Changing Reimbursement Criteria on Anti-VEGF Treatment Patterns Among Wet Age-Related Macular Degeneration and Diabetic Macular Edema Patients: An Interrupted Time Series Analysis.

BACKGROUND: To evaluate the impact of reimbursement criteria change on the utilization pattern of anti-vascular endothelial growth factor (anti-VEGF) among patients with wet age-related macular degeneration (wAMD) and diabetic macular edema (DME) separately in Taiwan. METHODS: An interrupted time series analysis (ITSA) was performed using Taiwan's National Health Insurance (NHI) database, and patients with wAMD or DME diagnosis at the first injection of anti-VEGF agents was identified from 2011 to 2019. The outcome of interest was treatment gaps between injections of anti-VEGF. This outcome was retrieved quarterly, and the study period was divided into three phases in wAMD (two criteria changed in August 2014 [intervention] and December 2016 [intervention]) and two phases in DME (three consecutive criteria changed in 2016 [intervention]). Segmented regression models adjusted for autocorrelation were used to estimate the change in level and the change in slope of the treatment gaps between each anti-VEGF injection. RESULTS: The treatment gaps between each anti-VEGF injection decreased from 2011 to 2019. The cancellation of the annual three needles limitation was associated with significantly shortened treatment gaps between the third and fourth needles (wAMD change in level: -228 days [95% CI -282, -173], DME change in level: -110 days [95% CI -141, -79]). The treatment gap between the fifth and sixth needles revealed a similar pattern but without significant change in DME patients. Other treatment gaps revealed considerable change in slopes in accordance with criteria changes. CONCLUSION: This is the first nationwide study using ITSA to demonstrate the impact of reimbursement policy on treatment gaps between each anti-VEGF injection. After canceling the annual limitation, we found that the treatment gaps significantly decreased among wAMD and DME patients. The shortened treatment gaps might further link to better visual outcomes according to previous studies. The different impacts from criteria changes can assist future policy shaping. Future studies were warranted to explore whether such changes are associated with the benefits of visual effects.

Burden of metabolic syndrome on primary healthcare costs among older adults: A cross-sectional study.

BACKGROUND: The impact of metabolic syndrome (MetS) on healthcare costs remains unclear in the literature. OBJECTIVES: To determine the impact of MetS on primary healthcare costs of adults, as well as to identify the impact of physical activity and other covariates on this phenomenon. DESIGN AND SETTING: This cross-sectional study was conducted in the city of Presidente Prudente, State of São Paulo/Brazil, in 2016. METHODS: The sample comprised 159 older adults (> 50 years) of both sexes (110 women) who were identified from their medical records in the Brazilian National Health Service. Healthcare costs (US$) were assessed through medical records and divided into medical consultations, medications, laboratory tests, and total costs. MetS was assessed using medical records. RESULTS: The Brazilian National Health Service spent more on consultations (US$ 22.75 versus US$ 19.39; + 17.3%) and medication (US$ 19.65 versus US$ 8.32; + 136.1%) among adults with MetS than among those without MetS, but the costs for laboratory tests were similar (P = 0.343). Total costs were 53.9% higher in adults with MetS than in those without the diagnosis of the disease (P = 0.001). Regarding total costs, there was an increase of US$ 38.97 when five components of MetS were present (P = 0.015), representing an increase of approximately 700%, even after adjusting for sex, age, and physical activity. CONCLUSION: In conclusion, the presence of the MetS is responsible for increasing primary care costs among older adults, especially in those related to medicines.

The Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) after four years of implementation - is it making an impact on quality of inpatient care and financial protection in India?

