Does community-based health insurance affect lifestyle and timing of treatment seeking behavior?Evidence from Ethiopia

Objectives This paper aims to investigate the effects of enrollment in the Ethiopian community-based health insurance(CBHI)scheme on household preventive care activities and the timing of treatment-seeking behavior for illness symptoms.There is growing concern about the financial sustainability of CBHI schemes in developing countries.However,few empirical studies have identified potential contributors,including ex-ante and ex-post moral hazards.Methods We implement a household fixed-effect panel data regression model,drawing on three rounds of household survey data collected face to face in districts where CBHI scheme is operational and in districts where it is not operational in Ethiopia.Results The findings show that enrolment in CBHI does not significantly influence household behaviour regarding preventive care activities such as water treatment before drinking and handwashing before meals.However,CBHI significantly increases delay in treatment-seeking behaviour for diseases symptoms.Particularly,on average,we estimate about 4-6 h delay for malaria symptoms,a little above 4 h for tetanus,and 10-11 h for tuberculosis among the insured households.Conclusions While there is evidence that CBHI improve the utilization of outpatient or primary care services,our study suggests that insured members may wait longer before visiting health facilities.This delay could be partly due to moral hazard problems,as insured households,particularly those from rural areas,may consider the opportunity costs associated with visiting health facilities for minor symptoms.Overall,it is essential to identify the primary causes of delays in seeking medical services and implement appropriate interventions to encourage insured individuals to seek early medical attention.

Incidence and in-hospital mortality of acute aortic dissection in China： analysis of China Health Insurance Research （CHIRA） Data 2011

Objective Acute aortic dissection （AAD） is a catastrophic event with high early mortality rate, but to date, no data on the incidence of AAD in China's Mainland is available. This study aimed to estimate the incidence of AAD in China and characterize the clinical profile, management and in-hospital outcomes of this vascular event. Methods We used the China Health Insurance Research Data （the CHIRA Data） 2011 which comprises all inpatient hospital records （300,886） during the period of Jan. 1st 2011 to Dec. 31 2011 of 3,335,000 randomly sampled beneficiaries （1,718,500 men and 1,616,500 women） from 25 cities and counties in different economic-geographic regions of China's Mainland. Patients with acute aortic dissection were identified according to International Classification of Disease 10m Revision （ICD-10） of I71.0, The estimated incidence of AAD was calculated using the equation： estimated incidence = 2.0 × （40% × hospital admission rate） ＋ 60% × hospital admission rate. Results The hospital admission rate was 2.0/100,000 （65/3,325,000, 95% CI： 1.2-2.8）. The estimated annual incidence of AAD was 2.8/100,000 （95% CI： 1.9-3.6） and was higher in male than in female （3.7 vs. 1.5, P 〈 0.001）. The mean age was 58.9 ± 13.4 years. During the mean hospital stay of 23 ±6 days, the overall in-hospital mortality was 13.9% （9/65）. Conclusions Our study showed relatively lower but not negligible incidence and in-hospital mortality of AAD in the mainland of China. The mean age of patients with AAD in Chinese was younger than that reported by researches from west countries, while the male to female incidence ratio is similar to those reported by other studies.

Household Perceptions, Willingness to Pay, Benefit Package Preferences, Health System Readiness for National Health Insurance Scheme in Southern Nigeria

Introduction: Several Nigerians are completely denied access to adequate health care because of cultural, temporal and financial factors with inequity. Objectives: To ascertain the household perceptions, willingness to pay, benefit package preferences, and health systems readiness for Insurance Scheme. Methods: A cross-sectional study of 400 heads of households and 43 health workers in Enugu, Southern Nigeria. Results: Awareness of NHIS among the heads of household was 56.8%, while it was 86% among the health workers. Awareness of NHIS among heads of households was significantly associated to both educational level (X2 = 16.083, P = 0.001), and occupation (X2 = 5.694, P = 0.017). More males (61.6%) had correct perceptions of NHIS compared to females (58.6%), but not statistically significant (X2 = 0.336, P = 0.562). Majority of households respondents 89% are willing to pay for NHIS. Willingness to pay was significantly associated to occupation (X2 = 5.169, df = 1, P = 0.023), but willingness to pay mandatory 5% premium was not significantly associated to occupation (X2 = 0.884, P = 347). Only 11.6% of the health facilities are enlisted as providers in the scheme. Conclusion: Willingness to pay was high, but majority are not ready to pay 5% premium of their earnings. Awareness creation programmes should be improved for the public, and more health facilities enlisted for wider coverage.

