Feasibility of implementing public-private mix approach for tuberculosis case management in Pokhara Metropolitan City of western Nepal: a qualitative study.

Background: The Public-Private Mix (PPM) approach is a strategic initiative that involves engaging all private and public health care providers in the fight against tuberculosis using international health care standards. For tuberculosis control in Nepal, the PPM approach could be a milestone. This study aimed to explore the barriers to a public-private mix approach in the management of tuberculosis cases in Nepal. Methods: We conducted key informant interviews with 20 participants, 14 of whom were from private clinics, polyclinics, and hospitals where the PPM approach was used, two from government hospitals, and four from policymakers. All data were audio-recorded, transcribed, and translated into English. The transcripts of the interviews were manually organized, and themes were generated and categorized into 1. TB case detection, 2. patient-related barriers, and 3. health-system-related barriers. Results: A total of 20 respondents participated in the study. Barriers to PPM were identified into following three themes: (1) Obstacles related to TB case detection, (2) Obstacles related to patients, and (3) Obstacles related to health-care system. PPM implementation was challenged by following sub-themes that included staff turnover, low private sector participation in workshops, a lack of trainings, poor recording and reporting, insufficient joint monitoring and supervision, poor financial benefit, lack of coordination and collaboration, and non-supportive TB-related policies and strategies. Conclusion: Government stakeholders can significantly benefit by applying a proactive role working with the private in monitoring and supervision. The joint efforts with private sector can then enable all stakeholders to follow the government policy, practice and protocols in case finding, holding and other preventive approaches. Future research are essential in exploring how PPM could be optimized.

Universal health coverage evolution, ongoing trend, and future challenge: A conceptual and historical policy review.

The goal of universal health coverage (UHC) from the United Nations (UN) has metamorphized from its early phase of primary health care (PHC) to the recent sustainable development goal (SDG). In this context, we aimed to document theoretical and philosophical efforts, historical analysis, financial and political aspects in various eras, and an assessment of coverage during those eras in relation to UHC in a global scenario. Searching with broad keywords circumadjacent to UHC with scope and inter-disciplinary linkages in conceptual analysis, we further narrated the review with the historical development of UHC in different time periods. We proposed, chronologically, these frames as eras of PHC, the millennium development goal (MDG), and the ongoing sustainable development goal (SDG). Literature showed that modern healthcare access and coverage were in extension stages during the PHC era flagshipped with "health for all (HFA)", prolifically achieving vaccination, communicable disease control, and the use of modern contraceptive methods. Following the PHC era, the MDG era markedly reduced maternal, neonatal, and child mortalities mainly in developing countries. Importantly, UHC has shifted its philosophic stand of HFA to a strategic health insurance and its extension. After 2015, the concept of SDG has evolved. The strategy was further reframed as service and financial assurance. Strategies for further resource allocation, integration of health service with social health protection, human resources for health, strategic community participation, and the challenges of financial securities in some global public health concerns like the public health emergency and travelers' and migrants' health are further discussed. Some policy departures such as global partnership, research collaboration, and experience sharing are broadly discussed for recommendation.

COVID-19 trends, public restrictions policies and vaccination status by economic ranking of countries: a longitudinal study from 110 countries.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has transitioned to a third phase and many variants have been originated. There has been millions of lives loss as well as billions in economic loss. The morbidity and mortality for COVID-19 varies by country. There were different preventive approaches and public restrictions policies have been applied to control the COVID-19 impacts and usually measured by Stringency Index. This study aimed to explore the COVID-19 trend, public restriction policies and vaccination status with economic ranking of countries. METHODS: We received open access data from Our World in Data. Data from 210 countries were available. Countries (n = 110) data related to testing, which is a key variable in the present study, were included for the analysis and remaining 100 countries were excluded due to incomplete data. The analysis period was set between January 22, 2020 (when COVID-19 was first officially reported) and December 28, 2021. All analyses were stratified by year and the World Bank income group. To analyze the associations among the major variables, we used a longitudinal fixed-effects model. RESULTS: Out of the 110 countries included in our analysis, there were 9 (8.18%), 25 (22.72%), 31 (28.18%), and 45 (40.90%) countries from low income countries (LIC), low and middle income countries (LMIC), upper middle income countries (UMIC) and high income countries (HIC) respectively. New case per million was similar in LMIC, UMIC and HIC but lower in LIC. The number of new COVID-19 test were reduced in HIC and LMIC but similar in UMIC and LIC. Stringency Index was negligible in LIC and similar in LMIC, UMIC and HIC. New positivity rate increased in LMIC and UMIC. The daily incidence rate was positively correlated with the daily mortality rate in both 2020 and 2021. In 2020, Stringency Index was positive in LIC and HIC but a negative association in LMIC and in 2021 there was a positive association between UMIC and HIC. Vaccination coverage did not appear to change with mortality in 2021. CONCLUSION: New COVID-19 cases, tests, vaccinations, positivity rates, and Stringency indices were low in LIC and highest in UMIC. Our findings suggest that the available resources of COVID-19 pandemic would be allocated by need of countries; LIC and UMIC.