BACKGROUND: India launched a national health insurance scheme named Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) in 2018 as a key policy for universal health coverage. The ambitious scheme covers 100 million poor households. None of the studies have examined its impact on the quality of care. The existing studies on the impact of AB-PMJAY on financial protection have been limited to early experiences of its implementation. Since then, the government has improved the scheme's design. The current study was aimed at evaluating the impact of AB-PMJAY on improving utilisation, quality, and financial protection for inpatient care after four years of its implementation. METHODS: Two annual waves of household surveys were conducted for years 2021 and 2022 in Chhattisgarh state. The surveys had a sample representative of the state's population, covering around 15,000 individuals. Quality was measured in terms of patient satisfaction and length of stay. Financial protection was measured through indicators of catastrophic health expenditure at different thresholds. Multivariate adjusted models and propensity score matching were applied to examine the impacts of AB-PMJAY. In addition, the instrumental variable method was used to address the selection problem. RESULTS: Enrollment under AB-PMJAY was not associated with increased utilisation of inpatient care. Among individuals enrolled under AB-PMJAY who utilised private hospitals, the proportion incurring catastrophic health expenditure at the threshold of 10% of annual consumption expenditure was 78.1% and 70.9% in 2021 and 2022, respectively. The utilisation of private hospitals was associated with greater catastrophic expenditure irrespective of AB-PMJAY coverage. Enrollment under AB-PMJAY was not associated with reduced out-of-pocket expenditure or catastrophic health expenditure. CONCLUSIONS: AB-PMJAY has achieved a large coverage of the population but after four years of implementation and an evidence-based increase in reimbursement prices for hospitals, it has not made an impact on improving utilisation, quality, or financial protection. The private hospitals contracted under the scheme continued to overcharge patients, and purchasing was ineffective in regulating provider behaviour. Further research is recommended to assess the impact of publicly funded health insurance schemes on financial protection in other low- and middle-income countries.

Federal transfers to municipalities through parliamentary amendments: implications for SUS funding. / Transferências federais por emendas parlamentares aos municípios: implicações para o financiamento do SUS.

The present article analyzes the transfers from parliamentary amendments by the Ministry of Health to municipalities to finance public health actions and services from 2015 to 2021. A descriptive and exploratory study was carried out with secondary data, including all Brazilian cities. Resources from amendments showed an increase, particularly from 2018 onwards, indicating the expansion of their relevance for financing SUS. From 2016 to 2021, over 80% was allocated to municipalities, representing 9.5% of all federal transfers, with 91.2% for operational expenses. Transfers from amendments differ from regular transfers due to greater instability and per capita variation among the amounts collected by municipalities and due to the fact that they allocate most resources to the Northeast and primary care to the detriment of the Southeast and medium and high complexity care. These transfers represent a differentiated modality of resource allocation in SUS that produces new distortions and asymmetries, with implications for intergovernmental relations, as well as between the executive and legislative powers, increasing the risk of the discontinuity of actions and services and imposing challenges for the municipal management.

O artigo tem como objetivo analisar as transferências por emendas parlamentares do Ministério da Saúde aos municípios para o financiamento de ações e serviços públicos de saúde, de 2015 a 2021. Foi realizado estudo descritivo e exploratório com dados secundários, abrangendo a totalidade de municípios brasileiros. Os recursos provenientes de emendas apresentaram aumento, em especial a partir de 2018, indicando a expansão de sua relevância para o financiamento do SUS. No período de 2016 a 2021, mais de 80% foram alocados aos municípios, representando 9,5% dos repasses federais, com 91,2% de natureza de custeio. As transferências por emendas diferem dos repasses regulares por possuir maior instabilidade e variação per capita entre os montantes captados pelos municípios, e por destinar a maior parte dos recursos ao Nordeste e à atenção primária, em detrimento do Sudeste e da média e alta complexidade. Configura-se uma modalidade diferenciada de alocação de recursos no SUS que produz novas distorções e assimetrias, com implicações para as relações intergovernamentais e entre os poderes executivo e legislativo, ampliando o risco de descontinuidade de ações e serviços e impondo desafios para as gestões municipais.

Hospital services utilisation and cost before and after COVID-19 hospital treatment: Evidence from Indonesia.

OBJECTIVE: To estimate hospital services utilisation and cost among the Indonesian population enrolled in the National Health Insurance (NHI) program before and after COVID-19 hospital treatment. METHODS: 28,159 Indonesian NHI enrolees treated with laboratory-confirmed COVID-19 in hospitals between May and August 2020 were compared to 8,995 individuals never diagnosed with COVID-19 in 2020. A difference-in-difference approach is used to contrast the monthly all-cause utilisation rate and total claims of hospital services between these two groups. A period of nine months before and three to six months after hospital treatment were included in the analysis. RESULTS: A substantial short-term increase in hospital services utilisation and cost before and after COVID-19 treatment was observed. Using the fifth month before treatment as the reference period, we observed an increased outpatient visits rate in 1-3 calendar months before and up to 2-4 months after treatment (p<0.001) among the COVID-19 group compared to the comparison group. We also found a higher admissions rate in 1-2 months before and one month after treatment (p<0.001). Consequently, increased hospital costs were observed in 1-3 calendar months before and 1-4 calendar months after the treatment (p<0.001). The elevated hospital resource utilisation was more prominent among individuals older than 40. Overall, no substantial increase in hospital outpatient visits, admissions, and costs beyond four months after and five months before COVID-19 treatment. CONCLUSION: Individuals with COVID-19 who required hospital treatment had considerably higher healthcare resource utilisation in the short-term, before and after the treatment. These findings indicated that the total cost of treating COVID-19 patients might include the pre- and post-acute period.