Assessing the Impact of Health Insurance on Household Financial Protection in Togo

Context: To facilitate financial access to care for the population, health insurance mechanisms have been established, in particular the National Health Insurance Institute, which covers civil servants and their dependents. In addition, other voluntary and community mechanisms have been developed. After several years of implementation, the level of catastrophic health expenditures among insured individuals shows that there is still a considerable level of financial risk associated with health care. This study aims to assess the impact of health insurance in Togo on insured populations. Methodology: The data used in this study come from the harmonized survey on household living conditions carried out in 2018 by the National Institute of Statistics, Economic and Demographic Studies. The propensity score matching method was used according to the following steps: estimation of propensity scores, verification of the conditional independence hypothesis (balancing property) and estimation of the average treatment effect on treated. Stata V14.2 software was used. Findings: The average effect of health insurance on household financial protection is −0.012 for the nearest neighbor method, −0.013 for the matching radius method, −0.015 for the Kernel and −0.016 for the stratification method. Results showed that health insurance contributes to reducing catastrophic health expenditures, but their effect remains very limited. This could be explained by the level of care package covered and the cost covered. Conclusion: Health insurance contributes to the reduction of catastrophic health expenses for households. However, it is important to widen the range of care covered and the cost covered. In addition, measures to extend this coverage to a larger proportion of the population will make it possible to have a greater impact.

The Acceptance Intention of Consumers for a Dynamic Payment Mechanism for Health Insurance Coverage

Currently, a consumer＇s monthly premium payment amount remitted to the National Health Insurance is based on the ＂monthly real wages,＂ while commercial health insurance uses ＂consumer age＂ as the basis for the premium amount charged. In reality, health, salary, and age have no visible connection. Therefore, the insurance premium scheme using salary and age as standards should be improved and adjusted upon. This study uses the Decomposed Theory of Planned Behavior as the research basis, and through the designed questionnaire, investigates the health data gathered from wearable devices and uses big data to process the constructed health assessment indicators. These indicators will be used to analyze whether consumers are willing to contribute to their health insurance using the dynamic payment mechanism. Subsequently, empirical research was performed using hypothesis architecture and structural equation.

Community-Based Health Insurance： An Evolutionary Approach to Achieving Universal Coverage in Low-Income Countries

The WHO World Health Assembly, and the most recent WHO World Health Report, have called for all health systems to move toward universal coverage. However, low-income countries have made little progress in this respect. We use existing evidence to describe the evolution of community-based health insurance in low-income countries through the three stages of basic model, enhanced model, and nationwide model. We have concluded that community-based health insurance development is a potential strategy to meet the urgent need for health financing in low-income countries. With careful planning and implementation, it is possible to adopt such evolutionary approach to achieve universal coverage by extending tax-based financing/social insurance characteristics to community-based health insurance schemes.

Assessing Drug Use Indicators in Health Insurance Facilities, Gezira State, Sudan, 2017-2018