Correction: Effect of parental smoking on their children's urine cotinine level in Korea: A population-based study.

[This corrects the article DOI: 10.1371/journal.pone.0248013.].

Effect of parental smoking on their children's urine cotinine level in Korea: A population-based study.

BACKGROUND: Children may be exposed to tobacco products in multiple ways if their parents smoke. The risks of exposure to secondhand smoke (SHS) are well known. This study aimed to investigate the association between parental smoking and the children's cotinine level in relation to restricting home smoking, in Korea. METHODS: Using the Korea National Health and Nutrition Health Examination Survey data from 2014 to 2017, we analyzed urine cotinine data of parents and their non-smoking children (n = 1,403), in whose homes parents prohibited smoking. We performed linear regression analysis by adjusting age, sex, house type, and household income to determine if parent smoking was related to the urine cotinine concentration of their children. In addition, analysis of covariance and Tukey's post-hoc tests were performed according to parent smoking pattern. FINDING: Children's urine cotinine concentrations were positively associated with those of their parents. Children of smoking parents had a significantly higher urine cotinine concentration than that in the group where both parents are non-smokers (diff = 0.933, P < .0001); mothers-only smoker group (diff = 0.511, P = 0.042); and fathers-only smoker group (diff = 0.712, P < .0001). In the fathers-only smoker group, the urine cotinine concentration was significantly higher than that in the group where both parents were non-smoker (diff = 0.221, P < .0001), but not significantly different compared to the mothers-only smoker group (diff = - -0.201, P = 0.388). Children living in apartments were more likely to be exposed to smoking substances. CONCLUSION: This study showed a correlation between parents' and children's urine cotinine concentrations, supporting the occurrence of home smoking exposure due to the parents' smoking habit in Korea. Although avoiding indoor home smoking can decrease the children's exposure to tobacco, there is a need to identify other ways of smoking exposure and ensure appropriate monitoring and enforcement of banning smoking in the home.

Status and determinants of enrollment and dropout of health insurance in Nepal: an explorative study.

BACKGROUND: Compared to other countries in the South Asia Nepal has seen a slow progress in the coverage of health insurance. Despite of a long history of the introduction of health insurance (HI) and a high priority of the government of Nepal it has not been able to push rapidly its social health insurance to its majority of the population. There are many challenges while to achieve universal health insurance in Nepal ranging from existing policy paralysis to program operation. This study aims to identify the enrollment and dropout rates of health insurance and its determinants in selected districts of Nepal. METHODS: The study was conducted while using a mixed method including both quantitative and qualitative approaches. Numerical data related to enrollment and dropout rates were taken from Health Insurance Board (HIB) of Nepal. For the qualitative data, three districts, Bardiya, Chitwan, and Gorkha of Nepal were selected purposively. Enrollment assistants (EA) of social health insurance program were taken as the participants of study. Focus group discussions (FGD) were arranged with the selected EAs using specific guidelines along with unstructured questions. The results from numerical data and focus group discussions are synthesized and presented accordingly. RESULTS: The findings of the study suggested variation in enrollment and dropout of health insurance in the districts. Enrollment coverage was 13,545 (1%), 249,104 (5%), 1,159,477 (9%) and 1,676,505 (11%) from 2016 to 2019 among total population and dropout rates were 9121(67%), 110,885 (44%) and 444,967 (38%) among total enrollment from 2016 to 2018 respectively. Of total coverage, more than one-third proportion was subsidy enrollment-free enrollment for vulnerable groups. The population characteristics of unwilling and dropout in social health insurance came from relatively well-off families, government employees, businessman, migrants' people, some local political leaders as well as the poor class families. The major determinants of poor enrollment and dropout were mainly due to unavailability of enough drugs, unfriendly behavior of health workers, and indifferent behavior of the care personnel to the insured patients in health care facilities and prefer to take health service in private clinic for their own benefits. The long maturation time to activate health service, limited health package and lack of copayment in different types of health care were the factors related to inefficient program and policy implementation. CONCLUSION: There is a high proportion of dropout and subsidy enrollment, the key challenge for sustainability of health insurance program in Nepal. Revisiting of existing HI policy on health care packages, more choices on copayment, capacity building of enrollment assistants and better coordination between health insurance board and health care facilities can increase the enrollment and minimize the dropout.