Cost-effectiveness of hospital-based treatment compared with community treatment centres: an analysis of Korea National Health Insurance claims data.

OBJECTIVES: We compared the cost-effectiveness of hospital-based treatment and that of community treatment centres (CTCs). DESIGN: We performed statistical analysis to compare the expenses incurred by COVID-19 patients who received hospital care with those incurred by COVID-19 patients who went to CTCs. SETTING AND PARTICIPANTS: A study was conducted on 411 530 COVID-19 inpatients and 243 329 CTC patients from January 2020 to December 2021. MAIN OUTCOME MEASURES: We calculated the probability of severe disease, hospitalisation period and medical expenses for inpatients and CTC patients. Subsequently, we analysed the cost-effectiveness of CTC compared with hospitalisation. RESULTS: Comparing medical expenses, CTC patients incurred 2 220 000 KRW on average, which is less than the expenses incurred by hospitalised COVID-19 patients. CONCLUSIONS: The study suggests that using a CTC may be more cost-effective than a hospital service alone.

Can financial incentives improve access to care? Evidence from a French experiment on specialist physicians.

In France, addressing balance billing is essential for equitable healthcare access and reducing physician income disparities. The National Health Insurance (NHI) introduced financial incentive programs, namely the "Contract for Access to Care" (CAS) in 2014 and the "Option for Controlled Pricing" (OPTAM) in 2017, to encourage physicians to reduce extra fees and adhere to regulated prices. This study analyzed the impact of these programs on self-employed physicians using a comprehensive administrative dataset covering specialist physicians from 2005 to 2017. The dataset comprised 9891 surgical specialists (30,972 observations) and 6926 medical specialists (21,650 observations) between 2005 and 2017. Applying a difference-in-differences design with a two-way fixed effect model and matching through the "Coarsened Exact Matching" method, the study examined CAS and/or OPTAM membership effects on physicians' activity and fees. The results indicate that both the CAS and OPTAM successfully enhance access to care. Physicians treat more patients, particularly those with lower incomes who might have previously avoided care because of the extra fees. However, an increased patient load translates to a higher workload for physicians. Despite a fee increase, it was observed to be smaller than the surge in activity. Furthermore, if all physicians are appropriately rewarded for their efforts, this improvement in access comes at a cost to NHI. This study's findings provide crucial insights into the nuanced effects of these financial incentive programs on physicians' behavior, highlighting the tradeoff between improved access and increased NHI costs. Ultimately, these findings underscore the complexity of balancing financial incentives, physician workload, and healthcare accessibility in pursuit of a more equitable healthcare system.

[Mental health problems among employees: service use and costs to the German healthcare system]. / Psychische Belastungen bei Erwerbstätigen: Leistungsinanspruchnahme und Kosten für das deutsche Gesundheitssystem.

BACKGROUND: Service use among employees with mental health problems and the associated costs for the health and social system have not yet been systematically analysed in studies or have only been recorded indirectly. The aim of this article is to report the service use in this target group, to estimate the costs for the health and social system and to identify possible influencing factors on the cost variance. METHODS: As part of a multicentre study, use and costs of health and social services were examined for a sample of 550 employees with mental health problems. Service use was recorded using the German version of the Client Sociodemographic Service Receipt Inventory (CSSRI). Costs were calculated for six months. A generalized linear regression model was used to examine influencing cost factors. RESULTS: At the start of the study, the average total costs for the past six months in the sample were €â€¯5227.12 per person (standard deviation €â€¯7704.21). The regression model indicates significant associations between increasing costs with increasing age and for people with depression, behavioural syndromes with physiological symptoms, and other diagnoses. DISCUSSION: The calculated costs were similar in comparison to clinical samples. It should be further examined in longitudinal studies whether this result changes through specific interventions.

