A systematic review of factors that affect uptake of community-based health insurance in low-income and middle-income countries

Why do rural residents in China withdraw from the health insurance system? -A qualitative study based on Y County in S Province, China

BACKGROUND

Since the 2009 healthcare reform, the Chinese government has been committed to establishing a universal healthcare system. This study aims to investigate the complex reasons behind rural residents' decision to forgo participation in the medical insurance system by examining causal relationships and interactions.

METHODS

This study employs content analysis, conducting in-depth interviews with 42 stakeholders, including government administration departments, tax departments, medical insurance departments, village committees, and residents who have withdrawn from the health insurance system.

RESULTS

The study finds that the primary reasons rural residents withdraw from the medical insurance system are fourfold: heavy economic burdens, unfair design of the medical insurance system, failure of conventional mobilization strategies, and the internet's impact on residents' cognitive biases.

CONCLUSION

The decision of rural residents in China to withdraw from the medical insurance system is influenced not only by economic factors but also by the system's design and various aspects of rural governance. Moving forward, the Chinese government should optimize the medical insurance system's design, implement more flexible mobilization and persuasion strategies, and prioritize the identification and regulation of misleading information.

Investigating membership attrition dynamics in community-based health insurance: a survival analysis of socioeconomic and program-specific determinants in the Amhara Region, Northwest Ethiopia

BACKGROUND

Despite substantial growth and increased enrollment in Ethiopia's CBHI program, achieving universal coverage and retaining members remain challenging. This study, however, focuses on the persistent issue of dropout rates, which threaten the program's sustainability, while previous research has often focused on enrollment.

METHOD

The dependent variable is"time to membership attrition,"defined as an event "Dropout,"with independent variables including socioeconomic and program factors. Using Cochran's formula, data were collected from 772 (208 failure) respondents across five administrative zones. Analysis was performed using Kaplan-Meier estimation, Cox Regression, and the Weibull AFT Model.

RESULT

Dropout rates peaked at an average membership duration of 4.09 years, with increasing hazard rates (Weibull shape parameter = 2.077, p < 0.001). The Kaplan-Meier analysis indicates safety net beneficiaries had a lower dropout rate (67.8%) than non-beneficiaries (76.6%) and longer survival (Chi-square = 4.083, p = 0.043). Respondents with 4-6 hectares had the shortest survival (5.88 years) and a higher dropout risk (B = 0.417, p = 0.042), while non-landowners had a higher attrition risk (HR = 1.266, p = 0.814), Farm owners had a lower dropout rate (70.7%) (Chi-square = 1.569, p = 0.021). Lower-middle-income members had a higher attrition risk (HR = 1.999, p = 0.042) with a mean survival of 6.28 years, compared to 6.47 years for upper-middle-income. Perceived healthcare quality influenced dropout risk, increasing it by 5.9% for fair quality than poor (HR = 3.368, p < 0.000), and significantly for good quality as well (HR = 2.284, p < 0.000). Moderate financial protection (not catastrophic spending) increased dropout risk by 7.3% compared to high protection (HR = 1.125, p = 0.040).

CONCLUSION

Dropout rates peak in the early years of membership and increase over time. Enrolling in safety nets and having smaller land sizes enhanced retention rates, while extensive landholdings and being classified as Lower-Middle Income led to higher dropout rates; however, ownership of modern amenities had minimal impact on retention. Perceived healthcare quality and financial protection significantly influence CBHI retention, while program service quality has little effect, underscoring the need for policies that prioritize improving service quality, accessibility, and affordability.

Willingness to join community-based health insurance and associated factors among households in Ethiopian: a systematic review and meta-analysis

BACKGROUND

In Ethiopia, out-of-pocket medical expenses make up one-third of all medical expenses, which makes it difficult for households to obtain and utilize healthcare. One of the prepayment mechanisms that shield low-income households from unaffordable medical bills is the community-based health insurance (CBHI) program. This systematic review and meta-analysis aimed to estimate the pooled willingness to join Community-based Health Insurance schemes and its associated factors among households in Ethiopia.

METHODS

Articles were searched from PubMed, Google Scholar, Web of Science, Scopus, Science Direct, and Ethiopian Universities' repositories for grey literature. The study used the modified PRISMA guidelines for rewriting and reviewing the literature. The quality of studies was assessed using Joanna Briggs Institute Critical Appraisal tools. Data was extracted using Microsoft Excel and exported to STATA version 16 software for analysis. Cochran's Q statistic and I2 tests were utilized to determine the heterogeneity between studies. Studies publication bias was determined using a funnel plot and Egger's test. Subgroup analysis was conducted to demonstrate variations of the effect sizes across study regions. Finally, we utilized a random-effect model to compute the overall willingness to join the CBHI scheme and its determinants among households in Ethiopia.

RESULT

We included thirty studies to determine the pooled prevalence of willingness to join the CBHI scheme and its determinants. The pooled magnitude of households' willingness to join the CBHI scheme was 60.42% (95% CI: 51.45%, 69.38%). Old aged (AOR = 2.17, [95% CI: 1.37, 3.44], I2 = 82.33%), formal educational status(AOR = 2.74, [95% CI: 2.10, 3.56], I2 = 59.85%), Rich wealth index (AOR = 2.51, [95% CI: 1.99, 3.18], I2 = 48.25%), good knowledge/awareness of CBHI scheme(AOR = 4.21, [95% CI: 3.01, 5.88], I2 = 66.0%), experienced illness in the last three months (AOR = 3.42, [95% CI: 2.19, 5.35], I2 = 71.15%), and large family size (AOR = 2.36, [95% CI: 1.95, 2.87], I2 = 50.81%) were determinants of willingness to join the CBHI scheme. In addition, affordability of CBHI premium (AOR = 3.12, [95% CI: 2.34, 4.14], I2 = 10.35%), poor health status (AOR = 3.23, [95% CI: 2.57, 4.06], I2 = 35.97%), trust in scheme (AOR = 4.38, [95% CI: 1.91, 10.06], I2 = 88.35%), chronic diseases (AOR = 3.24, [95% CI: 2.40, 4.37], I2 = 67.15%) and good quality of healthcare services (AOR = 2.91, [95%CI:2.08, 4.09], I2 = 65.40%) were also predictors of willingness to join the CBHI program.

CONCLUSION

The pooled prevalence of willingness to join the CBHI scheme was low and below the national target of 80%. Age, family size, educational status, wealth status, illnesses in last three months, presence of chronic illnesses, affordability of the premium for the CBHI scheme, self-reported health status, Knowledge/awareness of the scheme, trust in the scheme and perceived quality of healthcare service were significantly determine the willingness to join the CBHI scheme. Health providers should provide detailed awareness creation through health education on the concepts and principles of the CBHI scheme.

Role of Imaging in Nondegenerative Arthritis in Low- and Middle-Income Countries

Arthritis is an important cause of disability globally, with high prevalence in low- and middle-income countries. Although osteoarthritis is the most common type of arthritis, various types of nondegenerative arthritis are prevalent in low- and middle-income countries. Multiple imaging modalities, such as radiography, ultrasound, computed tomography, and magnetic resonance imaging, are helpful in diagnosing and prognosticating arthritis. Although imaging appearances can overlap between types of arthritis, specific imaging findings have been described for the different etiologies. Knowing these imaging findings, especially on radiographs and ultrasound in resource-constrained areas, can be helpful in managing arthritis effectively.

Households willingness to join and pay for community-based health insurance: implications for designing community-based health insurance based on economic Status in Ethiopia

BACKGROUND

Despite the encouraging results achieved by community-based health insurance in Ethiopia, the program faces significant challenges. Among these challenges is the current practice where premium contributions to Community Based Health Insurance are either a flat rate or based solely on family size, rather than considering households' socio-economic status The overall aim of this study was to assess households' willingness to join and pay for Community Based Health Insurance in reference to socio-economic status to design sliding scale-based Community Based Health Insurance contributions in Ethiopia.

METHODS

A community based cross-sectional study was conducted in districts from two different contexts: urban areas and agrarian areas in two major regions in Ethiopia, namely Oromia, and Amhara. A double-bounded dichotomous contingent valuation method was used to determine households' willingness to pay. Descriptive statistics were used to summarize the data. A chi-square test was used to assess background factors associated with willingness to join and pay for Community Based Health Insurance, and tobit regression analyses were conducted to identify factors that determine the amount of willingness to pay for Community Based Health Insurance. The statistical significance of all results was interpreted using an adjusted two-sided Type I error rate of 0.05.

RESULT

A total of 786 households participated in this study. Overall, 532 (67.7%) study households have ever participated in the Community Based Health Insurance scheme. The reason for never participating was unaffordability of payment (30.3%), and they stated that the service was unsatisfactory (21.7%). Generally, 647 (82.3%) of the households were willing to join Community Based Health Insurance or renew their scheme membership in the future, with higher willingness among rural and urban residents and households with food insecurity (p < 0.05. The average amount households were willing to pay was 538.2 Ethiopian Birr with mode (570.0 Ethiopian Birr). In contrast with the existing premium contribution policy, the vast majority of households preferred premium contributions that considered households' economic status (81.2%). Increased household size, better household food security, and being rural residents, increased satisfaction with the scheme; and rural households' economic status significantly predicted the value of money households are willing to contribute to Community Based Health Insurance (p < 0.05).

CONCLUSION

This study revealed a strong willingness among community members to participate in or renew their membership in the Community Based Health Insurance scheme, with a clear preference for a socio-economic-based sliding scale approach over current flat rate or family size-dependent premium systems. This preference highlights the potential for transforming towards more equitable citizen contributions. Policymakers should therefore consider household economic status, alongside factors like household food security and family size, in determining Community Based Health Insurance membership fees. Furthermore, enhancing the quality of healthcare services is essential to boosting Community Based Health Insurance member satisfaction and ensuring the program's long-term sustainability. This comprehensive approach not only improves health outcomes but also strengthens community trust and support for the Community Based Health Insurance initiative.

Predictors of community-based health insurance enrollment among reproductive-age women in Ethiopia based on the EDHS 2019 dataset: a study using SHAP analysis technique, 2024

Background

Out-of-pocket payments for health services can lead to health catastrophes and decreased service utilization. To address this issue, community-based health insurance has emerged as a strategy to provide financial protection against the costs of poor health. Despite the efforts made by the government of Ethiopia, enrollment rates have not reached the potential beneficiaries. Therefore, this study aimed to predict and identify the factors influencing community-based health insurance enrollment among reproductive-age women using SHapley Additive exPlanations (SHAP) analysis techniques.

Method

The study was conducted using the recent Demographic Health Survey 2019 dataset. Eight machine learning algorithm classifiers were applied to a total weighted sample of 9,013 reproductive-age women and evaluated using performance metrics to predict community-based health insurance enrollment with Python 3.12.2 software, utilizing the Anaconda extension. Additionally, SHAP analysis was used to identify the key predictors of community-based health insurance enrollment and the disproportionate impact of certain variables on others.

Result

The random forest was the most effective predictive model, achieving an accuracy of 91.64% and an area under the curve of 0.885. The SHAP analysis, based on this superior random forest model, indicated that residence, wealth, the age of the household head, the husband's education level, media exposure, family size, and the number of children under five were the most influential factors affecting enrollment in community-based health insurance.

Conclusion

This study highlights the significance of machine learning in predicting community-based health insurance enrollment and identifying the factors that hinder it. Residence, wealth status, and the age of the household head were identified as the primary predictors. The findings of this research indicate that sociodemographic, sociocultural, and economic factors should be considered when developing and implementing health policies aimed at increasing enrollment among reproductive-age women in Ethiopia, particularly in rural areas, as these factors significantly impact low enrollment levels.

