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1.  Players and processes behind the national health insurance scheme: a case study of Uganda 
Uganda is the last East African country to adopt a National Health Insurance Scheme (NHIS). To lessen the inequitable burden of healthcare spending, health financing reform has focused on the establishment of national health insurance. The objective of this research is to depict how stakeholders and their power and interests have shaped the process of agenda setting and policy formulation for Uganda’s proposed NHIS. The study provides a contextual analysis of the development of NHIS policy within the context of national policies and processes.
The methodology is a single case study of agenda setting and policy formulation related to the proposed NHIS in Uganda. It involves an analysis of the real-life context, the content of proposals, the process, and a retrospective stakeholder analysis in terms of policy development. Data collection comprised a literature review of published documents, technical reports, policy briefs, and memos obtained from Uganda’s Ministry of Health and other unpublished sources. Formal discussions were held with ministry staff involved in the design of the scheme and some members of the task force to obtain clarification, verify events, and gain additional information.
The process of developing the NHIS has been an incremental one, characterised by small-scale, gradual changes and repeated adjustments through various stakeholder engagements during the three phases of development: from 1995 to 1999; 2000 to 2005; and 2006 to 2011. Despite political will in the government, progress with the NHIS has been slow, and it has yet to be implemented. Stakeholders, notably the private sector, played an important role in influencing the pace of the development process and the currently proposed design of the scheme.
This study underscores the importance of stakeholder analysis in major health reforms. Early use of stakeholder analysis combined with an ongoing review and revision of NHIS policy proposals during stakeholder discussions would be an effective strategy for avoiding potential pitfalls and obstacles in policy implementation. Given the private sector’s influence on negotiations over health insurance design in Uganda, this paper also reviews the experience of two countries with similar stakeholder dynamics.
PMCID: PMC3849368  PMID: 24053551
Health insurance; Stakeholder analysis; Context analysis; Policy reform; Health financing; Case study; Uganda
2.  Something old or something new? Social health insurance in Ghana 
There is considerable interest at present in exploring the potential of social health insurance to increase access to and affordability of health care in Africa. A number of countries are currently experimenting with different approaches. Ghana's National Health Insurance Scheme (NHIS) was passed into law in 2003 but fully implemented from late 2005. It has already reached impressive coverage levels. This article aims to provide a preliminary assessment of the NHIS to date. This can inform the development of the NHIS itself but also other innovations in the region.
This article is based on analysis of routine data, on secondary literature and on key informant interviews conducted by the authors with stakeholders at national, regional and district levels over the period of 2005 to 2009.
In relation to its financing sources, the NHIS is heavily reliant on tax funding for 70–75% of its revenue. This has permitted quick expansion of coverage, partly through the inclusion of large exempted population groups. Card holders increased from 7% of the population in 2005 to 45% in 2008. However, only around a third of these are contributing to the scheme financially. This presents a sustainability problem, in that revenue is de-coupled from the growing membership. In addition, the NHIS offers a broad benefits package, with no co-payments and limited gate-keeping, and also faces cost escalation related to its new payment system and the growing utilisation of members. These features contributed to a growth in distressed schemes and failure to pay outstanding facility claims in 2008.
The NHIS has had a considerable impact on the health system as a whole, taking on a growing role in funding curative care. In 2009, it is expected to contribute 41% of the overall resource envelope. However there is evidence that this funding is not additional but has been switched from other funding channels. There are some equity concerns about this, as the new funding source (a VAT-based tax) may be more regressive. In addition, membership of the NHIS at present has a pro-rich bias, and a pro-urban bias in relation to renewals. Only a very small proportion is registered as indigent, and there is some evidence of 'squeezing out' of non-members from health care utilisation. Finally, considerable challenges remain in relation to strengthening the purchasing role of the NHIS, and also settling debates about its structure and accountability.
Some trade-offs will be necessary between the existing wide benefits package of the NHIS and the laudable desire to reach universal coverage. The overall resource envelope for health is likely to be stable rather than increasing over the medium-term. In the longer term, the investment costs in the NHIS will only be justified if it is able to increase the cost-effectiveness of purchasing and the responsiveness of the system as a whole.
PMCID: PMC2739838  PMID: 19715583
3.  Equity of the premium of the Ghanaian national health insurance scheme and the implications for achieving universal coverage 
The Ghanaian National Health Insurance Scheme (NHIS) was introduced to provide access to adequate health care regardless of ability to pay. By law the NHIS is mandatory but because the informal sector has to make premium payment before they are enrolled, the authorities are unable to enforce mandatory nature of the scheme. The ultimate goal of the Scheme then is to provide all residents with access to adequate health care at affordable cost. In other words, the Scheme intends to achieve universal coverage. An important factor for the achievement of universal coverage is that revenue collection be equitable. The purpose of this study is to examine the vertical and horizontal equity of the premium collection of the Scheme. The Kakwani index method as well as graphical analysis was used to study the vertical equity. Horizontal inequity was measured through the effect of the premium on redistribution of ability to pay of members. The extent to which the premium could cause catastrophic expenditure was also examined. The results showed that revenue collection was both vertically and horizontally inequitable. The horizontal inequity had a greater effect on redistribution of ability to pay than vertical inequity. The computation of catastrophic expenditure showed that a small minority of the poor were likely to incur catastrophic expenditure from paying the premium a situation that could impede the achievement of universal coverage. The study provides recommendations to improve the inequitable system of premium payment to help achieve universal coverage.
