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Specialist groups have often advised health ministers and other decision makers in developing countries on the use of social health insurance (SHI) as a way of mobilizing revenue for health, reforming health sector performance, and providing universal coverage. This book reviews the specific design and implementation challenges facing SHI in low- and middle-income countries and presents case studies on Ghana, Kenya, Philippines, Colombia, and Thailand.

Background Policymakers have embraced substitution of hospital care to more affordable primary care as a means to contain rising healthcare costs and provide care closer to home. Health insurers play an important role in the extent to which substitution of care takes place. This study explores the perspective of Dutch health insurers on barriers and facilitators to facilitate a shift from hospitals to general practice in the current healthcare system. Methods Semi-structured group interviews were conducted with healthcare purchasers from various health insurers, involving fifteen participants from seven insurers representing 76.5% of the market. Thematic analysis was used to identify perceived facilitators and barriers for effective substitution of care. Results Long-term contracts that enable strategic planning and collaboration between general practices and hospitals, as well as strong organizational structures in general practice and long waiting times in hospitals are reported to facilitate substitution. Uncertainties around collaboration under the Competition Act, inadequate compensation through the risk equalization model, complex billing codes for innovative initiatives, a rigid national budgetary framework and strong bargaining power of hospitals as opposed to insurers and general practices are stated to hinder the shift towards general practice. Conclusions Key areas for improvement to facilitate substitution, as reported by healthcare purchasers, include clear guidelines on insurer collaboration, adjustments to the risk equalization model, strengthening the bargaining power of general practices, and promoting long-term contracts. This study provides insights into the perceived barriers and facilitators for care substitution from the payer’s perspective. Addressing these barriers is essential for facilitating the shift from hospital to general practice care. Also, potential discrepancies between perceptions and current regulations highlight areas where enhanced dialogue and collaboration between policy makers and health insurers could improve mutual understanding and regulatory compliance.

Managed competition is a key driver in healthcare systems in countries like Germany, Switzerland, and The Netherlands. Trust in health insurers is vital but currently low in The Netherlands. This may be due to perceptions regarding profit motives, negative experiences, media coverage, and a lack of understanding of insurers’ roles. This study explores how enrollees perceive health insurers and how the aforementioned factors contribute to these perceptions. Semi-structured interviews were conducted with 17 participants from the Nivel Dutch Health Care Consumer Panel in March and April 2023. Data were analysed using Braun and Clarke’s six-step method for inductive thematic analysis. Participants generally view health insurers positively in terms of managing finances and ensuring care accessibility. However, some perceive insurers as profit-driven and prioritising cost reduction over individual needs, leading to dissatisfaction. Negative experiences and media coverage also shape these perceptions. Participants believe that insurers should ensure care accessibility and quality, distribute costs fairly, provide guidance, and prioritise preventive measures. To foster trust, insurers should communicate their non-profit status and use of benefits, increase transparency in purchasing decisions, and maintain clear communication about payment obligations. Enhancing communication about their contributions to healthcare and raising awareness of their broader roles may also help build trust.