Willingness to pay for hepatitis B immunoglobulin among pregnant women in Enugu metropolis, South-East, Nigeria: a cross-sectional study

BACKGROUND

Hepatitis B immunoprophylaxis reduces the rate of mother-to-child transmission of hepatitis B virus infection and has effectively reduced the global burden of the hepatitis B virus infection. However, the cost of hepatitis B immunoglobulin could be prohibitive hampering adequate utilization in pregnancy and childbirth. Cost may affect pregnant women's willingness to pay (WTP) for the immunoglobulin. The WTP for hepatitis B immunoglobulin has not been critically studied in Enugu, Nigeria. The objective of the study was to determine the willingness of pregnant women to pay for hepatitis B immunoglobulin and to identify the predictors of the level of WTP among pregnant women in Enugu, Nigeria.

METHODS

A cross-sectional study that involved 379 pregnant women who were selected through a multi-stage sampling technique from the health facilities in Enugu between March and November 2019 was conducted. A structured pre-tested interviewer-administered questionnaire was used for data collection. The contingent valuation technique was utilized for eliciting values attached to hepatitis B immunoglobulin by the pregnant women while the bidding game technique was used to determine the maximum amounts the participants were willing to pay. Data were analyzed using SPSS version 23. A p-value of 0.05 was regarded as significant.

RESULTS

Most respondents (86.2%) were willing to pay for the hepatitis B immunoglobulin. The mean maximum amount of WTP was ₦23178.34 (62.64 USD). The price of hepatitis B immunoglobulin (48.8%) was a major hindrance to WTP and 36.9% of the respondents believed that the government should pay for the vaccines. Predictors of the average WTP amount were the level of education (p = 0.038, AOR = 2.645 CI: 1.055-6.630), participants' husbands' occupation, and weekly expenditure on food items (P = 0.041; AOR = 3.828, CI: 1.055-13.893).

CONCLUSIONS

The rate of WTP for hepatitis B immunoglobulin was 86.2%, however, the mean WTP amount was far below the market value of hepatitis B immunoglobulin. The major hindrance to WTP was the cost of the vaccine as most participants believed that the vaccine should be administered freely and financed by the government and its agencies. The predictors of willingness to pay were the participant's level of education, husband's occupation and weekly expenditure on food.

TRIAL REGISTRATION

Not applicable.

Determinants of enrolment for community-based health insurance in Somali region of Ethiopia

Background

Community-based health insurance (CBHI) is a type of health insurance programme that provides financial protection against the cost of illnesses and improves access to healthcare services for communities in the informal sector.

Aim

The aim was to assess the determinants of enrolment for CBHI in Aw-barre district - an agro-pastoral setting in the Somali region, Ethiopia.

Setting

Ethiopia launched the CBHI scheme in 2011 as part of the revised healthcare financing strategy to realise universal health coverage. It was then scaled up in the rural part of the country in 2013, except the pastoralist regions including the Somali region which started as late as 2020.

Methods

A community-based, unmatched case-control study was conducted using a concurrent nested approach between March 2021 and April 2021, among 214 participants (54 enrolled and 160 non-enrolled). Quantitative data were analysed using SPSS version 20, and thematic analysis was performed for the qualitative data.

Results

Awareness of the CBHI scheme adjusted odds ratio (AOR) = 9.67 (1.26, 74.53), household income AOR = 3.56 (1.03, 12.30) and being a member of community-based solidarity groups AOR = 2.48 (1.17, 5.26) were the determinants for CBHI enrolment and were reaffirmed by the qualitative findings.

Conclusion

Increasing community awareness of the scheme via various platforms is essential. Leveraging community-based solidarity associations, and social protection platforms would help increase enrolment.

Contribution

Given the distinct sociodemographic, economic and geographic peculiarities of agro-pastoralists, the CBHI parameters and implementation strategies must be tailored to the setting before scaling it up.

Beneficiaries' satisfaction with health insurance and associated factors in Sub-Saharan Africa: a systematic review and meta-analysis

OBJECTIVE

Beneficiaries' satisfaction with health insurance schemes is crucial for the success of these programmes, influencing their effective implementation and reducing dropout rates. This systematic review and meta-analysis aimed to assess the proportion of beneficiaries satisfied with health insurance and identify factors associated with their satisfaction in Sub-Saharan Africa (SSA).

DESIGN

A systematic review and meta-analysis were conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines.

DATA SOURCES

PubMed/MEDLINE, African Journals Online, Cumulative Index to Nursing & Allied Health Literature and Google Scholar were searched up to 23 May 2024.

ELIGIBILITY CRITERIA

Observational and quantitative studies conducted in SSA that reported the proportion of health insurance beneficiaries satisfied with the scheme and/or determined factors associated with satisfaction were included.

DATA EXTRACTION AND SYNTHESIS

Data were extracted using Microsoft Excel and analysed with STATA V.17 software. The quality of studies was assessed using Joanna Briggs Institute checklists. A random-effects model was employed to estimate pooled outcomes. Publication bias was evaluated with a funnel plot and Egger's regression test, while heterogeneity was assessed using the I² statistic.

RESULT

The study included 29 primary studies with a total of 11,488 participants. Among the included studies, 17 (58.62%) were found to have a low risk of bias, while the remaining studies exhibited a moderate risk of bias. The findings suggested publication bias among the included studies. To address this, a trim-and-fill analysis imputed 10 hypothetical missing studies, resulting in a more symmetrical funnel plot. The pooled finding showed that 61.84% of beneficiaries were satisfied with their health insurance (95% CI: 55.14 to 68.55, (I2=98.6%, p<0.001)). Having a good knowledge of health insurance (OR=2.75, 95% CI: 1.42 to 5.34, (I2=95.3%, p<0.001)), availability of prescribed drugs (OR=5.69, 95% CI: 3.04 to 10.62, (I2=88.6%, p<0.001)) and availability of lab services (OR=4.20, 95% CI: 2.18 to 8.11, (I2=88.4%, p<0.001)) were significantly associated to higher satisfaction with health insurance.

CONCLUSION

The results of this review show that a significant number of beneficiaries are satisfied with their health insurance. The findings highlight that beneficiaries' satisfaction is significantly influenced by their knowledge of health insurance, as well as the availability of prescribed drugs and essential laboratory services. It is recommended that health insurance programmes in SSA focus on these factors to improve overall satisfaction among beneficiaries.

PROSPERO REGISTRATION NUMBER

CRD42024496847.

Women's enrollment in community-based health insurance and its determinants in Sidama national regional state, Ethiopia, 2024: A multilevel analysis

INTRODUCTION

Accessing affordable and high-quality healthcare remains a persistent challenge in low- and middle-income countries like Ethiopia. Community-based health insurance (CBHI) programs offer a promising solution to expand healthcare coverage and provide financial protection, particularly for vulnerable populations such as women. This study aimed to investigate the factors that influence CBHI enrollment among women in Sidama National Regional State, Ethiopia, using a multilevel analysis.

METHODS

A community-based cross-sectional study was conducted using a multistage sampling technique from December 15th to January 12th, 2024, in the central Sidama zone, Sidama National Regional State. The study included 835 women aged 18 years and older, residing both in rural and urban areas. Face-to-face interviews were conducted using a pre-tested questionnaire to collect comprehensive data on socio-demographic, economic, and scheme-related factors. Data collection utilized the Open Data Kit mobile application, and data analysis was performed using Stata version 16, employing multilevel modified Poisson modeling to identify determinants of CBHI enrollment.

RESULTS

Among 845 samples, 835 women were interviewed, resulting in a response rate of 98.8%. Individual-level factors such as older age (APR = 1.02, 95%CI: 1.01-1.03, p<0.001), larger family size (APR = 1.09, 95%CI: 1.03-1.16, p = 0.001), and moderate wealth index (APR = 2.72, 95%CI: 1.28-5.79, p = 0.009) showed positive associations with CBHI enrollment, depicted a higher likelihood of individuals joining the insurance scheme. In addition, at the community level, higher rates of women's literacy (APR = 1.73, 1.18-2.55, p = 0.005), and women's autonomy (APR = 2.64, 95%CI: 1.50-4.65, p = 0.001) were positively correlated with CBHI enrollment.

CONCLUSIONS

The study revealed that the enrollment rate among women in the CBHI scheme was 35%, indicating a need for improved outreach efforts. Significant factors that affected enrollment included older age, larger family size, and moderate wealth. Additionally, positive community-level influences such as higher literacy rates and increased autonomy for women contributed to higher enrollment. To improve CBHI enrollment, the target should focus on younger women and those from smaller families. Financial support, such as subsidies for low-income women, can also encourage participation. Investing in women's literacy and empowerment programs will enable them to make informed health choices, thereby increasing enrollment. Finally, ongoing research is necessary to track enrollment trends and identify barriers. Utilizing qualitative methods will yield insights into women's perceptions of CBHI, facilitating more effective strategies. Implementing these recommendations can enhance women's access to healthcare through CBHI.

Challenges and Opportunities of Universal Health Coverage in Africa: A Scoping Review

BACKGROUND

Universal health coverage (UHC) is a global priority, with the goal of ensuring that everyone has access to high-quality healthcare without suffering financial hardship. In Africa, most governments have prioritized UHC over the last two decades. Despite this, the transition to UHC in Africa is seen to be sluggish, with certain countries facing inertia. This study sought to examine the progress of UHC-focused health reform implementation in Africa, investigating the approaches utilized, the challenges faced, and potential solutions.

METHOD

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines, we scoped the literature to map out the evidence on UHC adoption, roll out, implementation, challenges, and opportunities in the African countries. Literature searches of the Cochrane database of systematic reviews, PUBMED, EBSCO, Eldis, SCOPUS, CINHAL, TRIP, and Google Scholar were conducted in 2023. Using predefined inclusion criteria, we focused on UHC adoption, rollout, implementation, and challenges and opportunities in African countries. Primary qualitative, quantitative, and mixed-methods evidence was included, as well as original analyses of secondary data. We employed thematic analysis to synthesize the evidence.

RESULTS

We found 9633 documents published between May 2005 and December 2023, of which 167 papers were included for analysis. A significant portion of UHC implementation in Africa has focused on establishing social health protection schemes, while others have focused on strengthening primary healthcare systems, and a few have taken integrated approaches. While progress has been made in some areas, considerable obstacles still exist. Financial constraints and supply-side challenges, such as a shortage of healthcare workers, limited infrastructure, and insufficient medical supplies, remain significant barriers to UHC implementation throughout Africa. Some of the promising solutions include boosting public funding for healthcare systems, strengthening public health systems, ensuring equity and inclusion in access to healthcare services, and strengthening governance and community engagement mechanisms.

CONCLUSION

Successful UHC implementation in Africa will require a multifaceted approach. This includes strengthening public health systems in addition to the health insurance schemes and exploring innovative financing mechanisms. Additionally, addressing the challenges of the informal sector, inequity in healthcare access, and ensuring political commitment and community engagement will be crucial in achieving sustainable and comprehensive healthcare coverage for all African citizens.

Universal health coverage for women of reproductive ages: a survey-based comprehensive assessment of service utilisation and health expenditure in Tanzania

Introduction

Universal health coverage (UHC) for women of reproductive ages is a critical component of country and global health strategies but most evidence in high-fertility settings is limited to maternity care. Our study aimed to comprehensively assess women's health service utilisation and expenditure, including an equity dimension.

Methods

We conducted a household survey among 15-49 years as a nested study within the Magu health and demographic surveillance study, northwest Tanzania, during 2020-2021. Data were collected on self-reported health, fertility, utilisation of health services, health expenditure and health insurance. We analysed key indicators by household wealth quintiles, place of residence and health insurance, using logistic regression models controlling for age and other confounders.

