Extending health insurance coverage to the informal sector: Lessons from a private micro health insurance scheme in Lagos, Nigeria.

BACKGROUND: As a growing number of low- and middle-income countries commit to achieving universal health coverage, one key challenge is how to extend coverage to informal sector workers. Micro health insurance (MHI) provides a potential model to finance health services for this population. This study presents lessons from a pilot study of a mandatory MHI plan offered by a private insurance company and distributed through a microfinance bank to urban, informal sector workers in Lagos, Nigeria. METHODS: Study methods included a survey of microfinance clients, key informant interviews, and a review of administrative records. RESULTS: Demographic, health care seeking, and willingness-to-pay data suggested that microfinance clients, particularly women, could benefit from a comprehensive MHI plan that improved access to health care and reduced out-of-pocket spending on health services. However, administrative data revealed declining enrollment, and key informant interviews further suggested low use of the health insurance plan. Key implementation challenges, including changes to mandatory enrollment requirements, insufficient client education and marketing, misaligned incentives, and weak back-office systems, undermined enrollment and use of the plan. CONCLUSIONS: Mandatory MHI plans, intended to mitigate adverse selection and facilitate private insurers' entry into new markets, present challenges for covering informal sector workers, including when distributed through agents such as a microfinance bank. Properly aligning the incentives of the insurer and the agent are critical to effectively distribute and service insurance. Further, an urban environment presents unique challenges for distributing MHI, addressing client perceptions of health insurance, and meeting their health care needs.

Quality maternity care for every woman, everywhere: a call to action.

To improve maternal health requires action to ensure quality maternal health care for all women and girls, and to guarantee access to care for those outside the system. In this paper, we highlight some of the most pressing issues in maternal health and ask: what steps can be taken in the next 5 years to catalyse action toward achieving the Sustainable Development Goal target of less than 70 maternal deaths per 100 000 livebirths by 2030, with no single country exceeding 140? What steps can be taken to ensure that high-quality maternal health care is prioritised for every woman and girl everywhere? We call on all stakeholders to work together in securing a healthy, prosperous future for all women. National and local governments must be supported by development partners, civil society, and the private sector in leading efforts to improve maternal-perinatal health. This effort means dedicating needed policies and resources, and sustaining implementation to address the many factors influencing maternal health-care provision and use. Five priority actions emerge for all partners: prioritise quality maternal health services that respond to the local specificities of need, and meet emerging challenges; promote equity through universal coverage of quality maternal health services, including for the most vulnerable women; increase the resilience and strength of health systems by optimising the health workforce, and improve facility capability; guarantee sustainable finances for maternal-perinatal health; and accelerate progress through evidence, advocacy, and accountability.

Estimating the budget impact of a Tuberculosis strategic purchasing pilot study in Medan, Indonesia (2018-2019).

BACKGROUND: Indonesia has the world's second-highest tuberculosis (TB) burden, with 969,000 annual TB infections. In 2017, Indonesia faced significant challenges in TB care, with 18% of cases missed, 29% of diagnosed cases unreported, and 55.4% of positive results not notified. The government is exploring a new approach called "strategic purchasing" to improve TB detection and treatment rates and offer cost-effective service delivery. OBJECTIVES: We aimed to analyze the financial impact of implementing a TB purchasing pilot in the city of Medan and assess the project's affordability and value for money. METHODS: We developed a budget impact model to estimate the cost-effectiveness of using strategic purchasing to improve TB reporting and treatment success rates. We used using data from Medan's budget impact model and the Ministry of Health's guidelines to predict the total cost and the cost per patient. RESULTS: The model showed that strategic purchasing would improve TB reporting by 63% and successful treatments by 64%. While this would lead to a rise in total spending on TB care by 60%, the cost per patient would decrease by 3%. This is because more care would be provided in primary healthcare settings, which are more cost-effective than hospitals. CONCLUSIONS: While strategic purchasing may increase overall spending, it could improve TB care in Indonesia by identifying more cases, treating them more effectively, and reducing the cost per patient. This could potentially lead to long-term cost savings and improved health outcomes.

Effect of health insurance on the use and provision of maternal health services and maternal and neonatal health outcomes: a systematic review.

