The experiences of merging health insurance funds in South Korea, Turkey, Thailand, and Indonesia: a cross-country comparative study

Analysis the status and spatio-temporal characteristics of the synergistic development of China's multi-level medical insurance system

Examined the synergistic development and spatio-temporal evolution of China's multi-level medical insurance system (MMIS) on a macroscopic level. We assess the comprehensive development of the MMIS across China's 31 provinces from 2011 to 2020 by constructing a comprehensive indicators evaluation model. Subsequently, a coupling coordination index (CCI) model is employed to provide precise insights into the coupling coordination effects among various medical insurance schemes comprising MMIS. Lastly, spatial autocorrelation analysis is conducted to evaluate both the global and local spatio-temporal evolutionary characteristics of MMIS. The CCI of MMIS at the national average level exhibited a fluctuating upward trend, progressing from the moderate disorder recession degree (0.287) in 2011 to the well-coordinated degree (0.887) in 2020. However, the majority of provinces (83.87%) still lingered within the realm of barely coordinated degree ([0.500-0.600]). Specifically, the CCI within the eastern coastal region surpassed that of the western and central regions, with the central region showing the most pronounced increase in CCI. Over the past decade, MMIS demonstrated significant spatial agglomeration, as evidenced by the global Moran's I ranging from [0.1668-0.3037]. Furthermore, findings from local spatial autocorrelation analysis suggest a gradual attenuation in the spatial clustering disparity of CCI across various provinces. Government ought to focus on the spatio-temporal evolution patterns of MMIS, and strengthen cooperation between the government and market in health governance, while utilizing information technology and data sharing to improve the overall quality of medical insurance benefits.

Policy Options for Contributory Health Insurance Schemes in Low and Lower-Middle Income Countries to Enable Progress Towards Universal Health Coverage

The promise of contributory health insurance to generate additional, self-sustaining funding for the health sector has not been achieved in many low- and lower-middle-income countries. Instead, contributory health insurance has been found to exacerbate inequities in access to health care because entitlements are linked to contributions. For these countries with contributory health insurance schemes, with separate institutional arrangements for revenue collection and purchasing, that operate alongside budget-funded and other health financing schemes, it is usually not politically or technically feasible to reverse or eliminate these arrangements even when they fragment the health system. We propose three complementary policy options for countries in this difficult position to enable progress towards UHC: (1) Merge existing schemes into a single scheme (or fewer schemes) to consolidate pooling and purchasing functions. (2) Build on what they have by: reducing reliance on contributions by increasing budget transfers; using existing revenue collection mechanisms to allow the insurance agency to focus on the purchasing function; and strengthening insurance agencies' operational capacity for purchasing. (3) Reframe the insurance agency's role within the overall health system, rather than treating it as a distinct system by: unifying data collection and analysis for all patient visits irrespective of scheme membership, and universalizing core benefits across the population. We urge countries to review the patchwork of schemes and avoid worsening fragmentation that compromises health system performance. Countries can then create a strategy to expand coverage more equitably in a sequential manner, while consolidating institutional capacity for purchasing and unifying data systems.

Data Integration of Health Financing Systems as a Critical Enabler for Objective-Oriented Health System Reform: A Scoping Review from India

Health financing fragmentation poses a challenge to reforms intended to address system-wide objectives vis-à-vis universal health coverage (UHC). India's experience with publicly subsidized health insurance schemes (PSHIs), such as Rashtriya Swasthya Bima Yojana (RSBY) and its state adaptations, testify to the challenges inherent in effecting objective-oriented health systems reforms, particularly owing to wide variation in programmatic and operational design. Recent efforts to defragment PSHIs under the aegis of a new government initiative called Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PMJAY) using, inter alia, a unified information and communication technology (ICT) interface provide important policy lessons. This paper presents a theory of change for the role that ICT systems can play in promoting the objectives of UHC and highlights the early effects of ICT reforms in India on UHC. Holistic and defragmented ICT systems have a positive effect on the processes and operations of government health programs, according to the literature reviewed. Streamlined ICT systems promote equity through the introduction of portability modules, which increase access to services and facilitate stronger transparency and accountability measures by using big data and machine learning for fraud detection. Although reliability issues persist on certain fronts, India's experience with homegrown, incremental reforms to defragment ICT systems for health financing have proven of paramount importance for progressing toward UHC.