Real GDP growth rates and healthcare spending - comparison between the G7 and the EM7 countries.

BACKGROUND: Accelerated globalisation has substantially contributed to the rise of emerging markets worldwide. The G7 and Emerging Markets Seven (EM7) behaved in significantly different macroeconomic ways before, during, and after the 2008 Global Crisis. Average real GDP growth rates remained substantially higher among the EM7, while unemployment rates changed their patterns after the crisis. Since 2017, however, approximately one half of the worldwide economic growth is attributable to the EM7, and only a quarter to the G7. This paper aims to analyse the association between the health spending and real GDP growth in the G7 and the EM7 countries. RESULTS: In terms of GDP growth, the EM7 exhibited a higher degree of resilience during the 2008 crisis, compared to the G7. Unemployment in the G7 nations was rising significantly, compared to pre-recession levels, but, in the EM7, it remained traditionally high. In the G7, the austerity (measured as a percentage of GDP) significantly decreased the public health expenditure, even more so than in the EM7. Out-of-pocket health expenditure grew at a far more concerning pace in the EM7 compared to the G7 during the crisis, exposing the vulnerability of households living close to the poverty line. Regression analysis demonstrated that, in the G7, real GDP growth had a positive impact on out-of-pocket expenditure, measured as a percentage of current health expenditure, expressed as a percentage of GDP (CHE). In the EM7, it negatively affected CHE, CHE per capita, and out-of-pocket expenditure per capita. CONCLUSION: The EM7 countries demonstrated stronger endurance, withstanding the consequences of the crisis as compared to the G7 economies. Evidence of this was most visible in real growth and unemployment rates, before, during and after the crisis. It influenced health spending patterns in both groups, although they tended to diverge instead of converge in several important areas.

Methodological issues on 'challenges and opportunities towards the road of universal health coverage (UHC) in Nepal: a systematic review'.

Challenges and opportunities towards the road of universal health coverage (UHC) in Nepal: a systematic review' is a policy review paper and we published in BMC - Archives of Public Health. Policy research is the process of conducting research, analysis of, a fundamental social problem in order to provide policymakers with pragmatic, action-oriented recommendations for alleviating the problem. The objective of this paper is to illustrate some methodological issues used in that paper.

Influence of Alcohol and Red Meat Consumption on Life Expectancy: Results of 164 Countries from 1992 to 2013.

BACKGROUND: High consumption of red meat, which is carcinogenic to humans, and misuse or abuse of alcohol drinking increase premature death and shortened life expectancy. The aim of this study was to examine the association of alcohol and red meat consumption with life expectancy (LE) by analyzing data from 164 countries using an ecological approach. DESIGN: This was a longitudinal ecological study using data from the United Nation's (UN) Food and Agriculture Organization (FAO) for 164 countries over the period 1992-2013. In regression analysis, the relationship of alcohol and red meat consumption with LE was estimated using a pooled ordinary least squares regression model. Alcohol and red meat consumption were measured every 5 years. RESULTS: The consumption of alcohol and red meat in high-income countries (HIC) was about 4 times (36.8-143.0 kcal/capita/day) and 5 times (11.2-51.9 kcal/capita/day) higher than that in low-income countries (LIC). Red meat and alcohol consumption had a negative estimated effect on LE in HIC (b = -1.616 p = <0.001 and b = -0.615, p = 0.003). Alcohol consumption was negatively associated with LE for all income groups, while positive relationships were found for all estimates associated with gross national income (GNI). CONCLUSIONS: Red meat and alcohol consumption appeared to have a negative impact on LE in high-income countries (HIC) and upper-middle-income countries (UMIC), although it had no significant association with LE in low-income countries (LIC) or lower-middle-income countries (LMIC). This study suggests reviewing the policies on the gradual reduction of alcohol abuse and the high consumption of red meat, particularly HIC and UMIC.