Results

Among 8665 women aged 15-49 years (response rate 81%), 3.0% reported poor or very poor health, 13% gave birth in the preceding year, and health insurance coverage was 5.1%. Coverage of antenatal (99.5%) and institutional delivery care (88%) were high; 7.3% of women reported at least one outpatient visit in the last 4 weeks, of which 81% were for their own non-maternal healthcare; 9.3% had been admitted to a hospital during the last year, and 74% of these admissions were for deliveries. The total average annual health expenditure per woman was about TZS 16 860 (US$7.50), of which 82% was for her own healthcare and 18% for maternity care. Additionally, women spent about TZS 23 172 (US$10.00) per year on self-treatment. The poorest women had poorer self-reported health, lower coverage of maternity care, lower utilisation of services for their own healthcare and lower health insurance coverage, and limited their expenditure by making greater use of nearby public services than richer women.

Conclusion

Women spent more financial resources on their own non-maternal healthcare than maternity care with poorer women still facing disadvantages for their own healthcare. Health insurance programmes were hardly but were associated with an increase in service use. Comprehensive assessments of women's health needs, service use and expenditures with an equity focus are crucial for shaping UHC strategies tailored to women of reproductive ages.

Scaling Up Departmental Health Insurance Units in Senegal: A Mixed-Method Study

In response to the failure of community-based health insurance (CBHI) at the municipal level, some African countries are implementing district or departmental CBHIs to improve universal health coverage. After creating two CBHIs at the departmental level in 2014, Senegal launched a campaign to disseminate the model in 2022. This article presents the stakeholders' perspectives on the factors and challenges of scaling up CBHI departmentalization in Senegal. The study uses a mixed-methods approach, utilizing concept mapping and a focus group to examine scaling up departmentalization. The sample size consists of 22 individuals involved in the process. The quantitative analysis includes hierarchical cluster analysis, multidimensional scaling analysis, and the Pearson coefficient test. The qualitative analysis involves content analysis to triangulate the findings. Participants identified 125 factors to consider for the departmentalization of CBHI. They were categorized into nine clusters according to their degree of importance (I) and ease to organize (F): service package (I: 4.07; F: 2,26), communication (I: 4.05; F: 2.96), governance (I: 3.96; F: 2,94), human and logistical resources (I: 3.94; F: 2,82), financing (I: 3.90; F: 2,31), involvement of the authorities (I: 3.82; F: 2.75), community involvement (I: 3.81; F: 2.76), membership (I: 3.70; F: 2.24, strategic planning and implementation (I: 3.57; F: 2,62). The main challenges faced were a process perceived as precipitous and vertical and needing more negotiation and consultation. The conditions for accompaniment and public funding availability need to be sufficiently considered. The study proposes avenues for action to promote the scaling up of CBHI departmentalization in Senegal.

Patient's willingness to pay for improved community health insurance in Tanzania

Globally, achieving universal health coverage remains significant challenge. Health insurance coverage in low- and middle-income countries is still low with only a few African countries managed to reach 50% coverage. This study aimed to investigate the factors influencing patients' willingness to pay (WTP) for medication and various versions of the improved Community Health Insurance Fund (iCHF) in Tanzania. A facility-based cross-sectional study was conducted in all hospitals, health centres, and eight randomly sampled dispensaries, sampling participant from the queue, one out of every three patient based on their order of entry into consultation room, and interviewed 1,748 patients in Kilombero and Same districts in Tanzania. We used multi-stage Contingent Valuation Methods exploring data collected during client exit interviews. We employed a random utility model and estimated WTP through an ordered logit model. The independent variables were; patient's gender, age, marital status, education, employment status, Non-Communicable Disease (NCD) status, health insurance status, and the type of healthcare facility level. Our findings revealed that most patients exhibited a WTP of an amount equivalent to the current iCHF premiums and would also be willing to pay for an augmented iCHF premium inclusive of additional medication coverage. Upon adjusting for demographic characteristics, we observed that patients enrolled in an insurance program or benefiting from user fee waivers demonstrated a lower WTP for medication, while those with non-communicable diseases (NCDs) and seeking care in private facilities exhibited a higher WTP. Furthermore, patients with a secondary education level or above generally displayed higher WTP for premiums. Conversely, patients enrolled in private insurance and availing user fee waivers, along with those accessing care in public facilities, demonstrated a lowered WTP for iCHF premiums. These results highlight the need for targeted interventions to address systemic deficiencies and improve access to medicines. Our conclusions is that policies considering NCD status, education levels and income status are important when designing health insurance schemes for the informal sector in Tanzania, with the goal of increasing uptake of CHF.

'The National Health Insurance scheme would be good and beneficial but I don't trust the system …': a cross-sectional mixed-methods study assessing the awareness and perceptions towards Uganda's proposed National Health Insurance scheme among informal sector workers in Iganga and Mayuge districts, Uganda

Background

Most low-income countries have prioritised implementing national health insurance schemes (NHIs) as a solution to reducing the high out-of-pocket expenditures on health and enhancing access to healthcare, especially among informal sector workers. However, their perceptions remain unexplored in Uganda. This study aimed to assess the awareness and perceptions of the informal sector workers towards the proposed NHIs in Iganga and Mayuge districts, Uganda.

Methodology

A cross-sectional mixed-methods study was conducted in the Iganga and Mayuge districts of eastern Uganda between April and May 2019. Informal sector workers were randomly selected to participate in the study. Six key informant interviews with health workers and seven focus group discussions with informal sector workers were also conducted. Quantitative data was analysed using STATA V.14. Qualitative data was analysed using a thematic analysis approach.

Results

A total of 853 respondents participated in the survey: 327/853 (38.3%) were peasant farmers, 248/853 (29.1%) were fishermen, 146/853 (17.1%) were business people and 132/853 (15.5%) were commercial cyclists. Very few, 14/853 (1.6%), were considered knowledgeable about health insurance. The majority 743/853 (87.1%) of the respondents believed that the proposed scheme was beneficial, with a few reservations about lack of trust. Qualitatively, most participants had never heard about health insurance. Most community and health workers welcomed the idea of introducing NHIs in Uganda, although many indicated their lack of trust in the system to deliver a beneficial scheme.

Conclusion

There was a high level of support for the proposed National Health Insurance scheme since many believed it would be beneficial. However, there was low awareness and a lack of trust in the system to successfully implement a beneficial scheme due to corruption. There is a need for intensive sensitisation campaigns to raise awareness and boost confidence and trust.

Spatial distribution and factors associated with health insurance subscription among women in Ghana

BACKGROUND

This study examined the spatial distribution and factors associated with health insurance subscription among women in Ghana.

METHODS

We analysed a representative sample of 9380 women aged 15-49 y from the 2014 Ghana Demographic and Health Survey. Descriptive and multilevel regression analyses were performed. The study also employed spatial analysis techniques, including spatial autocorrelation, hotspot analysis, cluster and outlier analysis, as well as geographically weighted regression to explore the geographic distribution and predictors of non-subscription to health insurance.

RESULTS

The analysis revealed a moderately high prevalence of health insurance subscription among women in Ghana (62.4%). The spatial analyses indicated substantial variations in health insurance subscription across different regions in Ghana. The coastal and middle zones reported higher rates of non-subscription compared with the northern zone. We observed that young women (aged 20-24 y) had a lower likelihood of subscribing compared with adolescent girls (aged 15-19 y). Also, higher educational attainment, listening to the radio, being in a marital union and higher wealth status were positively associated with health insurance subscription.

CONCLUSIONS

The study calls for targeted interventions and policies to promote equitable access to healthcare services, focusing on improving health infrastructure in coastal and middle zones, educational campaigns for individuals with lower education levels, leveraging media platforms for health insurance awareness and implementing equitable and affordable processes for individuals in poorer households.

Enrollment and associated factors of the national health insurance program of Nepal: Further analysis of the Nepal Demographic and Health Survey 2022

The focus of this study was on the current enrollment status of the government-funded health insurance (HI) program in Nepal, which is necessary to achieve universal health coverage by 2030. Despite the government's commitment, the program faces challenges of low enrollment and high dropout rates, hindering progress towards this goal. With a purpose to find out the associated factors for enrollment in HI, the cross-sectional study employs secondary data obtained from the Nepal Demographic and Health Survey 2022. A multi-stage sampling method yielded a representative sample of 14,280 households, and an interview was conducted with 14,845 females and 4,913 males aged 15-49. A weighted sample was employed and subsequently analyzed through the use of R. The analysis reveals a concerningly low enrollment rate, with only 10% of the surveyed population possessing government HI. Furthermore, significant geographical disparities were found to exist-Koshi Province had the highest coverage (21.8% men and 20.4% women), while Madhesh Province lagging far behind (3.1% men and 2.7% women). Additionally, the enrollment rates correlated positively with urban residence, higher socioeconomic statuses, and employment, with no subgroup surpassing 30% coverage, though. The study demonstrates a positive association between HI and healthcare utilization, with insured individuals exhibiting a higher likelihood of visiting health facilities and reporting fewer access-related issues. Respondents with higher levels of education and greater wealth were significantly more likely to enroll in HI than those with basic education and middle-level wealth, respectively. This pattern holds consistently for both males and females. These findings suggest that the program, aiming for 60% coverage by 2023/24, is currently off-track. Policymakers should interpret these data as a call for action, prompting the development and implementation of the targeted interventions to address enrollment disparities across Nepal. By focusing on the low-coverage areas and the vulnerable populations, the program can be strengthened and contribute meaningfully to achieving universal health coverage by 2030.

Effectiveness of community-based diabetes and hypertension prevention and management programmes in Indonesia and Viet Nam: a quasi-experimental study

INTRODUCTION

Non-communicable diseases (NCDs) have surpassed infectious diseases as the leading global cause of death, with the Southeast Asian region experiencing a significant rise in NCD prevalence over the past decades. Despite the escalating burden, screening for NCDs remains at very low levels, resulting in undetected cases, premature mortality and high public healthcare costs. We investigate whether community-based NCD prevention and management programmes are an effective solution.

METHODS

In Indonesia, we compare participants in the community-based NCD screening and management programme Pos Pembinaan Terpadu-Penyakit Tidak Menular with matched non-participants with respect to their uptake of screening activities, health-related behaviour and knowledge and metabolic risk factors. We use statistical matching to redress a possible selection bias (n=1669). In Viet Nam, we compare members of Intergenerational Self-Help Clubs, which were offered similar NCD health services, with members of other community groups, where such services were not offered. We can rely on two waves of data and use a double-difference approach to redress a possible selection bias and to measure the impacts of participation (n=1710). We discuss strengths and weaknesses of the two approaches in Indonesia and Viet Nam.

RESULTS

In Indonesia, participants have significantly higher uptake of screening for hypertension and diabetes (+13% from a control mean of 88% (95% CI 9% to 17%); +93% from a control mean of 48% (95% CI 79% to 108%)). In both countries, participants show a higher knowledge about risk factors, symptoms and complications of NCDs (Indonesia: +0.29 SD (0.13-0.45), Viet Nam: +0.17 SD (0.03-0.30)). Yet, the improved knowledge is only partly reflected in improved health behaviour (Viet Nam: fruit consumption +0.33 SD (0.15-0.51), vegetable consumption +0.27 SD (0.04-0.50)), body mass index (BMI) (Viet Nam: BMI -0.07 SD (-0.13 to -0.00)) or metabolic risk factors (Indonesia: systolic blood pressure: -0.13 SD (-0.26 to -0.00)).

CONCLUSION

Community-based NCD programmes are well suited to increase screening and to transmit health knowledge. Due to their extensive outreach within the community, they can serve as a valuable complement to the screening services provided at the primary healthcare level. Yet, limited coverage, insufficient resources and a high staff turnover remain a problem.