Background: Inappropriate use of medicines is a global concern with serious consequences related to prescribing, dispensing, and use. WHO estimated that 50% of medicines are not used correctly on their journey from the facility to home. Objective: To assess medicines use using WHO drug core indicators regarding prescribing, patient, and facilities. Setting: Outpatients, Health centers in Wadmadani locality (Urban area) in Gezira State, Sudan. Method: A cross-sectional, prospective, analytical study was conducted in 30 health centers and 60 patients from each center were selected using a simple random sampling technique. WHO indicators form was used to collect data containing different variables. T-test at a level of confidence of 95% was used to test differences between indicators. Statistical Package for Social Science (SPSS) was used for data analysis. Results: The main prescribing indicators were 2.5 ± 0.6 for drugs per encounter, 44.1% ± 14.2%. Generic 54 ± 18.0 antibiotics, 12.0% ± 9.3% injectable, and 95.2% ± 11.5% of drugs were prescribed according to the NHIF-EML. The main patient’s indicators were, 2.9 ± 0.8 minutes for consultation time, 99.5 ± 36.8 seconds for dispensing time, and 72.5% ± 16.0% for medicines actually dispensed, 49.0% ± 18.0% for medicines adequately labeled, and 22.5% ± 7.3% of the patient’s knowledge about the correct dose. The Facility specific indicators were 66.7% for the availability of a copy of EML, while the percentage of key drugs in the stock was 75.3% ± 11.6%. No statistically significant differences were found between direct and indirect facilities except in generic prescribing. Main Outcome Measure: • Interventions to improve Generic and antibiotics prescribing indicators. • The patient-to-physician ratio should be revised to optimize consultation time. • The availability of key drugs should be improved to make sure effective treatment. • The pharmacy cadre should be oriented and trained to improve patients’ compliance. Conclusion: The study concluded that there was irrational use of medicines when investigated by WHO drug core indicators. So, the study recommended interventions to improve the rationale prescribing, dispensing, and use of medicines.

Impact of Dialysis Coverage on the Provision of Universal Health Insurance in the Republic of the Congo

Introduction: The launch of health insurance in the Republic of the Congo took place against a backdrop of extremely high costs for dialysis, which was not one of the services financed within this framework. The aim of this study is to assess the impact of including dialysis in the health insurance package in Congo. Methodology: This is a descriptive cross-sectional study with an evaluative aim, analyzing the impact of dialysis on the financing capacity of health insurance and health facilities to provide this type of care. Results: The results show that including dialysis in the universal health insurance package will require an additional financial effort of 6.20% of the current total financing capacity of the care basket. Most dialysis sessions are provided by the private health sector (87.5%), whose health facilities are unevenly distributed across the country, and concentrated in the country’s two major cities. This problem is the dual consequence of the very high cost of a dialysis session (average cost 140,234,375 FCFA or 229 US Dollars) and the number of patients under care, which will increase in the absence of effective and ongoing prevention efforts against chronic diseases in general and end-stage renal failure in particular. Conclusion: Dialysis is a high-impact public health intervention. The impact of its inclusion in the universal health insurance care package is difficult to bear financially. For dialysis to be covered by universal health insurance, additional funding and improved technical facilities are needed.

Study of the Impact of the COVID-19 Pandemic on Health Insurance Fund of Hubei Province in 2020

Objective To provide a reference for future budget of health insurance fund for the COVID-19 pandemic in other parts of China or other major public health events.Meanwhile,it also offers a reference for the government to introduce and adjust the policy of health insurance funds after the pandemic.Methods Models of the income,expenditure and cumulative balance of health insurance fund in Hubei Province in 2020 were established and compared.The former was mainly established and tested using SPSS 26.0 and Excel,while the latter was obtained by inferential analysis.Results and Conclusion The COVID-19 pandemic reduced the income and increased expenditure of the health insurance fund in Hubei Province in 2020,resulting in a deficit.The COVID-19 outbreak has caused a deficit in health insurance fund of Hubei Province in the short term,but in the long term,the outbreak will not have a major impact on the health insurance fund.

Health Insurance:Better Safe than Sorry!

If your employer is sending you to China, chances are you will enjoy the status of an expatriate and all the benefits that come with it, including health insurance. However, if you＇re not that lucky, you＇ll have to deal with this painfully expensive matter on your own, unless, of course, you decide not to purchase health insurance. But in a country where serious or even fatal accidents and health emergencies can and do happen, you would literally be taking your life into your own hands.

