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Challenges encountered in offsetting medical bills propelled the establishment of National Health Insurance Scheme (NHIS) to cater for the formal sector and Community Based Health Insurance Scheme (CBHIS) to focus on the poor and, vulnerable people were to ensure equal and affordable accessibility to healthcare services. After years of implementation, questions remained about the effectiveness and viability of the scheme. To answer the questions, the study, using primary and secondary data, examined the effectiveness of the scheme, its state-local collaboration implication, and the implementation strategies of CBHIS. The study found that non-involvement of local government officials negatively affected the scheme.

Background The national health insurance scheme of Nigeria recently proposed a national premium for community based insurance scheme. This study determined the capacity of households in the rural and urban areas in Nigeria to pay for the premium and different hypothetical health insurance schemes namely national health insurance scheme, national urban health insurance scheme, national rural health insurance scheme and regional health insurance schemes. It determined the likely impact of different premiums on membership across socio-economic status quintiles, and then determined the threshold premium affordable to rural and urban households. Results The results show that the mean capacity to pay for the households in different regions ranged from US$194 ± 100 to US$986 ± 907. The threshold premiums of the national health insurance scheme, urban national health insurance and rural health insurance schemes were US$66, US$154 and US$53 respectively. Conclusions Overall, the threshold premium for rural national health insurance scheme and national health insurance schemes were affordable to the lowest socio economic group. Hence, it is recommended that threshold premium for rural national health insurance scheme be adopted as the maximum premium not to be exceeded in the proposed national health insurance scheme.

To address the growth in resultant out-of-pocket (OOP) payments and associated problems of financial barriers to access, the government issued several policies aimed at expanding coverage throughout the 1990s and 2000s, particularly for the poor and other vulnerable groups. Universal coverage (UC) can be an elusive concept and is about three objectives: (a) equity (linking care to need, and not to ability to pay); (b) financial protection (ensuring that health care use does not lead to impoverishment); (c) effective access to a comprehensive set of quality services (ensuring that providers make the right diagnosis and prescribe a treatment that is appropriate and affordable; and (d) to ensure that the financing needed to achieve UC is mobilized in a fiscally sustainable manner, and is used efficiently and equitably. The objective of this report is to assess the implementation of Vietnam social health insurance (SHI) and provide options for moving toward UC, with a view to contributing to the law revision process. It analyzes progress to date on the two major goals of the master plan. The report assesses Vietnam's readiness to meet these goals, the challenges it will face in achieving UC, and key reforms needed to overcome those challenges. It does so through a health financing lens, focusing on how resources are mobilized, pooled, and allocated, and how services are purchased. The report also examines the stewardship of financing that is, the organization, management, and governance of SHI as it has direct implications for achieving UC. The report ends by pulling together the recommendations in the form of an implementation road map.

Background Health insurance is an important mechanism to prevent financial hardship in the process of accessing health care. Since the launch of Nigeria’s National Health Insurance Scheme (NHIS) in 2005, only 5% of Nigerians have health insurance and 70% still finance their healthcare through Out-Of-Pocket (OOP) expenditure. Understanding the contextualized perspectives of stakeholders involved in NHIS is critical to advancing and implementing necessary reforms for expanding health insurance coverage at national and sub-national levels in Nigeria. This study explored the perspectives of sub-national level actors/stakeholders on the design and implementation challenges of Nigeria’s NHIS. Methods A descriptive case study design was used in this research. Data were collected in Ibadan, Oyo State in 2016 from health insurance regulators, healthcare providers, and policymakers. Key informant interviews (KII) were conducted among purposively selected stakeholders to examine their perspectives on the design and implementation challenges of Nigeria’s National Health Insurance Scheme. Data were analysed using inductive and deductive thematic approaches with the aid of NVIVO software package version 11. Results Implementation challenges identified include abject poverty, low level of awareness, low interest (in the scheme), superstitious beliefs, inefficient mode of payment, drug stock-out, weak administrative and supervisory capacity. The scheme is believed to have provided more coverage for the formal sector, its voluntary nature and lack of legal framework at the subnational levels were seen as the overarching policy challenge. Only NHIS staff currently make required financial co-contribution into the scheme, as all other federal employees are been paid for by the (federal) government. Conclusions Sub-national governments should create legal frameworks establishing compulsory health insurance schemes at the subnational levels. Effective and efficient platforms to get the informal sector enrolled in the scheme is desirable. CBHI schemes and the currently approved state supported health insurance programmes may provide a more acceptable platform than NHIS especially among the rural informal sector. These other two should be promoted. Awareness and education should also be raised to enlighten citizens. Stakeholders need to address these gaps as well as poverty.

