such as optimism; perseverance and hope seem to permeate the children's process of recovery. Strong networks of support; particularly friendships with other children; also seem to contribute to developing and sustaining resilience

Is Health Care Financing in Uganda Equitable?

Introduction: Health care financing provides the resources and economic incentives for operating health systems and is a key determinant of health system performance. Equitable financing is based on: financial protection; progressive financing and cross-subsidies. This paper describes Uganda's health care financing landscape and documents the key equity issues associated with the current financing mechanisms. Methods: We extensively reviewed government documents and relevant literature and conducted key informant interviews; with the aim of assessing whether Uganda's health care financing mechanisms exhibited the key principles of fair financing. Results: Uganda's health sector remains significantly under-funded; mainly relying on private sources of financing; especially out-of-pocket spending. At 9.6of total government expenditure; public spending on health is far below the Abuja target of 15that GoU committed to. Prepayments form a small proportion of funding for Uganda's health sector. There is limited cross-subsidisation and high fragmentation within and between health financing mechanisms; mainly due to high reliance on out-of-pocket payments and limited prepayment mechanisms. Without compulsory health insurance and low coverage of private health insurance; Uganda has limited pooling of resources; and hence minimal cross-subsidisation. Although tax revenue is equitable; the remaining financing mechanisms for Uganda are inequitable due to their regressive nature; their lack of financial protection and limited cross-subsidisation. Conclusion: Overall; Uganda's current health financing is inequitable and fragmented. The government should take explicit action to promote equitable health care financing by establishing pre-payment schemes; enhancing cross-subsidisation mechanisms and through appropriate integration of financing mechanisms

Will Private Health Insurance Schemes Subscriptions Continue after the Introduction of National Health Insurance in Uganda?

Introduction: Uganda is currently designing a National Health Insurance (NHI) scheme; with the aim of raising additional resources for the health sector. Very little was known about the health insurance market in Uganda before this study; so one of our main objectives was to investigate the nature of the private health insurance market in Uganda and the opinions of various stakeholders on NHI; with the view to establish the impact of NHI implementation on the existing PHI. Specifically; we aimed to gather the opinions of employees and employers on the likely impact of NHI on their PHI schemes. Methods: We conducted interviews with health insurance providers; and a sample of employers and employees in Kampala; using structured questionnaires and analysed quantitative data using STATA8. Qualitative data was analysed through grouping of emerging themes. Community-based health insurances were excluded from the study. Results: Health insurance and/or prepayment schemes are offered by a handful of organisations or private health providers; mainly in Kampala and cover a relatively small percentage of Uganda's population. The premiums charged and the benefit packages offered by the different agencies vary widely. There are 2 health insurance agencies; 2 HMOs and about 5 or more private providers offering pre-payment schemes to their patients. Responses from a significant proportion of employers and employees show that PHI schemes may be abandoned once the mandatory NHI scheme is implemented. A few respondents argued that they would maintain their PHI subscriptions because of their perceptions of the quality of services likely to be provided under the NHI scheme. Conclusion: If successfully introduced; the NHI scheme may displace existing private health insurance and/or pre-payment schemes in Uganda. The extent to which PHI schemes are displaced depends on whether NHI is successfully implemented and the quality of services being offered under the NHI scheme

Knowledge; Perceptions and Attitudes of Health Managers Towards the Proposed Social Health Insurance Scheme in Uganda

The government of Uganda planned to start Social Health Insurance (SHI) in July 2007; beginning with the formal employment sector; with a view to attain universal coverage in 15 years. Health workers in general and managers in particular; have a crucial role to play in the successful design and implementation of the SHI. This study; conducted in June 2007; meant to assess the knowledge and attitudes of Ugandan healthcare managers about SHI. In so doing; it assessed their readiness to play their role in the implementation of the policy and; generally; gave a clue about the readiness of the country to start the process. The situation does not seem to have changed much in 2009. A cross-sectional survey of health managers in 24 key public; private-not-for-profit and private hospitals; and 8 districts was done.The managers were found to be well aware of the proposed policy but ignorant of its context. They had very high hopes of a large benefit package and yet expected to contribute very little. They felt they had been marginalized in the process of designing the proposed scheme and their roles were not clear. There was no formal training in what they were expected to do once the scheme started. They also had doubts about the integrity of the proposed fund collection and disbursement mechanism. The paper recommended formal training of managers on the policy and its context; their roles; and involving them in the design of the scheme. It also supports postponement of the scheme until key infrastructure and capacity building has taken place