PMCID: PMC3585509  PMID: 23294982
4.  Community perceptions of health insurance and their preferred design features: implications for the design of universal health coverage reforms in Kenya 
Health insurance is currently being considered as a mechanism for promoting progress to universal health coverage (UHC) in many African countries. The concept of health insurance is relatively new in Africa, it is hardly well understood and remains unclear how it will function in countries where the majority of the population work outside the formal sector. Kenya has been considering introducing a national health insurance scheme (NHIS) since 2004. Progress has been slow, but commitment to achieve UHC through a NHIS remains. This study contributes to this process by exploring communities’ understanding and perceptions of health insurance and their preferred designs features. Communities are the major beneficiaries of UHC reforms. Kenyans should understand the implications of health financing reforms and their preferred design features considered to ensure acceptability and sustainability.
Data presented in this paper are part of a study that explored feasibility of health insurance in Kenya. Data collection methods included a cross-sectional household survey (n = 594 households) and focus group discussions (n = 16).
About half of the household survey respondents had at least one member in a health insurance scheme. There was high awareness of health insurance schemes but limited knowledge of how health insurance functions as well as understanding of key concepts related to income and risk cross-subsidization. Wide dissatisfaction with the public health system was reported. However, the government was the most preferred and trusted agency for collecting revenue as part of a NHIS. People preferred a comprehensive benefit package that included inpatient and outpatient care with no co-payments. Affordability of premiums, timing of contributions and the extent to which population needs would be met under a contributory scheme were major issues of concern for a NHIS design. Possibilities of funding health care through tax instead of NHIS were raised and preferred by the majority.
This study provides important information on community understanding and perceptions of health insurance. As Kenya continues to prepare for UHC, it is important that communities are educated and engaged to ensure that the NHIS is acceptable to the population it serves.
PMCID: PMC3842821  PMID: 24219335
5.  Assessing equity in health care through the national health insurance schemes of Nigeria and Ghana: a review-based comparative analysis 
Nigeria and Ghana have recently introduced a National Health Insurance Scheme (NHIS) with the aim of moving towards universal health care using more equitable financing mechanisms. This study compares health and economic indicators, describes the structure of each country’s NHIS within the wider healthcare system, and analyses impacts on equity in financing and access to health care.
The World Bank and other sources were used to provide comparative health and economic data. Pubmed, Embase and EconLit were searched to locate studies providing descriptions of each NHIS and empirical evidence regarding equity in financing and access to health care. A diagrammatical representation of revenue-raising, pooling, purchasing and provision was produced in order to analyse the two countries’ systems.
Over the period 2000–2010, Ghana maintained a marked advantage in life expectancy, infant mortality, under-5 year mortality, and has a lower burden of major diseases. Health care expenditure is about 5% of GDP in both countries but public expenditure in 2010 was 38% of total expenditure in Nigeria and 60% in Ghana. Financing and access are less equitable in Nigeria as, inter alia, private out-of-pocket expenditure has fallen from 80% to 66% of total spending in Ghana since the introduction of its NHIS but has remained at over 90% in Nigeria; NHIS membership in Nigeria and Ghana is approximately 3.5% and 65%, respectively; Nigeria offers a variable benefits package depending on membership category while Ghana has uniform benefits across all beneficiaries. Both countries exhibit improvements in equity but there is a pro-rich and pro-urban bias in membership.
Major health indicators are more favourable in Ghana and overall equity in financing and access are weaker in Nigeria. Nigeria is taking steps to expand NHIS membership and has potential to expand its public spending to achieve greater equity. However, heavy burdens of poverty, disease and remote settings make this a substantial challenge. Ghana’s relative success has to be tempered by the high number of exemptions through taxation and the threat of moral hazard. The results and methods are anticipated to be informative for policy makers and researchers in both countries and other developing countries more widely.
PMCID: PMC3626627  PMID: 23339606
Healthcare systems; Health economics; Health care expenditure; Access; Equity; Social health insurance; National Health Insurance Scheme; NHIS; Sub-Saharan Africa; Nigeria; Ghana
6.  Sustainability of Korean National Health Insurance 
Journal of Korean Medical Science  2012;27(Suppl):S21-S24.
Korean National Health Insurance (NHI) was established during only 12 yr from its inception (1977-1989), providing universal medical coverage to the entire nation and making a huge contribution to medical security. However, the program now faces many challenges in terms of sustainability. The low birth rates, aging population, low economic growth, and escalating demands for welfare, as well as unification issues, all add pressure to the sustainability of NHI. The old paradigm of low contribution - low benefits coverage - low NHI's fee schedule needs to be replaced by a new paradigm of proper contribution - adequate benefit coverage - fair NHI's fee schedule. This new paradigm will require reform of NHI's operating system, funding, and spending.
PMCID: PMC3360169  PMID: 22661866
Korean NHI (National Health Insurance); Universal Coverage; Financial Sustainability
7.  New evidence on financing equity in China's health care reform - A case study on Gansu province, China 
In the transition from a planned economy to a market-oriented economy, China’s state funding for health care declined and traditional coverage plans collapsed, leaving China’s poor exposed to potentially ruinous health care costs. In reforming health care for the 21st century, equity in health care financing has become a major policy goal. To assess progress towards this goal, this paper examines the equity characteristics of health care financing in a province of northwestern China, comparing the equity performance between urban and rural areas at two different points in time.