Network analysis of Iranian’s health insurance ecosystem before and after the introduction of Universal Health Insurance law

Introduction The policy-making process in health reform is challenging due to the complexity of organizations,overlapping roles,and diversity of responsibilities.The present study aims to investigate and analyze the network of actors in the Iran health insurance ecosystem regarding the laws before and after the adoption of the Universal Health Insurance(UHI).Methods The present study was done by sequential exploratory mixed method research,consisting of two distinct phases.During the qualitative phase,the actors and issues pertaining to the laws of the Iranian health insurance ecosystem from 1971 to 2021 were identified through a systematic search of the laws and regulations section of the Research Center of the Islamic Legislative Assembly website.Qualitative data was analyzed in three steps using directed content analysis.During the quantitative phase,in order to draw the communication network of the actors in Iran’s health insurance ecosystem,the data related to the nodes and links of the networks was collected.The communication networks were drawn using Gephi software and the micro-and macro-indicators of network were calculated and analyzed.Results There were 245 laws and 510 articles identified in the field of health insurance in Iran from 1971 to 2021.Most of the legal comments were on financial matters and credit allocation,and the payment of premiums.The number of actors before and after the enactment of the UHI Law was 33 and 137,respectively.The Ministry of Health and Medical Education and the Iran Health Insurance Organization were found the two main actors in the network before and after the approval of this law.Conclusions Adopting a UHI Law and delegating various legal missions and tasks,often with support to the health insurance organization,have facilitated the achievement of the law objectives.However,it has created a poor governance system and a network of actors with low coherence.Based on the results of the study,it is suggested to reduce actor roles and separate them for better governance and to prevent corruption in health insurance ecosystem.Introducing knowledge and technology brokers can be effective in strengthening governance and filling the structural gaps between actors.

Assessing the feasibility and appropriateness of introducing a national health insurance scheme in Malawi

Background:In May 2015 the Malawian Ministry of Health(MOH)contacted the German Development Cooperation to seek technical assistance from the P4H Network for Social Health Protection for an“Assessment of the appropriateness and feasibility of National Health Insurance in Malawi”against two alternative options:continuing with a tax(and donor)-funded National Health Service,and introducing a purchaser-provider split without a revenue collection function.Methods:A health financing benchmarking matrix was agreed with MOH,with six domains corresponding to six objectives:revenue mobilisation,technical efficiency,equity,financial risk protection,policy coordination,and health outcomes.The assessment comprised key informant interviews with Malawian stakeholders,a review of the relevant literature and datasets,rapid assessments of the Malawi Revenue Authority(MRA)and the Unified Beneficiary Registry(UBR),and projections of the National Health Insurance Scheme’s(NHIS)revenue collection costs and benefits.Results:A key finding was that introducing NHIS in Malawi would increase revenues for health,but these would come predominantly from the formal sector and would be unlikely to cover the health sector funding gap.The performance of existing poverty identification and targeting mechanisms was not commensurate with the requirements of a NHIS.Incentives to enrol in NHI are insufficient to reach scale unless service fees be introduced,which would negatively affect equity and financial risk protection.The assessment identified the Purchaser Scenario as the most favourable reform model.Conclusions:As ever more countries look towards implementing National Health Insurance,the proposed assessment framework can provide an orientation for evidence-based policy making in the area of health financing.