Situation, Impacts, and Future Challenges of Tobacco Control Policies for Youth: An Explorative Systematic Policy Review.

Background: Tobacco use in youths is a major public health challenge globally, and approaches to the challenge have not been sufficiently addressed. The existing policies for tobacco control are not well specified by age. Objective: Our study aims to systematically investigate existing tobacco control policies, potential impacts, and national and international challenges to control tobacco use targeting the youth. Data sources: We used the statistics of the Global Youth Tobacco Survey (GYTS), studies, and approaches of tobacco control policies targeting youth. Considering country, continent, age, and significance, PubMed, Health Inter-Network Access to Research Initiative (HINARI), Scopus, the Cochrane Library, Google, and Google Scholar were searched. The related keywords were tobacco control, youth, smoking, smoking reduction policies, prevalence of tobacco use in youth, classification of tobacco control policies, incentives to prevent young people from using tobacco, WHO Framework Convention on Tobacco Control (FTCT), etc. The search strategy was by timeline, specific and popular policies, reliability, significance, and applicability. Results: We found 122 studies related to this topic. There were 25 studies focusing on situation, significance, and theoretical aspects of tobacco control policies associated with youth; 41 studies on national population polices and challenges; and 7 studies for global challenges to overcome the youth tobacco epidemic. All national policies have been guided by WHO-MPOWER strategies. Increases in tobacco tax, warning signs on packaging, restriction of tobacco product advertisements, national law to discourage young people, and peer-based approaches to quit tobacco are popular policies. Smuggling of tobacco products by youth and ignorance of smokeless tobacco control approach are major challenges. Limitation: Our study was flexible for the standard age of youth and we were not able to include all countries in the world and most of the studies focused on smoking control rather than all smokeless tobaccos. Conclusion: The policies of tobacco control adopted by many countries are based on the WHO Framework Convention on Tobacco Control but not necessarily focused on youth. Due to the physical and economic burden of tobacco consumption by youth, this is a high priority that needs to be addressed. Youth-focused creative policies are necessary, and more priority must be given to tobacco prevention in youth. Tobacco control should be a social, public health, and quality-of-life concern rather than a business and trade issue. Implication of key findings: There is limited research on how and in what ways tobacco control policies reach young people and their engagement with these policies from physical, physiological, and psychological aspects. Analysis of these aspects, popular polices practiced in different countries, and creative strategies support the need to review current practices and future ways to discourage youth from tobacco use.

Challenges and opportunities towards the road of universal health coverage (UHC) in Nepal: a systematic review.

BACKGROUND: Universal health coverage (UHC) assures all types of health service and protects all citizens financially in any conditions due to illness. Globally, the UN sustainable development goal (SDG) provides high priority for UHC as a health related goal. The National health system of Nepal has prioritized in similar way. The aim of this study is to explore the challenges and opportunities on the road to UHC in Nepal. METHOD: We used varieties of search terminologies with popular search engines like PubMed, Google, Google Scholar, etc. to identify studies regarding Nepal's progress towards UHC. Reports of original studies, policies, guidelines and government manuals were taken from the web pages of Ministry of Health and its department/division. Searches were designed to identify the status of service coverage on UHC, financial protection on health particularly, health insurance coverage with its legal status. Other associated factors related to UHC were also explored and presented in Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart. RESULTS: We found 14 studies that were related to legal assurance, risk pulling and financing of health service, 11 studies associated to UHC service coverage status and, 7 articles linked to government stewardship, health system and governance on health care. Constitutional provision, global support, progress on the health insurance act, decentralization of health service to the grass root level, positive trends of increasing service coverage are seen as opportunities. However, existing volunteer types of health insurance, misleading role of trade unions and high proportion of population outside the country are main challenges. The political commitment under the changing political context, a sense of national priority and international support were identified as the facilitating factors towards UHC. CONCLUSION: To achieve UHC, service and population coverage of health services has to be expanded along with financial protection for marginalized communities. Government stewardship, support of stakeholders and fair contribution and distribution of resources by appropriate health financing modality can speed up the path of UHC in Nepal.

Structural Factors Responsible for Universal Health Coverage in Low- and Middle-Income Countries: Results From 118 Countries.