Financial barriers can affect timely access to maternal health services. Health insurance can influence the use and quality of these services and potentially improve maternal and neonatal health outcomes. We conducted a systematic review of the evidence on health insurance and its effects on the use and provision of maternal health services and on maternal and neonatal health outcomes in middle- and low-income countries. Studies were identified through a literature search in key databases and consultation with experts in healthcare financing and maternal health. Twenty-nine articles met the review criteria of focusing on health insurance and its effect on the use or quality of maternal health services, or maternal and neonatal health outcomes. Sixteen studies assessed demand-side effects of insurance, eight focused on supply-side effects, and the remainder addressed both. Geographically, the studies provided evidence from sub-Saharan Africa (n = 11), Asia (n = 9), Latin America (n = 8), and Turkey. The studies included examples from national or social insurance schemes (n = 7), government-run public health insurance schemes (n = 4), community-based health insurance schemes (n = 11), and private insurance (n = 3). Half of the studies used econometric analyses while the remaining provided descriptive statistics or qualitative results. There is relatively consistent evidence that health insurance is positively correlated with the use of maternal health services. Only four studies used methods that can establish this causal relationship. Six studies presented suggestive evidence of over-provision of caesarean sections in response to providers' payment incentives through health insurance. Few studies focused on the relationship between health insurance and the quality of maternal health services or maternal and neonatal health outcomes. The available evidence on the quality and health outcomes is inconclusive, given the differences in measurement, contradictory findings, and statistical limitations. Consistent with economic theories, the studies identified a positive relationship between health insurance and the use of maternal health services. However, more rigorous causal methods are needed to identify the extent to which the use of these services increases among the insured. Better measurement of quality and the use of cross-country analyses would solidify the evidence on the impact of insurance on the quality of maternal health services and maternal and neonatal health outcomes.

Effects of user fee exemptions on the provision and use of maternal health services: a review of literature.

User fee removal has been put forward as an approach to increasing priority health service utilization, reducing impoverishment, and ultimately reducing maternal and neonatal mortality. However, user fees are a source of facility revenue in many low-income countries, often used for purchasing drugs and supplies and paying incentives to health workers. This paper reviews evidence on the effects of user fee exemptions on maternal health service utilization, service provision, and outcomes, including both supply-side and demand-side effects. We reviewed 19 peer-reviewed research articles addressing user fee exemptions and maternal health services or outcomes published since 1990. Studies were identified through a USAID-commissioned call for evidence, key word search, and screening process. Teams of reviewers assigned criteria-based quality scores to each paper and prepared structured narrative reviews. The grade of the evidence was found to be relatively weak, mainly from short-term, non-controlled studies. The introduction of user fee exemptions appears to have resulted in increased rates of facility-based deliveries and caesarean sections in some contexts. Impacts on maternal and neonatal mortality have not been conclusively demonstrated; exemptions for delivery care may contribute to modest reductions in institutional maternal mortality but the evidence is very weak. User fee exemptions were found to have negative, neutral, or inconclusive effects on availability of inputs, provider motivation, and quality of services. The extent to which user fee revenue lost by facilities is replaced can directly affect service provision and may have unintended consequences for provider motivation. Few studies have looked at the equity effects of fee removal, despite clear evidence that fees disproportionately burden the poor. This review highlights potential and documented benefits (increased use of maternity services) as well as risks (decreased provider motivation and quality) of user fee exemption policies for maternal health services. Governments should link user fee exemption policies with the replacement of lost revenue for facilities as well as broader health system improvements, including facility upgrades, ensured supply of needed inputs, and improved human resources for health. Removing user fees may increase uptake but will not reduce mortality proportionally if the quality of facility-based care is poor. More rigorous evaluations of both demand- and supply-side effects of mature fee exemption programmes are needed.

Financial incentives and maternal health: where do we go from here?

Health financing strategies that incorporate financial incentives are being applied in many low- and middle-income countries, and improving maternal and neonatal health is often a central goal. As yet, there have been few reviews of such programmes and their impact on maternal health. The US Government Evidence Summit on Enhancing Provision and use of Maternal Health Services through Financial Incentives was convened on 24-25 April 2012 to address this gap. This article, the final in a series assessing the effects of financial incentives--performance-based incentives (PBIs), insurance, user fee exemption programmes, conditional cash transfers, and vouchers--summarizes the evidence and discusses issues of context, programme design and implementation, cost-effectiveness, and sustainability. We suggest key areas to consider when designing and implementing financial incentive programmes for enhancing maternal health and highlight gaps in evidence that could benefit from additional research. Although the methodological rigor of studies varies, the evidence, overall, suggests that financial incentives can enhance demand for and improve the supply of maternal health services. Definitive evidence demonstrating a link between incentives and improved health outcomes is lacking; however, the evidence suggests that financial incentives can increase the quantity and quality of maternal health services and address health systems and financial barriers that prevent women from accessing and providers from delivering quality, lifesaving maternal healthcare.