Background Chronic diseases contribute to a significant proportion (71%) of all deaths each year worldwide. Governments and other stakeholders worldwide have taken various actions to tackle the key risk factors contributing to the prevalence and impact of chronic diseases. Private health insurers (PHI) are one key stakeholders, particularly in Australian health system, and their engagement in chronic disease prevention is growing. Therefore, we investigated the impacts of chronic disease prevention interventions implemented by PHI both in Australia and internationally. Method We searched multiple databases (Business Source Complete, CINAHL, Global Health, Health Business Elite, Medline, PsycINFO, and Scopus) and grey literature for studies/reports published in English until September 2020 using search terms on the impacts of chronic disease prevention interventions delivered by PHIs. Two reviewers assessed the risk of bias using a quality assessment tool developed by Effective Public Healthcare Panacea Project. After data extraction, the literature was synthesised thematically based on the types of the interventions reported across studies. The study protocol was registered in PROSPERO, CRD42020145644. Results Of 7789 records, 29 studies were eligible for inclusion. There were predominantly four types of interventions implemented by PHIs: Financial incentives, health coaching, wellness programs, and group medical appointments. Outcome measures across studies were varied, making it challenging to compare the difference between the effectiveness of different intervention types. Most studies reported that the impacts of interventions, such as increase in healthy eating, physical activity, and lower hospital admissions, last for a shorter term if the length of the intervention is shorter. Interpretation Although it is challenging to conclude which intervention type was the most effective, it appeared that, regardless of the intervention types, PHI interventions of longer duration (at least 2 years) were more beneficial and outcomes were more sustained than those PHI interventions that lasted for a shorter period. Funding Primary source of funding was Geelong Medical and Hospital Benefits Association (GMHBA), an Australian private health insurer.

In health care systems based upon managed competition, insurers are expected to negotiate with providers about price and quality of care. The Dutch experience, however, shows that quality plays a limited role in insurer–provider negotiations. It has been suggested that this is partly due to a lack of cooperation among insurers. This raises the question whether cooperation amongst insurers is a precondition or a substitute for quality-based competition. To answer this question, we mapped insurers' cooperating activities to enhance quality of care using a six-stage continuum. The first three stages (defining, designing and measuring quality indicators) may enhance competition, whereas the next three stages (setting benchmarks, steering patients and selective contracting) may reduce it. We investigated which types of insurer cooperation currently take place in the Netherlands. Additionally, we organized focus groups among insurers, providers and other stakeholders to examine their perceptions on insurer cooperation. We find that all stakeholders see advantages of cooperation amongst insurers in the first stages of the continuum and sometimes cooperate in this domain. Cooperation in the next stages is almost absent and more controversial because without adequate quality information, it is difficult to assess whether the benefits outweigh the cost associated with reduced competition.

Over the past decade, many health care systems across the Global North have implemented elements of market mechanisms while also dealing with the consequences of the financial crisis. Although effects of these two developments have been researched separately, their combined impact on the governance of health care organizations has received less attention. The aim of this study is to understand how health care reforms and the financial crisis together shaped new roles and interactions within health care. The Netherlands – where dynamics between health care organizations and their financial stakeholders (i.e., banks and health insurers) were particularly impacted – provides an illustrative case. Through semi-structured interviews, additional document analysis and insights from institutional change theory, we show how banks intensified relationship management, increased demands on loan applications and shifted financial risks onto health care organizations, while health insurers tightened up their monitoring and accountability practices towards health care organizations. In return, health care organizations were urged to rearrange their operations and become more risk-minded. They became increasingly dependent on banks and health insurers for their existence. Moreover, with this study, we show how institutional arenas come about through both the long-term efforts of institutional agents and unpredictable implications of economic and societal crises.

Background In a demand oriented health care system based on managed competition, health insurers have incentives to become prudent buyers of care on behalf of their enrolees. They are allowed to selectively contract care providers. This is supposed to stimulate competition between care providers and both increase the quality of care and contain costs in the health care system. However, health insurers are reluctant to implement selective contracting; they believe their enrolees will not accept this. One reason, insurers believe, is that enrolees do not trust their health insurer. However, this has never been studied. This paper aims to study the role played by enrolees’ trust in the health insurer on their acceptance of selective contracting. Methods An online survey was conducted among 4,422 people insured through a large Dutch health insurance company. Trust in the health insurer, trust in the purchasing strategy of the health insurer and acceptance of selective contracting were measured using multiple item scales. A regression model was constructed to analyse the results. Results Trust in the health insurer turned out to be an important prerequisite for the acceptance of selective contracting among their enrolees. The association of trust in the purchasing strategy of the health insurer with acceptance of selective contracting is stronger for older people than younger people. Furthermore, it was found that men and healthier people accepted selective contracting by their health insurer more readily. This was also true for younger people with a low level of trust in their health insurer. Conclusion This study provides insight into factors that influence people’s acceptance of selective contracting by their health insurer. This may help health insurers to implement selective contracting in a way their enrolees will accept and, thus, help systems of managed competition to develop.

