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Ottie-Boakye D, Bawah AA, Dodoo ND, Anarfi JK. Prevalence, perceptions and associated factors of health insurance enrollment among older persons in selected cash grant communities in Ghana: a cross-sectional mixed method. BMC Geriatr 2024; 24:439. [PMID: 38762460 DOI: 10.1186/s12877-024-05037-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 05/02/2024] [Indexed: 05/20/2024] Open
Abstract
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.
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Affiliation(s)
- Doris Ottie-Boakye
- School of Public Health, College of Health Sciences, University of Ghana, Box LG 13, Legon, Accra, Ghana.
| | - Ayagah Agula Bawah
- Regional Institute for Population Studies, University of Ghana-Legon, Box LG 96, Accra, Ghana
| | - Naa Dodua Dodoo
- African Institute for Development Policy (AFIDEP), City Centre, Box 31024, Lilongwe 3, Malawi
| | - J K Anarfi
- Regional Institute for Population Studies, University of Ghana-Legon, Box LG 96, Accra, Ghana
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Damrongplasit K, Melnick G. Utilisation, out-of-pocket payments and access before and after COVID-19: Thailand's Universal Health Coverage Scheme. BMJ Glob Health 2024; 9:e015179. [PMID: 38740495 PMCID: PMC11097804 DOI: 10.1136/bmjgh-2024-015179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 04/25/2024] [Indexed: 05/16/2024] Open
Abstract
The goal of Universal Health Coverage (UHC) is that everyone needing healthcare can access quality services without financial hardship. Recent research covering countries with UHC systems documents the emergence, and acceleration following the COVID-19 pandemic of unapproved informal payment systems by providers that collect under-the-table payments from patients. In 2001, Thailand extended its '30 Baht' government-financed coverage to all uninsured people with little or no cost sharing. In this paper, we update the literature on the performance of Thailand's Universal Health Coverage Scheme (UCS) with data covering 2019 (pre-COVID-19) through 2021. We find that access to care for Thailand's UCS-covered population (53 million) is similar to access provided to populations covered by the other major public health insurance schemes covering government and private sector workers, and that, unlike reports from other UHC countries, no evidence that informal side payments have emerged, even in the face of COVID-19 related pressures. However, we do find that nearly one out of eight Thailand's UCS-covered patients seek care outside the UCS delivery system where they will incur out-of-pocket payments. This finding predates the COVID-19 pandemic and suggests the need for further research into the performance of the UHC-sponsored delivery system.
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Affiliation(s)
- Kannika Damrongplasit
- Faculty of Economics and Center of Excellence for Health Economics, Chulalongkorn University, Bangkok, Thailand
| | - Glenn Melnick
- Sol Price School of Public Policy and Center for Health Financing, Policy and Management, University of Southern California, Los Angeles, California, USA
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Shams L, Nasiri T, Darvish T, Hosseini-Shokouh SM, Amiri MM. Barriers to financial access of disabled people to health services in rural areas: A case study of Iran. J Educ Health Promot 2024; 13:89. [PMID: 38720686 PMCID: PMC11078468 DOI: 10.4103/jehp.jehp_63_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 04/29/2023] [Indexed: 05/12/2024]
Abstract
BACKGROUND People with disabilities (PWDs) account for a significant percentage of the world's population, with a higher prevalence in less developed countries. Access to healthcare services is the main component of health systems performance, with lower access for PWDs living in rural areas. The current study aimed to investigate PWD's access to healthcare services in rural areas of Iran and, secondly, factors that contribute to this issue. MATERIALS AND METHODS Following a cross-sectional design, the current descriptive-analytical study is performed in the north of Iran. Using the quota sampling technique, 471 PWDs were recruited. Data were collected using a valid and reliable questionnaire, covering three dimensions of access, by face-to-face interview. Data analysis was administered using central tendency indicators and multiple regression by SPSS version 17. Statistical significance was considered when the P value <0.05. RESULTS The mean score of PWD's access to healthcare services for dimensions of utilization, availability, and affordability was 8.91 (±6.86), 14.54 (±2.3), and 51.91 (±8.78), indicating very low, low, and moderate levels of access. All three regression models were significant (P < 0.05), and variables of gender, age, marital status, education level, residence status, the income of the household head, receiving financial aid, and house area showed a significant effect (P < 0.05). CONCLUSION This study demonstrated the seriousness of paying attention to PWD's financial access to healthcare services, particularly in rural areas of Iran. Hence, policymakers should better focus on this problem, mainly regarding accessibility and utilization and factors that result in inequalities.
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Affiliation(s)
- Lida Shams
- Department of Health Policy and Management, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Taha Nasiri
- Health Management Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
- Department of Health Services Management, Faculty of Health, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Tahere Darvish
- Department of Community Health Education, Virtual School of Medical and Management, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sayyed-Morteza Hosseini-Shokouh
- Health Management Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
- Department of Health Services Management, Faculty of Health, Baqiyatallah University of Medical Sciences, Tehran, Iran
- Health Management and Economics Research Center, Health Management Research Institute, Iran University of Medical Sciences, Tehran, Iran
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Mohanty SK, Padhi B, Singh RR, Sahoo U. Comparable estimates of out-of-pocket payment on hospitalisation and outpatient services in India, 2004-18. Clinical Epidemiology and Global Health 2022. [DOI: 10.1016/j.cegh.2022.101139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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Amu H, Dickson KS, Adde KS, Kissah-Korsah K, Darteh EKM, Kumi-Kyereme A. Prevalence and factors associated with health insurance coverage in urban sub-Saharan Africa: Multilevel analyses of demographic and health survey data. PLoS One 2022; 17:e0264162. [PMID: 35245301 PMCID: PMC8896727 DOI: 10.1371/journal.pone.0264162] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 02/04/2022] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION With the vision of achieving Universal Health Coverage (UHC) by the year 2030, many sub-Saharan African (SSA) countries have implemented health insurance schemes that seek to improve access to healthcare for their populace. In this study, we examined the prevalence and factors associated with health insurance coverage in urban sub-Saharan Africa (SSA). MATERIALS AND METHODS We used the most recent Demographic and Health Survey (DHS) data from 23 countries in SSA. We included 120,037 women and 54,254 men residing in urban centres in our analyses which were carried out using both bivariable and multivariable analyses. RESULTS We found that the overall prevalence of health insurance coverage was 10.6% among females and 14% among males. The probability of being covered by health insurance increased by level of education. Men and women with higher education, for instance, had 7.61 times (95%CI = 6.50-8.90) and 7.44 times (95%CI = 6.77-8.17) higher odds of being covered by health insurance than those with no formal education. Males and females who read newspaper or magazine (Males: AOR = 1.47, 95%CI = 1.37-1.57; Females: AOR = 2.19, 95%CI = 1.31-3.66) listened to radio (Males: AOR = 1.29, 95%CI = 1.18-1.41; Females: AOR = 1.42, 95%CI = 1.35-1.51), and who watched television (Males: AOR = 1.80, 95%CI = 1.64-1.97; Females: AOR = 1.86, 95%CI = 1.75-1.99) at least once a week had higher odds of being covered by health insurance. CONCLUSION The coverage of health insurance in SSA is generally low among urban dwellers. This has negative implications for the achievement of universal health coverage by the year 2030. We recommend increased public education on the benefits of being covered by health insurance using the mass media which we found to be an important factor associated with health insurance coverage. The focus of such mass media education could target the less educated urban dwellers, males in the lowest wealth quintile, and young adults (15-29 years).
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Affiliation(s)
- Hubert Amu
- Department of Population and Behavioural Sciences, School of Public Health, University of Health and Allied Sciences, Hohoe, Ghana
| | | | - Kenneth Setorwu Adde
- Department of Population and Health, University of Cape Coast, Cape Coast, Ghana
| | - Kwaku Kissah-Korsah
- Department of Population and Health, University of Cape Coast, Cape Coast, Ghana
| | | | - Akwasi Kumi-Kyereme
- Department of Population and Health, University of Cape Coast, Cape Coast, Ghana
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Kabia E, Goodman C, Balabanova D, Muraya K, Molyneux S, Barasa E. The hidden financial burden of healthcare: a systematic literature review of informal payments in Sub-Saharan Africa. Wellcome Open Res 2021; 6:297. [PMID: 36199622 PMCID: PMC9513412 DOI: 10.12688/wellcomeopenres.17228.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2021] [Indexed: 11/23/2022] Open
Abstract
Background: Informal payments limit equitable access to healthcare. Despite being a common phenomenon, there is a need for an in-depth analysis of informal charging practices in the Sub-Saharan Africa (SSA) context. We conducted a systematic literature review to synthesize existing evidence on the prevalence, characteristics, associated factors, and impact of informal payments in SSA. Methods: We searched for literature on PubMed, African Index Medicus, Directory of Open Access Journals, and Google Scholar databases
and relevant organizational websites. We included empirical studies on informal payments conducted in SSA regardless of the study design and year of publication and excluded reviews, editorials, and conference presentations. Framework analysis was conducted, and the review findings were synthesized. Results: A total of 1700 articles were retrieved, of which 23 were included in the review. Several studies ranging from large-scale nationally representative surveys to in-depth qualitative studies have shown that informal payments are prevalent in SSA regardless of the health service, facility level, and sector. Informal payments were initiated mostly by health workers compared to patients and they were largely made in cash rather than in kind. Patients made informal payments to access services, skip queues, receive higher quality of care, and express gratitude.