Understanding the role of the Tanzania national health insurance fund in improving service coverage and quality of care

Health insurance is one of the main financing mechanisms currently being used in low and middle-income countries to improve access to quality services. Tanzania has been running its National Health Insurance Fund (NHIF) since 2001 and has recently undergone significant reforms. However, there is limited attention to the causal mechanisms through which NHIF improves service coverage and quality of care. This paper aims to use a system dynamics (qualitative) approach to understand NHIF causal pathways and feedback loops for improving service coverage and quality of care at the primary healthcare level in Tanzania. We used qualitative interviews with 32 stakeholders from national, regional, district, and health facility levels conducted between May to July 2021. Based on the main findings and themes generated from the interviews, causal mechanisms, and feedback loops were created. The majority of feedback loops in the CLDs were reinforcing cycles for improving service coverage among beneficiaries and the quality of care by providers, with different external factors affecting these two actions. Our main feedback loop shows that the NHIF plays a crucial role in providing additional financial resources to facilities to purchase essential medical commodities to deliver care. However, this cycle is often interrupted by reimbursement delays. Additionally, beneficiaries' perception that lower-level facilities have poorer quality of care has reinforced care seeking at higher-levels. This has decreased lower level facilities' ability to benefit from the insurance and improve their capacity to deliver quality care. Another key finding was that the NHIF funding has resulted in better services for insured populations compared to the uninsured. To increase quality of care, the NHIF may benefit from improving its reimbursement administrative processes, increasing the capacity of lower levels of care to benefit from the insurance and appropriately incentivizing providers for continuity of care.

Health Insurance Schemes and Their Influences on Healthcare Variation in Asian Countries: A Realist Review and Theory's Testing in Thailand

BACKGROUND

Various features in health insurance schemes may lead to variation in healthcare. Unwarranted variations raise concerns about suboptimal quality of care, differing treatments for similar needs, or unnecessary financial burdens on patients and health systems. This realist review aims to explore insurance features that may contribute to healthcare variation in Asian countries; and to understand influencing mechanisms and contexts.

METHODS

We undertook a realist review. First, we developed an initial theory. Second, we conducted a systematic review of peer-reviewed literature in Scopus, MEDLINE, EMBASE, and Web of Science to produce a middle range theory for Asian countries. The Mixed Methods Appraisal Tool (MMAT) was used to appraise the methodological quality of included studies. Finally, we tested the theory in Thailand by interviewing nine experts, and further refined the theory.

RESULTS

Our systematic search identified 14 empirical studies. We produced a middle range theory in a context-mechanism-outcome configuration (CMOc) which presented seven insurance features: benefit package, cost-sharing policies, beneficiaries, contracted providers, provider payment methods, budget size, and administration and management, that influenced variation through 20 interlinked demand- and supply-side mechanisms. The refined theory for Thailand added eight mechanisms and discarded six mechanisms irrelevant to the local context.

CONCLUSION

Our middle range and refined theories provide information about health insurance features associated with healthcare variation. We encourage policy-makers and researchers to test the CMOc in their specific contexts. Appropriately validated, it can help design interventions in health insurance schemes to prevent or mitigate the detrimental effects of unwarranted healthcare variation.

Strategies for improving the financing of family medicine program: Evidence from Iran

Background and Aims

The impact of health financing on the performance of the entire health system, including access, quality, and efficiency of healthcare, has been emphasized in the Astana Declaration, and the need to strengthen primary healthcare (PHC) and policy integration has been emphasized. After about two decades, the family medicine (FM) program in Iran is still facing great challenges. The aim of this study is to explore strategies for strengthening financing of the FM program in Iran, a vital component of PHC.

Methods

A qualitative study was conducted in 2021. Purposeful sampling was used to select 34 policymakers, managers, and experts from various levels of the Ministry of Health, Iran universities of medical sciences, plan and budget organization of Iran, and health insurance organization in Iran. Thirty-four semistructured interviews were conducted to collect data, which were analyzed by content analysis.

Results

Through the analysis of interviews, our study has identified five strategies (identification and management of sustainable resources, pooling of sustainable resources, modeling of service provision, payment system model and its implementation process, and FM management structure), and 13 actions for strengthening financing of the FM program in Iran.

Conclusion

Our study has identified five strategies and 13 actions for strengthening the financing of the FM program in Iran. These strategies and actions should be considered by policymakers during the review of the FM program in Iran. Without implementation of the suggested strategies and action, allocated resources may be wasted.

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.

Health financing challenges in Southeast Asian countries for universal health coverage: a systematic review

BACKGROUND

Universal Health Coverage (UHC) has received much attention and many countries are striving to achieve it. The Southeast Asian region, in particular, comprises many developing countries with limited resources, exacerbating challenges around attaining UHC. This paper aims to specifically explore the health financing challenges these countries face in achieving UHC via a systematic review approach and formulate recommendations that will be useful for policymakers.

METHODS

The systematic review followed the guidelines as recommended by PRISMA. The narrative synthesis approach was used for data synthesis, followed by identifying common themes.

RESULTS

The initial search returned 160 articles, and 32 articles were included after the screening process. The identified challenges in health financing towards achieving UHC in the Southeast Asian region are categorised into six main themes, namely (1) Unsustainability of revenue-raising methods, (2) Fragmented health insurance schemes, (3) Incongruity between insurance benefits and people's needs, (4) Political and legislative indifference, (5) Intractable and rapidly rising healthcare cost, (6) Morally reprehensible behaviours.

