The "Universal" in UHC and Ghana's National Health Insurance Scheme: policy and implementation challenges and dilemmas of a lower middle income country.

BACKGROUND: Despite universal population coverage and equity being a stated policy goal of its NHIS, over a decade since passage of the first law in 2003, Ghana continues to struggle with how to attain it. The predominantly (about 70 %) tax funded NHIS currently has active enrolment hovering around 40 % of the population. This study explored in-depth enablers and barriers to enrolment in the NHIS to provide lessons and insights for Ghana and other low and middle income countries (LMIC) into attaining the goal of universality in Universal Health Coverage (UHC). METHODS: We conducted a cross sectional mixed methods study of an urban and a rural district in one region of Southern Ghana. Data came from document review, analysis of routine data on enrolment, key informant in-depth interviews with local government, regional and district insurance scheme and provider staff and community member in-depth interviews and focus group discussions. RESULTS: Population coverage in the NHIS in the study districts was not growing towards near universal because of failure of many of those who had ever enrolled to regularly renew annually as required by the NHIS policy. Factors facilitating and enabling enrolment were driven by the design details of the scheme that emanate from national level policy and program formulation, frontline purchaser and provider staff implementation arrangements and contextual factors. The factors inter-related and worked together to affect client experience of the scheme, which were not always the same as the declared policy intent. This then also affected the decision to enrol and stay enrolled. CONCLUSIONS: UHC policy and program design needs to be such that enrolment is effectively compulsory in practice. It also requires careful attention and responsiveness to actual and potential subscriber, purchaser and provider (stakeholder) incentives and related behaviour generated at implementation levels.

Regional factors associated with participation in the national health screening program: a multilevel analysis using national data.

High participation rates are important for maximizing the effects of a health screening program. Previous studies have suggested that individual or regional characteristics have effects on health behaviors. In this study, we investigated the determinants of participation in the National Screening Program for Transitional Ages by simultaneously analyzing individual and area-level factors by multilevel analysis. A total of 1,081,216 subjects, aged 40 and 66 yr and nested in 254 areas, were included. There was a significant variation in participation rates across the areas even after adjusting for individual and area-level variables. Among the individual-level variables, increasing age, sex, higher income, and mild disability grade were associated with a higher participation rate. In urban areas, the 40-yr-old group had higher participation rates than the 66-yr-old group. Deprived areas had significantly high participation rates for both age groups. The number of screening centers per 1,000 inhabitants had no significant effect on participation in the screening program. In conclusion, regional characteristics are associated with participation rates independent of personal features and regional factors have differential effects with respect to age. A multi-dimensional approach is recommended to promote participation in health screening programs.

Poverty in the midst of plenty: unmet needs and distribution of health care resources in South Korea.

BACKGROUND: The unmet needs for health care have been used as an alternative measurement to monitor equity in health services. We sought to examine contextual influences on unmet needs for health care whereas precedent studies have been focused on individual characteristics on them. METHODS AND FINDINGS: The current study conducted multilevel logistic regression analysis to assess the effects of individual- and contextual-level predictors in meeting individual health care needs in South Korea. We sampled 7,200 individuals over the age of 19 in the Fourth Korea National Health and Nutrition Examination Survey in 2009. Included in the regression model were individual predictors such as demographic variables, socio-economic status, and self-rated health; the density of beds and physicians in public and private sectors within different regions were used as contextual-level predictors. This study showed the inverse association between unmet needs and regional resources in private sectors after controlling for the effects of individual-level predictors. CONCLUSION: Our findings suggest that increasing regional resources in private sectors might produce inefficiency in the health care system and inequity in access to health services, particularly where the competition in private health care sectors was highly stimulated under the fee-for-service reimbursement scheme. Policies for the reallocation of health care resources and for reduction of individual health care costs are needed in Korea.

[The determinants of adolescent smoking by gender and type of school in Korea].

OBJECTIVES: This study assessed the influences of various factors that are related to youth smoking such as gender, age and type of school, and we wanted to provide supporting data for tailored and effective policy initiatives to reduce adolescent smoking. METHODS: A self-report survey was conducted on 14,910 teen-age students who were selected based on the nationwide distribution of students in large and small cities and counties, the gender ratio of the students and the ratio of students attending various type of school at 38 middle and high schools in six representative areas of each province. The survey was handled and managed by a health education teacher at each school. Binary and multinomial logistic regression was used in the analyses. RESULTS: Smoking by adolescents was associated with gender, age and even height. Male high school students tended to smoke more than female high school students, but this differences was not significant for middle school students. The older the adolescents were, the more likely that they smoked, except for the female high school students. Height was meaningful for all adolescents, except for the boys at the vocational high schools. Monthly allowance was significant for all adolescents. School factors such as type of school and the students' school performance were also crucial factors. Attending a vocational high school was strongly related to smoking, especially for girls. Students' school performance and the perceived level of stress were strongly associated with smoking, especially for boys. Home factors such as the relationship with parents and conversation time with family members were closely related to smoking behavior. Knowledge about the health hazard of smoking was also found to be strongly related to adolescent smoking. CONCLUSIONS: In conclusion, demographic factors, school factors, home surroundings and the perception on the harmfulness of smoking are strongly related to adolescent smoking behavior, but these differ from gender and type of school.