Factors associated with patient payments exceeding National Health Insurance fees and out-of-pocket payments in Lao PDR.

BACKGROUND: Attaining universal health coverage is a target in the Sustainable Development Goals. In Lao PDR, to achieve universal health coverage, the government is implementing a national insurance scheme, initially targeting the informal sector. OBJECTIVE: The purpose was to assess: i) the percentage of NHI patients who paid above the scheduled amount, based on individual billing payment; and ii) the factors related to overpayment. METHODS: Descriptive cross-sectional study based on a structured questionnaire administered at health facilities in face-to-face interviews with 1,850 patients in six provinces. RESULTS: All 1,850 participants worked in the informal sector. Of these, 78.8% of respondents (77.9% of in-patients; 79.5% of out-patients) made co-payments or were exempted from. Factors associated with in-patients paying above the scheduled fee were living in the province and district (OR = 2.8; 95%CI 1.2 to 6.3); not having documents with them (OR = 21.2; 95%CI 5.6 to 80.3); or not having documents (OR: 7.8; 95% CI 2.1 to 28.6). Significant factors associated with additional costs for out-patients were level of facility used at the provincial hospital (OR:1.4; 95% CI 1.1 to 1.9); older age (OR = 2.2; 95%CI 1.5 to 3.1); living in the province and district (OR = 2.3; 95%CI 1.5 to 3.7); living more than 5 km from the facility (OR = 1.4; 95%CI 1.1 to 1.9); buying medicine or supplies outside of the health facility (OR: 5.6; 95% CI 3.1 to 10.2); not bringing documents (OR:9.1; 95% CI 6.1 to 13.5), not having the right documents (OR: 8.9; 95% CI 5.4 to 14.8). CONCLUSIONS: A number of patients paid above scheduled fee rates, which may deter people from utilising services when needing them. There is a need for increased understanding of the benefits of the national insurance scheme among patients and healthcare staff.

Factors affecting knowledge of National Health Insurance Policy among out-patients in Lao PDR: an exit interview study.

BACKGROUND: Universal health coverage is target 3.8 of the Sustainable Development Goals. In many lower-middle-income countries, however, major coverage gaps exist. Those who do receive services often experience high out-of-pocket expenses. To achieve universal health coverage, Lao PDR, a lower-middle-income country in South-East Asia, is shifting from a fragmented model of health financing to a national health insurance scheme. OBJECTIVE: The objective of this cross-sectional survey was to assess the knowledge of the NHI in Lao PDR among insured in- and out-patients using health services at selected public health facilities at provincial, district and health centre level in six provinces. METHODS: This was a cross-sectional survey. Healthcare facilities were selected based on the rate of use of health services at the health facility and participants selected using systematic random sampling. Exit interviews were conducted with in- and out-patients of each selected health facility, using a pre-tested structured questionnaire. Descriptive statistics were generated including means (median), frequency and percentages. Poisson regression was applied to determine the factors associated with knowledge of the insurance scheme. RESULTS: In total 326 participants were recruited (response rate 93%). Of these, less than two-thirds (62.3%) said they had their eligibility documents with them. Only 23.6% knew the co-payment fee at the health centre level; while 18.1% and 18.7% knew about the co-payment fee at the district and provincial healthcare level, respectively. A key determinant of accessing NHI and health services was knowledge of the scheme and its benefits. CONCLUSION: This study suggests in Lao PDR, awareness about health insurance is low. More innovative demand-side strategies are needed to create awareness and understanding of the NHI and its benefits. Without an understanding of what insurance policies mean, universal health coverage cannot be achieved, even where appropriate and acceptable services are accessible.