The poor and people who were unaware of service charges, were more likely to pay informally. Supply-side factors associated with informal payments included low and irregular health worker salaries, weak accountability mechanisms, and perceptions of widespread corruption in the public sector. Informal payments limited access especially among the poor and the inability to pay was associated with delayed or forgone care and provision of lower-quality care. Conclusions: Addressing informal payments in SSA requires a multifaceted approach. Potential strategies include enhancing patient awareness of service fees, revisiting health worker incentives, strengthening accountability mechanisms, and increasing government spending on health.
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Affiliation(s)
- Evelyn Kabia
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
| | - Catherine Goodman
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Dina Balabanova
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Kui Muraya
- Health Systems & Research Ethics Department, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
| | - Sassy Molyneux
- Health Systems & Research Ethics Department, KEMRI Wellcome Trust Research Programme, Kilifi, Kenya
- Center for Tropical Medicine and Global Health,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Edwine Barasa
- Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
- Center for Tropical Medicine and Global Health,Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Habibov N, Auchynnikava A, Fan L, Lyu Y. How Different Motivations for Making Informal Out-Of-Pocket Payments Vary in Their Influence on Users' Satisfaction with Healthcare, Local and National Government, and Satisfaction with Life? Biomed Res Int 2021; 2021:5763003. [PMID: 34485519 DOI: 10.1155/2021/5763003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/22/2021] [Accepted: 07/28/2021] [Indexed: 11/17/2022]
Abstract
Background The dominant view in the literature is that informal payments in healthcare universally are a negative phenomenon. By contrast, we theorize that the motivation healthcare users for making informal payments (IP) can be classified into three categories: (1) a cultural norm, (2) “grease the wheels” payments if users offered to pay to get better services, and (3) “sand the wheels” payments if users were asked to pay by healthcare personnel or felt that payments were expected. We further hypothesize that these three categories of payments are differently associated with a user's outcomes, namely, satisfaction with healthcare, local and national government, satisfaction with life, and satisfaction with life of children in the future. Methods We used microdata from the 2016 Life-in-Transition survey. Multivariate regression analysis is used to quantify relationships between these categories of payments and users' outcomes. Results Payments that are the result of cultural norms are associated with better outcomes. On the contrary, “sand the wheel” payments are associated with worse outcomes. We find no association between making “grease the wheels” payments and outcomes. Conclusions This is the first paper which evaluates association between three different categories of informal payments with a wide range of users' outcomes on a diverse sample of countries. Focusing on informal payments in general, rather than explicitly examining specific motivations, obscures the true outcomes of making IP. It is important to distinguish between three different motivations for informal payment, namely, cultural norms, “grease the wheels,” and “sand the wheels” since they have varying associations with user outcomes. From a policy making standpoint, variation in the links between different motivations for making IP and measures of satisfaction suggest that decision-makers should put their primary focus on situations where IP are explicitly asked for or are implied by the situation and that they should differentiate this from cases of gratitude payments. If such measures are not implemented, then policy makers may unintentionally ban the behaviour that is linked with increased satisfaction with healthcare, government, and life (i.e., paying gratitude).
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Kosec K, Song J. The effects of income fluctuations on undernutrition and overnutrition across the lifecycle. Health Econ 2021; 30:2487-2509. [PMID: 34288201 DOI: 10.1002/hec.4379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 11/18/2020] [Accepted: 06/01/2021] [Indexed: 06/13/2023]
Abstract
This study uses individual level data from a 13-year, nationally representative rotating panel survey of Kyrgyzstan to estimate the effects of fluctuations in predicted income on health and nutrition outcomes from early childhood to adulthood. We consider impacts on both undernutrition and overnutrition side-by-side, and carefully consider the mechanisms at work. We address the endogeneity of income following Bartik (1991): We construct a measure of predicted income, obtained using the household's initial period share of income from different sources and aggregate national growth rates over time in each source. We find that young children (under age 5) exposed to reductions in predicted income experienced reductions in important measures of health and nutrition: weight, weight-for-age Z-scores, and weight-for-height Z-scores. We further identify reductions in both weight and height among older children (aged 5-18). Declines in child health and nutrition are most pronounced among households most dependent on agriculture and those living in rural areas. Reduced consumption of healthy foods and reduced parental time spent with children may help explain the results. A channel possibly offsetting negative impacts is increased use of contraceptives. At the same time, older children and adults experienced decreases in body mass index and-for adults-decreases in the incidence of overweight and obesity, suggesting selective health benefits for some groups.
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Affiliation(s)
- Katrina Kosec
- International Food Policy Research Institute (IFPRI), Washington, District of Columbia, USA
| | - Jie Song
- International Food Policy Research Institute (IFPRI), Washington, District of Columbia, USA
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Iamshchikova M, Mogilevskii R, Onah MN. Trends in out of pocket payments and catastrophic health expenditure in the Kyrgyz Republic post "Manas Taalimi" and "Den Sooluk" health reforms, 2012-2018. Int J Equity Health 2021; 20:30. [PMID: 33430869 PMCID: PMC7798228 DOI: 10.1186/s12939-020-01358-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 12/14/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Over the years, the Kyrgyz Republic has implemented health reforms that target health financing with the aim of removing financial barriers to healthcare including out-of-pocket health payments (OOPPs). This study examines the trends in OOPPs, and the incidence of catastrophic health expenditure (CHE) post the "Manas Taalimi" and "Den Sooluk" health reforms. METHODS We used data from the Kyrgyzstan Integrated Household Surveys (2012-2018). Population-weighted descriptive statistics were used to examine the trends in OOPPs and CHE at three thresholds; 10 percent of total household consumption expenditure (Cata10), 25 percent of total household consumption expenditure (Cata25) and 40 percent of total household non-food consumption expenditure (Cata40). Panel and cross-sectional logistic regression with marginal effects were used to examine the predictors of Cata10 and Cata40. FINDINGS Between 2012 and 2018, OOPPs increased by about US $6 and inpatient costs placed the highest cost burden on users (US $13.6), followed by self-treatment (US $10.7), and outpatient costs (US $9). Medication continues to predominantly drive inpatient, outpatient, and self-treatment OOPPs. About 0.378 to 2.084 million people (6 - 33 percent) of the population incurred catastrophic health expenditure at the three thresholds between 2012 and 2018. Residing in households headed by a widowed or single head, or residing in rural regions, increases the likelihood of incurring catastrophic health expenditure. CONCLUSIONS The initial gains in the reduction of OOPPs and catastrophic health expenditure appear to gradually erode since costs continue to increase after an initial decline and catastrophic health expenditure continues to rise unabated. This implies that households are increasingly incurring economic hardship from seeking healthcare. Considering that this could result to forgone expenditure on essential items including food and education, efforts should target the sustainability of these health reforms to maintain and grow the reduction of catastrophic health payments and its dire consequences.
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Affiliation(s)
- Mariia Iamshchikova
- Institute of Public Policy and Administration, Graduate School of Development, University of Central Asia, Bishkek, Kyrgyzstan
| | - Roman Mogilevskii
- Institute of Public Policy and Administration, Graduate School of Development, University of Central Asia, Bishkek, Kyrgyzstan
| | - Michael Nnachebe Onah
- Institute of Public Policy and Administration, Graduate School of Development, University of Central Asia, Bishkek, Kyrgyzstan.
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Otieno PO, Wambiya EOA, Mohamed SM, Mutua MK, Kibe PM, Mwangi B, Donfouet HPP. Access to primary healthcare services and associated factors in urban slums in Nairobi-Kenya. BMC Public Health 2020; 20:981. [PMID: 32571277 PMCID: PMC7310125 DOI: 10.1186/s12889-020-09106-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 06/12/2020] [Indexed: 11/18/2022] Open
Abstract
Background Access to primary healthcare is crucial for the delivery of Kenya’s universal health coverage policy. However, disparities in healthcare have proved to be the biggest challenge for implementing primary care in poor-urban resource settings. In this study, we assessed the level of access to primary healthcare services and associated factors in urban slums in Nairobi-Kenya. Methods The data were drawn from the Lown scholars’ study of 300 randomly selected households in Viwandani slums (Nairobi, Kenya), between June and July 2018. Access to primary care was measured using Penchansky and Thomas’ model. Access index was constructed using principal component analysis and recorded into tertiles with categories labeled as poor, moderate, and highest. Generalized ordinal logistic regression analysis was used to determine the factors associated with access to primary care. The adjusted odds ratios (AOR) and 95% confidence intervals were used to interpret the strength of associations. Results The odds of being in the highest access tertile versus the combined categories of lowest and moderate access tertile were three times higher for males than female-headed households (AOR 3.05 [95% CI 1.47–6.37]; p < .05). Households with an average quarterly out-of-pocket healthcare expenditure of ≥USD 30 had significantly lower odds of being in the highest versus combined categories of lowest and moderate access tertile compared to those spending ≤ USD 5 (AOR 0.36 [95% CI 0.18–0.74]; p < .05). Households that sought primary care from private facilities had significantly higher odds of being in the highest versus combined categories of lowest and moderate access tertiles compared to those who sought care from public facilities (AOR 6.64 [95% CI 3.67–12.01]; p < .001). Conclusion In Nairobi slums in Kenya, living in a female-headed household, seeking care from a public facility, and paying out-of-pocket for healthcare are significantly associated with low access to primary care. Therefore, the design of the UHC program in this setting should prioritize quality improvement in public health facilities and focus on policies that encourage economic empowerment of female-headed households to improve access to primary healthcare.