Background: Demography, politics, economy, and governance appear to be the major structural factors for health and well-being. These factors have a significant role to play in achieving universal health coverage (UHC). The majority of previous studies did not highlight those factors. The aim of this study is to explore the basic structural factors (political stability, demography, gross national income, governance, and transparency) associated with a UHC index of low- and middle-income countries because for a long time there has be a stagnation achieving universal health coverage. Methodology: This study was a cross-sectional study applying multiple indices as variables. Low- and middle-income countries' selected indicators were the study variables. Data concerned the current political stability, sociodemographic status, gross national income (GNI), and governance status as independent variables and the UHC index of the countries as the dependent variable. Mean and standard deviations were used for the average values of the variables, a raw correlation was shown among variables and a hierarchical linear regression model was used for multi variate analysis. Results: Government health expenditure is 6% out of the total budget in upper middle countries (UMIC) and ~5% in lower middle countries (LMIC) and low-income countries (LIC), population below poverty line is more than 2-fold higher in LIC in comparison with high income countries, UHC index, and socio-demographic index (SDI) index is similar in LMIC and LIC and slightly higher in UMIC. There is a positive association between government health expenditure, governance index, stability index, the SDI index, and GNI per capita and a negative association between populations below poverty line with UHC index. According to our full regression analysis model, governance, stability, and SDI index were associated with a significantly increased UHC index by 0.33, 0.41, and 0.57 (p < 0.05). Conclusion: To achieve UHC, good governance, political stability, and demographic balance are prerequisites and addressing these factors would help to meet by 2030 across countries.

Influence of Key Health Related Indicators on Adult Mortality: Result from UN Member Countries.

BACKGROUND: Adult mortality is associated with different demographic and behavioral risk factors including approaches to health care financing. Adult mortality rate significantly reflects the effectiveness of public health-related program and intervention. The aim of this study was to find strength of association between key health's related indicators and adult mortality rate. METHODS: This cross-sectional study used 5 sets of data combined into one from different organizations of 193 countries using record linkage theory. Eleven key health-related indicators were taken as independent variables and adult mortality of male and female were dependent variables from 2010 to 2013. Average mortality for male and female was shown by means and standard deviations, raw association by Pearson correlation and strength of association by hierarchical linear regression. RESULTS: The average adult mortality rate (AMR) of male was 0.209±0.106 and of female, 0.146 ±0.105 in years. In raw correlation, almost all health indicators were associated with AMR of male and female. In regression analysis, Universal Health Coverage (UHC) significantly reduced (male ∼0.43, female ∼0.30) adult mortality, in contrast, population growth significantly increased (male ∼ 0.37, female ∼0.43). Alcohol consumption per year increased AMR in male by 0.41 (P<0.01) and vaccination coverage (DPT 3) significantly reduced the AMR (0.26) in female. CONCLUSION: It is necessary to extend the UHC in remaining countries and still a need to control the population where there is high population growth. Effectively control of alcoholic drink in male and full coverage of vaccination in childhood mitigates adult mortality. The UHC is ambitious goal for SDG and special attention should be provided nationally and globally.

Association between the symptoms of benign prostatic hyperplasia and social disparities: Does social capital promote prostate health?

This cross-sectional study investigated the relationships between socioeconomic factors and social capital and benign prostatic hyperplasia symptoms. The participants were 100,000 adult men who participated in the Korea Community Health Survey. The surveyors used the International Prostate Symptom Score. As regards occupation, the prevalence of benign prostatic hyperplasia was higher in men with blue-collar occupations or those who were unemployed than in those with white-collar jobs. In terms of marital status, the prevalence of benign prostatic hyperplasia was 1.319 times higher among divorced men than married men. As regards social capital, the prevalence of benign prostatic hyperplasia in men with positive attitudes towards one's community scores that reflected good, poor and very poor community scores was 1.228, 1.246 and 1.447 times higher than that of men who had very good scores respectively. The groups with good, poor, and very poor community participation scores had 1.115, 1.202 and 1.364 times higher prevalence of benign prostatic hyperplasia than the group with very good scores. Social disparities and social capital of a community were associated with the prevalence of benign prostatic hyperplasia. Thus, the use of social capital in the community setting will be effective in the management of the condition.

Impact of Spiritual Behavior on Self-Reported Illness: A Cross-Sectional Study among Women in the Kailali District of Nepal.