TRIAL REGISTRATION NUMBER

NCT05239572.

Prevalence, perceptions and associated factors of health insurance enrollment among older persons in selected cash grant communities in Ghana: a cross-sectional mixed method

BACKGROUND

Universal Health Coverage has been openly recognized in the United Nations health-related Sustainable Development Goals by 2030, though missing under the Millennium Development Goals. Ghana implemented the National Health Insurance Scheme programme in 2004 to improve financial access to healthcare for its citizens. This programme targeting low-income individuals and households includes an Exempt policy for older persons and indigents. Despite population ageing, evidence of the participation and perceptions of older persons in the scheme in cash grant communities is unknown. Hence, this paper examined the prevalence, perceptions and factors associated with health insurance enrollment among older persons in cash grant communities in Ghana.

METHODS

Data were from a cross-sectional household survey of 400 older persons(60 + years) and eight FGDs between 2017 and 2018. For the survey, stratified and simple random sampling techniques were utilised in selecting participants. Purposive and stratified sampling techniques were employed in selecting the focus group discussion participants. Data analyses included descriptive, modified Poisson regression approach tested at a p-value of 0.05 and thematic analysis. Stata and Atlas-ti software were used in data management and analyses.

RESULTS

The mean age was 73.7 years. 59.3% were females, 56.5% resided in rural communities, while 34.5% had no formal education. Two-thirds were into agriculture. Three-fourth had non-communicable diseases. Health insurance coverage was 60%, and mainly achieved as Exempt by age. Being a female [Adjusted Prevalence Ratio (APR) 1.29, 95%CI:1.00-1.67], having self-rated health status as bad [APR = 1.34, 95%CI:1.09-1.64] and hospital healthcare utilisation [APR = 1.49, 95%CI:1.28-1.75] were positively significantly associated with health insurance enrollment respectively. Occupation in Agriculture reduced insurance enrollment by 20.0%. Cited reasons for poor perceptions of the scheme included technological challenges and unsatisfactory services.

CONCLUSION

Health insurance enrollment among older persons in cash grant communities is still not universal. Addressing identified challenges and integrating the views of older persons into the programme have positive implications for securing universal health coverage by 2030.

Educational status affects prognosis of patients with heart failure with reduced ejection fraction: A post-hoc analysis from the WARCEF trial

AIMS

The influence of social determinants of health (SDOH) on the prognosis of Heart Failure and reduced Ejection Fraction (HFrEF) is increasingly reported. We aim to evaluate the contribution of educational status on outcomes in patients with HFrEF.

METHODS

We used data from the WARCEF trial, which randomized HFrEF patients with sinus rhythm to receive Warfarin or Aspirin; educational status of patients enrolled was collected at baseline. We defined three levels of education: low, medium and high level, according to the highest qualification achieved or highest school grade attended. We analysed the impact of the educational status on the risk of the primary composite outcome of all-cause death, ischemic stroke (IS) and intracerebral haemorrhage (ICH); components of the primary outcome were also analysed as secondary outcomes.

RESULTS

2295 patients were included in this analysis; of these, 992 (43.2%) had a low educational level, 947 (41.3%) had a medium education level and the remaining 356 (15.5%) showed a high educational level. Compared to patients with high educational level, those with low educational status showed a high risk of the primary composite outcome (adjusted hazard ratio [aHR]: 1.31, 95% confidence intervals [CI] 1.02-1.69); a non-statistically significant association was observed in those with medium educational level (aHR: 1.20, 95%CI: .93-1.55). Similar results were observed for all-cause death, while no statistically significant differences were observed for IS or ICH.

CONCLUSION

Compared to patients with high educational levels, those with low educational status had worse prognosis. SDOH should be considered in patients with HFrEF.

CLINICAL TRIAL REGISTRATION

NCT00041938.

Effect of social capital on enrolment of informal sector occupational groups in the national health insurance scheme in Ghana: a cross-sectional survey

BACKGROUND

Enrolment of informal sector workers in Ghana's National Health Insurance Scheme (NHIS) is critical to achieving increased risk-pooling and attainment of Universal Health Coverage. However, the NHIS has struggled over the years to improve enrolment of this subpopulation. This study analysed effect of social capital on enrolment of informal sector workers in the NHIS.

METHODS

A cross-sectional survey was conducted among 528 members of hairdressers and beauticians, farmers, and commercial road transport drivers' groups. Descriptive statistics, principal component analysis, and multinomial logit regression model were used to analyse the data.

RESULTS

Social capital including membership in occupational group, trust, and collective action were significantly associated with enrolment in the NHIS, overall. Other factors such as household size, education, ethnicity, and usual source of health care were, however, correlated with both enrolment and dropout. Notwithstanding these factors, the chance of enrolling in the NHIS and staying active was 44.6% higher for the hairdressers and beauticians; the probability of dropping out of the scheme was 62.9% higher for the farmers; and the chance of never enrolling in the scheme was 22.3% higher for the commercial road transport drivers.

CONCLUSIONS

Social capital particularly collective action and predominantly female occupational groups are key determinants of informal sector workers' participation in the NHIS. Policy interventions to improve enrolment of this subpopulation should consider group enrolment, targeting female dominated informal sector occupational groups. Further studies should consider inclusion of mediating and moderating variables to provide a clearer picture of the relationship between occupational group social capital and enrolment in health insurance schemes.

Willingness to pay for National Health Insurance Services and Associated Factors in Africa and Asia: a systematic review and meta-analysis

Background

Universal health coverage (UHC) is crucial for public health, poverty eradication, and economic growth. However, 97% of low- and middle-income countries (LMICs), particularly Africa and Asia, lack it, relying on out-of-pocket (OOP) expenditure. National Health Insurance (NHI) guarantees equity and priorities aligned with medical needs, for which we aimed to determine the pooled willingness to pay (WTP) and its influencing factors from the available literature in Africa and Asia.

Methods

Database searches were conducted on Scopus, HINARI, PubMed, Google Scholar, and Semantic Scholar from March 31 to April 4, 2023. The Joanna Briggs Institute's (JBI's) tools and the "preferred reporting items for systematic reviews and meta-analyses (PRISMA) 2020 statement" were used to evaluate bias and frame the review, respectively. The data were analyzed using Stata 17. To assess heterogeneity, we conducted sensitivity and subgroup analyses, calculated the Luis Furuya-Kanamori (LFK) index, and used a random model to determine the effect estimates (proportions and odds ratios) with a p value less than 0.05 and a 95% CI.

Results

Nineteen studies were included in the review. The pooled WTP on the continents was 66.0% (95% CI, 54.0-77.0%) before outlier studies were not excluded, but increased to 71.0% (95% CI, 68-75%) after excluding them. The factors influencing the WTP were categorized as socio-demographic factors, income and economic issues, information level and sources, illness and illness expenditure, health service factors, factors related to financing schemes, as well as social capital and solidarity. Age has been found to be consistently and negatively related to the WTP for NHI, while income level was an almost consistent positive predictor of it.

Conclusion

The WTP for NHI was moderate, while it was slightly higher in Africa than Asia and was found to be affected by various factors, with age being reported to be consistently and negatively related to it, while an increase in income level was almost a positive determinant of it.

Barriers and Motivations for Health Insurance Subscription Among Health-Care Users in Cameroon

INTRODUCTION

Surgical care is a significant component of the overall health expenditure in low- and middle-income countries. In Cameroon, out-of-pocket payments for surgical service are very high with many patients declining potentially curative surgical procedures. Less than 2% of the population is enrolled in a health insurance scheme leading to a propensity for catastrophic health expenses when accessing care. To assess the perceived barriers and motivations for health insurance subscription among health-care users in Cameroon.

METHODS

This was a cross-sectional community-based qualitative study conducted in the Center Region of Cameroon. A total of 37 health-care users (health insurance subscribers and nonsubscribers) were purposively identified. Four focused group discussions and thirteen in-depth interviews were conducted. All anonymized transcripts were analyzed using a thematic analysis approach.

RESULTS

The six major themes identified as barriers to health insurance subscription were lack of trust in the existing health insurance schemes, inadequate knowledge on how health insurance works, premiums believed to be too expensive, the complexity of the claims processing system, minimal usage of health-care services and practice of self-medication. Motivational factors included the knowledge of having access to quality health services even without money in the event of an unforeseen illness and having a large family/household size. The importance of mass sensitization on the benefits of health insurance was noted.

CONCLUSION

Health insurance is still very underutilized in Cameroon. This results in significant out-of-pocket payment for health services by Cameroonians with catastrophic consequences to households. With most Cameroonians in the informal sector and underemployed, it is imperative to put in place a national strategic plan to overcome existing barriers and increase health insurance coverage especially among the poor. This has the potential to significantly increase access to safe, quality, timely and affordable surgical care.

Developing the improved Community Health Fund in Tanzania: was it a fair process?

Tanzania developed its 2016-26 health financing strategy to address existing inequities and inefficiencies in its health financing architecture. The strategy suggested the introduction of mandatory national health insurance, which requires long-term legal, interministerial and parliamentary procedures. In 2017/18, improved Community Health Fund (iCHF) was introduced to make short-term improvements in coverage and financial risk protection for the informal sector. Improvements involved purchaser-provider split, portability of services, uniformity in premium and risk pooling at the regional level. Using qualitative methods and drawing on the policy analysis triangle framework (context, content, actors and process) and criteria for procedural fairness, we examined the decision-making process around iCHF and the extent to which it met the criteria for a fair process. Data collection involved a document review and key informant interviews (n = 12). The iCHF reform was exempt from following the mandatory legislative procedures, including processes for involving the public, for policy reforms in Tanzania. The Ministry of Health, leading the process, formed a technical taskforce to review evidence, draw lessons from pilots and develop plans for implementing iCHF. The taskforce included representatives from ministries, civil society organizations and CHF implementing partners with experience in running iCHF pilots. However, beneficiaries and providers were not included in these processes. iCHF was largely informed by the evidence from pilots and literature, but the evidence to reduce administrative cost by changing the oversight role to the National Health Insurance Fund was not taken into account. Moreover, the iCHF process lacked transparency beyond its key stakeholders. The iCHF reform provided a partial solution to fragmentation in the health financing system in Tanzania by expanding the pool from the district to regional level. However, its decision-making process underscores the significance of giving greater consideration to procedural fairness in reforms guided by technical institutions, which can enhance responsiveness, legitimacy and implementation.

Effectiveness and impact of community-based health insurance on health service utilization in northwest Ethiopia: a quasi-experimental evaluation

Background

Addressing the health challenges of lower socioeconomic groups in Ethiopia is still a huge problem. In that regard, the government piloted the community-based health insurance (CBHI) in 2011 in a few districts and subsequently scaled up. However, the effectiveness of the program on the utilization of health services and its impact was not well explored. Thus, we aimed to evaluate the effectiveness of CBHI toward health services' utilization and its impact in northwest Ethiopia.

Methods

A quasi-experimental matched comparison group evaluation design with sequential explanatory mixed methods was employed. To evaluate the CBHI program, the effectiveness and impact dimensions from the Organization for Economic Cooperation and Development framework were used. A multistage sampling technique was used to select a total of 332 households enrolled in the CBHI program; 341 comparison households who did not enroll in the program were also randomly selected. A structured interviewer-administrated questionnaire was used to evaluate the effectiveness and impact of CBHI on health service utilization. The Propensity score matching model was employed for the estimation of the effect of the CBHI program on health service utilization. Challenges for program achievement toward health service utilization were explained through qualitative data and these were then analyzed thematically.