User fee exemptions and equity in access to caesarean sections: an analysis of patient survey data in Mali.

INTRODUCTION: Little rigorous evidence exists on how health service utilization varies across socioeconomic groups after a user fee exemption policy has been implemented, and the evidence that does exist is mixed. In this paper, we estimate the distribution of caesarean section deliveries across socioeconomic groups following Mali's implementation of a fee exemption policy for caesareans in 2005. METHODS: We conducted a patient survey in 2010 to collect socioeconomic data from 2,477 women who had caesareans in a representative sample of 25 facilities across all regions of Mali. We used these data along with data from the most recent Demographic and Health Survey to construct a wealth index and classify women into population-based wealth groupings. We compared the wealth distribution of women delivering via caesarean section to that of a nationally representative sample of women giving birth. RESULTS: We found that wealthier women make up a disproportionate share of those having free caesareans, five years after implementation of the fee exemption policy. Women in the richest two quintiles accounted for 58 percent of all caesareans, while women in the poorest two quintiles accounted for 27 percent of all caesareans. Fewer women in the poorest two-fifths of the population are receiving caesareans than what we would expect given their share in the population of women giving birth. CONCLUSIONS: While fee exemptions remove important financial barriers to accessing priority maternal health services, they are insufficient to ensure equal access among wealth groups.

A community-based approach to promote household water treatment in Rwanda.

Treatment of drinking water at the household level is one of the most effective preventive interventions against diarrhea, a leading cause of illness and death among children in developing countries. A pilot project in two districts in Rwanda aimed to increase use of Sûr'Eau, a chlorine solution for drinking water treatment, through a partnership between community-based health insurance schemes and community health workers who promoted and distributed the product. Evaluation of the pilot, drawing on a difference-in-differences design and data from pre- and post-pilot household surveys of 4,780 households, showed that after 18 months of pilot implementation, knowledge and use of the product increased significantly in two pilot districts, but remained unchanged in a control district. The pilot was associated with a 40-42 percentage point increase in ever use, and 8-9 percentage points increase in use of Sûr'Eau at time of the survey (self-reported measures). Our data suggest that exposure to inter-personal communication on Sûr'Eau and hearing about the product at community meetings and health centers were associated with an increase in use.

Social security health insurance for the informal sector in Nicaragua: a randomized evaluation.

This article presents the results from an experimental evaluation of a voluntary health insurance program for informal sector workers in Nicaragua. Costs of the premiums as well as enrollment location were randomly allocated. Overall, take-up of the program was low, with only 20% enrollment. Program costs and streamlined bureaucratic procedures were important determinants of enrollment. Participation of local microfinance institutions had a slight negative effect on enrollment. One year later, those who received insurance substituted toward services at covered facilities and total out-of-pocket expenditures fell. However, total expenditures fell by less than the insurance premiums. We find no evidence of an increase in health-care utilization among the newly insured. We also find very low retention rates after the expiration of the subsidy, with less than 10% of enrollees still enrolled after one year. To shed light on the findings from the experimental results, we present qualitative evidence of institutional and contextual factors that limited the success of this program.

Health system strengthening: prospects and threats for its sustainability on the global health policy agenda.

In 2013, Hafner and Shiffman applied Kingdon's public policy process model to explain the emergence of global attention to health system strengthening (HSS). They questioned, however, HSS's sustainability on the global health policy agenda, citing various concerns. Guided by the Grindle and Thomas interactive model of policy implementation, we advance and elaborate a proposition: a confluence of developments will contribute to maintaining HSS's prominent place on the agenda until at least 2030. Those developments include (1) technical, managerial, financial, and political responses to unpredictable public health crises that imperil the routine functioning of health systems, such as the 2014-2015 Ebola virus disease (Ebola) epidemic in West Africa; (2) similar responses to non-crisis situations requiring fully engaged, robust health systems, such as the pursuit of the new Sustainable Development Goal for health (SDG3); and (3) increased availability of new knowledge about system change at macro, meso, and micro levels and its effects on people's health and well-being. To gauge the accuracy of our proposition, we carried out a speculative assessment of credible threats to our premise by discussing all of the Hafner-Shiffman concerns. We conclude that (1) the components of our proposition and other forces that have the potential to promote continuing attention to HSS are of sufficient strength to counteract these concerns, and (2) prospective monitoring of HSS agenda status and further research on agenda sustainability can increase confidence in our threat assessment.

Determinants of child morbidity in Latin America: a pooled analysis of interactions between parental education and economic status.