Background The Nurse Work Instability Scale (Nurse-WIS) is an occupation-specific instrument that ascertains “work instability,” the interval before restricted work ability or prolonged sick leave occurs. The objective of the study was to assess if nurses with a high risk baseline-score in the Nurse-WIS take longer periods of sick leave due to musculoskeletal diseases and/or psychological impairments than other nurses. Methods A total of 4500 nurses randomly selected from one of the largest health insurance funds in Germany (DAK-Gesundheit) were invited by letter to participate in the study. The participants answered a questionnaire at baseline and gave consent to a transfer of data concerning sick leave during the twelve months following completion of the questionnaire from the health insurance to the study centre. Sensitivity, specificity and positive and negative predictive values (PPV and NPV) for long-term sick leave were calculated. In order to analyze the association between the Nurse-WIS and sick leave during follow-up, a multiple ordinal logistic model (proportional odds model) was applied. Results A total of 1592 nurses took part in the study (response 35.6%). No loss of follow-up occurred. The number of nurses with a high score (20–28 points) in the Nurse-WIS was 628 (39.4%), and 639 (40.1%) had taken sick leave due to musculoskeletal diseases or psychological impairment during the follow-up period. The odds ratio for sick leave in nurses with a high Nurse-WIS score was 3.42 (95%CI 2.54–4.60). Sensitivity for long-term sick leave (< 42 days) was 64.1%, specificity 63.4%, PPV 17.0% and NPP 93.8%. Conclusion The German version of the Nurse-WIS predicts long-term sick leave, but the PPV is rather low. Combining questionnaire data with secondary data from a health insurer was feasible. Therefore further studies employing this combination of data are advisable.

According to the Euro Health Consumer Index, the Dutch healthcare system is the champion of Europe. Yet we are living for longer, prosperity is increasing and the population is growing. If we do not continue to adjust our healthcare system to these trends, medical expenses in the Netherlands will double to € 174 billion (in 2040). We are also facing job market difficulties in healthcare. We risk a shortfall of 125 thousand employees in 2022. It is therefore time to restructure healthcare. Not tomorrow but today. Healthcare will increasingly be organised around the day-to-day lives of patients—at home or work, with offline and online healthcare seamlessly matching up to each other. The shortage of personnel also demands a different attitude to healthcare provision. As a health insurer we can help to improve healthcare, for instance by giving healthcare providers the financial capacity to organise their care differently. Or by conducting independent research so that conclusions can be drawn on the legal criterion of ‘the state of science and practice’. This is how it was possible, in conjunction with the Dutch Cardiology Centres, the Netherlands Society of Cardiology and FocusCura, to include the ‘Hartwacht’ telemonitoring service in health insurance policies.

Although mandatory health insurance programs are being proposed or expanded in many developing countries, relatively little attention has been given to how these programs are governed. The available literature focuses almost exclusively on operational features that are important but will necessarily change over time—such as eligibility, benefit packages, and premiums. Governing Mandatory Health Insurance instead looks at the institutional and political forces that affect the behavior of such programs within their social and historical contexts and how five dimensions of governance—coherent decision-making structures, stakeholder participation, transparency and information, supervision and regulation, and consistency and stability—can influence the long-term performance of health insurance programs in terms of coverage, financial protection, efficiency, and sustainability. Governing Mandatory Health Insurance addresses these issues by drawing on the experiences of four countries—Chile, Costa Rica, Estonia, and the Netherlands. It shows how governance works in these countries and extracts lessons for developing countries with mandatory health insurance programs, focusing on the mechanisms for assuring solvency, financial protection, and health care services of good quality.