Analysis of whether health care financing contributions were progressive according to income were made using the Kakwani index for each of the four health care financing channels of general taxes, public and private health insurance, and out-of-pocket payments. Two rounds of surveys were conducted, the first in 2003 (13,619 individuals in 3946 households) and the second in 2008 (12,973 individuals in 3958 households). Household socio-economic, health care payment, and utilization information were recorded in household interviews.
Low-income households have undertaken a larger share of the health care financing burden in recent years, reflected by negative Kakwani indices, which indicate a regressive system. We found that the indices for general taxation were −0.0024 (urban) and −0.0281 (rural) in 2002, and −0.0177 (urban) and −0.0097 (rural) in 2007. Public health insurance presented different financing distributions in urban and rural areas (urban: 0.0742 in 2002, 0.0661 in 2007; rural: –0.0615 in 2002,–0.1436 in 2007.). Out-of-pocket payments were progressive but not equitable. Public health insurance coverage has expanded but financing equity has decreased.
Health care financing policies in China need ongoing reform. Given the inequity of general consumption taxes, elimination of these would improve financing equity considerably. Optimizing benefit packages in public health insurance is as important as expanding coverage, both for health care financing and for utilization management as well. Although they are progressive, out-of-pocket payments are not equitable in China and have the effect of excluding the poor from health care as they cannot afford to pay for medical care and so withdraw from treatment.
PMCID: PMC3562140  PMID: 23244513
Equity; Chinese health care reform; Financing; Kakwani index
8.  Household out-of-pocket medical expenditures and national health insurance in Taiwan: income and regional inequality 
Unequal geographical distribution of medical care resources and insufficient healthcare coverage have been two long-standing problems with Taiwan's public health system. The implementation of National Health Insurance (NHI) attempted to mitigate the inequality in health care use. This study examines the degree to which Taiwan's National Health Insurance (NHI) has reduced out-of-pocket medical expenditures in households in different regions and varying levels of income.
Data used in this study were drawn from the 1994 and 1996 Surveys of Family Income and Expenditure. We pooled the data from 1994 and 1996 and included a year dummy variable (NHI), equal to 1 if the household data came from 1996 in order to assess the impact of NHI on household out-of-pocket medical care expenditures shortly after its implementation in 1995.
An individual who was older, female, married, unemployed, better educated, richer, head of a larger family household, or living in the central and eastern areas was more likely to have greater household out-of-pocket medical expenditures. NHI was found to have effectively reduced household out-of-pocket medical expenditures by 23.08%, particularly for more affluent households. With the implementation of NHI, lower and middle income quintiles had smaller decreases in out-of-pocket medical expenditure. NHI was also found to have reduced household out-of-pocket medical expenditures more for households in eastern Taiwan.
Although NHI was established to create free medical care for all, further effort is needed to reduce the medical costs for certain disadvantaged groups, particularly the poor and aborigines, if equality is to be achieved.
PMCID: PMC1208885  PMID: 16137336
9.  Promoting universal financial protection: constraints and enabling factors in scaling-up coverage with social health insurance in Nigeria 
The National Health Insurance Scheme (NHIS) in Nigeria was launched in 2005 as part of efforts by the federal government to achieve universal coverage using financial risk protection mechanisms. However, only 4% of the population, and mainly federal government employees, are currently covered by health insurance and this is primarily through the Formal Sector Social Health Insurance Programme (FSSHIP) of the NHIS. This study aimed to understand why different state (sub-national) governments decided whether or not to adopt the FSSHIP for their employees.
This study used a comparative case study approach. Data were collected through document reviews and 48 in-depth interviews with policy makers, programme managers, health providers, and civil servant leaders.
Although the programme’s benefits seemed acceptable to state policy makers and the intended beneficiaries (employees), the feasibility of employer contributions, concerns about transparency in the NHIS and the role of states in the FSSHIP, the roles of policy champions such as state governors and resistance by employees to making contributions, all influenced the decision of state governments on adoption. Overall, the power of state governments over state-level health reforms, attributed to the prevailing system of government that allows states to deliberate on certain national-level policies, enhanced by the NHIS legislation that made adoption voluntary, enabled states to adopt or not to adopt the program.
The study demonstrates and supports observations that even when the content of a programme is generally acceptable, context, actor roles, and the wider implications of programme design on actor interests can explain decision on policy adoption. Policy implementers involved in scaling-up the NHIS programme need to consider the prevailing contextual factors, and effectively engage policy champions to overcome known challenges in order to encourage adoption by sub-national governments. Policy makers and implementers in countries scaling-up health insurance coverage should, early enough, develop strategies to overcome political challenges inherent in the path to scaling-up, to avoid delay or stunting of the process. They should also consider the potential pitfalls of reforms that first focus on civil servants, especially when the use of public funds potentially compromises coverage for other citizens.