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Affiliation(s)
- Peter O Otieno
- African Population and Health Research Center, APHRC Campus, 2nd Floor, Manga Close, Off Kirawa Road, P.O. Box: 10787-00100, Nairobi, Kenya.
| | - Elvis O A Wambiya
- African Population and Health Research Center, APHRC Campus, 2nd Floor, Manga Close, Off Kirawa Road, P.O. Box: 10787-00100, Nairobi, Kenya
| | - Shukri M Mohamed
- African Population and Health Research Center, APHRC Campus, 2nd Floor, Manga Close, Off Kirawa Road, P.O. Box: 10787-00100, Nairobi, Kenya
| | - Martin Kavao Mutua
- African Population and Health Research Center, APHRC Campus, 2nd Floor, Manga Close, Off Kirawa Road, P.O. Box: 10787-00100, Nairobi, Kenya
| | - Peter M Kibe
- African Population and Health Research Center, APHRC Campus, 2nd Floor, Manga Close, Off Kirawa Road, P.O. Box: 10787-00100, Nairobi, Kenya
| | - Bonventure Mwangi
- African Population and Health Research Center, APHRC Campus, 2nd Floor, Manga Close, Off Kirawa Road, P.O. Box: 10787-00100, Nairobi, Kenya
| | - Hermann Pythagore Pierre Donfouet
- African Population and Health Research Center, APHRC Campus, 2nd Floor, Manga Close, Off Kirawa Road, P.O. Box: 10787-00100, Nairobi, Kenya
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Otieno PO, Wambiya EOA, Mohamed SF, Donfouet HPP, Mutua MK. Prevalence and factors associated with health insurance coverage in resource-poor urban settings in Nairobi, Kenya: a cross-sectional study. BMJ Open 2019; 9:e031543. [PMID: 31843827 PMCID: PMC6924758 DOI: 10.1136/bmjopen-2019-031543] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 10/07/2019] [Accepted: 11/11/2019] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To determine the prevalence of health insurance and associated factors among households in urban slum settings in Nairobi, Kenya. DESIGN The data for this study are from a cross-sectional survey of adults aged 18 years or older from randomly selected households in Viwandani slums (Nairobi, Kenya). Respondents participated in the Lown scholars' study conducted between June and July 2018. SETTING The Lown scholars' survey was nested in the Nairobi Urban Health and Demographic Surveillance System in Viwandani slums in Nairobi, Kenya. PARTICIPANTS A total of 300 randomly sampled households participated in the survey. The study respondents comprised of either the household head, their spouses or credible adult household members. PRIMARY OUTCOME MEASURE The primary outcome of this study was enrolment in a health insurance programme. The households were classified into two groups: those having at least one member covered by health insurance and those without any health insurance cover. RESULTS The prevalence of health insurance in the sample was 43%. Being unemployed (adjusted OR (aOR) 0.17; p<0.05; 95% CI 0.06 to 0.47) and seeking care from a public health facility (aOR 0.50; p<0.05; 95% CI 0.28 to 0.89) was significantly associated with lower odds of having a health insurance cover. The odds of having a health insurance cover were significantly lower among respondents who perceived their health status as good (aOR 0.62; p<0.05; 95% CI 1.17 to 5.66) and those who were unsatisfied with the cost of seeking primary care (aOR 0.34; p<0.05; 95% CI 0.17 to 0.69). CONCLUSIONS Health insurance coverage in Viwandani slums in Nairobi, Kenya, is low. As universal health coverage becomes the growing focus of Kenya's 'Big Four Agenda' for socioeconomic transformation, integrating enabling and need factors in the design of the national health insurance package may scale-up social health protection.
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Affiliation(s)
- Peter O Otieno
- Health and Systems for Health, African Population and Health Research Center, Nairobi, Kenya
| | | | - Shukri F Mohamed
- Health and Systems for Health, African Population and Health Research Center, Nairobi, Kenya
- University of Warwick, Coventry, UK
| | - Hermann Pythagore Pierre Donfouet
- Health and Systems for Health, African Population and Health Research Center, Nairobi, Kenya
- Data, Measurement and Evaluation, African Population and Health Research Center, Nairobi, Kenya
| | - Martin K Mutua
- Health and Systems for Health, African Population and Health Research Center, Nairobi, Kenya
- Data, Measurement and Evaluation, African Population and Health Research Center, Nairobi, Kenya
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Vogler S, Dedet G, Pedersen HB. Financial Burden of Prescribed Medicines Included in Outpatient Benefits Package Schemes: Comparative Analysis of Co-Payments for Reimbursable Medicines in European Countries. Appl Health Econ Health Policy 2019; 17:803-816. [PMID: 31506879 DOI: 10.1007/s40258-019-00509-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVE The study aimed to analyse the financial burden that co-payments for prescribed and reimbursed medicines pose on patients in European countries. METHODS Five medicines used in acute conditions (antibiotic, analgesic) and in chronic care (hypertension, asthma, diabetes) were selected. Co-payments (standard and five defined population groups, e.g. low-income people, patients with high consumption) were surveyed based on information retrieved from national price lists (September 2017) and co-payment regulation in nine countries (Albania, Austria, England, France, Germany, Greece, Hungary, Kyrgyzstan and Sweden). The financial burden of the selected medicines (originator and lowest-priced generic) was described as the percentage of patients' payments for 1 month's therapy or treatment of one episode in comparison to the national minimum monthly wage. RESULTS The study showed large variation in co-payments between the countries. Financial burden resulting from co-payments for reimbursed medicines tended to be higher in lower-income countries (Kyrgyzstan: 9% of minimum monthly wage for generic amlodipine; 2-4% for generic and originator salbutamol; Albania: approximately 3% for originator amoxicillin/clavulanic acid and metformin). Most studied countries applied reduction or exemption mechanisms (children were exempt in five countries, no or lower co-payments for low-income people in five countries, exemptions from co-payments upon reaching a threshold of expenses in six countries). CONCLUSIONS Co-payments for prescribed medicines can pose a substantial financial burden for outpatients, particularly in lower-income countries. The price of a medicine, availability of lower-priced medicines and the design of co-payments, including exemptions and reductions for specific groups, can considerably impact patients' expenses for medicines.
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Affiliation(s)
- Sabine Vogler
- WHO Collaborating Centre for Pharmaceutical Pricing and Reimbursement Policies, Pharmacoeconomics Department, Gesundheit Österreich GmbH (Austrian Public Health Institute), Stubenring 6, 1010, Vienna, Austria.
| | - Guillaume Dedet
- Health Division, Organisation for Economic Co-operation and Development (OECD), 75116, Paris, France
- World Health Organization (WHO) Regional Office for Europe, 2100, Copenhagen, Denmark
| | - Hanne Bak Pedersen
- World Health Organization (WHO) Regional Office for Europe, 2100, Copenhagen, Denmark
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Vogler S, Schneider P, Dedet G, Bak Pedersen H. Affordable and equitable access to subsidised outpatient medicines? Analysis of co-payments under the Additional Drug Package in Kyrgyzstan. Int J Equity Health 2019; 18:89. [PMID: 31196109 PMCID: PMC6567501 DOI: 10.1186/s12939-019-0990-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 05/23/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Out-of-pocket (OOP) payments can constitute a major barrier for affordable and equitable access to essential medicines. Household surveys in Kyrgyzstan pointed to a perceived growth in OOP payments for outpatient medicines, including those covered by the benefits package scheme (the Additional Drug Package, ADP). The study aimed to explore the extent of co-payments for ADP-listed medicines and to explain the reasons for developments. METHODS A descriptive statistical analysis was performed on prices and volumes of prescribed ADP-listed medicines dispensed in pharmacies during 2013-2015 (1,041,777 prescriptions claimed, data provided by the Mandatory Health Insurance Fund). Additionally, data on the value and volume of imported medicines in 2013-2015 (obtained from the National Medicines Regulatory Agency) were analysed. RESULTS In 2013-2015, co-payments for medicines dispensed under the ADP grew, on average, by 22.8%. Co-payments for ADP-listed medicines amounted to around 50% of a reimbursed baseline price, but as pharmacy retail prices were not regulated, co-payments tended to be higher in practice. The increase in co-payments coincided with a reduction in the number of prescriptions dispensed (by 14%) and an increase in average amounts reimbursed per prescription in nearly all therapeutic groups (by 22%) in the study period. While the decrease in prescriptions suggests possible underuse, as patients might forego filling prescriptions due to financial restraints, the growth in average amounts reimbursed could be an indication of inefficiencies in public funding. Variation between the regions suggests regional inequity. Devaluation of the national currency was observed, and the value of imported medicines increased by nearly 20%, whereas volumes of imports remained at around the same level in 2013-2015. Thus, patients and public procurers had to pay more for the same amount of medicines. CONCLUSIONS The findings suggest an increase in pharmacy retail prices as the major driver for higher co-payments. The national currency devaluation contributed to the price increases, and the absence of medicine price regulation aggravated the effects of the depreciation. It is recommended that Kyrgyzstan should introduce medicine price regulation and exemptions for low-income people from co-payments to ensure a more affordable and equitable access to medicines.