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

Background:In many low-income countries,households bear most of the health care costs.Community-based health insurance(CBHI)schemes have multiplied since the 1990s in West Africa.They have significantly improved their members’access to health care.However,a large proportion of users are reluctant to subscribe to a local CBHI.Identifying the major factors affecting membership will be useful for improving CBHI coverage.The objective of this research is to obtain a general overview of existing evidence on the determinants of CBHI membership in West Africa.Methods:A review of studies reporting on the factors determining membership in CBHI schemes in West Africa was conducted using guidelines developed by the Joanna Briggs Institute.Several databases were searched(PubMed,ScienceDirect,Global Health database,Embase,EconLit,Cairn.info,BDPS,Cochrane database and Google Scholar)for relevant articles available by August 15,2022,with no methodological or linguistic restrictions in electronic databases and grey literature.Results:The initial literature search resulted in 1611 studies,and 10 studies were identified by other sources.After eliminating duplicates,we reviewed the titles of the remaining 1275 studies and excluded 1080 irrelevant studies based on title and 124 studies based on abstracts.Of the 71 full texts assessed for eligibility,32 additional papers were excluded(not relevant,outside West Africa,poorly described results)and finally 39 studies were included in the synthesis.Factors that negatively affect CBHI membership include advanced age,low education,low household income,poor quality of care,lack of trust in providers and remoteness,rules considered too strict or inappropriate,low trust in administrators and inadequate information campaign.Conclusions:This study shows many lessons to be learned from a variety of countries and initiatives that could make CBHI an effective tool for increasing access to quality health care in order to achieve universal health coverage.Cover-age through CBHI schemes could be improved through communication,improved education and targeted financial support.

Health insurance and social capital inGhana: a cluster randomised controlled trial

Background:The National Health Insurance Scheme(NHIS)was introduced in Ghana in 2003,enrolment is still far from the desired target of universal coverage.Low community engagement in the design and management of the system was identified as one of the main barriers.The aim of the current study was to explore the role of social capital in NHIS enrolment in two regions of Ghana,Western and Greater Accra.Methods:The study involved a cluster-randomised controlled trial of 3246 clients of 64 healthcare facilities who completed both a baseline and a follow-up survey.Thirty-two facilities were randomly selected to receive two types of intervention.The remaining facilities served as control.The interventions were co-designed with stakeholders.Baseline and follow up surveys included measures of different types of social capital,as well as enrolment in the health insurance scheme.Results:The study found that the interventions encouraged NHIS enrolment(from 40.29 to 49.39%(intervention group)versus 36.49 to 36.75%(control group)).Secondly,certain types of social capital are associated with increased enrolment(log-odds ratios(p-values)of three types of vertical social capital are 0.127(<0.01),0.0952(<0.1)and 0.15(<0.01)).Effectiveness of the interventions was found dependent on initial levels of social capital:respondents with lowest measured level of interpersonal trust in the intervention group were about 25%more likely to be insured than similar respondents in the control group.Among highly trusting respondents this difference was insignificant.There was however no evidence that the interventions effect social capital.Limitations of the study are discussed.Conclusion:We showed that the interventions helped to increase enrolment but that the positive effect was not realized by changes in social capital that we hypothesised based on result of the first phase of our study.Future research should aim to identify other community factors that are part of the enrolment process,whether other interventions to improve the quality of services could help to increase enrolment and,as a result,could provide community benefits in terms of social capital.Our findings can guide the NHIS in Ghana and other health organizations to enhance enrolment.Trial registration:Ethical Clearance by Ghana Health Service Ethical Committee No.GHS-ERC 08.5.11.

Trends and characteristics of enrolment in the National Health Insurance Scheme in Ghana:a quantitative analysis of longitudinal data

Background:In 2004,Ghana started experimenting a National Health Insurance Scheme(NHIS)to reduce out-ofpocket payment for healthcare.Like many other social health insurance schemes in Africa,the NHIS is striving for universal health coverage(UHC).This paper examines trends and characteristics of enrolment in the scheme to inform policy decisions on attainment of UHC.Methods:We conducted trend analysis of longitudinal enrolment data of the NHIS for the period,2010-2017.Descriptive statistics were used to examine trends and characteristics of enrolment by geographical region and member groups.Results:Over the 8-year period,the population enrolled in the scheme increased from 33%(8.2 million)to 41%(11.3 million)between 2010 and 2015 and dropped to 35%(10.3 million)in 2017.Members who renewed their membership increased from 44%to 75.4%between 2010 and 2013 and then dropped to 73%in 2017.On average,the urban regions had significantly higher number of new enrolments than the rural ones.Similarly,the urban and peri-urban regions recorded significantly higher number of renewals than the other regions.In addition,persons below the age of 18 years and the informal sector workers had significantly higher number of enrolment than any other member group.Conclusions:Enrolment in the NHIS is declining and there are significant differences among geographical regions and member groups.Managers of the NHIS need to enforce the mandatory enrolment provision in the Act governing the scheme,employ innovative strategies such as mobile phone application for registration and renewals and address delays in healthcare provider claims to improve enrolment.