PMCID: PMC3686590  PMID: 23764306
Case study; Health financing; Nigeria; Social health insurance; Universal coverage
10.  Ghana’s National Health Insurance Scheme: a national level investigation of members’ perceptions of service provision 
Ghana’s National Health Insurance Scheme (NHIS), established into law in 2003 and implemented in 2005 as a ‘pro-poor’ method of health financing, has made great progress in enrolling members of the general population. While many studies have focused on predictors of enrolment this study offers a novel analysis of NHIS members’ perceptions of service provision at the national level.
Using data from the 2008 Ghana Demographic Health Survey we analyzed the perceptions of service provision as indicated by members enrolled in the NHIS at the time of the survey (n = 3468; m = 1422; f = 2046). Ordinal Logistic Regression was applied to examine the relationship between perceptions of service provision and theoretically relevant socioeconomic and demographic variables.
Results demonstrate that wealth, gender and ethnicity all play a role in influencing members’ perceptions of NHIS service provision, distinctive from its influence on enrolment. Notably, although wealth predicted enrolment in other studies, our study found that compared to the poorest men and uneducated women, wealthy men and educated women were less likely to perceive their service provision as better/same (more likely to report it was worse). Wealth was not an important factor for women, suggesting that household gender dynamics supersede household wealth status in influencing perceptions. As well, when compared to Akan women, women from all other ethnic groups were about half as likely to perceive the service provision to be better/same.
Findings of this study suggest there is an important difference between originally enrolling in the NHIS because one believes it is potentially beneficial, and using the NHIS and perceiving it to be of benefit. We conclude that understanding the nature of this relationship is essential for Ghana’s NHIS to ensure its longevity and meet its pro-poor mandate. As national health insurance systems are a relatively new phenomenon in sub-Saharan Africa little is known about their long term viability; understanding user perceptions of service provision is an important piece of that puzzle.
PMCID: PMC3765400  PMID: 23968385
Health care; Ghana; Health insurance; National health insurance scheme; Perceptions; Service
11.  Poverty Increases Type 2 Diabetes Incidence and Inequality of Care Despite Universal Health Coverage 
Diabetes Care  2012;35(11):2286-2292.
The discrepancy of diabetes incidence and care between socioeconomic statuses has seldom been studied concurrently in nations with universal health coverage. We aimed to delineate whether income disparity is associated with diabetes incidence and inequality of care under a national health insurance (NHI) program in Asia.
From the Taiwan NHI database in 2000, a representative cohort aged ≥20 years and free of diabetes (n = 600,662) were followed up until 2005. We regarded individuals exempt from paying the NHI premium as being poor. Adjusted hazard ratios (HRs) were used to discover any excess risk of diabetes in the poor population. The indicators used to evaluate quality of diabetes care included the proportion of diabetic patients identified through hospitalization, visits to diabetes clinics, and completion of recommended diabetes tests.
The incidence of type 2 diabetes in the poor population was 20.4 per 1,000 person-years (HR, 1.5; 95% CI, 1.3–1.7). Compared with their middle-income counterparts, the adjusted odds ratio (OR) for the poor population incidentally identified as having diabetes through hospitalization was 2.2 (P < 0.001). Poor persons with diabetes were less likely to visit any diabetes clinic (OR, 0.4; P < 0.001). The ORs for the poor population with diabetes to receive tests for glycated hemoglobin, low-density lipoprotein cholesterol, triglycerides, and retinopathy were 0.6 (0.4–0.9), 0.4 (0.2–0.7), 0.5 (0.4–0.8), and 0.4 (0.2–0.9), respectively.
Poverty is associated not only with higher diabetes incidence but also with inequality of diabetes care in a northeast Asian population, despite universal health coverage.
PMCID: PMC3476930  PMID: 22912425
12.  Ordering Social Objectives: National Health Service and National Health Insurance as Policy Options in Organizing the Medical Care System 
For many years, a sharp distinction was made between NHS and NHI on the basis of payment and program focus. First, NHS was defined as a program essentially based on Congressional appropriations (general revenues); while NHI would be based on premiums largely derived from the insured. Second, NHS guaranteed service while NHI guaranteed only payment for services rendered.
The distinctions were later extended from these definitions to include differences in response to resource needs, changing task descriptions and personnel assignments, more equitable redistribution of manpower, centralized administration and consumer participation.
In general, if the goal were equity, NHS seemed more responsive than NHI.
However, in recent years, the approach to NHI has been modified in response to criticism as well as increasing recognition of changed needs, and proposals for NHI like the Kennedy-Corman bill have become more like proposals for a NHS. In short, the difference today is largely one of immediate as against eventual transformation of the medical care system into a social instrument aiming to achieve equity. The major disagreement is whether the present medical care system lends itself to modification so as to achieve that end.
PMCID: PMC2595663  PMID: 685298
13.  Assessing the Value of the NHIS for Studying Changes in State Coverage Policies: The Case of New York 
Health Services Research  2007;42(6 Pt 2):2332-2353.
Research Objective
(1) To assess the effects of New York's Health Care Reform Act of 2000 on the insurance coverage of eligible adults and (2) to explore the feasibility of using the National Health Interview Survey (NHIS) as opposed to the Current Population Survey (CPS) to conduct evaluations of state health reform initiatives.
