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As the world recently turned its attention to the struggle of expanding health insurance coverage for 40 million people in the United States, it is important not to forget the 4 billion people in low- and middle-income countries that face the same hardship. Millions of the poor have already fallen back into poverty as a result of the ongoing global financial crisis. Millions more are at risk before full recovery. It is the poor and most vulnerable that are at greatest risk due to lack of protection against the impoverishing effects of illness. The research for this volume shows that, when properly designed and coupled with public subsidies, health insurance can contribute to the well-being of poor and middle-class households, not just the rich. And it can contribute to development goals such as improved access to health care, better financial protection against the cost of illness, and reduced social exclusion. Opponents vilify health insurance as an evil to be avoided at all cost. To them, health insurance leads to overconsumption of care, escalating costs-especially administrative costs-fraud and abuse, shunting of scarce resources away from the poor, cream skimming, adverse selection, moral hazard, and an inequitable health care system. Today many low-and middle-income countries are no longer listening to this dichotomized debate between vertical and horizontal approaches to health care. Instead, they are experimenting with new and innovative approaches to health care financing. Health insurance is becoming a new paradigm for reaching the Millennium Development Goals (MDGs). They emphasize the need to combine several instruments to achieve three major development objectives in health care financing: 1) sustainable access to needed health care; 2) greater financial protection against the impoverishing cost of illness; and 3) reduction in social exclusion from organized health financing instruments. The use of insurance was recommended to pay for less frequent, higher-cost risks and subsidies to cover affordability for poorer patients to higher-frequency, lower-cost health problems.

In Morocco, AMO-Tadamon is a basic mandatory health insurance scheme designed to ensure right to health for all. Implementation of this reform is advantageous for access to healthcare services. However, its impact on continuity of care needs to be assessed. In this study, we aimed to evaluate its impact on continuity of care for breast cancer patients at the Oncology Center of CHU Mohammed VI-Tangier between September 2022 and September 2023. This was a mixed longitudinal cohort study. Follow-up information was collected over 13 months. December 1, 2022 was the index-event. Continuity of care was measured using \"Bice-Boxerman Continuity of Care Index\" and \"Usual Provider Continuity\" over three chronological sequences. We recorded 74 cases in total, 16/74 were lost to follow-up (21.6%). Significant association (p=0.001; CI (0.01-0.04)) was observed between AMO-Tadamon generalization and continuity of care in our patients. For both indicators (UPC and COCI), mean continuity of care scores ranged from 0.25 to 0.75 over the three reference periods. This indicates a moderate overall continuity of care. During the first 4 months of this reform, significant positive associations were found between Therapy postponement and its implementation (p=0.003; CI (0.01--0.04)). Moreover, access to expensive drugs was significantly higher in the postgeneralization period (p=0.027; CI (0.01-0.04)). Our study suggests a negative impact of this reform on patient care during the period of its generalization and a positive effect on access to expensive drugs after its generalization. A long-term follow-up study is planned. This will assess the impact of this reform on survival.

BackgroundWhilst several systematic reviews conducted in Low- and Middle-Income Countries (LMICs) have revealed that coverage under social (SHI), national (NHI) and community-based (CBHI) health insurance has led to increased utilization of health care services, it remains unknown whether, and what aspects of, these shifts in financing result in improvements to mental health care utilization. The main aim of this review was to examine the impact of SHI, NHI and CBHI enrollment on mental health care utilization in LMICs.MethodsSystematic searches were performed in nine databases of peer-reviewed journal articles: Pubmed, Scopus, SciELO via Web of Science, Africa Wide, CINAHL, PsychInfo, Academic Search Premier, Health Source Nursing Academic and EconLit for studies published before October 2018. The quality of the studies was assessed using the Effective Public Health Practice Project quality assessment tool for quantitative studies. The systematic review was reported according to the PRISMA guidelines (PROSPERO;2018; CRD42018111576).ResultsEighteen studies were included in the review. Despite some heterogeneity across countries, the results demonstrated that enrollment in SHI, CBHI and NHI schemes increased utilization of mental health care. This was consistent for the length of inpatient admissions, number of hospitalizations, outpatient use of rehabilitation services, having ever received treatment for diagnosed schizophrenia and depression, compliance with drug therapies and the prescriptions of more favorable medications and therapies, when compared to the uninsured. The majority of included studies did not describe the insurance schemes and their organizational details at length, with limited discussion of the links between these features and the outcomes. Given the complexity of mental health service utilization in these diverse contexts, it was difficult to draw overall judgements on whether the impact of insurance enrollment was positive or negative for mental health care outcomes.ConclusionsStudies that explore the impact of SHI, NHI and CBHI enrollment on mental health care utilization are limited both in number and scope. Despite the fact that many LMICs have been hailed for financing reforms towards universal health coverage, evidence on the positive impact of the reforms on mental health care utilization is only available for a small sub-set of these countries.

Background: To assess progress in improving affordability of medicines since the introduction of mandatory health insurance in the Republic of Moldova. Method: Using data from national health insurance, we estimate affordability of partially reimbursed medicines for the treatment of non-communicable diseases, and analyse which factors contributed to changes in affordability. Results: Affordability of subsidized medicines improved over time. In 2013, it took a median of 0.84 days of income for the lowest income quintile (ranging from 0 to 3.32 days) to purchase 1 month of treatment for cardiovascular conditions in comparison to 1.85 days in 2006. This improvement however was mainly driven by higher incomes rather than deeper coverage through the reimbursement list. Conclusion: If mandatory health insurance is to improve affordability of medicines for the Moldovan population, more funds need to be (re-)allocated to enable higher percentage coverage of essential medicines and efficiencies need to be generated within the health system. These should include a budget reallocation between secondary and primary care, strengthening primary care to manage chronic conditions and raise population awareness, implementation of evidence-based selection and quality use of medicines in both outpatient and inpatient settings, improving monitoring and regulation of prices and the supply chain; and alignment of national treatment guidelines and clinical practice with international best practices and evidence-based medicine.

