This study investigated the determinants of renewing membership and paying the National Health Insurance Scheme premium through a mobile phone. The prospective cross-sectional survey was used to solicit information from 1192 respondents living in Kumasi Metropolis, Atwima Nwabiaya and Sekyere Central Districts of Ghana to estimate the determinants of paying the National Health Insurance Scheme premium with the mobile phone. The study found that residing in an urban area, senior high education, tertiary education and informal employees are the determinants of paying the NHIS premium with the mobile phone. It was recommended that the NHIS consider making the mobile payment as simple as possible for the less educated and for rural members to access it.
This report provides an overview of the discussions around Primary Health Care (PHC) and the private sector, which took place during the 5th Global Symposium on Health Systems Research 2018: Advancing health systems for all in the SDG era. Universal Health Coverage (UHC) and how health systems are working to deliver this global goal by 2030 was a major theme of the conference. Discussions were captured through session data capture and semi-structured interviews. 26 conference rapporteurs captured data in 93 sessions; and 21 interviews were conducted with policy makers, implementers and practitioners from the public and private sector. The discussions referred to initiatives to better engage, train and support small private providers such as community pharmacists to broaden their role and regulate their prescribing to develop safer PHC services. Urgent policy level exploration was called for on public-private links to achieve comprehensive PHC and UHC and clear mechanisms and legal frameworks for strategic purchasing and regulation that consider the power of purchasing medicines and supplies across countries within geographic regions.
For the purpose of effective implementation of a National Health Insurance (NHI) policy the authors argue that it is necessary to have an understanding of the awareness and perceptions of and support for such policy among clients using the healthcare system. The South African National Health and Nutrition Examination Survey asked household heads a series of questions on healthcare utilisation and access and collected information on knowledge and perceptions of and support for national health insurance. Comparisons are drawn between private sector healthcare users with medical aid and public sector healthcare users without medical aid, using descriptive and regression analysis. Inequalities in access to quality healthcare remain stark. Only 8.5% of private users had postponed seeking healthcare compared to 23.9% of public users. Only 11.9% of public users were very satisfied with the quality of healthcare services compared to 50.2% of private users. More than eighty percent of healthcare users however were of the opinion that NHI is a top priority. The findings suggest that this requires a national health insurance that provides better quality healthcare, increasing the probability of support for an NHI with lower cost and full coverage by 10.1%. The authors suggest that it is imperative to provide better quality healthcare services in the public sector for private sector users to be supportive of national health insurance. Concerted efforts are also required to develop a proper communication strategy to disseminate information on and garner support for national health insurance, both in the public and private healthcare sectors.
This paper pulled together data collected from private providers, patients, and social health insurance (SHI) officials in Kenya and Ghana to answer the question: does participation in an SHI scheme affect private providers’ ability to serve poorer patient populations with quality health services? In-depth interviews were held with 204 providers over three rounds of data collection in Kenya and Ghana. The authors also conducted client exit interviews in 2013 and 2017 for a total of 106 patient interviews. Ten focus group discussions were conducted in Kenya and Ghana respectively in 2013 for a total of 171 FGD participants. A total of 13 in-depth interviews also were conducted with officials from the Ghana National Health Insurance Agency and the Kenya National Hospital Insurance Fund across four rounds of data collection. Provider interviews covered reasons for enrollment in the health insurance system, experiences with the accreditation process, and benefits and challenges with the system. Client exit interviews covered provider choice, clinic experience, and SHI experience. Focus Group Discussions covered the local healthcare landscape. Interviews with SHI officials covered officials’ experiences working with private providers, and the opportunities and challenges they faced both accrediting providers and enrolling members. Private providers and patients agreed that SHI schemes are beneficial for reducing out-of-pocket costs to patients and many providers felt they had to become SHI-accredited in order to keep their facilities open. The SHI officials in both countries corroborated these sentiments. However, due to misunderstanding of the system, providers tended to charge clients for services they felt were above and beyond reimbursable expenses. Services were sometimes limited as well. Significant delays in SHI reimbursement in Ghana exacerbated these problems and compromised providers’ abilities to cover basic expenses without charging patients. While patients recognized the potential benefits of SHI coverage and many sought it out, a number of patients reported allowing their enrollment to lapse for cost reasons or because they felt the coverage was useless when they were still asked to pay for services out-of-pocket at the health facility.
