Understanding the role of the Tanzania national health insurance fund in improving service coverage and quality of care.

Health insurance is one of the main financing mechanisms currently being used in low and middle-income countries to improve access to quality services. Tanzania has been running its National Health Insurance Fund (NHIF) since 2001 and has recently undergone significant reforms. However, there is limited attention to the causal mechanisms through which NHIF improves service coverage and quality of care. This paper aims to use a system dynamics (qualitative) approach to understand NHIF causal pathways and feedback loops for improving service coverage and quality of care at the primary healthcare level in Tanzania. We used qualitative interviews with 32 stakeholders from national, regional, district, and health facility levels conducted between May to July 2021. Based on the main findings and themes generated from the interviews, causal mechanisms, and feedback loops were created. The majority of feedback loops in the CLDs were reinforcing cycles for improving service coverage among beneficiaries and the quality of care by providers, with different external factors affecting these two actions. Our main feedback loop shows that the NHIF plays a crucial role in providing additional financial resources to facilities to purchase essential medical commodities to deliver care. However, this cycle is often interrupted by reimbursement delays. Additionally, beneficiaries' perception that lower-level facilities have poorer quality of care has reinforced care seeking at higher-levels. This has decreased lower level facilities' ability to benefit from the insurance and improve their capacity to deliver quality care. Another key finding was that the NHIF funding has resulted in better services for insured populations compared to the uninsured. To increase quality of care, the NHIF may benefit from improving its reimbursement administrative processes, increasing the capacity of lower levels of care to benefit from the insurance and appropriately incentivizing providers for continuity of care.

Effects of Health Insurance on Quality of Care in Low-Income Countries: A Systematic Review.

Objectives: To evaluate the effectiveness of health insurance on quality of care in low-income countries (LICs). Methods: We conducted a systematic review following PRISMA guidelines. We searched seven databases for studies published between 2010 and August 2022. We included studies that evaluated the effects of health insurance on quality of care in LICs using randomized experiments or quasi-experimental study designs. Study outcomes were classified using the Donabedian framework. Results: We included 15 studies out of the 6,129 identified. Available evidence seems to suggest that health insurance has limited effects on structural quality, and its effects on the process of care remain mixed. At the population level, health insurance is linked to improved anthropometric measures for children and biomarkers such as blood pressure and hemoglobin levels. Conclusion: Based on the currently available evidence, it appears that health insurance in LICs has limited effects on the quality of care. Further studies are required to delve into the mechanisms that underlie the impact of health insurance on the quality of care and identify the most effective strategies to ensure quality within insurance programs. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=219984, identifier PROSPERO CRD42020219984.

Purchasing for high-quality care using National Health Insurance: evidence from Zambia.

Improving the quality of care is essential for progress towards universal health coverage. Health financing arrangements offer opportunities for governments to incentivize and reward improvements in the quality of care provided. This study examines the extent to which the purchasing arrangements established within Zambia's new National Health Insurance can improve equitable access to high-quality care. We adopt the Strategic Purchasing Progress and the Lancet Commission for High-Quality Health Systems frameworks to critically examine the broader health system and the purchasing dimensions of this insurance scheme and its implications for quality care. We reviewed policy documents and conducted 31 key-informant interviews with stakeholders at national, subnational and health facility levels. We find that the new health insurance could boost financial resources in higher levels of care, improve access to high-cost interventions, improve care experiences for its beneficiaries and integrate the public and private sectors. Our findings also suggest that health insurance will likely improve some aspects of structural quality but may not be able to influence process and outcome measures of quality. It is also not clear if health insurance will improve the efficiency of service delivery and whether the benefits realized will be distributed equitably. These potential limitations are attributable to the existing governance and financial challenges, low investments in primary care and shortcomings in the design and implementation of the purchasing arrangements of health insurance. Although Zambia has made progress in a short span, there is a need to improve its provider payment mechanisms, and monitoring and accounting for a higher quality of care.

Confidence in the health system and health insurance enrollment among the informal sector population in Lusaka, Zambia.

BACKGROUND: To improve equitable access to quality essential services and reduce financial hardship, low-and-middle-income countries are increasingly relying on prepayment strategies such as health insurance schemes. Among the informal sector population, confidence in the health system to provide effective treatment and trust in institutions can play an important role in health insurance enrollment. The objective of this study was to examine the extent to which confidence and trust affect enrollment into the recently introduced Zambia National Health insurance. METHODS: We conducted a regionally representative cross-sectional household survey in Lusaka, Zambia collecting information on demographics, health expenditure, ratings of last health facility visit, health insurance status and confidence in the health system. We used multivariable logistic regression to assess the association between enrollment and confidence in the private and public health sector as well as trust in the government in general. RESULTS: Of the 620 respondents interviewed, 70% were enrolled or planning to enroll in the health insurance. Only about one-fifth of respondents were very confident that they would receive effective care in the public health sector 'if they became sick tomorrow' while 48% were very confident in the private health sector. While confidence in the public system was only weakly associated with enrollment, confidence in the private health sector was strongly associated with enrollment (Adjusted odds ratio (AOR) 3.40 95% CI 1.73 - 6.68). No association was found between enrollment and trust in government or perceived government performance. CONCLUSIONS: Our results suggest that confidence in the health system, particularly in the private health sector, is strongly associated with health insurance enrollment. Focusing on achieving high quality of care across all levels of the health system may be an effective strategy to increase enrollment in health insurance.

Examining African contributions to global health: Reflections on knowledge circulation and innovation.