The impact of the expanded health insurance coverage policy on healthcare spending: evidence from Korea.

BACKGROUND: South Korea's National Health Insurance (NHI) system pursues universal health coverage, but it has not been able to alleviate patients' financial burden owing to limited coverage and a high proportion of out-of-pocket expenses. In 2017, the government announced a plan to strengthen universality by providing coverage for all unincluded services, expanding coverage, and alleviating household financial burden. We aimed to evaluate the effect of "Moon Care" with a focus on changes in health expenditures following policy implementation, and to provide empirical evidence for future policies to strengthen the NHI system's universality. METHODS: Using data from the 2016 and 2018 Korea Health Panel (KHP), we established a treatment group affected by the policy and an unaffected control group; we ensured homogeneity between the groups using propensity score matching (PSM). Subsequently, we examined changes in NHI payments, non-payments, and out-of-pocket payments (OOP); we performed difference-in-differences (DID) analysis to evaluate the policy's effect. RESULTS: Following policy implementation, the control group had a higher increase than the treatment group in all categories of health expenditures, including NHI payments, non-payments, and OOP. We noted significant decreases in all three categories of health expenditures when comparing the differences before and after policy implementation, as well as between the treatment and control groups. However, we witnessed a significant decrease in the interaction term, which confirms the policy's effect, but only for non-payments. CONCLUSIONS: We observed the policy's intervention effect over time as a decrease in non-payments, on the effectivity of remunerating covered medical services. However, the policy did not work for NHI payments and OOP, suggesting that it failed to control the creation of new non-covered services as noncovered services were converted into covered ones. Thus, it is crucial to discuss the financial spending of health insurance regarding the inclusion of non-covered services in the NHI benefits package.

Understanding the extent of economic evidence usage for informing policy decisions in the context of India's national health insurance scheme: Ayushman Bharat Pradhan Mantri Jan Aarogya Yojana (PM-JAY).

INTRODUCTION: Ayushman Bharat Pradhan Mantri Jan Aarogya Yojana (PM-JAY) is one of the world's largest tax-funded insurance schemes. The present study was conducted to understand the decision-making process around the evolution (and revision) of health benefit packages (HBPs) and reimbursement rates within PM-JAY, with a specific focus on assessing the extent of use of economic evidence and role of various stakeholders in shaping these policy decisions. METHODS: A mixed-methods study was adopted involving in-depth interviews with seven key stakeholders involved in HBP design and reimbursement rates decisions, and a survey of 80 government staff and other relevant stakeholders engaged in the implementation of PM-JAY. The data gathered were thematically analysed, and a coding framework was developed to explore specific themes. Additionally, publicly available documents were reviewed to ensure a comprehensive understanding of the decision-making processes. RESULTS: Findings reveal a progressive transition towards evidence-based practices for policy decisions within PM-JAY. The initial version of HBP relied heavily on key criteria like disease burden, utilisation rates, and out-of-pocket expenditures, along with clinical opinion in shaping decisions around the inclusion of services in the HBP and setting reimbursement rates. Revised HBPs were informed based on evidence from a national-level costing study and broader stakeholder consultations. The use of health economic evidence increased with each additional revision with consideration of health technology assessment (HTA) evidence for some packages and reimbursement rates based on empirical cost evidence in the most recent update. The establishment of the Health Financing and Technology Assessment unit further signifies the use of evidence-based policymaking within PM-JAY. However, challenges persist, notably with regard to staff capacity and understanding of HTA principles, necessitating ongoing education and training initiatives. CONCLUSION: While substantial progress has been made in transitioning towards evidence-based practices within PM-JAY, sustained efforts and political commitment are required for the ongoing systematisation of processes.

Burden of disease and direct costs to the health system attributable to high body mass index in Brazil.