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

Background Community-based health insurance(CBHI)schemes are crucial for households to avoid financial hardship,improve healthcare quality,and engage in health policies.Household satisfaction is a key indicator for assessing healthcare quality and identifying service gaps.However,research on household satisfaction with CBHI in Ethiopia is limited.Therefore,this study aimed to evaluate household satisfaction and associated factors with CBHI schemes in Ethiopia.Methods A comprehensive search of relevant literature was conducted using multiple databases,including Pub-Med,Google Scholar,Africa Journal Online,and Ethiopian Universities’institutional open-access online repositories.The search was carried out between January 25,2023,and February 28,2023.Twelve primary studies,including eight published and four unpublished,were identified and included in the analysis with a total sample size of 5311 participants.A protocol with the registration number CRD20531345698 is recorded on the Prospero database.Two authors,DT and MK,independently extracted the required data using a standardized form.The extracted data were then analyzed using STATA version 17 software.Heterogeneity was assessed using the Cochrane Q-test and I2 tests.Finally,a random-effect model was employed to calculate the overall household satisfaction with CBHI and to determine the associated factors.Results The meta-analysis showed that the overall household satisfaction with CBHI in Ethiopia was 62.26%(95%CI 53.25-71.21%).The study found regional variations in household satisfaction,with 63.40%in Oromia,64.01%in Amhara,49.58%in Addis Ababa,and 66.76%in SNNPs.The study identified several factors associated with household satisfaction and the CBHI scheme,including the availability of drugs(OR 2.13,95%CI 1.47-2.78),friendly services(OR 3.85,95%CI 1.60-6.10),affordability of premium(OR 2.80,95%CI 1.97-3.63),and knowledge/awareness of CBHI(OR 2.52,95%CI 1.73-3.33).Conclusions The study provides valuable insights into household satisfaction with CBHI in Ethiopia,with a considerable proportion of enrolees being satisfied.The finding highlights regional variations in household satisfaction and underscores the need for tailored interventions and monitoring to enhance CBHI sustainability and effectiveness.The results suggest that healthcare providers and policymakers should prioritize the availability of drugs,friendly services,affordable premiums,and education to improve household satisfaction with CBHI schemes.

Community perceptions of enrolment of indigents into the National Health Insurance Scheme in Ghana:a case study of the Livelihood Empowerment against Poverty Programme

Background:The Livelihood Empowerment against Poverty(LEAP)programme in Ghana as part of its beneficiary programme,identifies the poor/indigents for exemptions from premium payments in the National Health Insurance Scheme(NHIS).This paper sought to understand community perceptions of enrolling the poor in the NHIS through LEAP in order to inform policy.Methods:The study adopted a descriptive cross-sectional study design by using a qualitative approach.The study was conducted in three geographical regions of Ghana:Greater Accra,Brong-Ahafo and Northern region representing the three ecological zones of Ghana between October 2017 and February 2018.The study population included community members,health workers,NHIS staff and social welfare officers/social development officers.Eighty-one in-depth interviews and 23 Focus Group Discussions were conducted across the three regions.Data were analysed thematically and verbatim quotes from participants were used to support the views of participants.Results:The study shows that participants were aware of the existence of LEAP and its benefits.There was,however,a general belief that the process of LEAP had been politicized and therefore favours only people who were sympathizers of the ruling government as they got enrolled into the NHIS.Participants held the view that the process of selecting beneficiaries lacked transparency,thus,they were not satisfied with the selection process.However,the study shows the ability of the community to identify the poor.The study reports varying concepts of poverty and its identification across the three ecological zones of Ghana.Conclusion:There is a general perception of politicization and lack of transparency of the selection of the poor into the NHIS through the LEAP programme in Ghana.Community-based approaches in the selection of the indigent are recommended to safeguard the NHIS-LEAP beneficiary process.