Results

The evaluation showed 1.3 visits per capita per year of health service utilization among CBHI members. Households enrolled in CBHI increased health service utilization by 6.9 percentage points (ATT = 0.069; 95% CI: 0.034, 0.114). There was an improvement in health service utilization after the introduction of CBHI, however, there are challenges: (i) shortage of human resources, (ii) out-of-stock of drugs and medical supplies, and (iii) long waiting times for service and reimbursement claims. These issues limit the success of the program toward health service utilization.

Conclusion

The CBHI program contributed to health service utilization improvement among CBHI members. However, the utilization rate of health services among CBHI members is still less than the target stated for the program and also the WHO recommendation. Therefore, the findings of this evaluation can be used by program implementers, policy makers, and other stakeholders to overcome the identified challenges and to increase the success of the program.

The Impact of Health Maintenance Organizations in the Implementation of the Nigeria National Health Insurance Scheme in the Federal Capital Territory (Abuja), Nigeria

Background

The activities of Health maintenance organizations (HMO) are central to the achievement of universal health coverage. This study sought to examine the number of HMOs actively operating in the FCT and to determine whether the HMOs are promoting or inhibiting universal coverage and proffer recommendations for the overall progress of the scheme.

Methodology

A descriptive prospective cross-sectional study design was used and mixed (qualitative and quantitative) methods A pre-tested interviewer-administered questionnaire make was used to collect quantitative data while qualitative data were collected through a review of literature and in-depth interviews to examine the roles of HMOs from stakeholders' points of view. A total of 250 participants comprised predominantly 230 enrollees into three major programs of the NHIS that is the formal sector social insurance program (FS-SHIP), tertiary institution social health insurance program (TI-SHIP), and community-based social health insurance program (CB-SHIP). The remaining 20 (twenty) enrollees comprised NHIA desk officers, HMO managers, community-based representatives, and healthcare providers.

Results

The majority of the respondents (64.8%) reported a high level of awareness of the knowledge of NHIS, while fewer than 19% indicated a lack of awareness as compared to 17% who did not respond to the question. Similarly, most of the respondents (62.2%) reported having satisfactory knowledge of the structure-function modalities of HMOs, while 20.4% were not aware of the mode of operation of HMOs.Contrasting contributions of HMOs to NHIS implementation, approximately half of the respondents (50%) reported dissatisfaction. Likewise, about 50% of the study subjects were of the view that HMOs are not putting the desired commitment towards achieving this goal of universal health coverage. The report from the in-depth interview reiterated that the enrollees were not well satisfied due to the perceived poor and inadequate operational mechanisms of both the HMOs and NHIS.

Conclusions

The study revealed a high level of awareness of the knowledge of NHIS and good working knowledge of the structure and function of the HMOs. However, this study demonstrated a low understanding of the working interactions between the NHIS and HMO, among the respondents. Understanding HMOs and how they work is critical for choosing a health plan during open enrollment, hence, there is a need for more client enlightenment.

Household satisfaction and associated factors with community-based health insurance scheme in Ethiopia: systematic review and meta-analysis

BACKGROUND

Community-based health insurance (CBHI) schemes are crucial for households to avoid financial hardship, improve healthcare quality, and engage in health policies. Household satisfaction is a key indicator for assessing healthcare quality and identifying service gaps. However, research on household satisfaction with CBHI in Ethiopia is limited. Therefore, this study aimed to evaluate household satisfaction and associated factors with CBHI schemes in Ethiopia.

METHODS

A comprehensive search of relevant literature was conducted using multiple databases, including PubMed, Google Scholar, Africa Journal Online, and Ethiopian Universities' institutional open-access online repositories. The search was carried out between January 25, 2023, and February 28, 2023. Twelve primary studies, including eight published and four unpublished, were identified and included in the analysis with a total sample size of 5311 participants. A protocol with the registration number CRD20531345698 is recorded on the Prospero database. Two authors, DT and MK, independently extracted the required data using a standardized form. The extracted data were then analyzed using STATA version 17 software. Heterogeneity was assessed using the Cochrane Q-test and I2 tests. Finally, a random-effect model was employed to calculate the overall household satisfaction with CBHI and to determine the associated factors.

RESULTS

The meta-analysis showed that the overall household satisfaction with CBHI in Ethiopia was 62.26% (95% CI 53.25-71.21%). The study found regional variations in household satisfaction, with 63.40% in Oromia, 64.01% in Amhara, 49.58% in Addis Ababa, and 66.76% in SNNPs. The study identified several factors associated with household satisfaction and the CBHI scheme, including the availability of drugs (OR 2.13, 95% CI 1.47-2.78), friendly services (OR 3.85, 95% CI 1.60-6.10), affordability of premium (OR 2.80, 95% CI 1.97-3.63), and knowledge/awareness of CBHI (OR 2.52, 95% CI 1.73-3.33).

CONCLUSIONS

The study provides valuable insights into household satisfaction with CBHI in Ethiopia, with a considerable proportion of enrolees being satisfied. The finding highlights regional variations in household satisfaction and underscores the need for tailored interventions and monitoring to enhance CBHI sustainability and effectiveness. The results suggest that healthcare providers and policymakers should prioritize the availability of drugs, friendly services, affordable premiums, and education to improve household satisfaction with CBHI schemes.

A review of neurological health disparities in Peru

Peru is a historically unique and culturally diverse Latin American country. As a low-to-middle-income country (LMIC), Peru faces health implications from the spread of communicable diseases as well as a growing rate of noncommunicable diseases, both of which have been worsened by the recent COVID-19 pandemic's impact on the national health system. Over the past two decades, the country has aimed to improve health access for its population through various efforts described in this review. Despite this, there are notable neurological health disparities that exist today. This narrative review investigates such disparities through the leading neurological contributors to the national burden of disease in the country, including migraine headaches, cerebrovascular disease, and dementia. Public health disparities that contribute to other major neurological diseases in the country, including epilepsy, neurocysticercosis, Chagas disease, multiple sclerosis, traumatic brain injury, traumatic and non-traumatic spinal cord injuries are also investigated. We also explore potential solutions for overcoming the various neurological health disparities covered in this review that may be applied through public policies, as well as in similar LMICs in Latin America. By overcoming such disparities, the country may be able to successfully address the major contributors of neurological disease burden and create a healthcare environment that can sustainably and equitably improve health outcomes for Peruvian people.

Catastrophic health care spending in managing type 2 diabetes before and during the COVID-19 pandemic in Tanzania

COVID-19 disrupted health care provision and access and reduced household income. Households with chronically ill patients are more vulnerable to these effects as they access routine health care. Yet, a few studies have analysed the effect of COVID-19 on household income, health care access costs, and financial catastrophe due to health care among patients with type 2 diabetes (T2D), especially in developing countries. This study fills that knowledge gap. We used data from a cross-sectional survey of 500 people with T2D, who were adults diagnosed with T2D before COVID-19 in Tanzania (March 2020). Data were collected in February 2022, reflecting the experience before and during COVID-19. During COVID-19, household income decreased on average by 16.6%, while health care costs decreased by 0.8% and transport costs increased by 10.6%. The overall financing burden for health care and transport relative to household income increased by 32.1% and 45%, respectively. The incidences of catastrophic spending above 10% of household income increased by 10% (due to health care costs) and by 55% (due to transport costs). The incidences of catastrophic spending due to health care costs were higher than transport costs, but the relative increase was higher for transport than health care costs (10% vs. 55% change from pre-COVID-19). The likelihood of incurring catastrophic health spending was lower among better educated patients, with health insurance, and from better-off households. COVID-19 was associated with reduced household income, increased transport costs, increased financing burden and financial catastrophe among patients with T2D in Tanzania. Policymakers need to ensure financial risk protection by expanding health insurance coverage and removing user fees, particularly for people with chronic illnesses. Efforts are also needed to reduce transport costs by investing more in primary health facilities to offer quality services closer to the population and engaging multiple sectors, including infrastructure and transportation.

Willingness to enroll and pay for community-based health insurance, decision motives, and associated factors among rural households in Enugu State, Southeast Nigeria

Background

Over 70% of Nigeria's population is poor and rural, and most lack financial risk protection against ill health. Community-based health insurance (CBHI) may be an essential intervention strategy for ensuring that quality healthcare reaches the informal and rural populations.

Aim

This article explores the willingness to enroll (WTE) and willingness to pay (WTP) for CBHI by community members, their decision considerations, and associated factors in Enugu State, Nigeria.

Materials and Methods

We adopted a cross-sectional survey design with a multi-stage sampling approach. A validated and pre-tested questionnaire was used to elicit information from the respondents. WTE and WTP for CBHI was determined using the bid contingent valuation method. A test of correlation/association (Chi-square and ordinary least square regression) was conducted to ascertain the relationship between WTP for CBHI and other variables at a 95% confidence interval. The socioeconomic status index was generated using principal component analysis. A test of association was conducted between the demographic characteristics and WTE and WTP variables.

Key Findings

A total of 501 household heads or their representatives were included in the study which yielded a return rate of 98.2%. The finding showed that most (92.4%) of the respondents indicated a WTE in CBHI. 86.6% indicated a willingness to pay cash for CBHI, while 84.4% indicated a willingness to pay other household members for CBHI. There was a significant association between gender, marital status, education, location, and willingness to pay. The study shows that 81.6% of the respondent stated that qualified staff availability motivates their WTE/WTP for CBHI, while 78.1% would be willing to enroll and pay for CBHI if services were provided free, and 324 (74.6%) stated that proximity to a health facility would encourage them to enroll and pay for the CBHI.

Conclusion

This community demand analysis shows that rural and peri-urban community members are open to using a contributory mechanism for their health care, raising the prospect of establishing CBHI. To achieve universal health coverage, policy measures need to be taken to promote participation, provide financial and non-financial incentives and ensure that the service delivery mechanism is affordable and accessible. Further studies are needed to explore ways to encourage participation and enrollment in CBHI and other contributory schemes among under-served populations and improve access to and utilization of healthcare services.

The level of household satisfaction with community-based health insurance and associated factors in Southern Ethiopia

Background

Community-based health insurance (CBHI) is a program intended to prevent financial hardship brought on by the cost of medical care. All of Ethiopia's regions are implementing it; however, it has not yet been researched how the program is being received by the local population. This study's objective is to determine how satisfied Southern Ethiopian households are with community-based health insurance programs and connected variables.

Methods

A community-based cross-sectional study was conducted from April to May 2021. Information was gathered from 528 households (HHs) selected at random in the Gurage Zone of Southern Ethiopia using a questionnaire. Bivariate and multivariate logistic regression, as well as descriptive statistics, were applied. p values less than 0.05 was used as a cutoff point for identifying the self-determining factors.

Results

The adjusted odds ratio (AOR) for HHs with the poorest wealth status was 2.40 (95% confidence interval:1.14-4.90); for HHs with a good knowledge of the CBHI, it was 1.81 (95% CI: 1.87-3.40); and for households with illness in the past 3  months, it was 5.22 (95% CI: 2.91-9.34). Recurrent visits to the facility (AOR:5.04, 95% CI:1.18-23.44), a Model household in rural health extension program (AOR:3.21, 95% CI:1.76-5.85), being enrolled in the scheme for three years or less (AOR:0.55, 95% CI: 0.30-0.95), and having faith in the leadership of the governing board (AOR:10.53, 95% CI:4.690-23.54) and the availability of the prescribed medication (AOR:14.64, 95% CI:5.37-39.84) were the significant influencing factors.

Conclusion

This study revealed several variables that affected HHs' satisfaction with CBHI. We strongly advise all responsible parties to focus on increasing HH knowledge of the CBHI scheme, supporting HHs to serve as role models for rural health extension packages, and completing the CBHI pledged package to improve HHs' satisfaction with the CBHI scheme, which may then play a role in the sustainability of CBHI.