Diarrhea and respiratory infections account for more than two-fifths of all deaths among children under five. Parental education and economic status are well-known risk factors for child morbidity, but little is known about whether education and economic status operate synergistically or independently to influence children's health. Confirming the presence and direction of such interactions is important to better target education and development policies. Our objective is to test for interactions between parental education and economic status in predicting the risk of diarrhea and respiratory illness among children under five, before and after adjusting for key proximate risk factors. We pool 12 Demographic and Health Surveys (DHS) and nine Living Standards Measurement Surveys (LSMS) from Latin America, creating two large databases. Quintiles of economic status are constructed from principal components asset indices. We use logistic regression to analyze episodes of diarrhea and respiratory illness, and interactions between economic quintile and maternal and paternal education are evaluated via likelihood ratio tests. We find that mother's education and quintile interact synergistically in the DHS data, while results are inconclusive in the LSMS data. The effect of increasing maternal education appears to be more protective for children in wealthy families than for children in poor families. Conversely, improvements in economic status reduce health risks more for children whose mothers are better educated. Father's education is protective and operates independently of economic status. Our findings imply that poverty alleviation efforts occurring in concert with programs to educate women and girls will be more effective for improving children's health than either approach alone.

Encouraging maternal health service utilization: an evaluation of the Bangladesh voucher program.

With the ultimate goal of reducing maternal and neonatal mortality, many countries have recently adopted innovative financing mechanisms to encourage the use of professional maternal health services. The current study evaluates one such initiative - a pilot voucher program in Bangladesh. The program provides poor women with cash incentives and free access to antenatal, delivery, and postnatal care, as well as cash incentives for providers to offer these services. We conducted a household survey of 2208 women who delivered in the 6 months before the survey (conducted in 2009) in 16 intervention and 16 matched comparison sub-districts. Probit and linear regressions are used to analyze the effects of residing in voucher sub-districts on the use of professional maternal health services and associated out-of-pocket expenditures. Using information on birth history, we conducted sensitivity analyses employing difference-in-differences methods, comparing women's reported births before and after the program's initiation in the intervention and comparison sub-districts. We found that the program significantly increased the use of antenatal, delivery, and postnatal care with qualified providers. Compared to women in matched comparison sub-districts, women in intervention areas had a 46.4 percentage point higher probability of using a qualified provider and 13.6 percentage point higher probability of institutional delivery. They also paid approximately Taka 640 (US$ 9.43) less for maternal health services, equivalent to 64% of the sample's average monthly household expenditure per capita. No significant effect of vouchers was found on the rate of Cesarean section. Our findings therefore support voucher program expansion targeting the economically disadvantaged to improve the use of priority health services. The Bangladesh voucher program is a useful example for other developing countries interested in improving maternal health service utilization.

Did professional attendance at home births improve early neonatal survival in Indonesia?

BACKGROUND Early neonatal mortality has been persistently high in developing countries. Indonesia, with its national policy of home-based, midwife-assisted birth, is an apt context for assessing the effect of home-based professional birth attendance on early neonatal survival. METHODS We pooled four Indonesian Demographic and Health Surveys and used multivariate logistic regression to analyse trends in first-day and early neonatal mortality. We measured the effect of the context of delivery, including place and type of provider, and tested for changes in trend when the 'Midwife in the Village' programme was initiated. RESULTS Reported first-day mortality did not decrease significantly between 1986 and 2002, whereas early neonatal mortality decreased by an average of 3.2% annually. The rate of the decline did not change over the time period, either in 1989 when the Midwife in the Village programme was initiated, or in any year following when uptake of professional care increased. In simple and multivariate analyses, there were no significant differences in first-day or early neonatal death rates comparing home-based births with or without a professional midwife. Early neonatal mortality was higher in public facilities, likely due to selection. Biological determinants (twin births, male sex, short birth interval, previous early neonatal loss) were important for both outcomes. CONCLUSIONS Decreasing newborn death rates in Indonesia are encouraging, but it is not clear that these decreases are associated with greater uptake of professional delivery care at home or in health facilities. This may suggest a need for improved training in immediate newborn care, strengthened emergency referral, and continued support for family planning policies.

The role of private providers in treating child diarrhoea in Latin America.