BACKGROUND: Different health behaviors influence health and illness. Spiritual well-being is one of the most important aspects of health promotion. The aim of this study was to identify the association between spiritual behavior in relation to meditation, worship, and physical exercise during yoga with self-reported disease/illness among women of the Kailali district of Nepal. METHODS: This was a cross-sectional study with 453 randomly selected women in the Kailali district of Nepal within 1 municipality and 4 village development committees (VDC) using cluster sampling. We used a semi-structured interview to collect the data for selected respondents. Socioeconomics, lifestyle, self-care, and spiritual behavior variables were independent variables, and self-reported illness in the past year was a dependent variable. Descriptive statistics, chi square, hierarchical logistic regression for odds ratio, and 95% CI were used when appropriate. RESULTS: Study results showed that 89% of participants were from the rural area, 29.3% were housewives, 51.4% had no formal education, 43.2% used tobacco, 42.1% did yoga, and 16.9% engaged in regular worship. Self-reported illness was associated with safe toilet-using behavior, tobacco use, junk food consumption, yoga and regular exercise, worship, and regular sleeping habits. Comparing odds ratios and 95% CIs, the women who had safe toilet behavior and did not use tobacco were 2.48 (1.98-7.98) and 2.86 (1.74-7.34) times less likely to be ill, respectively. Likewise, women who consumed junk food; did not regularly exercise, meditate, or worship; and had irregular sleeping habits were 1.65 (1.32-4.61), 2.81(1.91-5.62), 2.56 (2.01-4.88), 4.56 (3.91-8.26), and 2.45 (2.12-5.03) times more likely to become ill, respectively. CONCLUSION: Our study concludes that spiritual behavior is effective for better health and low risk for disease occurrence. A spiritual health policy and separate curriculum for basic education and medical education should be promoted globally, and further research is recommended.

Predisposing, enabling, and need factors associated with utilization of institutional delivery services: A community-based cross-sectional study in far-western Nepal.

Use of institutional delivery services can be effective in reducing maternal and infant mortality. In Nepal, however, the majority of women deliver at home. Using Andersen's behavioral model of use of health care services, this cross-sectional study aimed to identify factors associated with use of institutional delivery services in four villages and one municipality in Kailali district, Nepal. Mothers (N = 500) who had given birth in the 5 years preceding the survey (conducted between January and February 2015) were randomly selected by cluster sampling and interviewed using a semi-structured questionnaire. Bivariate analyses and multivariate hierarchical logistic regression analyses were performed. Among the women surveyed, 65.6% had used institutional delivery services for their last delivery, a higher proportion than the national average. Primiparity, having a secondary or higher education level, living in the Durgauli village, having husbands with occupations other than agriculture or professional/technical jobs, and having attended four or more antenatal care (ANC) visits had significantly increased use of institutional deliveries. Also, belonging to the richest 20% of the community and having experienced pregnancy complications were marginally significantly associated. These findings demonstrate the need for improving mother's education, encouraging them to attend ANC visits and addressing disparities between different regions.

A Comparative Study on Outcome of Government and Co-Operative Community-Based Health Insurance in Nepal.

BACKGROUND: There are different models for community-based health insurance (CBHI), and in Nepal, among them, the government and the local communities (co-ops) are responsible for operating the CBHI models that are in practice. AIMS: The aim of this study is to compare the outcomes in relation to benefit packages, population coverage, inclusiveness, healthcare utilization, and promptness of treatment for the two types of CBHI models in Nepal. METHODS: This study was an observational and interactive descriptive study using the concurrent mixed approach of data collection, framing, and compilation. Quantitative data were collected from records, and qualitative data were collected from key informants in all 12 CBHI groups. Unstructured questionnaires, observation checklists, and memo notepads were used for data collection. Descriptive statistics and the Mann-Whitney U test were used when appropriate. Ethically, written informed consent was obtained from the respondents who participated in the study, and they were told that they could withdraw from the study anytime. RESULTS: The study revealed the following: new enrolment did not increase in either group; however, the healthcare utilization rate did (Government 107% and co-ops 137%), while the benefit packages remained almost same for both groups. Overall, inclusiveness was higher for the government group. For the CBHI co-ops, enrollment among the religious minority and the discount negotiated with the hospitals for treatment were significantly higher, and the promptness in reaching a hospital was significantly faster (p < 0.05) than that in the government-operated CBHI. CONCLUSION: Findings indicate that CBHI through co-ops would be a better model because of its lower costs and ability to enhance self-responsiveness and the overall health system. Health insurance coverage is the most important component to achieve universal health coverage.