Open tibial shaft fractures: treatment patterns in sub-Saharan Africa

Objective

Open tibial shaft fractures are a leading cause of disability worldwide, particularly in low and middle-income countries (LMICs). Guidelines for these injuries have been developed in many high-income countries, but treatment patterns across Africa are less well-documented.

Methods

A survey was distributed to orthopaedic service providers across sub-Saharan Africa. Information gathered included surgeon and practice setting demographics and treatment preferences for open tibial shaft fractures across 3 domains: initial debridement, antibiotic administration, and fracture stabilization. Responses were grouped according to country income level and were compared between LMICs and upper middle-income countries (UMICs).

Results

Responses from 261 survey participants from 31 countries were analyzed, with 80% of respondents practicing in LMICs. Most respondents were male practicing orthopaedic surgeons at a tertiary referral hospital. For all respondents, initial debridement occurred most frequently in the operating room (OR) within the first 24 hours, but LMIC surgeons more frequently reported delays due to equipment availability, treatment cost, and OR availability. Compared with their UMIC counterparts, LMIC surgeons less frequently confirmed tetanus vaccination status and more frequently used extended courses of postoperative antibiotics. LMIC surgeons reported lower rates of using internal fixation, particularly for high-grade and late-presenting fractures.

Conclusions

This study describes management characteristics of open tibial shaft fractures in sub-Saharan Africa. Notably, there were reported differences in wound management, antibiotic administration, and fracture stabilization between LMICs and UMICs. These findings suggest opportunities for standardization where evidence is available and further research where it is lacking.

Level of Evidence

VI-Cross-Sectional Study.

Potential demand for National Health Insurance in Zimbabwe: Evidence from selected urban informal sector clusters in Harare

BACKGROUND

Zimbabwe's tax-based healthcare financing model has been characterised by perennial financing deficits and widespread application of user fees and has thus been socially exclusive. The country's urban informal sector population is not spared from these challenges. The study explored the potential demand for National Health Insurance (NHI) among respondents from selected urban informal sector clusters of Harare. The following clusters were targeted: Glenview furniture complex, Harare home industries, Mupedzanhamo flea market, Mbare new wholesale market and Mbare retail market.

METHODS

A cross-sectional survey was administered to 388 respondents from the selected clusters, and data on the determinants of Willingness to Join (WTJ) and Willingness to Pay (WTP) was gathered. Respondents were recruited via a multi-stage sampling procedure. In the first stage, the five informal sector clusters were purposely selected. The second stage involved a proportional allocation of respondents by cluster size. Finally, based on the stalls allocated by municipal authorities in each area, respondents were selected using systematic sampling. The sampling interval (k) was determined by dividing the total number of allocated stalls in a cluster (N) by the sample size proportionate to that cluster (n). For each cluster, the first stall (respondent) was randomly chosen, and thereafter, a respondent from every 10th stall was selected and interviewed at their workplace. Contingent valuation was adopted to elicit WTP. Logit models and interval regression were applied for the econometric analyses.

RESULTS

A total of 388 respondents participated in the survey. The dominant informal sector activity among the surveyed clusters was the sale of clothing and shoes (39.2%), followed by the sale of agricultural products (27.1%). Concerning employment status, the majority were own-account workers (73.1%). Most of the respondents (84.8%) completed secondary school. On monthly income from informal sector activities, the highest frequency (37.1%) was observed in the Zw$(1000 to <3000) or US$(28.57 to <85.71) category. The mean age of respondents was 36 years. Out of the 388 respondents, 325 (83.8%) were willing to join the proposed NHI scheme. WTJ was influenced by the following factors: health insurance awareness, health insurance perception, membership to a resource-pooling scheme, solidarity with the sick, and household recently experiencing difficulties paying for healthcare. On average, respondents were willing to pay Zw$72.13 (approximately US$2.06) per person per month. The key determinants of WTP were household size, respondent's education level, income, and health insurance perception.

CONCLUSIONS

Since the majority of respondents from the sampled clusters were willing to join and pay for the contributory NHI scheme, it follows that there is potential to implement the scheme for the urban informal sector workers from the clusters studied. However, some issues require careful consideration. The informal sector workers need to be educated on the concept of risk pooling and the benefits of being members of an NHI scheme. Household size and income are factors that require special attention when deciding on the premiums for the scheme. Moreover, given that price instability hurts financial products such as health insurance, there is a need for ensuring macroeconomic stability.

The Role of Health Policy and Systems in the Uptake of Community-Based Health Insurance Schemes in Low- and Middle-Income Countries: A Narrative Review

This study explores how health policies and systems can affect voluntary uptake of community-based health insurance (CBHI) schemes in low- and middle-income countries (LMICs). A narrative review was conducted involving searches of 10 databases (Medline, Global Index Medicus, Cumulative Index to Nursing, and Allied Health Literature, Health Systems Evidence, Worldwide Political Science Abstracts, PsycINFO, International Bibliography of the Social Sciences, EconLit, Bibliography of Asian Studies, and Africa Wide Information) across the social sciences, economics, and medical sciences. A total of 8107 articles were identified through the database searches, 12 of which were retained for analysis and narrative synthesis after 2 stages of screening. Our findings suggest that in the absence of directly subsidizing CBHI schemes by governments in LMICs, government policies can nonetheless promote voluntary uptake of CBHIs through intentional actions in 3 key areas: (a) improving quality of care, (b) providing a regulatory framework that integrates CBHIs into the national health system and its goals, and (c) leveraging administrative and managerial capacity to facilitate enrollment. The findings of this study highlight several considerations for CBHI planners and governments in LMICs to promote voluntary enrollment in CBHIs. Governments can effectively extend their outreach toward marginalized and vulnerable populations that are excluded from social protection by formulating supportive regulatory, policy, and administrative provisions that enhance voluntary uptake of CBHI schemes.

The role of risk preferences: voluntary health insurance in rural Tanzania

BACKGROUND

Lower-middle-income countries (LMICs) have a common goal to achieve universal health coverage (UHC) through voluntary health insurance schemes. This is important to improve access to healthcare services and ensure financial protection for all by reducing out-of-pocket expenditures. This study aimed to examine the role of risk preferences on enrollment status (currently insured, previously insured, and never insured) into a Tanzanian voluntary health insurance scheme targeted at the informal sector.

METHODS

Data were collected from households in a random sample of 722 respondents. The risk preference measure was based on a hypothetical lottery game which applies the BJKS instrument. This instrument measures income risk where the respondents are to choose between a certain income and a lottery. Both multinomial and simple logistic regression models have been used to analyze the relationship between risk aversion and enrollment status.

RESULTS

On average, the respondents have a high degree of risk aversion, and the insured are more risk averse than the uninsured (previously insured and never insured). There is a weak tendency for the wealthiest, measured by household income or total household expenditure, to be somewhat more risk averse than the less wealthy. Logistic and multinomial logistic regressions show that risk aversion is strongly associated with enrollment status. A higher degree of risk aversion significantly increases the probability of being insured, relative to being previously insured, and relative to being never insured.

CONCLUSION

Risk aversion matters in a decision to enroll into the iCHF scheme. Strengthening the benefit package for the scheme, might increase the enrollment rate and hence improve access to healthcare services for people in rural areas and those employed in the informal sector.

Innovations in mutuality: challenges and learnings for the Universal Health Insurance Plan in Mali

BACKGROUND

Many Sahel countries in Africa are looking for solutions for universal health coverage (UHC). Mali is in the process of adopting the Universal Health Insurance Plan, which allows for the mutualisation of existing schemes. Its operationalisation requires numerous adjustments to the current mutualist proposal and innovations in the system. The study focuses on innovations experienced in mutuality and their conditions of scale for UHC in Mali.

METHODS

This is qualitative research by multiple case studies. It is based on the collection of data by interviews (n=136), at a national and local level, on the analysis of documents (n=42) and a long field observation (7 months). The analytical framework concerns the dissemination and maintenance of health innovations (Greenhalgh et al, 2004).

RESULT

The analysis of this innovation shows an interest in the technical and institutional viability that determines its performance and scale-up. The procrastination and scepticism displayed at the highest level of the state and the international level, the reluctance, both financial and ideological, to renew the old mutualist proposal, penalise this Malian experiment.

CONCLUSION

This innovation is a decisive step in ensuring the health coverage of Mali's agricultural and informal sectors. The reform will need to be amplified and supported in the future to expect the scale-up of a cheaper, technically and institutionally more efficient system. Without a political intention to mobilise national resources and accept a fundamental paradigm shift in health financing, the search for the financial viability of mutuality may, again, be at the expense of the performance.

In Ethiopia's Kutaber district, does community-based health insurance protect households from catastrophic health-care costs? A community- based comparative cross-sectional study

OBJECTIVE

Every health system needs to take action to shield households from the expense of medical costs. The Ethiopian government implemented community-based health insurance (CBHI) to protect households from catastrophic health care expenditure (CHE) and enhance the utilization of health care services. The impact of CBHI on CHE with total household expenditure and non-food expenditure measures hadn't been studied, so the study aimed to evaluate the impact of CBHI on CHE among households in Kutaber district, Ethiopia.

METHODS

A total of 472 households (225 insured and 247 uninsured) were selected by multistage sampling techniques. Households total out-of-pocket (OOP) health payments ≥10% threshold of total household expenditure or ≥40% threshold of household non-food expenditure categorized as CHE. The co-variants for participation in the CBHI scheme were estimated by using a probit regression model. A propensity score matching analysis was used to determine the impact of CBHI on CHE. A Chi-square (χ2) test was computed to compare CHE between insured and uninsured households.

RESULTS

The magnitude of CHE was 39.1% with total household expenditure and 1.8% with non-food expenditure measures among insured households. Insured households were 46.3% protected from CHE when compared to uninsured households with total household expenditure measures and 24.2% to 25% with non-food expenditure measures.

CONCLUSION

The magnitude of CHE was lower among CBHI-enrolled households. CBHI is an effective means of financial protection benefits for households as a share of total household expenditure and non-food expenditure measures. Therefore, increasing the upper limits of benefit packages, minimizing exclusions, and CBHI scale-up to uninsured households is essential.

Determinants of national health insurance enrolment among people at risk of statelessness in the Awutu Senya East Municipality and Gomoa East District of Ghana

BACKGROUND

This paper investigates the factors influencing the decision to enrol in Ghana's National Health Insurance Scheme (NHIS) among people at risk of statelessness, with emphasis on the individual's demographic and socioeconomic factors.  METHODS: The study used data from a cross-sectional household survey undertaken in the Awutu Senya East Municipality and Gomoa East District of Ghana's Central Region between March 9 and June 26, 2021, on healthcare utilization culture among people at risk of statelessness. Descriptive statistics and binary logistic regression were used in analysing data from a sample of 384 people at risk of statelessness.  RESULTS: The results reveal that about 51% of the at-risk population have ever enrolled while 48% of the respondents were enrolled on the NHIS at the time of the survey (active members). The majority of the enrolled members acquired their membership through self-payment of the enrolment fee. Additionally, respondents aged 26-35 had higher odds of enrolling, whiles those within 56-65 years had lower odds of enrolling in health insurance. Also, persons who are married and have a high school education or an equivalent qualification were more likely to enrol, while persons with no employment were less likely to enrol.

CONCLUSION

According to the paper, while the gap in coverage between rich and poor, married and single appears to have narrowed, these factors continue to determine NHIS coverage among people at risk of statelessness. The same is true for education. Efforts must be increased to ensure equal access to healthcare financing interventions for better access to health services.

