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.

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.

Disparity in reimbursement for tuberculosis care among different health insurance schemes: evidence from three counties in central China

Background:Health inequity is an important issue all around the world.The Chinese basic medical security system comprises three major insurance schemes,namely the Urban Employee Basic Medical Insurance(UEBMI),the Urban Resident Basic Medical Insurance(URBMI),and the New Cooperative Medical Scheme(NCMS).Little research has been conducted to look into the disparity in payments among the health insurance schemes in China.In this study,we aimed to evaluate the disparity in reimbursements for tuberculosis(TB)care among the abovementioned health insurance schemes.Methods:This study uses a World Health Organization(WHO)framework to analyze the disparities and equity relating to the three dimensions of health insurance:population coverage,the range of services covered,and the extent to which costs are covered.Each of the health insurance scheme’s policies were categorized and analyzed.An analysis of the claims database of all hospitalizations reimbursed from 2010 to 2012 in three counties of Yichang city(YC),which included 1506 discharges,was conducted to identify the differences in reimbursement rates and out-of-pocket(OOP)expenses among the health insurance schemes.Results:Tuberculosis patients had various inpatient expenses depending on which scheme they were covered by(TB patients covered by the NCMS have less inpatient expenses than those who were covered by the URBMI,who have less inpatient expenses than those covered by the UEBMI).We found a significant horizontal inequity of healthcare utilization among the lower socioeconomic groups.In terms of financial inequity,TB patients who earned less paid more.The NCMS provides modest financial protection,based on income.Overall,TB patients from lower socioeconomic groups were the most vulnerable.Conclusion:There are large disparities in reimbursement for TB care among the three health insurance schemes and this,in turn,hampers TB control.Reducing the gap in health outcomes between the three health insurance schemes in China should be a focus of TB care and control.Achieving equity through integrated policies that avoid discrimination is likely to be effective.

Effect of the new maternity insurance scheme on medical expenditures for caesarean delivery in Wuxi, China： a retrospective pre/post-reform case study

Aiming to control rising medical expenditures and help improve China＇s healthcare systems, this study examined whether a cap-based medical insurance scheme with shared financial interest between the insurance and healthcare providers is effective in containing hospitals＇ C-section medical expenditures. We used 6547 caesarean delivery case records from a teaching tertiary-level general public hospital located in Wuxi, China （2004-2013）, and used the Chow test to investigate the possibility of significant variation in mean medical expenditures for caesarean deliveries pre- and post-reform. We also used paired sample t-tests and linear regression models to compare the mean medical expenditures between insured and uninsured women undergoing caesarean delivery during the post-reform period. After the scheme＇s implementation, medical expenditures for caesarean deliveries declined and the medical expenditures of women covered by the scheme were significantly lower than those of uninsured patients. These findings indicated the scheme＇s effectiveness in minimizing caesarean delivery expenditures. The cap-based medical insurance scheme with shared financial interest between insurance and healthcare providers would likely steer healtbcare providers＇ behaviors in a more cost-effective direction.

The Insurance Market of Natural Hazards for Residential Properties in Italy

Insurance is an effective complementary countermeasure for unexpected losses brought about by natural hazards. Coverage can be a useful tool considering in particular that public funds available to compensate for damages are limited and the consequences of catastrophes are becoming more severe over the time. Bearing this in mind, the authors performed a study aiming to clear up the main aspects and limits of the insurance market of natural hazards for residential properties in Italy. The opening sections of the paper give an overview of both the historical extreme events in Europe and Italy, and the reasons for the low insurance penetration rate in Italy. After that, the paper goes to the core of the research casting light upon the insurance market in Italy and examining the features and possible drawbacks of the available insurance covers. In this paper, the geophysical (seismic and volcanic) and hydrological (landslide and flood) hazards are analysed, and the residential stock is taken as a reference. After deepening in the local insurance market, the research focuses on the possible suggestions to stakeholders of how to increase the insurance penetration rate by taking advantage of the international experiences.

Patterns of human-wildlife conflict and compensation practices around Daxueshan Nature Reserve, China

Understanding the spatial patterns of human-wildlife conflict is essential to inform management decisions to encourage coexistence, but it is constrained by the lack of spatially-explicit data. We collected spatially-implicit data of human-wildlife conflicts from 2009-2015 around Daxueshan Nature Reserve, Yunnan, China, and investigated the patterns and drivers of these conflicts. A questionnaire was also designed to capture local resident attitudes toward insurance-based compensation for the losses caused by targeted wildlife. We found that the Asiatic black bear （Ursus thibetanus） was the most conflict-prone animal around the reserve, followed by the rhesus macaque （Macaca mulatta） and Southeast Asian sambar （Cervus equinus）. Conflicts were unevenly distributed among seasons, villages, and communities, with several grids identified as conflict hotspots. Poisson models revealed that human-bear conflicts were negatively related to distance to the reserve and proportion of forest, but positively correlated to the proportion of cropland. Binomial models showed that communities affected by crop depredation were positively correlated with the proportion of cropland and negatively correlated with distance to the reserve, whereas communities affected by livestock depredation were negatively correlated with the proportion of cropland. The insurance-based scheme has compensated over 90% of losses, to the satisfaction of 90.6% of respondents. Our results suggest that human-bear conflict could be potentially reduced by eliminating food crops near the reserve boundary and livestock grazing at conflict hotspots.In addition, the insurance-based scheme could be replicated at a broader scale with improvement in loss assessment.

ICT-Enabled Universal Health Coverage Monitoring and Evaluation in Sub-Saharan Health Facilities： Study in 8 Reference Hospitals of Rwanda, Burundi, the Democratic Republic of Congo and Mali

Abstract： UHC （Universal Health Coverage） is at the center of the Sustainable Development Agenda. In this study, the authors made an evaluation of the indicators allowing quantification of the impact of health coverage schemes on patients, applied in 4 sub-Saharan Africa countries： Rwanda, Burundi, the DRC （Democratic Republic of Congo） and Mall After an analysis of potential health coverage indicators, the most relevant ones were calculated on the basis of patient administrative and health insurance data, collected via OpenClinic GA, an HIMS （health information management system） used in 8 sub-Saharan hospitals during the period 2010-2016. The results show that the PHSC （patient health services coverage） rate is highest （81.5%-92.7%） in the 2 hospitals of Rwanda and in 2 hospitals of Burundi （37.7%-77.7%）. The PHSP （patient health service payment） rate as the proportion of costs paid by the patient versus total health service costs is below the 25% threshold recommended by WHO only for the 2 hospitals in Rwanda. The POOP （patient out-of-pocket） payment is below the threshold of 180USD per patient per year for all hospitals. The HIEXs （health insurance expenditures） are funded by the university private insurance （86% of expenses covered） in 2 university teaching hospitals in DRC, by CBHI （community based health insurance） （69%） in 2 hospitals in Rwanda, by the free care policy （77%） in 2 hospitals in Burundi and by the SHI （social health insurance） （100%） in the 2 hospitals in Mali. PHSC in the 8 reference hospitals reflects the national trend towards UHC in each country. With this study, we demonstrate the possibility to assess the degree of UHC in developing countries, by a methodology based on indicators calculated via information extraction from routine data in electronic health records.