This case study examined government resource contributions (GRCs) to private-not-for-profit (PNFP) providers in Uganda. It focuses on Primary Health Care (PHC) grants to the largest non-profit provider network, the Uganda Catholic Medical Bureau (UCMB), from 1997 to 2015. The framework of complex adaptive systems was used to explain changes in resource contributions and the relationship between the Government and UCMB. Documents and key informant interviews with the important actors provided the main sources of qualitative data. Trends for GRCs and service outputs for the study period were constructed from existing databases used to monitor service inputs and outputs. The case study’s findings were validated during two meetings with a broad set of stakeholders. Three major phases were identified in the evolution of GRCs and the relationship between the Government and UCMB: 1) Initiation, 2) Rapid increase in GRCs, and 3) Declining GRCs. The main factors affecting the relationship’s evolution were: 1) Financial deficits at PNFP facilities, 2) advocacy by PNFP network leaders, 3) changes in the government financial resource envelope, 4) variations in the “good will” of government actors, and 5) changes in donor funding modalities. Responses to the above dynamics included changes in user fees, operational costs of PNFPs, and government expectations of UCMB. Quantitative findings showed a progressive increase in service outputs despite the declining value of GRCs during the study period. The authors concluded that GRCs in Uganda have evolved influenced by various factors and the complex interactions between government and PNFPs. The Universal Health Coverage (UHC) agenda should pay attention to these factors and their interactions when shaping how governments work with PNFPs to advance UHC.
This paper reports on the design and implementation of service agreements between local governments and non-state providers for the provision of primary health care services in Tanzania. The authors used qualitative analytical methods to study the Tanzanian experience with contracting- out. Data were drawn from document reviews and in-depth interviews with 39 key informants, including six interviews at the national and regional levels and 33 interviews at the district level. The institutional frameworks shaping the engagement of the government with non-state providers are rooted in Tanzania’s long history of public-private partnerships in the health sector. Demand for contractual arrangements emerged from both the government and the faith-based organizations that manage non-state providers facilities. Development partners provided significant technical and financial support, signalling their approval of the approach. Although districts gained the mandate and power to make contractual agreements with non-state providers, financing the contracts remained largely dependent on external funds via central government budget support. Delays in reimbursements, limited financial and technical capacity of local government authorities and lack of trust between the government and private partners affected the implementation of the contractual arrangements. The authors indicate that Tanzania’s central government needs to further develop the technical and financial capacity necessary to better support districts in establishing and financing contractual agreements with non-state providers for primary health care services; and that forums for continuous dialogue between the government and contracted non-state providers be fostered to clarify the expectations of all parties and resolve any misunderstandings.
In this paper, the authors examine government resource contributions (GRCs) to providers in Uganda focusing on Primary Health Care (PHC) grants to the largest non-profit provider network, the Uganda Catholic Medical Bureau (UCMB), from 1997 to 2015. The framework of complex adaptive systems was used to explain changes in resource contributions and the relationship between the Government and UCMB. Documents and key informant interviews with the important actors provided the main sources of qualitative data. Trends for government resource contributions (GRCs) and service outputs for the study period were constructed from existing databases used to monitor service inputs and outputs. The case study’s findings were validated during two meetings with a broad set of stakeholders. Three major phases were identified in the evolution of GRCs and the relationship between the Government and UCMB initiation, rapid increase in GRCs, and declining GRCs. The main factors affecting the relationship’s evolution were: financial deficits at private-not-for-profit (PNFP) facilities, advocacy by PNFP network leaders, changes in the government financial resource envelope, variations in the “good will” of government actors, and changes in donor funding modalities. Responses to the above dynamics included changes in user fees, operational costs of PNFPs, and government expectations of UCMB. Quantitative findings showed a progressive increase in service outputs despite the declining value of GRCs during the study period. GRCs in Uganda have evolved influenced by various factors and the complex interactions between government and PNFPs. The authors argue that the Universal Health Coverage (UHC) agenda should pay attention to these factors and their interactions when shaping how governments work with PNFPs to advance UHC. GRCs could be leveraged to mitigate the financial burden on communities served by PNFPs. They further suggest that governments seeking to advance UHC goals should explore policies to expand GRCs and other modalities to subsidize the operational costs of PNFPs.