Determinants of enrolment in health insurance scheme among HIV patients attending a clinic in a tertiary hospital in South-eastern Nigeria

Objective

The study aimed to assess the determinants of enrolment in health insurance schemes among people living with HIV.

Design

The study was a cross-sectional study. A pre-tested interviewer-administered questionnaire was used to collect information from 371 HIV clients attending the clinic. Chi-square statistic was used for bi-variate analysis, and analytical decisions were considered significant at a p-value less than 0.05. Logistic regression was done to determine predictors of enrolment in health insurance.

Setting

The study was carried out in the HIV clinic of Alex Ekwueme Federal University Teaching Hospital Abakaliki, Nigeria.

Participants

HIV clients attending a clinic.

Result

Mean age of respondents was 45.4±10.3, and 51.8% were males. Almost all the respondents were Christians. Only 47.7% were married, and most lived in the urban area. Over 70% had at least secondary education, and only 34.5% were civil servants. About 60% of the respondents were enrolled in a health insurance scheme. Being single (AOR: 0.374, CI:0.204-0.688), being self-employed (AOR: 4.088, CI: 2.315-7.217), having a smaller family size (AOR: 0.124, CI: 0.067-0.228), and having the higher income (AOR: 4.142, CI: 2.07-8.286) were predictors of enrolment in a health insurance scheme.

Conclusion

The study has shown that enrolment in a health insurance scheme is high among PLHIV, and being single, self-employed, having a smaller family size, and having a higher monthly income are predictors of enrolment in the health insurance scheme. Increasing the number of dependants that can be enrolled so that larger families can be motivated to enrol in health insurance is recommended.

Funding

None declared.

Factors determining membership in community-based health insurance in West Africa: a scoping review

BACKGROUND

In many low-income countries, households bear most of the health care costs. Community-based health insurance (CBHI) schemes have multiplied since the 1990s in West Africa. They have significantly improved their members' access to health care. However, a large proportion of users are reluctant to subscribe to a local CBHI. Identifying the major factors affecting membership will be useful for improving CBHI coverage. The objective of this research is to obtain a general overview of existing evidence on the determinants of CBHI membership in West Africa.

METHODS

A review of studies reporting on the factors determining membership in CBHI schemes in West Africa was conducted using guidelines developed by the Joanna Briggs Institute. Several databases were searched (PubMed, ScienceDirect, Global Health database, Embase, EconLit, Cairn.info, BDPS, Cochrane database and Google Scholar) for relevant articles available by August 15, 2022, with no methodological or linguistic restrictions in electronic databases and grey literature.

RESULTS

The initial literature search resulted in 1611 studies, and 10 studies were identified by other sources. After eliminating duplicates, we reviewed the titles of the remaining 1275 studies and excluded 1080 irrelevant studies based on title and 124 studies based on abstracts. Of the 71 full texts assessed for eligibility, 32 additional papers were excluded (not relevant, outside West Africa, poorly described results) and finally 39 studies were included in the synthesis. Factors that negatively affect CBHI membership include advanced age, low education, low household income, poor quality of care, lack of trust in providers and remoteness, rules considered too strict or inappropriate, low trust in administrators and inadequate information campaign.

CONCLUSIONS

This study shows many lessons to be learned from a variety of countries and initiatives that could make CBHI an effective tool for increasing access to quality health care in order to achieve universal health coverage. Coverage through CBHI schemes could be improved through communication, improved education and targeted financial support.

"Magnitude of community-based health insurance utilization and associated factors in Bassona Worena District, North Shoa Zone, Ethiopia: a community-based cross-sectional study"

INTRODUCTION

The health insurance system has been proven to offer effective and efficient health care for the community, particularly community-based health insurance is expected to ensure health care access for people with low economic status and vulnerable groups. Despite the significance of evidence-based systems and implementation, there is a limited report about the magnitude of CBHI utilization. Therefore, this study was done to assess factors associated with community-based health insurance utilization in Basona Worena District, North Shewa Zone, Ethiopia.

METHOD

A community-based cross-sectional study was employed. We have included 530 households from 6 randomly selected kebeles. The data was entered using Epi-Data V 3.1 and exported to SPSS version 20.0 for statistical analysis. Bi-variable and multivariable logistic regression analyses were computed to determine factors associated with community-based health insurance utilization.

RESULT

The study finding shows that 58.6% of the respondents were members of community-based health insurance. Respondents who had primary and secondary education levels were 2 times more likely to be members than those who had no formal education. As compared to those who had awareness, respondents who had no awareness about CBHI were 0.27 times less likely to be insured. Respondents who did not experience illness were 0.27 times less likely to be members than respondents who experienced illness.

CONCLUSION

Educational status, awareness about CBHI, perception of CBHI scheme and illness experience of family influence CBHI utilization. There is a need to strengthen awareness creation to improve the CBHI utilization.

Willingness to pay for community-based health insurance and associated factors in Ethiopia: A systematic review and meta-analysis

In Ethiopia, there is low enrollment and a wide discrepancy in willingness to pay for community-based health insurance schemes, and there is a lack of nationally representative data on willingness to pay for community-based health insurance. Thus, this systematic review and meta-analysis aimed to estimate the pooled prevalence of willingness to pay for community-based health insurance and associated factors in Ethiopia. This was developed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Databases such as PubMed/Medline, CINAHL, African Journals Online, and Google Scholar searches were performed to retrieve available published and unpublished studies from December 15 to May 17, 2022. Two independent reviewers screened the retrieved articles. Critical quality appraisal was performed using the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument. To investigate the sources of heterogeneity, subgroup analysis and meta-regression were performed based on region, study setting (rural/urban), and sample size. RevMan software and STATA 14 software were used for the statistical analysis. A random-effect model was used to estimate the effect size at a 95% confidence interval. A total of 190 studies were retrieved, and six studies were included in the final meta-analysis. The pooled prevalence of willingness to pay for community-based health insurance was 78 (95% confidence interval: 74, 81). A subgroup analysis by region indicated the lowest proportion of willingness to pay community-based health insurance in the Oromia region, 76% (95% confidence interval: 68, 84), and the highest in the Amhara region, 79% (95% confidence interval: 77, 81). Nearly three in four households were willing to pay for community-based health insurance in Ethiopia. Thus, awareness of willingness to pay community-based health insurance is mandatory to improve the implementation of community-based health insurance.

Is Ethiopian community-based health insurance affordable? Willingness to pay analysis among households in South Central, Ethiopia

Background

Community-based Health Insurance (CBHI) is a voluntary prepayment mechanism that guarantees the provision of basic healthcare services without financial barriers to underserved segments of the population in developing countries. The Government of Ethiopia launched the CBHI program to protect the community from high out-of-pocket health expenditure and improve health service utilization a decade ago. However, to improve the quality of healthcare services delivery in health facilities and cover the changing costs of healthcare, the government should revise the contribution of the CBHI scheme. Therefore, we determined the willingness to pay for a CBHI scheme and associated factors among rural households of Lemu and Bilbilo district, South Central Ethiopia.

Methods

We conducted a community-based cross-sectional study design to assess willingness to pay for the CBHI scheme and its associated factors among households in Lemu and Bilbilo districts, South Central Ethiopia. We used a double bounded contingent valuation method to elicit households’ willingness to pay for the CBHI scheme. Data were coded, cleaned, entered into Statistical Package for Social Science (SPSS) version 25, and exported to STATA 16 for analysis. A logistic regression analysis was conducted to determine the presence of statistically significant associations between the willingness to pay for the CBHI scheme and independent variables at a p-value <0.05 and Adjusted odds ratio (AOR) values with 95% CI. Finally, we checked the fitness of the model using Hosmer and Lemeshow’s goodness-of-fit test.

Results

Of the 476 study participants, 82.9% (95% CI: 79.2%, 86.01%) were willing to pay for the CBHI scheme and only 62% of them can afford the average amount of 358.32ETB ($7.68) per household per annum. Primary education (AOR = 3.17; 95% CI: 1.74–5.80), secondary and above education (AOR = 4.13; 95% CI: 1.86–9.18), large family size (AOR = 2.75; 95% CI: 1.26–5.97), monthly income of 500-1000ETB (AOR = 3.75; 95% CI: 1.97–7.13) and distance to public health facilities (AOR = 2.14, 95% CI: 1.04–4.39 were significantly associated with willingness to pay for the CBHI scheme.

Conclusion

In this study, around 83% of respondents were willing to pay for the CBHI and meet the government expectation for 2020. The study also revealed that educational status, family size, monthly income, and distance from the health facilities were significant factors associated with WTP for the CBHI scheme. In addition, we found that a large number of the respondents couldn’t afford the average amount of money that the participants were willing to pay for the CBHI scheme. So, the government should consider the economic status of the communities while revising the CBHI scheme premium not to miss those who cannot afford the contribution.

Perceived quality of care among households ever enrolled in a community-based health insurance scheme in two districts of northeast Ethiopia: a community-based, cross-sectional study

OBJECTIVES

To examine how clients perceived the quality of healthcare they received and identify associated factors both at the individual and facility levels.

DESIGN

A community-based, cross-sectional study.

SETTING

Two rural districts of northeast Ethiopia, Tehulederie and Kallu.

PARTICIPANTS

1081 rural households who had ever been enrolled in community-based health insurance and visited a health centre at least once in the previous 12 months. Furthermore, 194 healthcare providers participated in the study to provide cluster-level data.

OUTCOME MEASURES

The outcome variable of interest was the perceived quality of care, which was measured using a 17-item scale. Respondents were asked to rate the degree to which they agreed on 5-point response items relating to their experiences with healthcare in the outpatient departments of nearby health centres. A multilevel linear regression analysis was used to identify predictors of perceived quality of care.

RESULTS

The mean perceived quality of care was 70.28 (SD=8.39). Five dimensions of perceived quality of care were extracted from the factor analysis, with the patient-provider communication dimension having the highest mean score (M=77.84, SD=10.12), and information provision having the lowest (M=64.67, SD=13.87). Wealth status, current insurance status, perceived health status, presence of chronic illness and time to a recent health centre visit were individual-level variables that showed a significant association with the outcome variable. At the cluster level, the work experience of healthcare providers, patient volume and an interaction term between patient volume and staff job satisfaction also showed a significant association.

CONCLUSIONS

Much work remains to improve the quality of care, especially on information provision and access to care quality dimensions. A range of individual-level and cluster-level characteristics influence the perceived quality of care. For a better quality of care, it is vital to optimise the patient-provider ratio and enhance staff job satisfaction.

The effects of individual and community-level factors on community-based health insurance enrollment of households in Ethiopia

Introduction

Community-based health insurance (CBHI) is a type of volunteer health insurance that has been adopted all over the world in which people of the community pool funds to protect themselves from the high costs of seeking medical care and treatment for the disease. In Ethiopia, healthcare services are underutilized due to a lack of resources in the healthcare system. The study aims to identify the individual and community level factors associated with community-based health insurance enrollment of households in Ethiopia.

Methods

Data from the Ethiopian mini demographic and health survey 2019 were used to identify factors associated with community-based health insurance enrollment of households in Ethiopia. Multilevel logistic regression analysis was used on a nationally representative sample of 8,663 households nested within 305 communities, considering the data’s layered structure. We used a p-value<0.05 with a 95% confidence interval for the results.

Result

The prevalence of community-based health insurance enrollment in Ethiopia was 20.2%. The enrollment rate of households in the scheme was high in both Amhara (57.9), and Tigray (57.9%) regions and low (3.0%) in the Afar region. At the individual level; the age of household heads, number of children 5 and under, number of household members, has land for agriculture, has a mobile telephone, receiving cash of food from the safety Net Program, Owning livestock, and herds of farm animals, wealth index, and at the community level; the region had a significant association with community-based health insurance enrollment.