Attitudes of Private not for Profit (PNFP) Health Workers in Jinja Diocese to the Proposed Social Health Insurance in Uganda

Uganda proposes to introduce Social Health Insurance (SHI). Whereas the idea of SHI is good; the scheme has to be designed properly and carefully; in order to avoid dangers like fraud and especially; cost escalation due to over-prescription. Health workers are; particularly; key takeholders in preventing cost escalation. Attempting to start a SHI scheme without educating; convincing and winning over the health and attitudes of Ugandan health workers to the proposed scheme. It was done in one network of faithbased private-not-for-profit (PNFP) health facilities under the Catholic Diocese of Jinja; in SE Uganda. Despite being done close to the starting of the scheme; the study found that most of the health workers were not knowledgeable about the scheme at all and that they had a negative attitude but at the same time focusing on improving the design of the scheme to prevent common pitfalls e.g. fraud and cost escalation

A Content Analysis of the Ghana National Health Insurance Scheme

Several African countries are contemplating the introduction of national health insurance and a few have already started implementing. It is a popular understanding among these countries that by moving away from fee-for-service to a system like national health insurance; the poor and marginalised who are most often the sickest will be protected. The issue of National Health Insurance (NHI) as an alternative health financing system was a popular option in Ghana. However; the desire for NHI and its popularity was not determined by a critical look at the technicalities involved in setting up such a system. Attention was not paid to the fact that the implementation of national health insurance is constrained by a country's economic; social and political context and the inherent technical limitations of health insurance. To determine feasibility in the context of existing constraints; detailed work ought to have been done on the administrative capacity available to technically design the scheme; manage the process and thereafter manage the schemes. Earnings especially of the informal sector; the collection of contributions and the existing health care infrastructure and the commitment and incentives for health providers to make such a complex system work needed equal attention. Careful assessment is critical in producing a policy that is not only desirable but also feasible. It is apparent that the reasoning behind the Ghana Scheme was more towards a general look at risk pooling and providing access by reducing the individual financial burden than a close look at cost containment; efficiency and sustainability

Universal Health Coverage in Rwanda: Dream or Reality

Introduction: Universal Health Coverage (UHC) has been a global concern for a long time and even more nowadays. While a number of publications are almost unanimous that Rwanda is not far from UHC; very few have focused on its financial sustainability and on its extreme external financial dependency. The objectives of this study are: (i) To assess Rwanda UHC based mainly on Community-Based Health Insurance (CBHI) from 2000 to 2012; (ii) to inform policy makers about observed gaps for a better way forward. Methods: A retrospective (2000-2012) SWOT analysis was applied to six metrics as key indicators of UHC achievement related to WHO definition; i.e. (i) health insurance and access to care; (ii) equity; (iii) package of services; (iv) rights-based approach; (v) quality of health care; (vi) financial-risk protection; and (vii) CBHI self-financing capacity (SFC) was added by the authors. Results: The first metric with 96;15 of overall health insurance coverage and 1.07 visit per capita per year versus 1 visit recommended by WHO; the second with 24;8 indigent people subsidized versus 24;1 living in extreme poverty; the third; the fourth; and the fifth metrics excellently performing; the sixth with 10.80 versus ?40 as limit acceptable of catastrophic health spending level and lastly the CBHI SFC i.e. proper cost recovery estimated at 82.55 in 2011/2012; Rwanda UHC achievements are objectively convincing. Conclusion: Rwanda UHC is not a dream but a reality if we consider all convincing results issued of the seven metrics

Group premiums in micro health insurance experiences from Tanzania

Objective: The main objective was to assess how group premiums can help poor people in the informal economy prepay for health care services. Methods: A comparative approach was adopted to study four groups of informal economy operators (cobblers; welders; carpenters; small scale market retailers) focusing on a method of prepayment which could help them access health care services. Two groups with a total of 714 operators were organized to prepay for health care services through a group premium; while the other two groups with a total of 702 operators were not organized to prepay through this approach. They prepaid through individual premium; each operator paying from his or her sources. Data on the four groups which lived in the same city was collected through a questionnaire and focus group discussions. Data collected was focused on health problems; health seeking behaviour and payment for health care services. Training of all the groups on prepaid health care financing based on individual based premium payment and group based premium payment was done. Groups were then free to choose which method to use in prepaying for health care. Prepayment through the two methods was then observed over a period of three years. Trends of membership attrition and retention were documented for both approaches. Results: Data collected showed that the four groups were similar in many respects. These similarities included levels of education; housing; and social services such as water supplies; health problems; family size and health seeking behaviour. At the end of a period of three years 76 of the members from the two groups who chose group premium payment were still members of the prepayment health scheme and were receiving health care. For the two groups which opted for individual premium payment only 15 of their members were still receiving health care services at the end of three years. Conclusion: Group premium is a useful tool in improving accessibility to health care services in the poorer segments of the population especially the informal economy operators