This paper provides a unique opportunity to understand the dynamics of non-state providers (NSP) engagement in different contexts. A standard template was developed and used to summarize the main findings from the country studies. The summaries were then organized according to emergent themes and a narrative built around these themes. Governments contracted NSPs for a variety of reasons – limited public sector capacity, inability of public sector services to reach certain populations or geographic areas, and the widespread presence of NSPs in the health sector. Underlying these reasons was a recognition that purchasing services from NSPs was necessary to increase coverage of health services. Yet, institutional NSPs faced many service delivery challenges. Like the public sector, institutional NSPs faced challenges in recruiting and retaining health workers, and ensuring service quality. Properly managing relationships between all actors involved was critical to contracting success and the role of NSPs as strategic partners in achieving national health goals. Further, the relationship between the central and lower administrative levels in contract management, as well as government stewardship capacity for monitoring contractual performance were vital for NSP performance. The authors suggest that for countries with a sizeable NSP sector, making full use of the available human and other resources by contracting NSPs and appropriately managing them, offers an important way for expanding coverage of publicly financed health services and moving towards universal health coverage.
This paper presents a mapping of faith-based health assets in Ghana using both qualitative and quantitative evidence to provide a visual representation of changes in the spatial footprint of the faith-based non-profit (FBNP) health sector. The geospatial maps show that FBNPs were originally located in rural remote areas of the country but that this service footprint has evolved over time, in line with changing social, political and economic contexts. The sector has had a long-standing role in the provision of health services and remains a valuable asset within national health systems in Ghana and sub-Saharan Africa more broadly. The authors observe that collaboration between the public sector and such non-state providers, drawing on the comparative strengths and resources of FBNPs and focusing on whole system strengthening, is essential for the achievement of universal health coverage.
The South African private healthcare sector comprises a complex set of interrelated stakeholders that interact in markets that are not transparent and so not easily understood. This report highlights key features that describe how the private healthcare sector operates. The author identifies features of the private healthcare sector that, alone or in combination, prevent, restrict or distort competition. The report presents recommendations to remedy these adverse effects on competition. Overall, the market is characterised by high and rising costs of healthcare and medical scheme cover, highly concentrated funders’ and facilities’ markets, disempowered and uninformed consumers, a general absence of value-based purchasing, ineffective constraints on rising volumes of care, practitioners that are subject to little regulation and failures of accountability at many levels. An incomplete regulatory regime is attributed to a failure in implementation on the part of regulators and inadequate stewardship by the Department of Health over the years. Intrinsic and extrinsic incentives in the market have promoted over-servicing by medical practitioners which include increased admissions to hospitals, increased length of stay, higher levels of care, greater intensity of care or use of more expensive modalities of care than can be explained by the disease burden of the population. The report presents We evidence of supply induced demand. Various marketing choices are reported to leave consumers confused and disempowered, compounding their inability to use choice as a pressure on schemes. The market is characterized by a dominance of a few schemes and by an absence of effective direct competition between the three big hospital groups. The report recommends changes to the way scheme options are structured to increase comparability between schemes and increase competition in that market; a system to increase transparency on health outcomes to allow for value purchasing and a set of interventions to improve competition in the market through a supply side regulator.