Study Design
We take advantage of the natural experiment that occurred in New York to compare health insurance coverage for adults before and after the state implemented its coverage initiative using a difference-in-differences framework. We estimate the effects of New York's initiative on insurance coverage using the NHIS, comparing the results to estimates based on the CPS, the most widely used data source for studies of state coverage policy changes. Although the sample sizes are smaller in the NHIS, the NHIS addresses a key limitation of the CPS for such evaluations by providing a better measure of health insurance status. Given the complexity of the timing of the expansion efforts in New York (which encompassed the September 11, 2001 terrorist attacks), we allow for difference in the effects of the state's policy changes over time. In particular, we allow for differences between the period of Disaster Relief Medicaid (DRM), which was a temporary program implemented immediately after September 11th, and the original components of the state's reform efforts—Family Health Plus (FHP), an expansion of direct Medicaid coverage, and Healthy New York (HNY), an effort to make private coverage more affordable.
Data Sources
2000–2004 CPS; 1999–2004 NHIS.
Principal Findings
We find evidence of a significant reduction in uninsurance for parents in New York, particularly in the period following DRM. For childless adults, for whom the coverage expansion was more circumscribed, the program effects are less promising, as we find no evidence of a significant decline in uninsurance.
The success of New York at reducing uninsurance for parents through expansions of both public and private coverage offers hope for new strategies to expand coverage. The NHIS is a strong data source for evaluations of many state health reform initiatives, providing a better measure of insurance status and supporting a more comprehensive study of state innovations than is possible with the CPS.
PMCID: PMC2151317  PMID: 17995546
Health insurance; Medicaid; state health reform
14.  The impact of universal National Health Insurance on population health: the experience of Taiwan 
Taiwan established a system of universal National Health Insurance (NHI) in March, 1995. Today, the NHI covers more than 98% of Taiwan's population and enrollees enjoy almost free access to healthcare with small co-payment by most clinics and hospitals. Yet while this expansion of coverage will almost inevitably have improved access to health care, however, it cannot be assumed that it will necessarily have improved the health of the population. The aim of this study was to determine whether the introduction of National Health Insurance (NHI) in Taiwan in 1995 was associated with a change in deaths from causes amenable to health care.
Identification of discontinuities in trends in mortality considered amenable to health care and all other conditions (non-amenable mortality) using joinpoint regression analysis from 1981 to 2005.
Deaths from amenable causes declined between 1981 and 1993 but slowed between 1993 and 1996. Once NHI was implemented, the decline accelerated significantly, falling at 5.83% per year between 1996 and 1999. In contrast, there was little change in non-amenable causes (0.64% per year between 1981 and 1999). The effect of NHI was highest among the young and old, and lowest among those of working age, consistent with changes in the pattern of coverage. NHI was associated with substantial reductions in deaths from circulatory disorders and, for men, infections, whilst an earlier upward trend in female cancer deaths was reversed.
NHI was associated in a reduction in deaths considered amenable to health care; particularly among those age groups least likely to have been insured previously.
PMCID: PMC2924329  PMID: 20682077
15.  Financing equitable access to antiretroviral treatment in South Africa 
BMC Health Services Research  2010;10(Suppl 1):S2.
While South Africa spends approximately 7.4% of GDP on healthcare, only 43% of these funds are spent in the public system, which is tasked with the provision of care to the majority of the population including a large proportion of those in need of antiretroviral treatment (ART). South Africa is currently debating the introduction of a National Health Insurance (NHI) system. Because such a universal health system could mean increased public healthcare funding and improved access to human resources, it could improve the sustainability of ART provision. This paper considers the minimum resources that would be required to achieve the proposed universal health system and contrasts these with the costs of scaled up access to ART between 2010 and 2020.
The costs of ART and universal coverage (UC) are assessed through multiplying unit costs, utilization and estimates of the population in need during each year of the planning cycle. Costs are from the provider’s perspective reflected in real 2007 prices.
The annual costs of providing ART increase from US$1 billion in 2010 to US$3.6 billion in 2020. If increases in funding to public healthcare only keep pace with projected real GDP growth, then close to 30% of these resources would be required for ART by 2020. However, an increase in the public healthcare resource envelope from 3.2% to 5%-6% of GDP would be sufficient to finance both ART and other services under a universal system (if based on a largely public sector model) and the annual costs of ART would not exceed 15% of the universal health system budget.
Responding to the HIV-epidemic is one of the many challenges currently facing South Africa. Whether this response becomes a “resource for democracy” or whether it undermines social cohesiveness within poor communities and between rich and poor communities will be partially determined by the steps that are taken during the next ten years. While the introduction of a universal system will be complex, it could generate a health system responsive to the needs of all South Africans.
PMCID: PMC2895746  PMID: 20594368
16.  Equity in health care financing: The case of Malaysia 
Equitable financing is a key objective of health care systems. Its importance is evidenced in policy documents, policy statements, the work of health economists and policy analysts. The conventional categorisations of finance sources for health care are taxation, social health insurance, private health insurance and out-of-pocket payments. There are nonetheless increasing variations in the finance sources used to fund health care. An understanding of the equity implications would help policy makers in achieving equitable financing.
The primary purpose of this paper was to comprehensively assess the equity of health care financing in Malaysia, which represents a new country context for the quantitative techniques used. The paper evaluated each of the five financing sources (direct taxes, indirect taxes, contributions to Employee Provident Fund and Social Security Organization, private insurance and out-of-pocket payments) independently, and subsequently by combined the financing sources to evaluate the whole financing system.