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Affiliation(s)
- Sabine Vogler
- WHO Collaborating Centre for Pharmaceutical Pricing and Reimbursement Policies, Pharmacoeconomics Department, Gesundheit Österreich GmbH (GÖG / Austrian Public Health Institute), Vienna, Austria
| | - Peter Schneider
- WHO Collaborating Centre for Pharmaceutical Pricing and Reimbursement Policies, Pharmacoeconomics Department, Gesundheit Österreich GmbH (GÖG / Austrian Public Health Institute), Vienna, Austria
| | - Guillaume Dedet
- Organisation for Economic Co-operation and Development (OECD), Paris, France
| | - Hanne Bak Pedersen
- World Health Organization, Regional Office for Europe, Copenhagen, Denmark
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Abstract
OBJECTIVE To investigate the association of caesarean section rates with the health system characteristics in the public hospitals of Kosovo. DESIGN Cross-sectional survey. SETTING Five largest public hospitals in Kosovo. PARTICIPANTS 859 women with low-risk deliveries who delivered from April to May 2015 in five public hospitals in Kosovo. OUTCOME MEASURES The prespecified outcomes were the crude and adjusted OR of births delivered with caesarean section by health system characteristics such as delivery by the physician who provided antenatal care, health insurance status and other. Additional prespecified outcomes were caesarean section rates and crude ORs for delivery with caesarean in each public hospital. RESULTS Women with personal monthly income had increased odds for caesarean (OR 1.55, 95% CI 1.06 to 2.27), as did women with private health insurance coverage (OR 3.44, 95% CI 1.20 to 9.85). Women instructed by a midwife on preparation for delivery had decreasing odds (OR 0.32, 95% CI 0.19 to 0.51) while women having preference for a caesarean had increasing odds for delivery with caesarean (OR 3.84, 95% CI 1.96 to 7.51). The odds for caesarean increased also in the case of delivery by a physician who provided antenatal care (OR 2.06, 95% CI 1.16 to 3.67) and delivery during office hours (OR 2.36, 95% CI 1.37 to 4.05), while delivery at the University Clinical Centre of Kosovo decreased the odds for caesarean (OR 0.46, 95% CI 0.24 to 0.90). CONCLUSIONS We found that several health system characteristics are associated with the increase of caesarean sections in a low-risk population of delivering women in public hospitals of Kosovo. These findings should be explored further and addressed via policy measures that would tackle provision of unnecessary caesareans. The study findings could assist Kosovo to develop corrective policies in addressing overuse of caesareans and may provide useful information for other middle-income countries.
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Affiliation(s)
- Ilir Hoxha
- Department of Community and Family Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
- Heimerer College, Prishtina, Kosovo
- Action for Mother and Children, Prishtina, Kosovo
| | | | - Mrika Aliu
- Action for Mother and Children, Prishtina, Kosovo
| | - Peter Jüni
- Applied Health Research Centre (AHRC), Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Department of Medicine, and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - David C Goodman
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire, USA
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Abstract
This study evaluates the direct causal effects of household wealth on health. We discuss several specific mechanisms that that could relate poverty with worse health and hypothesize that poverty will undermine population health. This hypothesis was tested based on data drawn from a recent cross-country survey in 12 post-Soviet countries and Mongolia using classic regression (OLS) and instrumental variable 2SLS regressions. The results indicate that poverty does indeed lead to worsening health. This negative effect of poverty on health remains unchanged after controlling for a wide range of individual characteristics, healthcare performance indicators, trust in individuals, government, parliament, and political parties, as well as country-level unobserved characteristics. Using an instrumental variable increases our confidence in being able to isolate the effects of poverty on health status and confirms that our results are not due to endogeneity. In addition, the strong negative effect of poverty on health remains robust to the use of a set of country-level aggregated indicators (e.g. GDP and Gini) instead of country dummies, the employment of a subjective self-assessment indicator of poverty instead of an objective one, and an alternative conceptualization of health status as a binomial variable (for bad and very bad health) instead of a continuous one.
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Williams CC, Horodnic AV. Rethinking informal payments by patients in Europe: An institutional approach. Health Policy 2017; 121:1053-1062. [PMID: 28867153 DOI: 10.1016/j.healthpol.2017.08.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 07/12/2017] [Accepted: 08/18/2017] [Indexed: 10/19/2022]
Abstract
The aim of this paper is to explain informal payments by patients to healthcare professionals for the first time through the lens of institutional theory as arising when there are formal institutional imperfections and asymmetry between norms, values and practices and the codified formal laws and regulations. Reporting a 2013 Eurobarometer survey of the prevalence of informal payments by patients in 28 European countries, a strong association is revealed between the degree to which formal and informal institutions are unaligned and the propensity to make informal payments. The association between informal payments and formal institutional imperfections is then explored to evaluate which structural conditions might reduce this institutional asymmetry, and thus the propensity to make informal payments. The paper concludes by exploring the implications for tackling such informal practices.
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Affiliation(s)
- Colin C Williams
- Sheffield University Management School (SUMS), University of Sheffield, Conduit Road, Sheffield S10 1FL, Room: D038.a, United Kingdom.
| | - Adrian V Horodnic
- Sheffield University Management School (SUMS), University of Sheffield, Conduit Road, Sheffield S10 1FL, Room: D038.a, United Kingdom
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Stepurko T, Pavlova M, Gryga I, Gaál P, Groot W. Patterns of informal patient payments in Bulgaria, Hungary and Ukraine: a comparison across countries, years and type of services. Health Policy Plan 2017; 32:453-466. [PMID: 27993960 DOI: 10.1093/heapol/czw147] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2016] [Indexed: 11/12/2022] Open
Abstract
Informal payments for health care are a well-known phenomenon in many health care systems around the world. While informal payments could be an important source of health care financing, they have an adverse impact on efficiency and access to care, and are a major impediment to ongoing health care reforms. This paper aims to study the scale and patterns of informal patient payments for out-patient and in-patient services in three former-socialist countries: Bulgaria, Hungary and Ukraine. The data are collected in 2010 and 2011 based on national representative samples and are analysed in pooled models to explain variations in payments. The results of the cross-country comparison suggest a relatively higher prevalence of informal patient payments in Ukraine and Hungary than in Bulgaria, where patients also have to pay formal user charges in the public sector. Nevertheless, informal payments for hospitalization in Bulgaria are quite extensive. We observe some differences in informal payments across the years. Variations in payment size are mainly explained by the nature, type and need for services, fee awareness and, on some occasions, by household income. Interpreted within the context of structural differences (e.g. reform paths, regulations, funding, user fees, anti-corruption policies), the findings of our study have implications on how to address informal payments for health care.
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Affiliation(s)
- Tetiana Stepurko
- School of Public Health, National University of 'Kyiv-Mohyla Academy'; Ukraine, Skovorody street 2, Kiev, Ukraine.,Department of Health Services Research, CAPHRI, Maastricht University Medical Center, Faculty of Health, Medicine and Life Sciences, Maastricht University, The Netherlands
| | - Milena Pavlova
- Department of Health Services Research, CAPHRI, Maastricht University Medical Center, Faculty of Health, Medicine and Life Sciences, Maastricht University, The Netherlands
| | - Irena Gryga
- School of Public Health, National University of 'Kyiv-Mohyla Academy'; Ukraine, Skovorody street 2, Kiev, Ukraine
| | - Péter Gaál
- Faculty of Health and Public Services, Semmelweis University, Budapest, Hungary
| | - Wim Groot
- Department of Health Services Research, CAPHRI, Maastricht University Medical Center, Faculty of Health, Medicine and Life Sciences, Maastricht University, The Netherlands.,Top Institute Evidence-Based Education Research (TIER); Maastricht University, The Netherlands
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18
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Habibov N, Cheung A. Revisiting informal payments in 29 transitional countries: The scale and socio-economic correlates. Soc Sci Med 2017; 178:28-37. [DOI: 10.1016/j.socscimed.2017.02.003] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 12/22/2016] [Accepted: 02/01/2017] [Indexed: 11/25/2022]
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Mackey TK, Kohler JC, Savedoff WD, Vogl F, Lewis M, Sale J, Michaud J, Vian T. The disease of corruption: views on how to fight corruption to advance 21 st century global health goals. BMC Med 2016; 14:149. [PMID: 27680102 PMCID: PMC5041569 DOI: 10.1186/s12916-016-0696-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 09/15/2016] [Indexed: 11/10/2022] Open
Abstract
Corruption has been described as a disease. When corruption infiltrates global health, it can be particularly devastating, threatening hard gained improvements in human and economic development, international security, and population health. Yet, the multifaceted and complex nature of global health corruption makes it extremely difficult to tackle, despite its enormous costs, which have been estimated in the billions of dollars. In this forum article, we asked anti-corruption experts to identify key priority areas that urgently need global attention in order to advance the fight against global health corruption. The views shared by this multidisciplinary group of contributors reveal several fundamental challenges and allow us to explore potential solutions to address the unique risks posed by health-related corruption. Collectively, these perspectives also provide a roadmap that can be used in support of global health anti-corruption efforts in the post-2015 development agenda.