OBJECTIVES: Excess weight, measured by a high body mass index (BMI), is associated with the onset of many diseases, which can, in turn, lead to disability and premature death, subsequently placing a significant burden on healthcare services. This study analysed the burden of disease and the direct costs to the Brazilian Unified Health System (Sistema Único de Saúde [SUS]) attributable to high BMI in the Brazilian population. STUDY DESIGN: Ecological study. METHODS: This ecological study had two components: (1) a time-series assessment to analyse the burden of diseases attributable to high BMI from 1990 to 2019 in Brazil; and (2) a cross-sectional design to estimate the direct costs of SUS hospitalisations and outpatient procedures attributable to high BMI in 2019. Estimates from the Global Burden of Disease study and the costs of hospital admissions and outpatient procedures from the Department of Informatics of the Brazilian Unified Health System were used. Deaths, years of life lost to premature death (YLLs), years lived with disability (YLDs), and years of life lost adjusted for disability (DALYs) were analysed. The direct health cost was obtained in Brazilian Real (R$) and converted in international Dollars (INT$). RESULTS: The current study found a reduction in the number of DALYs, YLLs, and deaths per 100,000 population of cardiovascular disease (CVD) attributable to high BMI and an increase in YLD due to diabetes and cardiovascular disease attributable to high BMI from 1990 to 2019. In 2019, high BMI resulted in 2404 DALYs, 658 YLDs, 1746 YLLs, and 76 deaths per 100,000 inhabitants. In the same year, INT$377.30 million was spent on hospitalisations and high- and medium-complexity procedures to control non-communicable diseases attributable to high BMI. The states in the South and Southeast regions of Brazil presented the highest total cost per 10,000 inhabitants. CVDs and chronic kidney disease showed the highest costs per hospital admission, whereas neoplasms and CVDs presented the highest costs for outpatient procedures. CONCLUSIONS: High BMI causes significant disease burden and financial costs. The highest expenses observed were not in locations with the highest burden of disease attributable to high BMI. These findings highlight the need to improve current public policies and apply cost-effective intervention packages, focussing on equity and the promotion of healthier lifestyles to reduce overweight/obesity, especially in localities with low socioeconomic status.

Analysis of the costs of teleconsultation for the treatment of diabetes mellitus in the SUS.

OBJECTIVE: To present the results of a cost analysis of remote consultations (teleconsultations) compared to in-person consultations for patients with type 2 diabetes, in the Brazilian public healthcare system (SUS) in the city of Joinville, Santa Catarina (SC). In addition to the costs from the local manager's perspective, the article also presents estimates from the patient's perspective, based on the transportation costs associated with each type of consultation. METHOD: Data were collected from 246 consultations, both remote and in-person, between 2021 and 2023, in the context of a randomized clinical trial on the impact of teleconsultation carried out in the city of Joinville, SC. Teleconsultations were carried out at Primary Health Units (PHU) and in-person consultations at the Specialized Health Center. The consultation costs were calculate by the method time and activity-based costing (TDABC), and for the estimate of transportation costs data was collected directly from the research participants . The mean costs and time required to carry out each type of consultation in different scenarios and perspectives were analyzed and compared descriptively. RESULTS: Considering only the local SUS manager's perspective, the costs for carrying out a teleconsultation were 4.5% higher than for an in-person consultation. However, when considering the transportation costs associated with each patient, the estimated value of the in-person consultation becomes 7.7% higher and, in the case of consultations in other municipalities, 15% higher than the teleconsultation. CONCLUSION: The results demonstrate that the incorporation of teleconsultation within the SUS can bring economic advantages depending on the perspective and scenario considered, in addition to being a strategy with the potential to increase access to specialized care in the public network.

The impact of national health insurance on the cost of auricular reconstruction with skin expansion for microtia in China: A single-center retrospective study based on 1290 surgeries.

BACKGROUND: Congenital microtia presents challenges that encompass physical disabilities and psychosocial distress. It is reported that people with low income have a higher possibility of giving birth to babies with congenital malformations. At the end of June 2023, auricular reconstruction was partially incorporated into national health insurance in our hospital. METHODS: Briefly, 1290 surgeries, including stage-I and stage-II auricular reconstruction with tissue expansion were performed in 2023, involving 779 patients. Patient data, including age, sex, length of stay, residence, and costs, were retrieved from the electronic medical record system. The final cost before and after health insurance coverage, as well as the medical insurance reimbursement ratio in each province and municipality were statistically analyzed. RESULTS: Following insurance coverage, a significant increase in the number of surgeries was observed (514 [39.84%] vs. 776 [60.16%], χ2 = 45.99, p = 0.000), with notable reductions in out-of-pocket costs for unilateral and bilateral stage-I and -II auricular reconstructions ($3915.01 vs. $6645.28, p < 0.05; $11546.80 vs. $5198.08, p < 0.05). Disparities in reimbursement rates across regions were evident, but showed no correlation to the local GDP per capita. There was a positive correlation between the length of stay and inpatient cost. Patient's age was not related to the inpatient cost, but to the length of stay. CONCLUSION: The health insurance coverage for microtia treatment significantly alleviated financial burdens on the patients' family and increased the number of auricular reconstruction surgeries. These findings underscore the critical role of insurance coverage in enhancing healthcare accessibility and affordability for patients with congenital microtia.