Diarrhoeal disease, a leading cause of child mortality, disproportionately affects children in low-income countries - where private and non-governmental providers are often an important source of health care. We use 10 Living Standards Measurement Surveys from Latin America to model the choice of care for child diarrhoea in the private sector compared to the public sector. A total of 36.8% of children in the combined data set saw a private provider rather than a public one when taken for treatment. Each additional quintile of household economic status is associated with an increase of 6.5 percentage points in the probability that a child with diarrhoea is taken to a private provider (p<0.001). However, treatments provided in the private sector are manifestly of worse quality than in the public sector. A total of 33.0% of children visiting a public provider received Oral Rehydration Solution, compared to 13.7% of those visiting a private provider. Conversely, children treated by a private provider are more likely to receive drugs, most commonly unnecessary antibiotics. Ironically, when it comes to treatment for child diarrhoea, wealthier and better educated households in Latin America are paying for treatment in the private sector that is ineffective in comparison with treatments that are commonly and inexpensively available.

Did the strategy of skilled attendance at birth reach the poor in Indonesia?

OBJECTIVE: To assess whether the strategy of "a midwife in every village" in Indonesia achieved its aim of increasing professional delivery care for the poorest women. METHODS: Using pooled Demographic and Health Surveys (DHS) data from 1986-2002, we examined trends in the percentage of births attended by a health professional and deliveries via caesarean section. We tested for effects of the economic crisis of 1997, which had a negative impact on Indonesias health system. We used logistic regression, allowing for time-trend interactions with wealth quintile and urban/rural residence. FINDINGS: There was no change in rates of professional attendance or caesarean section before the programmes full implementation (1986-1991). After 1991, the greatest increases in professional attendance occurred among the poorest two quintiles -- 11% per year compared with 6% per year for women in the middle quintile (P = 0.02). These patterns persisted after the economic crisis had ended. In contrast, most of the increase in rates of caesarean section occurred among women in the wealthiest quintile. Rates of caesarean deliveries remained at less than 1% for the poorest two-fifths of the population, but rose to 10% for the wealthiest fifth. CONCLUSION: The Indonesian village midwife programme dramatically reduced socioeconomic inequalities in professional attendance at birth, but the gap in access to potentially life-saving emergency obstetric care widened. This underscores the importance of understanding the barriers to accessing emergency obstetric care and of the ways to overcome them, especially among the poor.

Working with the private sector for child health.

Private sector providers are the most commonly consulted source of care for child illnesses in many countries, offering significant opportunities to expand the reach of essential child health services and products. Yet collaboration with private providers presents major challenges - the suitability and quality of the services they provide is often questionable and governments' capacity to regulate them is limited. This article assesses the actual and potential contributions of the private sector to child health, and classifies and evaluates public sector strategies to promote and rationalize the contributions of private sector actors. Governments and international organizations can use a variety of strategies to collaborate with and influence private sector actors to improve child health - including contracting, regulating, financing and social marketing, training, coordinating and informing the public. These mutually reinforcing strategies can both improve the quality of services currently delivered in the private sector, and expand and rationalize the coverage of these services. One lesson from this review is that the private sector is very heterogeneous. At the country level, feasible strategies depend on the potential of the different components of the private sector and the capacity of governments and their partners for collaboration. To date, experience with private sector strategies offers considerable promise for children's health, but also raises many questions about the feasibility and impact of these strategies. Where possible, future interventions should be designed as experiments, with careful assessment of the intervention design and the environment in which they are implemented.

Quality-based purchasing in health care.

Quality-based purchasing is a growing trend that seeks to improve healthcare quality through the purchaser-provider relationship. This article provides a unifying conceptual framework, presents examples of the purchaser-provider relationship in countries at different income levels, and identifies important supporting mechanisms for quality-based purchasing. As countries become wealthier, a higher proportion of healthcare spending is channeled through pooled arrangements, allowing for greater involvement of purchasers in promoting the quality of service provision. Global and line item budgets are the most common type of provider payment system in low and middle-income countries. In these countries, improving public hospital performance through contracting and incentives is a key issue. In middle and high-income countries, there are several documented examples of governments contracting to private or non-governmental health care providers, resulting in higher perceived quality of care and lower delivery costs. Encouraging quality through employer purchasing arrangements has been promoted in several countries, particularly the United States. Community-based financing schemes are an increasingly common form of health financing in parts of sub-Saharan Africa and Asia, but these schemes still cover less than 10% of national populations in countries in which they are active. To date, there is little evidence of their impact on healthcare quality. The availability of information--concerning healthcare service provision and outcomes--determines the options for establishing and monitoring contract provisions and promoting quality. Regardless of the context, quality-based purchasing depends critically on informa-tion--reporting, monitoring, and providing useful information to healthcare consumers. In many low and middle-income countries, the lack of availability of information is the principal constraint on measuring performance, a critical component of quality-based purchasing.