Cross-sectional analyses were performed on the Household Expenditure Survey Malaysia 1998/99, using Stata statistical software package. In order to assess inequality, progressivity of each finance sources and the whole financing system was measured by Kakwani's progressivity index.
Results showed that Malaysia's predominantly tax-financed system was slightly progressive with a Kakwani's progressivity index of 0.186. The net progressive effect was produced by four progressive finance sources (in the decreasing order of direct taxes, private insurance premiums, out-of-pocket payments, contributions to EPF and SOCSO) and a regressive finance source (indirect taxes).
Malaysia's two tier health system, of a heavily subsidised public sector and a user charged private sector, has produced a progressive health financing system. The case of Malaysia exemplifies that policy makers can gain an in depth understanding of the equity impact, in order to help shape health financing strategies for the nation.
PMCID: PMC2467419  PMID: 18541025
17.  The Impacts of State Health Reform Initiatives on Adults in New York and Massachusetts 
Health Services Research  2011;46(1p2):365-387.
To analyze the effects of health reform efforts in two large states—New York and Massachusetts.
Data Sources/Study Setting
National Health Interview Survey (NHIS) data from 1999 to 2008.
Study Design
We take advantage of the “natural experiments” that occurred in New York and Massachusetts to compare health insurance coverage and health care access and use for adults before and after the implementation of the health policy changes. To control for underlying trends not related to the reform initiatives, we subtract changes in the outcomes over the same time period for comparison groups of adults who were not affected by the policy changes using a differences-in-differences framework. The analyses are conducted using multiple comparison groups and different time periods as a check on the robustness of the findings.
Data Collection/Extraction Methods
Nonelderly adults ages 19–64 in the NHIS.
Principal Findings
We find evidence of the success of the initiatives in New York and Massachusetts at expanding insurance coverage, with the greatest gains reported by the initiative that was broadest in scope—the Massachusetts push toward universal coverage. There is no evidence of improvements in access to care in New York, reflecting the small gains in coverage under that state's reform effort and the narrow focus of the initiative. In contrast, there were significant gains in access to care in Massachusetts, where the impact on insurance coverage was greater and a more comprehensive set of reforms were implemented to improve access to a full array of health care services. The estimated gains in coverage and access to care reported here for Massachusetts were achieved in the early period under health reform, before the state's reform initiative was fully implemented.
Comprehensive reform initiatives are more successful at addressing gaps in coverage and access to care than are narrower efforts, highlighting the potential gains under national health reform. Tracking the implications of national health reform will be challenging, as sample sizes and content in existing national surveys are not currently sufficient for in-depth evaluations of the impacts of reform within many states.
PMCID: PMC3037788  PMID: 21091471
Health reform; uninsurance; public coverage; employer-sponsored insurance coverage; crowd-out; health care access and use
18.  Use of selected ambulatory dental services in Taiwan before and after global budgeting: a longitudinal study to identify trends in hospital and clinic-based services 
The Taiwan government adopted National Health Insurance (NHI) in 1995, providing universal health care to all citizens. It was financed by mandatory premium contributions made by employers, employees, and the government. Since then, the government has faced increasing challenges to control NHI expenditures. The aim of this study was to determine trends in the provision of dental services in Taiwan after the implementation of global budgeting in 1998 and to identify areas of possible concern.
This longitudinal before/after study was based on data from the National Health Insurance Research Database from 1996 to 2001. These data were subjected to logistic regression analysis. Linear regression analysis was used to examine changes in delivery of specific services after global budgeting implementation. Utilization of hospital and clinic services was compared.
Reimbursement for dental services increased significantly while the number of visits per patient remained steady in both hospitals and clinics. In hospitals, visits for root canal procedures, ionomer restoration, tooth extraction and tooth scaling increased significantly. In dental clinics, visits for amalgam restoration decreased significantly while those for ionomer restoration, tooth extraction, and tooth scaling increased significantly. After the adoption of global budgeting, expenditures for dental services increased dramatically while the number of visits per patient did not, indicating a possible shift in patients to hospital facilities that received additional National Health Insurance funding.
The identified trends indicate increased utilization of dental services and uneven distribution of care and dentists. These trends may be compromising the quality of dental care delivered in Taiwan.
PMCID: PMC3506517  PMID: 23009095
Global budgeting; National health insurance; Taiwan; Dental services
19.  Health Financing And Insurance Reform In Morocco 
Health affairs (Project Hope)  2007;26(4):1009-1016.
The government of Morocco approved two reforms in 2005 to expand health insurance coverage. The first is a payroll-based mandatory health insurance plan for public-and formal private–sector employees to extend coverage from the current 16 percent of the population to 30 percent. The second creates a publicly financed fund to cover services for the poor. Both reforms aim to improve access to high-quality care and reduce disparities in access and financing between income groups and between rural and urban dwellers. In this paper we analyze these reforms: the pre-reform debate, benefits covered, financing, administration, and oversight. We also examine prospects and future challenges for implementing the reforms.
PMCID: PMC2898512  PMID: 17630444
20.  An in-depth assessment of a diagnosis-based risk adjustment model based on national health insurance claims: the application of the Johns Hopkins Adjusted Clinical Group case-mix system in Taiwan 
BMC Medicine  2010;8:7.