Many countries that subscribe to the Millennium Development Goals (MDGs) have committed to ensuring access to basic health services for their citizens. Health insurance has been considered and promoted as the major financing mechanism to improve access to health services, as well as to provide financial risk protection. In Africa, several countries have already spent scarce time, money, and effort on health insurance initiatives. Ethiopia, Ghana, Kenya, Nigeria, Rwanda, and Tanzania are just a few of them. However, many of these schemes, both public and private, cover only a small proportion of the population, with the poor less likely to be covered. In fact, unless carefully designed to be pro-poor, health insurance can widen inequity as higher income groups are more likely to be insured and use health care services, taking advantage of their insurance coverage. The purpose of this handbook is to provide policy makers and health insurance designers with practical, action-oriented support that will deepen their understanding of health insurance concepts, help them identify design and implementation challenges, and define realistic steps for the development and scaling up of equitable, efficient, and sustainable health insurance schemes. The handbook takes policy makers and health insurance designers through a step-by-step series of considerations and tasks that need to be achieved. The handbook's philosophy is to not be dogmatic, ideological, or prescriptive. This handbook was prepared to be used in a six-day regional workshop. Clearly, health insurance design is an intensive political and technical process that takes much longer than six days. The expectation for the workshop is that by the end of the week, each team has a clear idea of next steps that they could take back home to engage other stakeholders and move toward scaling up and improving the performance of health insurance in their country.

Background Community-based health insurance (CBHI) has evolved as an alternative health financing mechanism to out of pocket payments in low- and middle-income countries (LMICs), particularly in areas where government or employer-based health insurance is minimal. This systematic review aimed to assess the barriers and facilitators to implementation, uptake and sustainability of CHBI schemes in LMICs. Methods We searched six electronic databases and grey literature. We included both quantitative and qualitative studies written in English language and published after year 1992. Two reviewers worked in duplicate and independently to complete study selection, data abstraction, and assessment of methodological features. We synthesized the findings based on thematic analysis and categorized according to the ecological model into individual, interpersonal, community and systems levels. Results Of 15,510 citations, 51 met the eligibility criteria. Individual factors included awareness and understanding of the concept of CBHI, trust in scheme and scheme managers, perceived service quality, and demographic characteristics, which influenced enrollment and sustainability. Interpersonal factors such as household dynamics, other family members enrolled in the scheme, and social solidarity influenced enrollment and renewal of membership. Community-level factors such as culture and community involvement in scheme development influenced enrollment and sustainability of scheme. Systems-level factors encompassed governance, financial and delivery arrangement. Government involvement, accountability of scheme management, and strong policymaker-implementer relation facilitated implementation and sustainability of scheme. Packages that covered outpatient and inpatient care and those tailored to community needs contributed to increased enrollment. Amount and timing of premium collection was reported to negatively influence enrollment while factors reported as threats to sustainability included facility bankruptcy, operating on small budgets, rising healthcare costs, small risk pool, irregular contributions, and overutilization of services. At the delivery level, accessibility of facilities, facility environment, and health personnel influenced enrollment, service utilization and dropout rates. Conclusion There are a multitude of interrelated factors at the individual, interpersonal, community and systems levels that drive the implementation, uptake and sustainability of CBHI schemes. We discuss the implications of the findings at the policy and research level. Trial registration The review protocol is registered in PROSPERO International prospective register of systematic reviews (ID =  CRD42015019812 ).

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 In 2003, Ghana implemented a National Health Insurance Scheme (NHIS) designed to promote universal health coverage and equitable access to health care. The scheme has largely been successful, yet it is confronted with many challenges threatening its sustainability. Out-of-pocket payments (OOP) by insured clients is one of such challenges of the scheme. This study sought to examine the types of services OOP charges are made for by insured clients and how much insured clients pay out-of-pocket. Methods This was a descriptive cross-sectional health facility survey. A total of 2066 respondents were interviewed using structured questionnaires at the point of health care exit in the Ashanti, Northern and Central regions of Ghana. Health facilities of different levels were selected from 3 districts in each of the three regions. Data were collected between April and June 2018. Using Epidata and STATA Version 13.1 data analyses were done using multiple logistic regression and simple descriptive statistics and the results presented as proportions and means. Results Of all the survey respondents 49.7% reported paying out-of-pocket for out-patient care while 46.9% of the insured clients paid out-of-pocket. Forty-two percent of the insured poorest quintile also paid out-of-pocket. Insured clients paid for consultation (75%) and drugs (63.2%) while 34.9% purchased drugs outside the health facility they visited. The unavailability of drugs (67.9%) and drugs not covered by the NHIS (20.8%) at the health facility led to out-of-pocket payments. On average, patients paid GHS33.00 (USD6.6) out-of-pocket. Compared to the Ashanti region, patients living in the Northern region were 74% less at odds to pay out-of-pocket for health care. Conclusion and recommendation Insured clients of Ghana’s NHIS seeking health care in accredited health facilities make out-of-pocket payments for consultation and drugs that are covered by the scheme. The out-of-pocket payments are largely attributed to unavailability of drugs at the facilities while the consultation fees are charged to meet the administrative costs of services. These charges occur in disadvantaged regions and in all health facilities. The high reliance on out-of-pocket payments can impede Ghana’s progress towards achieving Universal Health Coverage and the Sustainable Development Goal 3, seeking to end poverty and reduce inequalities. In order to build trust and confidence in the NHIS there is the need to eliminate out-of-pocket payments for consultation and medicines by insured clients.