Assisted reproductive technologies (ART) are an infertility treatment tool. In Russia, more than 250 centers implementing infertility treatment with the help of ART have been opened in 67 regions. In 2014, in vitro fertilization (IVF) was included in the programme of state guarantees, and since 2016 the service can be obtained within the Mandatory Health Insurance (MHI) system. Author of this study analyzes how the impact of economic factors on fertility with the use of ART has changed in relation to the inclusion of IVF in the MHI system, and what social factors affect the usage of this technology. The analysis bases on the panel data for the regions of Russia covering the period from 2011 to 2017. The fixed effects method was used to assess the impact of various factors. The study shows that the population income level has a significant positive impact on the proportion of births with the use of ART even after the inclusion of IVF into the MHI programme. At the same time, the inclusion of IVF in the MHI programme has led to an increase in the proportion of births using ART. The positive effect of this inclusion is higher in wealthier regions. Among social factors, a significant impact has the accessibility of information about the procedure, which is measured by the share of population having access to the Internet.

Background Implementation of a mandatory insurance scheme depends on several issues, and among them are regulation, management, and program design which are very crucial. Sometimes a well-designed insurance scheme cannot attract an adequate number of people toward the scheme. Therefore, this study is aimed to explore the implementation challenges of Sajida Foundation’s health insurance scheme. Methods An exploratory qualitative research design has been applied to explore the challenges that normally exist in regular implementation process. The study population was both field and official level employees who are directly involved in the implementation process of Nirapotta scheme in Karanigoni branch. Results Successful implementation of the health insurance scheme of Sajida Foundation is getting constraints by several factors, and among them are lack of dedicated staff for this program, less involvement with community people, inadequate program knowledge dissemination to the people, and not providing incentive for work of Nirapotta are considered as the major challenges of implementation of Nirapotta Scheme. Challenges faced by policy-makers include incoordination with Microfinance Regulatory Authority and not having the latest software for perfect monitoring and evaluation of the Nirapotta program. Apart from this, there are some challenges in implementation which are normally faced in program; some of the most noteworthy findings are incoordination between employees especially in branch level, transient position of Sajida bondhu in the Nirapotta program, and low payment scale compared to other organizations. Conclusions Implementation of Nirapotta scheme is getting constraints by multiple factors which can easily be overcome by involving all necessary stakeholders and taking their valuable concern for further development of the scheme to ensure long-term sustainability of the program.

This paper examines the effects of mandatory health insurance on access and equity in access to public and private outpatient care in Indonesia. Data from the second round of the 1997 Indonesian Family Life Survey were used. We adopted the concentration index as a measure of equity, and this was calculated from actual data and from predicted probability of outpatient-care use saved from a multinomial logit regression. The study found that a mandatory insurance scheme for civil servants (Askes) had a strongly positive impact on access to public outpatient care, while a mandatory insurance scheme for private employees (Jamsostek) had a positive impact on access to both public and private outpatient care. The greatest effects of Jamsostek were observed amongst poor beneficiaries. A substantial increase in access will be gained by expanding insurance to the whole population. However, neither Askes nor Jamsostek had a positive impact on equity. Policy implications are discussed.

under the Mandatory Health Insurance (MHI) scheme, liberal doctors signed their first national convention in the year of 2006. The delay in renewing this agreement could negatively affect the accessibility of the insured persons to medical care. The objective of this study was to explore the knowledge, attitude and practice of the liberal doctors towards their adherence to the national convention signed under MHI scheme and to propose some improvements. our study is cross-sectional based on a descriptive survey targeting the population of liberal doctors adhering to the signed convention under the MHI in Morocco. The material used was a questionnaire that was administered to doctors selected. The processing and analyzing of results were performed with SPSS 13.0. the study, conducted in 2016, examines included 40 liberal doctors. 97.5% of them reported dissatisfaction with the National Reference Pricing. 60% of the them were demotivated to the application of the national convention because of the lack in educational materials. There was no significant difference in the attitudes between general practitioners and specialists, all of whom considered that remuneration was unfair under MHI (p = 0.689), they also considered that working conditions have deteriorated (p = 0.256). the behavior of liberal doctors towards the national convention signed within the framework of the MHI hides a general dissatisfaction whatever the place of practice. This dissatisfaction was felt by physicians regardless of their seniority or specialty. Several efforts should be made to find a compromise between doctors and the health insurance system to improve patient access to care.

¶Objectives: To establish the number of psychotherapists with professional backgrounds; psychotherapeutic provision and its cost; change in cost in case of integration of non-medical psychotherapy into the mandatory minimum health care benefit.¶Methods: A population-based survey using computer-assisted telephone interviews in a randomly selected sample of medical and non-medical psychotherapists (NMP), stratified by professional status and language regions.¶Results: 1633 psychiatrists, 2332 general practitioners and 2616 NMP provide psychotherapy in Switzerland. NMP by training: 1674 (64%) hold a university degree in psychology; 539 (21%) hold a professional school degree in psychology; and 403 (15%) have various backgrounds. In 2000, 146000 patients utilised 4.52 million hours of medical psychotherapy, which cost CHF 579 million, CHF 396 million of which were reimbursed by mandatory health insurance (MHI). Reimbursement of NMP by MHI would result in additional expenditures of CHF 102-252 million.¶Conclusions: NMP provide 46% of psychotherapy which is currently partly reimbursed by the MHI. An integration of NMP into the MHI benefit package would incur additional costs to MHI of CHF 102-252 million.[PUBLICATION ABSTRACT]