Diagnosis-based risk adjustment is becoming an important issue globally as a result of its implications for payment, high-risk predictive modelling and provider performance assessment. The Taiwanese National Health Insurance (NHI) programme provides universal coverage and maintains a single national computerized claims database, which enables the application of diagnosis-based risk adjustment. However, research regarding risk adjustment is limited. This study aims to examine the performance of the Adjusted Clinical Group (ACG) case-mix system using claims-based diagnosis information from the Taiwanese NHI programme.
A random sample of NHI enrollees was selected. Those continuously enrolled in 2002 were included for concurrent analyses (n = 173,234), while those in both 2002 and 2003 were included for prospective analyses (n = 164,562). Health status measures derived from 2002 diagnoses were used to explain the 2002 and 2003 health expenditure. A multivariate linear regression model was adopted after comparing the performance of seven different statistical models. Split-validation was performed in order to avoid overfitting. The performance measures were adjusted R2 and mean absolute prediction error of five types of expenditure at individual level, and predictive ratio of total expenditure at group level.
The more comprehensive models performed better when used for explaining resource utilization. Adjusted R2 of total expenditure in concurrent/prospective analyses were 4.2%/4.4% in the demographic model, 15%/10% in the ACGs or ADGs (Aggregated Diagnosis Group) model, and 40%/22% in the models containing EDCs (Expanded Diagnosis Cluster). When predicting expenditure for groups based on expenditure quintiles, all models underpredicted the highest expenditure group and overpredicted the four other groups. For groups based on morbidity burden, the ACGs model had the best performance overall.
Given the widespread availability of claims data and the superior explanatory power of claims-based risk adjustment models over demographics-only models, Taiwan's government should consider using claims-based models for policy-relevant applications. The performance of the ACG case-mix system in Taiwan was comparable to that found in other countries. This suggested that the ACG system could be applied to Taiwan's NHI even though it was originally developed in the USA. Many of the findings in this paper are likely to be relevant to other diagnosis-based risk adjustment methodologies.
PMCID: PMC2830174  PMID: 20082689
21.  The national health insurance scheme: perceptions and experiences of health care providers and clients in two districts of Ghana 
Prepayments and risk pooling through social health insurance has been advocated by international development organizations. Social health insurance is seen as a mechanism that helps mobilize resources for health, pool risk, and provide more access to health care services for the poor. Hence Ghana implemented the National Health Insurance Scheme (NHIS) to help promote access to health care services for Ghanaians. The study examined the influence of the NHIS on the behavior of health care providers in their treatment of insured and uninsured clients.
The study took place in Bolgatanga (urban) and Builsa (rural) districts in Ghana. Data was collected through exit survey with 200 insured and uninsured clients, 15 in-depth interviews with health care providers and health insurance managers, and 8 focus group discussions with insured and uninsured community members.
The NHIS promoted access for insured and mobilized revenue for health care providers. Both insured and uninsured were satisfied with care (survey finding). However, increased utilization of health care services by the insured leading to increased workloads for providers influenced their behavior towards the insured. Most of the insured perceived and experienced long waiting times, verbal abuse, not being physically examined and discrimination in favor of the affluent and uninsured. The insured attributed their experience to the fact that they were not making immediate payments for services. A core challenge of the NHIS was a delay in reimbursement which affected the operations of health facilities and hence influenced providers’ behavior as well. Providers preferred clients who would make instant payments for health care services. Few of the uninsured were utilizing health facilities and visit only in critical conditions. This is due to the increased cost of health care services under the NHIS.
The perceived opportunistic behavior of the insured by providers was responsible for the difference in the behavior of providers favoring the uninsured. Besides, the delay in reimbursement also accounted for providers’ negative attitude towards the insured. There is urgent need to address these issues in order to promote confidence in the NHIS, as well as its sustainability for the achievement of universal coverage.
PMCID: PMC3505458  PMID: 22828034
National health insurance; Social health insurance; Universal health coverage; Perceptions; Experiences; Health care providers’ behavior; Insured; Uninsured; Ghana
22.  Achieving universal health care coverage: Current debates in Ghana on covering those outside the formal sector 
Globally, extending financial protection and equitable access to health services to those outside the formal sector employment is a major challenge for achieving universal coverage. While some favour contributory schemes, others have embraced tax-funded health service cover for those outside the formal sector. This paper critically examines the issue of how to cover those outside the formal sector through the lens of stakeholder views on the proposed one-time premium payment (OTPP) policy in Ghana.
Ghana in 2004 implemented a National Health Insurance Scheme, based on a contributory model where service benefits are restricted to those who contribute (with some groups exempted from contributing), as the policy direction for moving towards universal coverage. In 2008, the OTPP system was proposed as an alternative way of ensuring coverage for those outside formal sector employment. There are divergent stakeholder views with regard to the meaning of the one-time premium and how it will be financed and sustained. Our stakeholder interviews indicate that the underlying issue being debated is whether the current contributory NHIS model for those outside the formal employment sector should be maintained or whether services for this group should be tax funded. However, the advantages and disadvantages of these alternatives are not being explored in an explicit or systematic way and are obscured by the considerable confusion about the likely design of the OTPP policy. We attempt to contribute to the broader debate about how best to fund coverage for those outside the formal sector by unpacking some of these issues and pointing to the empirical evidence needed to shed even further light on appropriate funding mechanisms for universal health systems.