Background: Universal health coverage (UHC) is a global priority, with the goal of ensuring that everyone has access to high-quality healthcare without suffering financial hardship. In Africa, most governments have prioritized UHC over the last two decades. Despite this, the transition to UHC in Africa is seen to be sluggish, with certain countries facing inertia. This study sought to examine the progress of UHC-focused health reform implementation in Africa, investigating the approaches utilized, the challenges faced, and potential solutions. Method: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines, we scoped the literature to map out the evidence on UHC adoption, roll out, implementation, challenges, and opportunities in the African countries. Literature searches of the Cochrane database of systematic reviews, PUBMED, EBSCO, Eldis, SCOPUS, CINHAL, TRIP, and Google Scholar were conducted in 2023. Using predefined inclusion criteria, we focused on UHC adoption, rollout, implementation, and challenges and opportunities in African countries. Primary qualitative, quantitative, and mixed-methods evidence was included, as well as original analyses of secondary data. We employed thematic analysis to synthesize the evidence. Results: We found 9633 documents published between May 2005 and December 2023, of which 167 papers were included for analysis. A significant portion of UHC implementation in Africa has focused on establishing social health protection schemes, while others have focused on strengthening primary healthcare systems, and a few have taken integrated approaches. While progress has been made in some areas, considerable obstacles still exist. Financial constraints and supply-side challenges, such as a shortage of healthcare workers, limited infrastructure, and insufficient medical supplies, remain significant barriers to UHC implementation throughout Africa. Some of the promising solutions include boosting public funding for healthcare systems, strengthening public health systems, ensuring equity and inclusion in access to healthcare services, and strengthening governance and community engagement mechanisms. Conclusion: Successful UHC implementation in Africa will require a multifaceted approach. This includes strengthening public health systems in addition to the health insurance schemes and exploring innovative financing mechanisms. Additionally, addressing the challenges of the informal sector, inequity in healthcare access, and ensuring political commitment and community engagement will be crucial in achieving sustainable and comprehensive healthcare coverage for all African citizens.

Background Over 150 million people, mostly from low and middle-income countries (LMICs) suffer from catastrophic health expenditure (CHE) every year because of high out-of-pocket (OOP) payments. In Tanzania, OOP payments account for about a quarter of the total health expenditure. This paper compares healthcare utilization and the incidence of CHE among improved Community Health Fund (iCHF) members and non-members in central Tanzania. Methods A survey was conducted in 722 households in Bahi and Chamwino districts in Dodoma region. CHE was defined as a household health expenditure exceeding 40% of total non-food expenditure (capacity to pay). Concentration index (CI) and logistic regression were used to assess the socioeconomic inequalities in the distribution of healthcare utilization and the association between CHE and iCHF enrollment status, respectively. Results 50% of the members and 29% of the non-members utilized outpatient care in the previous month, while 19% (members) and 15% (non-members) utilized inpatient care in the previous twelve months. The degree of inequality for utilization of inpatient care was higher (insured, CI = 0.38; noninsured CI = 0.29) than for outpatient care (insured, CI = 0.09; noninsured CI = 0.16). Overall, 15% of the households experienced CHE, however, when disaggregated by enrollment status, the incidence of CHE was 13% and 15% among members and non-members, respectively. The odds of iCHF-members incurring CHE were 0.4 times less compared to non-members (OR = 0.41, 95%CI: 0.27–0.63). The key determinants of CHE were iCHF enrollment status, health status, socioeconomic status, chronic illness, and the utilization of inpatient and outpatient care. Conclusion The utilization of healthcare services was higher while the incidence of CHE was lower among households enrolled in the iCHF insurance scheme relative to those not enrolled. More studies are needed to establish the reasons for the relatively high incidence of CHE among iCHF members and the low degree of healthcare utilization among households with low socioeconomic status.