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Affiliation(s)
- Tim K Mackey
- Department of Anesthesiology, University of California, San Diego School of Medicine, San Diego, CA, USA. .,Division of Global Public Health, University of California, San Diego School of Medicine, Department of Medicine, San Diego, CA, USA. .,Global Health Policy Institute, 6256 Greenwich Drive, Mail Code: 0172X, San Diego, CA, 92122, USA. .,WHO Collaborating Centre for Governance, Transparency and Accountability in the Pharmaceutical Sector, University of Toronto, Toronto, Ontario, Canada.
| | - Jillian Clare Kohler
- WHO Collaborating Centre for Governance, Transparency and Accountability in the Pharmaceutical Sector, University of Toronto, Toronto, Ontario, Canada.,Leslie Dan Faculty of Pharmacy, Munk School of Global Affairs, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | | | - Frank Vogl
- Transparency International, Secretariat, Berlin, Germany.,The Partnership for Transparency Fund, Washington, DC, USA
| | - Maureen Lewis
- Georgetown University, Washington, DC, USA.,Aceso Global, Washington, DC, USA
| | - James Sale
- Transparency International UK, London, UK
| | - Joshua Michaud
- Kaiser Family Foundation, Washington, DC, USA.,Johns Hopkins University School of Advanced International Studies, Washington, DC, USA
| | - Taryn Vian
- Boston University School of Public Health, Boston, MA, USA
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20
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Abstract
BACKGROUND Corruption is the abuse or complicity in abuse, of public or private position, power or authority to benefit oneself, a group, an organisation or others close to oneself; where the benefits may be financial, material or non-material. It is wide-spread in the health sector and represents a major problem. OBJECTIVES Our primary objective was to systematically summarise empirical evidence of the effects of strategies to reduce corruption in the health sector. Our secondary objective was to describe the range of strategies that have been tried and to guide future evaluations of promising strategies for which there is insufficient evidence. SEARCH METHODS We searched 14 electronic databases up to January 2014, including: CENTRAL; MEDLINE; EMBASE; sociological, economic, political and other health databases; Human Resources Abstracts up to November 2010; Euroethics up to August 2015; and PubMed alerts from January 2014 to June 2016. We searched another 23 websites and online databases for grey literature up to August 2015, including the World Bank, the International Monetary Fund, the U4 Anti-Corruption Resource Centre, Transparency International, healthcare anti-fraud association websites and trial registries. We conducted citation searches in Science Citation Index and Google Scholar, and searched PubMed for related articles up to August 2015. We contacted corruption researchers in December 2015, and screened reference lists of articles up to May 2016. SELECTION CRITERIA For the primary analysis, we included randomised trials, non-randomised trials, interrupted time series studies and controlled before-after studies that evaluated the effects of an intervention to reduce corruption in the health sector. For the secondary analysis, we included case studies that clearly described an intervention to reduce corruption in the health sector, addressed either our primary or secondary objective, and stated the methods that the study authors used to collect and analyse data. DATA COLLECTION AND ANALYSIS One review author extracted data from the included studies and a second review author checked the extracted data against the reports of the included studies. We undertook a structured synthesis of the findings. We constructed a results table and 'Summaries of findings' tables. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of the evidence. MAIN RESULTS No studies met the inclusion criteria of the primary analysis. We included nine studies that met the inclusion criteria for the secondary analysis.One study found that a package of interventions coordinated by the US Department of Health and Human Services and Department of Justice recovered a large amount of money and resulted in hundreds of new cases and convictions each year (high certainty of the evidence). Another study from the USA found that establishment of an independent agency to investigate and enforce efforts against overbilling might lead to a small reduction in overbilling, but the certainty of this evidence was very low. A third study from India suggested that the impacts of coordinated efforts to reduce corruption through increased detection and enforcement are dependent on continued political support and that they can be limited by a dysfunctional judicial system (very low certainty of the evidence).One study in South Korea and two in the USA evaluated increased efforts to investigate and punish corruption in clinics and hospitals without establishing an independent agency to coordinate these efforts. It is unclear whether these were effective because the evidence is of very low certainty.One study from Kyrgyzstan suggested that increased transparency and accountability for co-payments together with reduction of incentives for demanding informal payments may reduce informal payments (low certainty of the evidence).One study from Germany suggested that guidelines that prohibit hospital doctors from accepting any form of benefits from the pharmaceutical industry may improve doctors' attitudes about the influence of pharmaceutical companies on their choice of medicines (low certainty of the evidence).A study in the USA, evaluated the effects of introducing a law that required pharmaceutical companies to report the gifts they gave to healthcare workers. Another study in the USA evaluated the effects of a variety of internal control mechanisms used by community health centres to stop corruption. The effects of these strategies is unclear because the evidence was of very low certainty. AUTHORS' CONCLUSIONS There is a paucity of evidence regarding how best to reduce corruption. Promising interventions include improvements in the detection and punishment of corruption, especially efforts that are coordinated by an independent agency. Other promising interventions include guidelines that prohibit doctors from accepting benefits from the pharmaceutical industry, internal control practices in community health centres, and increased transparency and accountability for co-payments combined with reduced incentives for informal payments. The extent to which increased transparency alone reduces corruption is uncertain. There is a need to monitor and evaluate the impacts of all interventions to reduce corruption, including their potential adverse effects.
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Affiliation(s)
- Rakhal Gaitonde
- Umeå UniversityDepartment of Public Health and Clinical MedicineUmeåSweden
- Indian Institute of Technology – MadrasCentre of Technology and PolicyChennaiIndia
| | - Andrew D Oxman
- Norwegian Institute of Public HealthP.O. Box 4404, NydalenOsloNorwayN‐0403
| | - Peter O Okebukola
- Johns Hopkins Bloomberg School of Public HealthDepartment of Health Policy and Management615 North Wolfe StreetBaltimoreMarylandUSA21205
| | - Gabriel Rada
- Pontificia Universidad Católica de ChileDepartment of Internal Medicine and Evidence‐Based Healthcare Program, Faculty of MedicineLira 44, Decanato Primer pisoSantiagoChile
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Abstract
This paper introduces the notion of 'risky encounters', referring to the way in which contacts with doctors are commonly perceived by the inhabitants of Bishkek, the capital city of Kyrgyzstan. The author's research conducted between 2011 and 2013 revealed that most people were extremely critical of biomedical personnel, despite positive assessments of healthcare reforms expressed by experts. Owing to the prevailing distrust of doctors, their interventions are often considered risky to one's health, which strongly influences people's health-related strategies in the context of medical diversity. This perception of risk is deeply embedded in feelings of uncertainty and anxiety, which should be viewed from the more general perspective of the political, economic and social uncertainties resulting from the difficulties of the period of post-Soviet transformation. It is evident that medical diversity in Bishkek provides people in need with many non-biomedical treatment options, and a distrust of doctors significantly contributes to the popularity of complementary medicine. Economic constraints and local concepts of health, illness and efficacy are among the many other factors that play a role in therapeutic choices. However, the current paper focuses on risk, uncertainty and trust, as emotions that are central to an understanding of the health-related strategies and tactics used by the inhabitants of present-day Bishkek.
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Affiliation(s)
- Danuta Penkala-Gawęcka
- a Adam Mickiewicz University in Poznań , Department of Ethnology and Cultural Anthropology , Umultowska Street 89 D, 61-614 Poznań , Poland
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Murphy A, Jakab M, McKee M, Richardson E. Persistent low adherence to hypertension treatment in Kyrgyzstan: How can we understand the role of drug affordability? Health Policy Plan 2016; 31:1384-1390. [PMID: 27315830 DOI: 10.1093/heapol/czw080] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2016] [Indexed: 11/13/2022] Open
Abstract
It is well known that cardiovascular diseases (CVD) are a growing cause of mortality and morbidity in low-and middle-income countries (LMIC). While hypertension (HTN), a leading risk factor for CVD, can be easily managed with widely available medicines, there is a huge gap in treatment for HTN in many LMIC. One such country is Kyrgyzstan, where HTN is a major public health concern and adherence to medication is low. The reasons for low adherence in Kyrgyzstan are not well understood, but some evidence suggests that HTN medicines may be unaffordable for low-income families, resulting in inequitable access to HTN treatment. With data from the 2010 Kyrgyzstan Integrated Household Survey, we estimate the prevalence and factors associated with adherence to HTN medication in Kyrgyzstan. We then investigate the hypothesis that affordability may be an important factor in adherence to HTN medication. Using the coarsened exact matching approach, we estimate the economic burden faced by households with at least one member with elevated blood pressure (EBP) in Kyrgyzstan and their risk of catastrophic spending on health care. We find that EBP households have significantly higher total expenditure on health, as well as on medicines, and are more likely to experience catastrophic health spending, suggesting that out-of-pocket expenditure for EBP may be prohibitively expensive for the poorest in Kyrgyzstan. Our findings also reveal a high prevalence of self-medication (i.e. purchasing and using medication without a doctor's prescription), and increased expenditure due to self-medication, among those with EBP. Our research suggests that affordability of HTN medicines may be an important factor in low adherence to treatment in Kyrgyzstan. Low affordability may be due partly to the prescription of medicines that are not reimbursable under the national drug benefit plan, but more research is needed to identify solutions to the affordability problem.