Solidarity in Community-Based Health Insurance in Senegal: Rhetoric or Reality

Continued low rates of enrolment in community-based health insurance (CBHI) suggest that in many countries strategies proposed for scaling up have not been well-designed or successfully implemented. One reason may be a lack of systematic incorporation of social and political context into CBHI policy. In this study; solidarity in CBHI is analysed from a sociological perspective in order to answer the following research questions: What are local definitions and perceptions of solidarity in CBHI? To what extent are these borne out in practice? Three case studies of Senegalese CBHI schemes using specific criteria were studied. Transcripts of interviews with 64 CBHI stakeholders were analysed using inductive coding. A conceptual framework of four dimensions of solidarity (health risk; vertical equity; scale and source) was developed to interpret the results. The results suggest that the concept of solidarity in CBHI is complex. Each dimension and source of solidarity was either not borne out in practice or highly contested; with views diverging between stakeholders and the target population. This suggests that policy-makers need to engage in a more rigorous public discussion of solidarity as regards CBHI and universal health coverage policy more widely; in order to move towards policies which both resonate with and meet the expectations of the people they aim to serve

Increasing Equity among Community-Based Health Insurance Members in Rwanda

The community-based health insurance (CBHI) scheme launched by the Government of Rwanda (GoR); reached 91% of the population in 2010; starting from 7% in 2003. Initially; all CBHI members paid the same fees; regardless of their personal income; and the poorest citizens faced challenges in paying premiums (almost US$ 1.50 per person). A mechanism was thus urgently needed to guarantee access to health care for the most vulnerable and promote equity among members. The GoR decided to introduce a stratification system based on the socioeconomic status of the population; referred to as Ubudehe. Together with partners; including the Integrated Health Systems Strengthening Project (IHSSP); the GoR developed a national database that stratifies Rwandan citizens by income. To date; more than 10 million residents' records; representing 96% of Rwanda's population; have been entered into the database. This database helped identify the most vulnerable based on socioeconomic status (about 25% of the population). Identification of the poorest among the population has allowed an increase in CBHI funds due to identification of individuals who have a greater capacity to pay. The database thus improved the financial viability and management capacity of the CBHI scheme

National Health Accounts for Uganda: Tracking Expenditure in the Health Sector - Both Public and Private for the Financial Year 1997-1998

National Health Accounts (NHA) is a descriptive tool designed to estimate total health expenditure in the country. It gives detailed analysis of flow of funds from sources to funding to financial intermediaries; and from these to providers. In the NHA methodology; financing intermediaries are defined as theose entities; which have as their major roles the receipt; and expenditure and funds for health care functions or services. Examples include Ministries; private health insurance firms and private and parastatal employers on behalf of their employees. Providers are categorised according to the familiar topology of various discrete service delivery organisations such as MoH; Hospitals; and lower level units. This report presents results from a study of Uganda's National health Accounts for the fiscal 1997/98. It describes the flow of funds in Uganda's Health Care system for both public and private sectors. It is the first study on national health accounts in Uganda; and will hopefully be repeated annually. Using a comprehensive view of the health sector and standard definitions of entities and spending; NHA can provide valuable data for deceion-making in the health sector. The NHA analytical tool provides comprehensive data to allow for informed policy decisions; in general; and to measure real allocation of resources against stated priorities; in particular. The matrix approach requires that all expenditures from each source be allocated to specific uses (either by financing intermediaries or by providers) and that all spending on health services provision be traceable back to specific financing intermediates and ultimately to primary sources. Uganda's current population is estimated at 21.9 million; with an annual population growth rate of 2.5. its GDP per capita is $300. The current public health expenditure is at $4. This cannot finance the essential health package. The minimum health care expenditure recommended by the World Bank/World Health Organisation is US$12 per capita. The minimum health expenditure by an country. The demand for healthcare continues to grow; due to high population growth rate; and the HIV/AIDS pandemic. As a result; external sources have been predominant in financing health service delivery; and this raises questions of sustainability and affordability