An Analysis and Prediction of Health Insurance Costs Using Machine Learning-Based Regressor Techniques

One of the most significant annual expenses that a person has is their health insurance coverage. Health insurance accounts for one-third of GDP, and everyone needs medical treatment to varying degrees. Changes in medicine, pharmaceutical trends, and political factors are only a few of the many factors that cause annual fluctuations in healthcare costs. This paper describes how a system may analyse a person’s medical history to display their insurance plans and make predictions about their health insurance premiums. The performance of four ML models—XGBoost, Lasso, KNN, and Ridge—is evaluated using R2-score and RMSE. The analysis of medical health insurance cost prediction using Lasso regression, Ridge regression, and K-Nearest Neighbours (KNN), and XGBoost (XGB) highlights notable differences in performance. KNN has the lowest R2-score of 55.21 and an RMSE of 4431.1, indicating limited predictive ability. Ridge Regression improves on this by an R2-score of 78.38 but has a higher RMSE of 4652.06. Lasso Regression slightly edges out Ridge with an R2-score of 79.78, yet it suffers from an advanced RMSE of 5671.6. In contrast, XGBoost excels with the highest R2-score of 86.81 and the lowermost RMSE of 4450.4, demonstrating superior predictive accuracy and making it the most effective model for this task. The best method for accurately predicting health insurance premiums was XGBoost Regression. The findings beneficial for policymakers, insurers, and healthcare providers as they can use this information to allocate resources more efficiently and enhance cost-effectiveness in the healthcare industry.

Factors contributing to low uptake and renewal of health insurance:a qualitative study in Ghana

Background:The effort to expand access to healthcare and reduce health inequalities in many low income countries have meant that many have adopted different levels of social health protection mechanisms.Ghana introduced a National Health Insurance Scheme(NHIS)in 2005 with the aim of removing previous barriers created by the user fees financing system.Although the NHIS has made health accessible to some category of people,the majority of Ghanaians(60%)are not enroled on the scheme.Earlier studies have looked at various factors that account for this low uptake.However,we recognise that this qualitative study will nuance the depth of these barriers to enrolment.Methods:Minimally structured,qualitative interviews were conducted with key stakeholders at the district,regional and national levels.Focus group discussions were also undertaken at the community level.Using an inductive and content analytic approach,the transcripts were analyzed to identify and define categories that explain low uptake of health insurance.Results:The results are presented under two broad themes:sociocultural and systemic factors.Sociocultural factors identified were 1)vulnerability within certain groups such as the aged and the disabled groups which impeded access to the NHIS 2)cultural and religious norms which discouraged enrolment into the scheme.System-wide factors were 1)inadequate distribution of social infrastructure such as healthcare facilities,2)weak administrative processes within the NHIS,and 3)poor quality of care.Conclusions:Mapping the interplay of these dynamic relations between the NHIS,its clients and service providers,the study identifies critical factors at the policy-making level,service provider level,and client level(reflective in household and community level institutional arrangements)that affect enrolment in the scheme.Our findings inform a number of potential reforms in the area of distribution of health resources and cost containment to expand coverage,increase choices and meeting the needs of the end user.

Enlightenment of German social health insurance system reform on China

According to the latest Chinese Healthcare Reform .Plan, the medical insurance system is one ofthe four components of the healthcare sector. The Healthcare financing and payment in China are mainly based on medical insurance. So it is important to learn the experiences of the developed countries. This paper examines the key issues of the German Healthcare system and reforms, with a particular emphasis on basic social medical insurance, which has the broadest coverage in Germany. It reviews the evolution of the background of the German social medical insurance system, describes how the system functions, and analyzes the existing and emerging problems with the system which push the Germany government to adapt a series of reforms.