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Affiliation(s)
- Adrianna Murphy
- Centre for Health and Social Change, London School of Hygiene and Tropical Medicine, London, UK
| | - Melitta Jakab
- World Health Organization Office for Europe, Regional Office for Health Systems Strengthening, Barcelona, Spain
| | - Martin McKee
- Centre for Health and Social Change, London School of Hygiene and Tropical Medicine, London, UK
| | - Erica Richardson
- European Centre on Health of Societies in Transition, London School of Hygiene and Tropical Medicine, London, UK
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Arnold M, Beran D, Haghparast-Bidgoli H, Batura N, Akkazieva B, Abdraimova A, Skordis-Worrall J. Coping with the economic burden of Diabetes, TB and co-prevalence: evidence from Bishkek, Kyrgyzstan. BMC Health Serv Res 2016; 16:118. [PMID: 27048370 PMCID: PMC4822315 DOI: 10.1186/s12913-016-1369-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 04/01/2016] [Indexed: 11/18/2022] Open
Abstract
Background The increasing number of patients co-affected with Diabetes and TB may place individuals with low socio-economic status at particular risk of persistent poverty. Kyrgyz health sector reforms aim at reducing this burden, with the provision of essential health services free at the point of use through a State-Guaranteed Benefit Package (SGBP). However, despite a declining trend in out-of-pocket expenditure, there is still a considerable funding gap in the SGBP. Using data from Bishkek, Kyrgyzstan, this study aims to explore how households cope with the economic burden of Diabetes, TB and co-prevalence. Methods This study uses cross-sectional data collected in 2010 from Diabetes and TB patients in Bishkek, Kyrgyzstan. Quantitative questionnaires were administered to 309 individuals capturing information on patients’ socioeconomic status and a range of coping strategies. Coarsened exact matching (CEM) is used to generate socio-economically balanced patient groups. Descriptive statistics and logistic regression are used for data analysis. Results TB patients are much younger than Diabetes and co-affected patients. Old age affects not only the health of the patients, but also the patient’s socio-economic context. TB patients are more likely to be employed and to have higher incomes while Diabetes patients are more likely to be retired. Co-affected patients, despite being in the same age group as Diabetes patients, are less likely to receive pensions but often earn income in informal arrangements. Out-of-pocket (OOP) payments are higher for Diabetes care than for TB care. Diabetes patients cope with the economic burden by using social welfare support. TB patients are most often in a position to draw on income or savings. Co-affected patients are less likely to receive social welfare support than Diabetes patients. Catastrophic health spending is more likely in Diabetes and co-affected patients than in TB patients. Conclusions This study shows that while OOP are moderate for TB affected patients, there are severe consequences for Diabetes affected patients. As a result of the underfunding of the SGBP, Diabetes and co-affected patients are challenged by OOP. Especially those who belong to lower socio-economic groups are challenged in coping with the economic burden. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1369-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Matthias Arnold
- Munich Center of Health Sciences, Ludwig-Maximilians-Universität, Munich, Germany. .,Institute of Health Economics and Health Care Management, Helmholtz Zentrum München, Neuherberg, Germany.
| | - David Beran
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals and University of Geneva, Geneva, Switzerland
| | | | - Neha Batura
- Institute for Global Health, UCL, London, UK
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Habibov N. Effect of corruption on healthcare satisfaction in post-soviet nations: A cross-country instrumental variable analysis of twelve countries. Soc Sci Med 2016; 152:119-24. [DOI: 10.1016/j.socscimed.2016.01.044] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 01/15/2016] [Accepted: 01/25/2016] [Indexed: 12/01/2022]
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Sweileh WM, Al-Jabi SW, Sawalha AF, AbuTaha AS, Zyoud SH. Bibliometric analysis of medicine-related publications on poverty (2005-2015). Springerplus 2016; 5:1888. [PMID: 27843745 PMCID: PMC5084147 DOI: 10.1186/s40064-016-3593-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 10/21/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Poverty is a global problem. The war against poverty requires not only financial support, but also poverty-related research to pinpoint areas of high need of intervention. In line with international efforts to fight poverty and negative consequences, we carried out this study to give a bibliometric overview of medicine-related literature on poverty. Such a s study is an indicator of the extent of interaction of various international key players on the war against poverty-related health problems. METHODS Scopus was used to achieve the objective of this study. The time span set for this study was 2005-2015. Poverty-related articles under the subject area "Medicine" were used to give bibliometric indicators such as annual growth of publications, international collaboration, highly cited articles, active countries, institutions, journals, and authors. RESULTS The total number of retrieved articles was 1583. The Hirsh-index of retrieved articles was 56. A modest and fluctuating increase was seen over the study period. Visualization map of retrieved articles showed that "HIV", infectious diseases, mental health, India, and Africa were most commonly encountered terms. No significant dominance of any particular author or journal was observed in retrieved articles. The United States of America had the largest share in the number of published articles. The World Health Organization and Centers for Disease Prevention and Control were among top active institutions/organizations. International collaboration was observed in less than one third of publications. Top cited articles focused on three poverty-related health issues, mainly, infectious diseases, malnutrition, and child development/psychology. Most of top articles were published in high impact journals. CONCLUSIONS Data indicated that articles on poverty were published in high influential medical journals indicative of the importance of poverty as a global health problem. However, the number publications and the extent of international collaborations was lower than expected given the huge burden of poverty-related health problems.
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Affiliation(s)
- Waleed M. Sweileh
- Department of Physiology, Pharmacology, and Toxicology, College of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
| | - Samah W. Al-Jabi
- Department of Clinical and Community Pharmacy, College of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
| | - Ansam F. Sawalha
- Department of Physiology, Pharmacology, and Toxicology, College of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
| | - Adham S. AbuTaha
- Department of Physiology, Pharmacology, and Toxicology, College of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
| | - Sa’ed H. Zyoud
- Department of Clinical and Community Pharmacy, College of Medicine and Health Sciences, An-Najah National University, Nablus, Palestine
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Vian T, Feeley FG, Domente S, Negruta A, Matei A, Habicht J. Barriers to universal health coverage in Republic of Moldova: a policy analysis of formal and informal out-of-pocket payments. BMC Health Serv Res 2015; 15:319. [PMID: 26260324 PMCID: PMC4531477 DOI: 10.1186/s12913-015-0984-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 08/02/2015] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Universal Health Coverage seeks to assure that everyone can obtain the health services they need without financial hardship. Countries which rely heavily on out-of-pocket (OOP) payments, including informal payments (IP), to finance total health expenditures are not likely to achieve universal coverage. The Republic of Moldova is committed to promoting universal coverage, reducing inequities, and expanding financial protection. To achieve these goals, the country must reduce the proportion of total health expenditures paid by households. This study documents the extent of OOP payments and IP in Moldova, analyses trends over time, and identifies factors which may be driving these payments. METHODS The study includes analysis of household budget survey data and previous research and policy documents. The team also conducted a review of administrative law intended to control OOP payments and IPs. Focus groups, interviews, and a policy dialogue with key stakeholders were held to validate and discuss findings. RESULTS OOP payments account for 45% of total health expenditures. Sixteen percent of outpatients and 30% of inpatients reporting that they made OOP payments when seeking care at a health facility in 2012, more than two-thirds of whom also reported paying for medicines at a pharmacy. Among those who paid anything, 36% of outpatients and 82% of inpatients reported paying informally, with the proportion increasing over time for inpatient care. Although many patients consider these payments to be gifts, around one-third of IPs appear to be forced, posing a threat to health care access. Patients perceive that payments are driven by the limited list of reimbursable medicines, a desire to receive better treatment, and fear or extortion. Providers suggested irrational prescribing and ordering of tests as drivers. Providers may believe that IPs are gifts and do not cause harm for patients and the health system in general. CONCLUSIONS Efforts to expand financial protection should focus on reducing household spending on medicines and hospital-based IPs. Reforms should consider ways to reduce medicine prices and promote rational use, strengthen administrative controls, and increase incentives for quality health care provision.
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Affiliation(s)
- Taryn Vian
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown Building 3rd floor, Boston, MA, 02118, USA.
| | - Frank G Feeley
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown Building 3rd floor, Boston, MA, 02118, USA.
| | - Silviu Domente
- World Health Organization Country Office in Republic of Moldova, Sfatul Tarii Str. 29, MD-2012, Chisinau, Republic of Moldova.
| | - Ala Negruta
- National Bureau of Statistics, 106 Grenoble Str., MD-2019, Chisinau, Republic of Moldova.
| | - Andrei Matei
- World Health Organization Country Office in Republic of Moldova, Sfatul Tarii Str. 29, MD-2012, Chisinau, Republic of Moldova.
| | - Jarno Habicht
- World Health Organization Country Office in Republic of Moldova, Sfatul Tarii Str. 29, MD-2012, Chisinau, Republic of Moldova.