The Ghanaian debate on OTPP is related to one of the most important challenges facing low- and middle-income countries seeking to achieve a universal health care system. It is critical that there is more extensive debate on the advantages and disadvantages of alternative funding mechanisms, supported by a solid evidence base, and with the policy objective of universal coverage providing the guiding light.
PMCID: PMC3532243  PMID: 23102454
Universal health care coverage; National health insurance; Policy objective; Policy options; Those outside formal sector employment; Tax funding; One-time premium payment; Ghana
23.  Effects of Consumer and Provider Moral Hazard at a Municipal Hospital Out-Patient Department on Ghana's National Health Insurance Scheme 
Ghana Medical Journal  2012;46(4):200-210.
In 2003, Ghana introduced the national health insurance scheme (NHIS) to promote access to healthcare. This study determines consumer and provider factors which most influence the NHIS at a municipal health facility in Ghana.
This is an analytical cross-sectional study at the Winneba Municipal Hospital (WHM) in Ghana between January–March 2010. A total of 170 insured and 175 uninsured out-patients were interviewed and information extracted from their folders using a questionnaire. Consumers were from both the urban and rural areas of the municipality.
The mean number of visits by insured consumers to a health facility in previous six months was 2.48 +/− 1.007 and that for uninsured consumers was 1.18 +/− 0.387(p-value<0.001). Insured consumers visited the health facility at significantly more frequent intervals than uninsured consumers (χ2 = 55.413, p-value< 0.001). Overall, insured consumers received more different types of medications for similar disease conditions and more laboratory tests per visit than the uninsured. In treating malaria (commonest condition seen), providers added multivitamins, haematinics, vitamin C and intramuscular injections as additional medications more for insured consumers than for uninsured consumers.
Findings suggest consumer and provider moral hazard may be two critical factors affecting the NHIS in the Effutu Municipality. These have implications for the optimal functioning of the NHIS and may affect long-term sustainability of NHIS in the municipality. Further studies to quantify financial/ economic cost to NHIS arising from moral hazard, will be of immense benefit to the optimal functioning of the NHIS.
PMCID: PMC3645178  PMID: 23661838
Social health insurance; low-income countries; Ghana; consumer moral hazard and provider moral hazard
24.  Promoting universal financial protection: how the Thai universal coverage scheme was designed to ensure equity 
Empirical evidence demonstrates that the Thai Universal Coverage Scheme (UCS) has improved equity of health financing and provided a relatively high level of financial risk protection. Several UCS design features contribute to these outcomes: a tax-financed scheme, a comprehensive benefit package and gradual extension of coverage to illnesses that can lead to catastrophic household costs, and capacity of the National Health Security Office (NHSO) to mobilise adequate resources. This study assesses the policy processes related to making decisions on these features.
The study employs qualitative methods including reviews of relevant documents, in-depth interviews of 25 key informants, and triangulation amongst information sources.
Continued political and financial commitments to the UCS, despite political rivalry, played a key role. The Thai Rak Thai (TRT)-led coalition government introduced UCS; staying in power 8 of the 11 years between 2001 and 2011 was long enough to nurture and strengthen the UCS and overcome resistance from various opponents. Prime Minister Surayud’s government, replacing the ousted TRT government, introduced universal renal replacement therapy, which deepened financial risk protection.
Commitment to their manifesto and fiscal capacity pushed the TRT to adopt a general tax-financed universal scheme; collecting premiums from people engaged in the informal sector was neither politically palatable nor technically feasible. The relatively stable tenure of NHSO Secretary Generals and the chairs of the Financing and the Benefit Package subcommittees provided a platform for continued deepening of financial risk protection. NHSO exerted monopsonistic purchasing power to control prices, resulting in greater patient access and better systems efficiency than might have been the case with a different design.
The approach of proposing an annual per capita budget changed the conventional line-item programme budgeting system by basing negotiations between the Bureau of Budget, the NHSO and other stakeholders on evidence of service utilization and unit costs.
Future success of Thai UCS requires coverage of effective interventions that address primary and secondary prevention of non-communicable diseases and long-term care policies in view of epidemiologic and demographic transitions. Lessons for other countries include the importance of continued political support, evidence informed decisions, and a capable purchaser organization.
PMCID: PMC3735425  PMID: 23919275
Continued political support; Financial risk protection; Tax-financed universal scheme; Thailand; Universal health coverage
25.  The Effect of Ghana's National Health Insurance Scheme on Health Care Utilisation 
Ghana Medical Journal  2012;46(2):76-84.
The study investigates the effect of Ghana's National Health Insurance Scheme (NHIS) on health care utilisation.
We provide a short history of health insurance in Ghana, and briefly discuss general patterns of enrolment in Ghana as well as in Accra in a first step. In a second step, we use data from the Women's Health Study of Accra wave II to evaluate the effect of insurance on health seeking behaviour using propensity score matching.
We find that on average individuals enrolled in the insurance scheme are significantly more likely to obtain prescriptions, visit clinics and seek formal health care when sick.
These results suggest that the government's objective to increase access to the formal health care sector through health insurance has at least partially been achieved.
PMCID: PMC3426378  PMID: 22942455
Health insurance; health care utilisation; treatment differentials

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