This article unites different disciplinary debates on 'southern innovation', 'theory from the South', and 'decolonisation of knowledge' in order to discuss existing understandings around the role of Africa in the production of health-related knowledge, public health policy, and medical innovation. Arguing that high-income countries have much to learn from the global South when it comes to health-related knowledge and practices, we propose an interdisciplinary research approach to uncovering and examining African contributions to global health, drawing on an ongoing collaborative project funded by the Swiss National Science Foundation. We present four empirical case studies concerning drug development, healthcare systems, and urban planning to critically enquire into both historical and contemporary transcontinental knowledge circulation and learning potentials, as much as cases of forgetting and silencing. On this basis, we argue that 'learning from the South' must mean more than transplanting quick and cheap technological fixes to serve societies in the global North, but rather recognising the vast contributions that Africans have made to global epistemologies, without losing sight of the asymmetries inherent in South-North knowledge exchanges. Lessons learned might apply to fields other than those discussed here and go far beyond 'reverse innovation'.

Equity in health insurance schemes enrollment in low and middle-income countries: A systematic review and meta-analysis.

BACKGROUND: Ensuring access to essential quality health services and reducing financial hardship for all individuals regardless of their ability to pay are the main goals of universal health coverage. Various health insurance schemes have been recently implemented in low- and middle-income countries (LMICs) to achieve both of these objectives. We systematically reviewed all available literature to assess the extent to which current health insurance schemes truly reach the poor and underserved populations in LMICs. METHODS: In the systematic review, we searched on PubMed, Web of Science, EconLit and Google Scholar to identify eligible studies which captured health insurance enrollment information in LMICs from 2010 up to September 2019. Two authors independently selected studies, extracted data, and appraised included studies. The primary outcome of interest was health insurance enrollment of the most vulnerable populations relative to enrollment of the best-off subgroups. We classified households both with respect to their highest educational attainment and their relative wealth and used random-effects meta-analysis to estimate average enrollment gaps. RESULTS: 48 studies from 17 countries met the inclusion criteria. The average enrollment rate into health insurance schemes for vulnerable populations was 36% with an inter-quartile range of 26%. On average, across countries, households from the wealthiest subgroup had 61% higher odds (95% CI: 1.49 to 1.73) of insurance enrollment than households in the poorest group in the same country. Similarly, the most educated groups had 64% (95% CI: 1.32 to 1.95) higher odds of enrollment than the least educated groups. CONCLUSION: The results of this study show that despite major efforts by governments, health insurance schemes in low-and middle-income countries are generally not reaching the targeted underserved populations and predominantly supporting better-off population groups. Current health insurance designs should be carefully scrutinized, and the extent to which health insurance can be used to support the most vulnerable populations carefully re-assessed by countries, which are aiming to use health insurance schemes as means to reach their UHC goals. Furthermore, studies exploring best practices to include vulnerable groups in health insurance schemes are needed. REGISTRATION: Not available.

Governance factors that affect the implementation of health financing reforms in Tanzania: an exploratory study of stakeholders' perspectives.

The development of effective and inclusive health financing reforms is crucial for the progressive realisation of universal health coverage in low-income and middle-income countries. Tanzania has been reforming health financing policies to expand health insurance coverage and achieve better access to quality healthcare for all. Recent reforms have included improved community health funds (iCHFs), and others are underway to implement a mandatory national health insurance scheme in order to expand access to services and improve financial risk protection. Governance is a crucial structural determinant for the successful implementation of health financing reforms, however there is little understanding of the governance elements that hinder the implementation of health financing reforms such as the iCHF in Tanzania. Therefore, this study used the perspectives of health sector stakeholders to explore governance factors that influence the implementation of health financing reforms in Tanzania. We interviewed 36 stakeholders including implementers of health financing reforms, policymakers and health insurance beneficiaries in the regions of Dodoma, Dar es Salaam and Kilimanjaro. Normalisation process theory and governance elements guided the structure of the in-depth interviews and analysis. Governance factors that emerged from participants as facilitators included a shared strategic vision for a single mandatory health insurance, community engagement and collaboration with diverse stakeholders in the implementation of health financing policies and enhanced monitoring of iCHF enrolment due to digitisation of registration process. Governance factors that emerged as barriers to the implementation were a lack of transparency, limited involvement of the private sector in service delivery, weak accountability for revenues generated from community level and limited resources due to iCHF design. If stakeholders do not address the governance factors that hinder the implementation of health financing reforms, then current efforts to expand health insurance coverage are unlikely to succeed on their own.

Monitoring Quality of Care in the WHO Africa Region-A study design for measurement and tracking, towards UHC attainment.

This paper reports on the design of a study to generate a quality of care index for countries in the World Health Organization Africa Region.Quality of care, for all people at all times, remains pivotal to the advancement of the 2030 agenda and the attainment of Universal Health Coverage. We present a study protocol for deriving a quality of care index, hinged on indicators and data elements currently monitored through routine information systems and institutionalized facility assessments in the World Health Organization Africa Region.This paper seeks to offer more insight into options in the Region for strengthening monitoring processes of quality of care, as a step towards generating empirical evidence which can galvanize action towards an improved care process.The methodology proposed in this study design has broad implications for policymaking and priority setting for countries, emphasizing the need for robust empirical measures to understand the functionality of health systems for the delivery of quality essential services. Application of this protocol will guide policymaking, as countries work to increasingly improve quality of care and adopt policies that will best facilitate their advancement towards Universal Health Coverage.