CONCLUSIONS

The challenges identified are diverse and therefore require a multifaceted approach. Regional collaborative efforts between countries will play an essential role in the progress towards UHC and in narrowing the inequity gap. At the national level, individual countries must work towards sustainable health financing strategies by leveraging innovative digital technologies and constantly adapting to dynamic health trends.

REGISTRATION

This study is registered with PROSPERO, under registration number CRD42022336624.

The impact of integrated urban and rural resident basic medical insurance on health service equity: Evidence from China

Background

Many countries and regions worldwide are improving their healthcare systems through the integration and unification of health insurance programs covering different groups of people. In China, the past 10 years has been the time when Chinese government promote the Urban and Rural Residents Basic Medical Insurance (URRBMI) by integrating the Urban Residents' Basic Medical Insurance (URBMI) and New Rural Cooperative Medical Scheme (NRCMS).

Objectives

To evaluate the impact of the URRBMI on equity in relation to health services.

Methods

The quantitative data used in this study were obtained from the CFPS 2014–2020 database, and all respondents with health insurance type UEBMI, URBMI, and NRCMS were included. UEBMI respondents were set as the control group and URBMI or NRCMS as the intervention group, and a DID method model was used to analyze the impact of integrating health insurance on health service utilization, costs and health status. Heterogeneity analysis was also conducted after stratifying the sample according to income level and chronic disease status. This was done to investigate whether there were differences in the effects of the integrated health insurance program across different social groups.

Results

The implementation of URRBMI is found to be associated with a significant increase in inpatient service utilization (OR = 1.51, P < 0.01) among rural Chinese residents. Regression results by income stratum show that the utilization of inpatient services increased in rural areas for high-, middle- and low-income groups, with the fastest increase (OR = 1.78, P < 0.05) emerging for low-income groups. Analysis by chronic disease status shows that rural residents with chronic disease are associated with a higher increase in hospitalization rates (OR = 1.64, P < 0.01).

Conclusion

The implementation of URRBMI is found to have improved health insurance's ability to withstand risks and effectively improve access to health services for rural residents. In this regard, it can be considered as playing a positive role in bridging the gap in health service utilization between rural and urban areas and in improving regional equity.

Effects of incentive-based population policies on sustainability of China's recent maternity insurance system reform: a system dynamics simulation

BACKGROUND

This paper seeks to assess the sustainability of the reformed maternity insurance system and the extent to which China's current maternity insurance system can support different levels of fertility incentives in the future. Our findings will serve as a reference for countries in a similar demographic predicament and those about to face it.

METHODS

This study used a combination of qualitative and quantitative methods. In the qualitative assessment, we used a grounded theory model to generalize the factors influencing the sustainability of maternity insurance funds. For the quantitative analysis, we used a novel and comprehensive system dynamics model to visualize the status of the combined operation of maternity and health insurance. Data are mainly derived from the historical data of the Statistical Yearbook of Jiangsu Province and the National Bureau of Statistics of China.

RESULTS

In the short term, fertility incentive payments can be set to motivate people to have children. It is therefore recommended that when the scope of the fertility incentive policy is limited to two children, and an average amount above RMB 10 000 could be set, it would be prudent to set the amount at a level not exceeding RMB 10 000 when the scope of the fertility incentive policy is for all newborns. In the long term, a system of incentives for childbirth should be built from education policy, house price regulation, tax relief and childcare services.

CONCLUSION

Our research not only highlights the significance of improving the resilience of maternity insurance by combining maternity insurance and health insurance funds, but also suggests a way to economically incentivize beneficiaries to have children so as to mitigate the decline in China's birth rate and cope with the crisis of an ageing population.

Moral Hazard and the Demand for Dental Treatment: Evidence from a Nationally Representative Survey in Thailand

Even though there are examples in the health economics literature of evidence investigating moral hazard in health insurance provided by general healthcare services, studies of moral hazard in dental care in developing countries are still scarce, especially when it comes to nationally representative data on dental care demand and expenditure. Using Thailand as a case study, we investigate here whether moral hazard in dental insurance exists and, if so, the extent to which it affects different dental insurance on the demand for dental care in developing countries. We use a nationally representative sample of 269,206 individuals to quantify the impacts of dental care insurance on four sets of dependent variables describing demand for dental care. They are: (i) dental care utilization, (ii) numbers of dental care visits, (iii) dental care expenditure, and (iv) each type of dental care. Our probit and tobit estimations show that there is no evidence of the existence of moral hazard in terms of dental care utilization and dental care expenditure. However, there is a moral hazard of dental insurance existence on the number of dental care visits and type of dental care. People with generous dental benefits coverage tend to use preventive dental treatments along with necessary treatment but also use costly restorative dental treatments more than do those with lower coverage. It can thus be concluded that, in the case of developing countries, dental care insurance is found to increase the use of dental care, especially for preventive care.