Conclusion

Both individual and community-level characteristics were significant predictors of community-based health insurance enrollment in households. Furthermore, the ministry of health, health bureaus, and other concerning bodies prioritize clusters with low health insurance coverage to strengthen health system financing and intervene in factors that negatively affect the CBHI enrollment of households.

Barriers to the implementation, uptake and scaling up of the healthy plate model among regular street food consumers: a qualitative inquiry in Dar-es-Salaam city, Tanzania

INTRODUCTION

The healthy plate model is considered one of the practical approaches to reduce the average portion of staple food in main meals, consequently reducing the risks associated with diabetes and other Non-communicable Diseases (NCDs). Despite its potential benefits, studies on the implementation of the healthy plate model are limited in Africa. An inquiry explored barriers to implementation, uptake, and scaling up of the healthy plate model among street food vendors and consumers in three districts of Dar-es-Salaam city in Tanzania.

METHODS

A qualitative research design was adopted. Qualitative data collection techniques were employed including; Key Informant Interviews (KIIs) with purposefully selected food and nutrition stakeholders at the National, Regional, District and Ward levels. Focus Group Discussions (FGDs) were conducted with purposefully selected street food consumers and vendors. A total of (13) KIIs were conducted as well as (6) FGDs with street food vendors (2 FGDs) and consumers (4 FGDs). Interview data was managed using Nvivo 12 Software and analyzed thematically.

RESULTS

Three key themes emerged from participants' accounts: (i) strategic policy barriers, (ii) food production and preparation environment barriers (producers and vendors), and (iii) individual barriers (consumers and vendors). The strategic policy barriers included absence of guidelines and regulations that focus on NCDs linked to nutrition and lack of education guidance for vendors and consumers. The food production and preparation environment barriers included safety and risks concerns regarding the quality of water used for irrigation and washing fruits and vegetables and the areas where vegetables and fruits are grown and prepared. Individual barriers included low consumer income, knowledge on nutrition, unhealthy eating practices and; low vendors' knowledge as well as low investment capital.

CONCLUSION

Implementation, uptake and scaling up of the healthy plate model for street food consumers in Dar es Salaam City continues to be constrained by barriers in policy, food production and preparation environment, and individual obstacles. Strengthening of food and nutrition policies, ensuring safety of the food production and preparation environment and, consumer and vendor awareness creation and income generation efforts, provide useful entry points for the successful scaling up of a healthy plate model. This could consequently contribute towards prevention of diet related NCDs, including diabetes.

Factors influencing drop-out of households from community based health insurance membership in rural districts of Gurage Zone, Southern Ethiopia: Community based case-control study

Background

Financial risk-sharing through community-based health insurance is a critical component of universal health coverage. However, its development is a great challenge, not only due to low enrollment but also due to the high dropout rate of members from the program, which threatens its sustainability. So far, the few existing studies in this area have focused on household enrollment into community-based health insurance, rather than on the number of members dropping out. This study aims to identify factors influencing households to drop out of community-based health insurance membership in rural districts of the Gurage Zone, Southern Ethiopia.

Methods

A community-based case-control study was carried out from May to July 2021. Supplemented by qualitative focus group discussions. Multi-stage sampling was employed. An interviewer-administered prearranged tool was used for collecting data. Epi-data version 3.1 and SPSS version 21 were used for data entry and analysis. The association between factor and outcome variable was determined using binary logistic regression analysis at p < 0.05 and 95% CI. Qualitative data were analyzed thematically and triangulated.

Results

From 525 (175 cases and 350 controls) rural household heads 171 cases and 342 controls responded, yielding a response rate of 97.7%. Of those, 73.1 and 69.0% were males in cases and controls, respectively. The statistically significant influencing factors associated with dropout from community-based health insurance were: highest wealth status (adjusted odds ratio [AOR] = 2.36, 95% confidence interval [CI]:1.14-4.87), unfavorable attitude toward CBHI (AOR: 1.81, 95% CI: 1.87-3.37), no illness experienced in the last 3 months (AOR: 5.21, 95% CI: 2.90-9.33). no frequent health facility visits (AOR:5.03, 95% CI:1.17-23.43), no exposure to indigenous community insurance (AOR:0.10, 95% CI: 0.03-0.37), not graduated in the model household (AOR: 3.20, 95% CI:1.75-5.83), being a member in the program for more than 3 years (AOR:0.55, 95% CI: 0.29-0.94), not trusting governing bodies (AOR:10.52, 95% CI:4.70-23.53), the ordered drug was not available in the contractual facility (AOR:14.62, 95% CI:5.37-39.83), waiting time was >3 h (AOR:4.26, 95% CI:1.70-10.66), and poor perception of service quality (AOR:12.38, 95%CI:2.46-62.24).

Conclusion

The findings of this study illustrated various factors which positively and negatively influenced households to drop out from CBHI: wealth status, attitude toward CBHI, perceived poor provider attitude toward CBHI members, illness experience in the household, the experience of frequent health facility visits, model household graduation status, trust on CBHI committee (governing bodies), availability of a prescribed drug in the contractual health facility, waiting time and perceived quality of health service from the contractual facility, exposure to any of the indigenous insurance (IDIR and/or IQUB) and length of membership in program. We strongly recommend all responsible stakeholders give strong attention to promoting the community, and for providers to project a favorable attitude toward community-based health insurance, to achieve model household graduation, and improve quality of service by addressing the basic quality-related areas like waiting time, and drug availability).

Community-Based Health Insurance Membership Renewal Rate and Associated Factors among Households in Gedeo Zone, Southern Ethiopia

Background

Community-based health insurance (CBHI) scheme is an emerging strategy to achieve universal health coverage and protect communities in developing countries from catastrophic financial expenditure at the service delivery point. However, high membership discontinuation from the CBHI scheme remained the challenge to progress toward universal financial protection in resource-constrained countries. Therefore, this study assessed the community-based health insurance membership renewal rate and associated factors in the Gedeo zone, Southern Ethiopia.

Methods

We conducted a community-based cross-sectional study among households in the Yirga Chafe district, Gedeo zone, Southern Ethiopia, from September 10 to 30, 2021. We used a multistage simple random sampling to recruit 537 respondents. We entered data into Epi-Info 7 and exported it to SPSS version 25 for analysis. We used a logistic regression model to determine factors associated with the CBHI scheme membership renewal. Variables with a P value of <0.05 and a 95% confidence level were considered to be significantly associated with the outcome variable.

Results

We found the respondents' CBHI membership renewal rate was 82.68%. Those who enrolled in the CBHI scheme >3years (AOR = 3.12; 95% CI: 1.40–6.97), having illnesses in the last three months (AOR = 2.97; 95% CI: 1.47–5.99), the CBHI premium affordability (AOR = 12.64; 95% CI: 3.25–49.38), good knowledge of the CBHI scheme (AOR = 21.11; 95% CI: 10.63–41.93), perceived quality of health service (AOR = 4.21; 95% CI: 1.52–11.68), and favorable attitude towards the CBHI scheme (AOR = 3.89, 95% CI: 1.67–9.04) were significantly associated with the CBHI program membership renewal rate.

Conclusion

In our study, we found the magnitude of CBHI members who discontinued their CBHI scheme membership was high. Besides, we found that the affordability of the CBHI premium, respondents' attitude, and knowledge of the CBHI program were predictor factors for dropout from the CBHI membership. Therefore, the government should consider the economic status of communities during setting the CBHI program contribution. Moreover, awareness creation through health education should be provided to improve participants' knowledge and perception of the CBHI program.

Towards universal health coverage: The level and determinants of enrollment in the Community-Based Health Insurance (CBHI) scheme in Ethiopia: A systematic review and meta-analysis

BACKGROUND

Community-based health insurance (CBHI) is a risk-pooling approach that tries to disperse health expenditures across families with varying health profiles to provide greater access to healthcare services by allowing cross-subsidies from wealthy to poor populations. It is crucial to assess the level of CBHI enrolment and its determinants in Ethiopia, where government health spending is limited to less than 5% of GDP, far below the Alma Ata Declaration's benchmark of 15%. Although various epidemiological studies on CBHI enrolment status and its determinants have been undertaken in Ethiopia, the results have been inconsistent, with significant variability. However, no nationwide study assessing the pooled estimates exists today. Furthermore, the estimated strength of association at the country level varied and was inconsistent across studies. Hence, this systematic review and meta-analysis aimed at estimating the pooled prevalence of CBHI enrolment and its determinants in Ethiopia.

METHODS

A comprehensive search of studies was done by using PubMed, EMBASE, Science Direct, HINARI, Scopus, Web of Science, and the Cochrane Library. The database search was complemented by google scholar and some repositories for grey literature. The search was carried out from February 11 to March 12, 2022. The relevant data were extracted using a Microsoft Excel 2013 spreadsheet and analyzed using STATATM Version 16. Studies reporting the level and determinants of CBHI enrolment in Ethiopia were considered. A weighted DerSimonian Laired random effect model was applied to estimate the pooled national prevalence of CBHI enrolment. The Cochrane Q test statistics and I2 tests were used to assess the heterogeneity of the included studies. A funnel plot, Begg's and Egger's tests, were used to check for the presence of publication bias.

RESULTS

Fifteen studies were eligible for this systematic review and meta-analysis with a total of 8418 study participants. The overall pooled prevalence of CBHI enrolment in Ethiopia was 45.5% (95% CI: 32.19, 58.50). Affordability of premium for the scheme[OR = 2.58, 95% CI 1.68, 3.47], knowledge of respondents on the CBHI scheme[OR = 4.35, 95% CI 2.69, 6.01], perceived quality of service[OR = 3.21, 95% CI 2.04, 4.38], trust in the scheme[OR = 2.32, 95% CI 1.57, 3.07], and the presence of a person with a chronic disease in the household [OR = 3.58, 95% CI 2.37, 4.78] were all found to influence CBHI enrolment.

CONCLUSION

Community health workers (CHWs) need to make a high effort to improve knowledge of CBHI in rural communities by providing health education. To deal with the issue of affordability, due emphasis should be placed on building local solidarity groups and strengthening local initiatives to aid poor members. Stakeholders in the health service delivery points need to focus on the dimensions of high service quality. The financial gap created by the adverse selection of households with chronically ill members should be rectified by implementing targeted subsidies with robust plans.

An integrative review on individual determinants of enrolment in National Health Insurance Scheme among older adults in Ghana

BACKGROUND

We conducted an integrative review in an attempt to methodically and systematically understand the individual (personal factors) that influence National Health Insurance Scheme [NHIS] enrolment among older adults aged 50 years and above. The study was premised on evidence pointing to a state of little or no change in the enrolment rates [especially among older adults], which contrasts with the initial euphoria that greeted the launch of the scheme - which culminated in high enrolment rates.

METHODS

The integrative literature review was conducted to synthesise the available evidence on individual determinants of NHIS among older adults. The methodological approach of the integrative literature review follows a five-stage interdependent and interconnected procedure of problem identification, literature search, data evaluation, data analysis and results presentation. Studies that met the inclusion criteria were peer-reviewed articles published in the English Language, from January 2010 to July 2020 and have Ghana as its setting or study area. The Andersen's Behavioural Model was used to categorize the predictor variables.

RESULTS

Predisposing factors [gender, age, level of education and marital status], enabling factors [income] and need factors [health conditions or health attributes of older adults] were identified as individual predictors of NHIS enrolment among older adults. The findings support argument of Andersen's Behavioural Model [where predisposing, enabling and need factors are considered as individual determinants of health behaviour].

CONCLUSIONS

The findings call for policy reforms that take into account the aforementioned individual predictors of NHIS enrolment, especially among the aged.