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Rezapour A, Ebadifard Azar F, Azami Aghdash S, Tanoomand A, Ahmadzadeh N, Sarabi Asiabar A. Inequity in household's capacity to pay and health payments in Tehran-Iran-2013. Med J Islam Repub Iran 2015; 29:245. [PMID: 26793636 PMCID: PMC4715421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 05/21/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Health inequality monitoring especially in Health care financing field is very important. Hence, this study tends to assess the inequality in household's capacity to pay and out-of-pocket health carepaymentsin Tehran metropolis. METHODS This cross-sectional study was performed in 2013.Thestudy population was selected by stratified cluster sampling, and they constitute the typical households living in Tehran (2200 households). The required data were collected through questionnaires and analyzed using Excel and Stata v.11. Concentration Index on inequality was used for measuring inequality status in capacity to pay and household payments for health care expenses; and also the concentration index for out-of-pocket payments and capacity to pay was used to determine the extent of inequality. The recall period for inpatient care was one year and 1 month for outpatient. RESULTS The average of out-of-pocket payments for receiving the outpatient services was determined to be 44.33US$ and for each inpatient1861.11 US$. Concentration index for household's outof- pocket payments for inpatient health care, out-of-pocket payments for outpatient health care and health prepayments were calculated 0.13, -0.10 and -0.11, respectively. Also, concentration index in household's capacity to pay was estimated to be 0.11whichindicatedinequality to the benefit of the rich. The households used financing strategies like savings, borrowing or lending to pay their health care expenditures. CONCLUSION According to this study, the poor spend a greater portion of their capacity to pay for outpatient and inpatient health care costs and prepayment, in comparison to the rich. Thus, supporting the vulnerable groups of the society to decrease out-of-pocket payments and increasing the household's capacity to pay through government support in order to improve the household economic potential, must be considered very important.
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Affiliation(s)
- Aziz Rezapour
- PhD, Department of Health Economics, School of Health Management and information Sciences& Health management and Economics Research Center &Center of Excellence in Health Management and Economics, Iran University of Medical Sciences. Tehran, Iran.
| | - Farbod Ebadifard Azar
- PhD, Department of Health Education and promotion, School of Health &Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran.
| | - Saber Azami Aghdash
- PhD Candidate in Health Policy, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran.
| | - Asghar Tanoomand
- PhD, Department of Microbiology, Faculty of Medical Sciences, Maragheh University of Medical Sciences, Maragheh, Iran.
| | - Nahal Ahmadzadeh
- MA Management Systems and Efficiency, the Deputy of Health in Social Affairs, Management and Planning Organization, Tehran, Iran.
| | - Ali Sarabi Asiabar
- MSc in Public Administration, Health Management and Economics Research Center, Iran university of Medical Sciences, Tehran, Iran.
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Damrongplasit K, Melnick G. Funding, coverage, and access under Thailand's universal health insurance program: an update after ten years. Appl Health Econ Health Policy 2015; 13:157-166. [PMID: 25566748 DOI: 10.1007/s40258-014-0148-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND In 2001, Thailand implemented a universal coverage program by expanding government-funded health coverage to uninsured citizens and limited their out-of-pocket payments to 30 Baht per encounter and, in 2006, eliminated out-of-pocket payments entirely. Prior research covering the early years of the program showed that the program effectively expanded coverage while a more recent paper of the early effects of the program found that improved access from the program led to a reduction in infant mortality. OBJECTIVE We expand and update previous analyses of the effects of the 30 Baht program on access and out-of-pocket payments. DATA AND METHODS We analyze national survey and governmental budgeting data through 2011 to examine trends in health care financing, coverage and access, including out-of-pocket payments. RESULTS By 2011, only 1.64 % of the population remained uninsured in Thailand (down from 2.61 % in 2009). While government funding increased 75 % between 2005 and 2010, budgetary requests by health care providers exceeded approved amounts in many years. The 30 Baht program beneficiaries paid zero out-of-pocket payments for both outpatient and inpatient care. Inpatient and outpatient contact rates across all insurance categories fell slightly over time. CONCLUSIONS Overall, the statistical results suggest that the program is continuing to achieve its goals after 10 years of operation. Insurance coverage is now virtually universal, access has been more or less maintained, government funding has continued to grow, though at rates below requested levels and 30 Baht patients are still guaranteed access to care with limited or no out-of-pocket costs. Important issues going forward are the ability of the government to sustain continued funding increases while minimizing cost sharing.
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Affiliation(s)
- Kannika Damrongplasit
- Faculty of Economics, Chulalongkorn University, Phayathai Road, Bangkok, 10330, Thailand,
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Abuya T, Maina T, Chuma J. Historical account of the national health insurance formulation in Kenya: experiences from the past decade. BMC Health Serv Res 2015; 15:56. [PMID: 25884159 PMCID: PMC4332452 DOI: 10.1186/s12913-015-0692-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 01/09/2015] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Many Low-and-Middle-Income countries are considering reviewing their health financing systems to meet the principles of Universal Health Coverage (UHC). One financing mechanism, which has dominated UHC reforms, is the development of health insurance schemes. We trace the historical development of the National Health Insurance (NHI) policy, illuminate stakeholders' perceptions on the design to inform future development of health financing policies in Kenya. METHODS We conducted a retrospective policy analysis of the development of a NHI policy in Kenya using data from document reviews and seven in depth interviews with key stakeholders involved in the NHI design. Analysis was conducted using a thematic framework. RESULTS The design of a NHI scheme was marked by complex interaction of the actor's understanding of the design, proposed implementation strategies and the covert opposition of the reform due to several reasons. First, actor's perception of the cost of the NHI design and its implication to the economy generated opposition. This was due to inadequate communication strategies to articulate the policy, leading to a vacuum of factual information flow to various players. Secondly, perceived fear of implications of the changes among private sector players threatened support and success gained. Thirdly, underlying mistrust associated with perceived lack of government's commitment towards transparency and good governance affected active engagement of all key players dampening the spirit of collective bargain breeding opposition. Finally, some international actors perceived a clash of their role and that of international programs based on vertical approaches that were inherent in the health system. CONCLUSION The thrust towards UHC using NHI schemes should not only focus on the design of a viable NHI package but should also involve stakeholder engagements, devise ways of improving the health care system, enhance transparency and develop adequate governance structures to institutions mandated to provide leadership in the reform process to overcome covert opposition.
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Affiliation(s)
- Timothy Abuya
- Population Council, P.O Box 17643-00500, Nairobi, Kenya.
| | - Thomas Maina
- Futures Group, Health Policy Project, P.O Box 3170-00100, Nairobi, Kenya.
- Ministry of Health, P.O. Box: 30016-00100, Nairobi, Kenya.
| | - Jane Chuma
- KEMRI-Wellcome Trust Research Programme, P.O Box 230-80108, Kilifi, Kenya.
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.
- School of Economics, University of Nairobi, P. O. Box 30197-00100, Nairobi, Kenya.
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Footman K, Richardson E, Roberts B, Alimbekova G, Pachulia M, Rotman D, Gasparishvili A, McKee M. Foregoing medicines in the former Soviet Union: changes between 2001 and 2010. Health Policy 2014; 118:184-92. [PMID: 25263591 DOI: 10.1016/j.healthpol.2014.09.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Revised: 09/03/2014] [Accepted: 09/08/2014] [Indexed: 10/24/2022]
Abstract
Pharmaceutical costs dominate out-of-pocket payments in former Soviet countries, posing a severe threat to financial equity and access to health services. Nationally representative household survey data collected in Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia and Ukraine were analysed to compare the level of population having to forego medicines in 2001 and 2010. Subgroup analysis was conducted to assess differences between populations of different economic status, and rural and urban populations. A substantial proportion of the population did forego medicines in 2010, from 29.2% in Belarus to 72.9% in Georgia. There was a decline in people foregoing medicines between 2001 and 2010; the greatest decline was seen in Moldova [rate ratio (RR)=0.67 (0.63; 0.71)] and Kyrgyzstan [RR=0.63 (0.60; 0.67)], while very little improvement took place in countries with a higher Gross National Income (GNI) per capita and greater GNI growth over the decade such as Armenia [RR=0.92 (0.87; 0.96)] and Georgia [RR=0.95 (0.92; 0.98)]. Wealthier, urban populations have benefited more than poorer, rural households in some countries. Countries experiencing the greatest improvement over the study period were those that have implemented policies such as price controls, expanded benefits packages, and encouragement of rational prescribing. Greater commitment to pharmaceutical reform is needed to ensure that people are not forced to forego medicines.
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Affiliation(s)
- Katharine Footman
- European Centre on Health of Societies in Transition, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK.
| | - Erica Richardson
- European Observatory on Health Systems and Policies, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Bayard Roberts
- European Centre on Health of Societies in Transition, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
| | - Gulzhan Alimbekova
- Center for Study of Public Opinion, 38 Pushkin Street, Almaty 050002, Kazakhstan
| | - Merab Pachulia
- Georgian Opinion Research Business International, 34 Tashkenti Street, Tbilisi, Georgia
| | - David Rotman
- Center for Sociological and Political Research, Belarussian State University, 14 Leningradskaya, Minsk 20050, Belarus
| | - Alexander Gasparishvili
- Centre for Sociological Studies, Moscow State University, Leninskie Gory, Moscow 119991, Russian Federation
| | - Martin McKee
- European Centre on Health of Societies in Transition, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK
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Kimani JK, Ettarh R, Warren C, Bellows B. Determinants of health insurance ownership among women in Kenya: evidence from the 2008-09 Kenya demographic and health survey. Int J Equity Health 2014; 13:27. [PMID: 24678655 PMCID: PMC3973618 DOI: 10.1186/1475-9276-13-27] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Accepted: 03/25/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Government of Kenya is making plans to implement a social health insurance program by transforming the National Hospital Insurance Fund (NHIF) into a universal health coverage program. The objective of this study was to examine the determinants associated with health insurance ownership among women in Kenya. METHODS Data came from the 2008-09 Kenya Demographic and Health Survey, a nationally representative survey. The sample comprised 8,435 women aged 15-49 years. Descriptive statistics and multivariable logistic regression analysis were used to describe the characteristics of the sample and to identify factors associated with health insurance ownership. RESULTS Being employed in the formal sector, being married, exposure to the mass media, having secondary education or higher, residing in households in the middle or rich wealth index categories and residing in a female-headed household were associated with having health insurance. However, region of residence was associated with a lower likelihood of having insurance coverage. Women residing in Central (OR = 0.4; p < 0.01) and North Eastern (OR = 0.1; p < 0.5) provinces were less likely to be insured compared to their counterparts in Nairobi province. CONCLUSIONS As the Kenyan government transforms the NHIF into a universal health program, it is important to implement a program that will increase equity and access to health care services among the poor and vulnerable groups.