Determinants of Turkish households' out-of-pocket expenditures on three categories of health care services: A multivariate probit approach

This study identifies the driving forces that contribute to the probabilities of incidence of out-of-pocket (OOP) expenditures by households in Turkey. Factors affecting the probability of OOP expenditures on medical products/devices/supplies (MP), outpatient services (OTS), and inpatient services (ITS) are examined using the Household Budget Survey data gathered by the Turkish Statistical Institute in 2018. The study applies the multivariate probit model. The incidence of OOP spending varied with 48.9% of the households reporting OOP expenditure on MP, 22.4% on OTS, and 25.4% on ITS. The largest probability changes were associated with household disposable annual income, household type and size, age category, and having private health insurance. Gender and marital status also influenced expenditures in some categories. Lifestyle choices had small and mixed effects, with smoking and alcohol consumption lowering the probability of OOP spending. From a policy standpoint, households with the lowest incomes, large households, and those where the household head was 'others' (retiree, student, housewife, not actively working, etc.) or had a condition preventing employment seemed to report OOP expenditures less frequently and may have chosen not to receive healthcare services, leading to the need for more healthcare services later.

Identifying priorities for research on financial risk protection to achieve universal health coverage: a scoping overview of reviews

OBJECTIVES

Financial risk protection (FRP) is an indicator of the Sustainable Development Goal 3 universal health coverage (UHC) target. We sought to characterise what is known about FRP in the UHC context and to identify evidence gaps to prioritise in future research.

DESIGN

Scoping overview of reviews using the Arksey & O'Malley and Levac & Colquhoun framework and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews reporting guidelines.

DATA SOURCES

MEDLINE, PsycINFO, CINAHL-Plus and PAIS Index were systematically searched for studies published between 1 January 1995 and 20 July 2021.

ELIGIBILITY CRITERIA

Records were screened by two independent reviewers in duplicate using the following criteria: (1) literature review; (2) focus on UHC achievement through FRP; (3) English or French language; (4) published after 1995 and (5) peer-reviewed.

DATA EXTRACTION AND SYNTHESIS

Two reviewers extracted data using a standard form and descriptive content analysis was performed to synthesise findings.

RESULTS

50 studies were included. Most studies were systematic reviews focusing on low-income and middle-income countries. Study periods spanned 1990 and 2020. While FRP was recognised as a dimension of UHC, it was rarely defined as a concept. Out-of-pocket, catastrophic and impoverishing health expenditures were most commonly used to measure FRP. Pooling arrangements, expansion of insurance coverage and financial incentives were the main interventions for achieving FRP. Evidence gaps pertained to the effectiveness, cost-effectiveness and equity implications of efforts aimed at increasing FRP. Methodological gaps related to trade-offs between single-country and multicountry analyses; lack of process evaluations; inadequate mixed-methods evidence, disaggregated by relevant characteristics; lack of comparable and standardised measurement and short follow-up periods.

CONCLUSIONS

This scoping overview of reviews characterised what is known about FRP as a UHC dimension and found evidence gaps related to the effectiveness, cost-effectiveness and equity implications of FRP interventions. Theory-informed mixed-methods research using high-quality, longitudinal and disaggregated data is needed to address these objectives.

Equity of health care financing in South Korea: 1990-2016

Background

The National Health Insurance in Korea has been in operation for more than 30 years since having achieved universal health coverage in 1989 and has gone through several policy reforms. Despite its achievements, the Korean health insurance has some shortfalls, one of which concerns the fairness of paying for health care.

Method

Using the population representative Household Income and Expenditure Survey data in Korea, this study examined the yearly changes in the vertical equity of paying for health care between 1990 and 2016 by the source of financing using the Kakwani index, considering health insurance and other related policy reforms in Korea during this period.

Results

The study results suggest that direct tax was the most progressive mode of health care financing in all years, whereas indirect tax was proportional. The out-of-pocket payments were weakly regressive in all years. The Kakwani index for health insurance contributions was regressive but now is proportional to the ability to pay, whereas the Kakwani index for private health insurance premiums turned from progressive to weakly regressive. The Kakwani index for overall health care financing showed a weak regressivity during the study period.

Discussion

The overall health care financing in Korea has transformed from a slight regressivity to proportional over time between 1990 and 2016. It is expected that these changes were closely related to the improved equity of health insurance contributions from 1998 to 2008, which was the result of a merger of the health insurance societies and an amendment in the health insurance contribution structure. These results suggest that standardizing insurance managing organizations and financing rules potentially has positive implications for the equity of healthcare financing in a country where the major method of health care financing is social health insurance.