Willingness to pay for National Health Insurance Services and Associated Factors in Africa and Asia: a systematic review and meta-analysis.

Background: Universal health coverage (UHC) is crucial for public health, poverty eradication, and economic growth. However, 97% of low- and middle-income countries (LMICs), particularly Africa and Asia, lack it, relying on out-of-pocket (OOP) expenditure. National Health Insurance (NHI) guarantees equity and priorities aligned with medical needs, for which we aimed to determine the pooled willingness to pay (WTP) and its influencing factors from the available literature in Africa and Asia. Methods: Database searches were conducted on Scopus, HINARI, PubMed, Google Scholar, and Semantic Scholar from March 31 to April 4, 2023. The Joanna Briggs Institute's (JBI's) tools and the "preferred reporting items for systematic reviews and meta-analyses (PRISMA) 2020 statement" were used to evaluate bias and frame the review, respectively. The data were analyzed using Stata 17. To assess heterogeneity, we conducted sensitivity and subgroup analyses, calculated the Luis Furuya-Kanamori (LFK) index, and used a random model to determine the effect estimates (proportions and odds ratios) with a p value less than 0.05 and a 95% CI. Results: Nineteen studies were included in the review. The pooled WTP on the continents was 66.0% (95% CI, 54.0-77.0%) before outlier studies were not excluded, but increased to 71.0% (95% CI, 68-75%) after excluding them. The factors influencing the WTP were categorized as socio-demographic factors, income and economic issues, information level and sources, illness and illness expenditure, health service factors, factors related to financing schemes, as well as social capital and solidarity. Age has been found to be consistently and negatively related to the WTP for NHI, while income level was an almost consistent positive predictor of it. Conclusion: The WTP for NHI was moderate, while it was slightly higher in Africa than Asia and was found to be affected by various factors, with age being reported to be consistently and negatively related to it, while an increase in income level was almost a positive determinant of it.

Prevalence, perceptions and associated factors of health insurance enrollment among older persons in selected cash grant communities in Ghana: a cross-sectional mixed method.

BACKGROUND: Universal Health Coverage has been openly recognized in the United Nations health-related Sustainable Development Goals by 2030, though missing under the Millennium Development Goals. Ghana implemented the National Health Insurance Scheme programme in 2004 to improve financial access to healthcare for its citizens. This programme targeting low-income individuals and households includes an Exempt policy for older persons and indigents. Despite population ageing, evidence of the participation and perceptions of older persons in the scheme in cash grant communities is unknown. Hence, this paper examined the prevalence, perceptions and factors associated with health insurance enrollment among older persons in cash grant communities in Ghana. METHODS: Data were from a cross-sectional household survey of 400 older persons(60 + years) and eight FGDs between 2017 and 2018. For the survey, stratified and simple random sampling techniques were utilised in selecting participants. Purposive and stratified sampling techniques were employed in selecting the focus group discussion participants. Data analyses included descriptive, modified Poisson regression approach tested at a p-value of 0.05 and thematic analysis. Stata and Atlas-ti software were used in data management and analyses. RESULTS: The mean age was 73.7 years. 59.3% were females, 56.5% resided in rural communities, while 34.5% had no formal education. Two-thirds were into agriculture. Three-fourth had non-communicable diseases. Health insurance coverage was 60%, and mainly achieved as Exempt by age. Being a female [Adjusted Prevalence Ratio (APR) 1.29, 95%CI:1.00-1.67], having self-rated health status as bad [APR = 1.34, 95%CI:1.09-1.64] and hospital healthcare utilisation [APR = 1.49, 95%CI:1.28-1.75] were positively significantly associated with health insurance enrollment respectively. Occupation in Agriculture reduced insurance enrollment by 20.0%. Cited reasons for poor perceptions of the scheme included technological challenges and unsatisfactory services. CONCLUSION: Health insurance enrollment among older persons in cash grant communities is still not universal. Addressing identified challenges and integrating the views of older persons into the programme have positive implications for securing universal health coverage by 2030.