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Affiliation(s)
- James K Kimani
- Population Council, General Accident Insurance House, Ralph Bunche Road, P,O, Box 17643-00500, Nairobi, Kenya.
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Balabanova D, Mills A, Conteh L, Akkazieva B, Banteyerga H, Dash U, Gilson L, Harmer A, Ibraimova A, Islam Z, Kidanu A, Koehlmoos TP, Limwattananon S, Muraleedharan VR, Murzalieva G, Palafox B, Panichkriangkrai W, Patcharanarumol W, Penn-Kekana L, Powell-Jackson T, Tangcharoensathien V, McKee M. Good Health at Low Cost 25 years on: lessons for the future of health systems strengthening. Lancet 2013; 381:2118-33. [PMID: 23574803 DOI: 10.1016/s0140-6736(12)62000-5] [Citation(s) in RCA: 177] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
In 1985, the Rockefeller Foundation published Good health at low cost to discuss why some countries or regions achieve better health and social outcomes than do others at a similar level of income and to show the role of political will and socially progressive policies. 25 years on, the Good Health at Low Cost project revisited these places but looked anew at Bangladesh, Ethiopia, Kyrgyzstan, Thailand, and the Indian state of Tamil Nadu, which have all either achieved substantial improvements in health or access to services or implemented innovative health policies relative to their neighbours. A series of comparative case studies (2009-11) looked at how and why each region accomplished these changes. Attributes of success included good governance and political commitment, effective bureaucracies that preserve institutional memory and can learn from experience, and the ability to innovate and adapt to resource limitations. Furthermore, the capacity to respond to population needs and build resilience into health systems in the face of political unrest, economic crises, and natural disasters was important. Transport infrastructure, female empowerment, and education also played a part. Health systems are complex and no simple recipe exists for success. Yet in the countries and regions studied, progress has been assisted by institutional stability, with continuity of reforms despite political and economic turmoil, learning lessons from experience, seizing windows of opportunity, and ensuring sensitivity to context. These experiences show that improvements in health can still be achieved in countries with relatively few resources, though strategic investment is necessary to address new challenges such as complex chronic diseases and growing population expectations.
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Affiliation(s)
- Dina Balabanova
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.
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Arsenijevic J, Pavlova M, Groot W. Measuring the catastrophic and impoverishing effect of household health care spending in Serbia. Soc Sci Med 2013; 78:17-25. [DOI: 10.1016/j.socscimed.2012.11.014] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2011] [Revised: 10/30/2012] [Accepted: 11/12/2012] [Indexed: 10/27/2022]
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Beran D, Abdraimova A, Akkazieva B, McKee M, Balabanova D, Yudkin JS. Diabetes in Kyrgyzstan: changes between 2002 and 2009. Int J Health Plann Manage 2012; 28:e121-37. [DOI: 10.1002/hpm.2145] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2011] [Revised: 04/30/2012] [Accepted: 09/13/2012] [Indexed: 11/09/2022] Open
Affiliation(s)
| | | | | | - Martin McKee
- London School of Hygiene and Tropical Medicine; London; UK
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Abstract
Introduction Prevailing sociopolitical and economic obstacles have been implicated in the inadequate utilization and delivery of the Armenian health care system. Methods A random survey of 1,000 local residents, from all administrative regions of Armenia, concerned with health care services cost and satisfaction was conducted. Participation in the survey was voluntary and the information was collected using anonymous telephone interviews. Results The utilization of health care services was low, particularly in rural areas. This under-utilization of services correlated with low income of the population surveyed. The state funded health care services are inadequate to ensure availability of free-of-charge services even to economically disadvantaged groups. Continued reliance on direct out-of pocket and illicit payments, for medical services, are serious issues which plague healthcare, pharmaceutical and medical technology sectors of Armenia. Conclusions Restructuring of the health care system to implement a cost-effective approach to the prevention and treatment of diseases, especially disproportionately affect the poor, should be undertaken. Public payments, increasing the amount of subsidies for poor and lower income groups through a compulsory health insurance system should be evaluated and included as appropriate in this health system redesign. Current medical services reimbursement practices undermine the principle of equity in financing and access. Measures designed to improve healthcare access and affordability for poor and disadvantaged households should be enacted.
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Affiliation(s)
- Tamara Tonoyan
- Yerevan State Medical University (YSMU), 2 Koryun str., Yerevan 0025, Republic of Armenia.
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Kimani JK, Ettarh R, Kyobutungi C, Mberu B, Muindi K. Determinants for participation in a public health insurance program among residents of urban slums in Nairobi, Kenya: results from a cross-sectional survey. BMC Health Serv Res 2012; 12:66. [PMID: 22424445 DOI: 10.1186/1472-6963-12-66] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2010] [Accepted: 03/19/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The government of Kenya is making plans to implement a social health insurance program by transforming the National Hospital Insurance Fund (NHIF) into a universal health coverage program. This paper examines the determinants associated with participation in the NHIF among residents of urban slums in Nairobi city. METHODS The study used data from the Nairobi Urban Health and Demographic Surveillance System in two slums in Nairobi city, where a total of about 60,000 individuals living in approximately 23,000 households are under surveillance. Descriptive statistics and multivariate logistic regression analysis were used to describe the characteristics of the sample and to identify factors associated with participation in the NHIF program. RESULTS Only 10% of the respondents were participating in the NHIF program, while less than 1% (0.8%) had private insurance coverage. The majority of the respondents (89%) did not have any type of insurance coverage. Females were more likely to participate in the NHIF program (OR = 2.4; p < 0.001), while respondents who were formerly in a union (OR = 0.5; p < 0.05) and who were never in a union (OR = 0.6; p < 0.05) were less likely to have public insurance coverage. Respondents working in the formal employment sector (OR = 4.1; p < 0.001) were more likely to be enrolled in the NHIF program compared to those in the informal sector. Membership in microfinance institutions such as savings and credit cooperative organizations (SACCOs) and community-based savings and credit groups were important determinants of access to health insurance. CONCLUSIONS The proportion of slum residents without any type of insurance is high, which underscores the need for a social health insurance program to ensure equitable access to health care among the poor and vulnerable segments of the population. As the Kenyan government moves toward transforming the NHIF into a universal health program, it is important to harness the unique opportunities offered by both the formal and informal microfinance institutions in improving health care capacity by considering them as viable financing options within a comprehensive national health financing policy framework.
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Abstract
OBJECTIVE To assess accessibility and affordability of health care in eight countries of the former Soviet Union. DATA SOURCES/STUDY SETTING Primary data collection conducted in 2010 in Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Moldova, Russia, and Ukraine. STUDY DESIGN Cross-sectional household survey using multistage stratified random sampling. DATA COLLECTION/EXTRACTION METHODS Data were collected using standardized questionnaires with subjects aged 18+ on demographic, socioeconomic, and health care access characteristics. Descriptive and multivariate regression analyses were used. PRINCIPAL FINDINGS Almost half of respondents who had a health problem in the previous month which they viewed as needing care had not sought care. Respondents significantly less likely to seek care included those living in Armenia, Georgia, or Ukraine, in rural areas, aged 35-49, with a poor household economic situation, and high alcohol consumption. Cost was most often cited as the reason for not seeking health care. Most respondents who did obtain care made out-of-pocket payments, with median amounts varying from $13 in Belarus to $100 in Azerbaijan. CONCLUSIONS Access to health care and within-country inequalities appear to have improved over the past decade. However, considerable problems remain, including out-of-pocket payments and unaffordability despite efforts to improve financial protection.
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Affiliation(s)
- Dina Balabanova
- London School of Hygiene and Tropical Medicine, Faculty of Public Health and Policy, 15-17 Tavistock Place, London, WC1H 9SH, UK.
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Rechel B, Ahmedov M, Akkazieva B, Katsaga A, Khodjamurodov G, McKee M. Lessons from two decades of health reform in Central Asia. Health Policy Plan 2011; 27:281-7. [PMID: 21609971 DOI: 10.1093/heapol/czr040] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Since becoming independent at the break-up of the Soviet Union in 1991, the countries of Central Asia have made profound changes to their health systems, affecting organization and governance, financing and delivery of care. The changes took place in a context of adversity, with major political transition, economic recession, and, in the case of Tajikistan, civil war, and with varying degrees of success. In this paper we review these experiences in this rarely studied part of the world to identify what has worked. This includes effective governance, the co-ordination of donor activities, linkage of health care restructuring to new economic instruments, and the importance of pilot projects as precursors to national implementation, as well as gathering support among both health workers and the public.
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Affiliation(s)
- B Rechel
- European Observatory on Health Systems and Policies, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.
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