The impact of National Health Insurance upon accessibility of health services and financial protection from catastrophic health expenditure: a case study of Savannakhet province, the Lao People’s Democratic Republic (original) (raw)
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Social Science & Medicine, 2013
There is now widespread acceptance of the universal coverage approach, presented in the 2010 World Health Report. There are more and more voices for the benefit of creating a single national risk pool. Now, a body of literature is emerging on institutional design and organizational practice for universal coverage, related to management of the three health-financing functions: collection, pooling and purchasing. While all countries can move towards universal coverage, lower-income countries face particular challenges, including scarce resources and limited capacity. Recently, the Lao PDR has been preparing options for moving to a single national health insurance scheme. The aim is to combine four different social health protection schemes into a national health insurance authority (NHIA) with a single national fund-and risk-pool. This paper investigates the main institutional and organizational challenges related to the creation of the NHIA. The paper uses a qualitative approach, drawing on the World Health Organization's institutional and Organizational Assessment for Improving and Strengthening health financing (OASIS) conceptual framework for data analysis. Data were collected from a review of key health financing policy documents and from 17 semi-structured key informant interviews. Policy makers and advisors are confronting issues related to institutional arrangements, funding sources for the authority and government support for subsidies to the demand-side health financing schemes. Compulsory membership is proposed, but the means for covering the informal sector have not been resolved. While unification of existing schemes may be the basis for creating a single risk pool, challenges related to administrative capacity and cross-subsidies remain. The example of Lao PDR illustrates the need to include consideration of national context, the sequencing of reforms and the timescale appropriate for achieving universal coverage.
2022
Laos has difficulties in accessing and obtaining proper health services compared to more developed countries, due to the availability of health facilities and health financing programs. Hemodialysis (HD) is currently under the coverage of the National Health Insurance (NHI). However, there are several technical barriers related to health service utilization. This study aims to carefully analyze the role of Laos' National Health Insurance on issues of accessibility and the possibility of encountering catastrophic health expenditures for chronic kidney disease patients. In addition, this study is also willing to provide policy recommendations for policymakers in offering organ transplantation under NHI in the future. The Savannakhet Province is purposively selected as a study site, where 342 respondents participated in the study. Two logistic regression models have been used to assess the effectiveness of the NHI in terms of accessibility and financial protection against catastrop...
Health Economics, 2013
The effect of voluntary health insurance on preventive health has received limited research attention in developing countries, even when they suffer immensely from easily preventable illnesses. This paper surveys households in rural southwestern Uganda, which are geographically serviced by a voluntary Community-based health insurance scheme, and applied propensity score matching to assess the effect of enrolment on using mosquito nets and deworming under-five children. We find that enrolment in the scheme increased the probability of using a mosquito net by 26% and deworming by 18%. We postulate that these findings are partly mediated by information diffusion and social networks, financial protection, which gives households the capacity to save and use service more, especially curative services that are delivered alongside preventive services. This paper provides more insight into the broader effects of health insurance in developing countries, beyond financial protection and utilisation of hospital-based services.
Household costs associated with health care seeking at three tertiary care hospitals in Lao PDR
The Southeast Asian Journal of Tropical Medicine and Public Health, 2012
The objective of this study was to estimate household costs (direct medical, direct non-medical and opportunity costs) associated with outpatient consultations and inpatient admissions at three tertiary hospitals in Lao PDR (national, university and regional hospitals). Revolving drug funds are the main sources of revenue for the facilities. We used outpatient exit interviews and interviews with discharged inpatients to obtain data. A total of 280 outpatients and 149 patients discharged from internal medicine wards were interviewed. The average cost for the outpatient services was USD16.0 per patient. Direct medical costs accounted for more than half the amount. Patient interviews revealed it was common for the hospital to require patients to come back the following day to obtain the results of ancillary services which will result in higher transportation and opportunity costs to the patient. The average cost for inpatient admission was USD292; this ranged from USD118 (regional hospital) to USD407 (national hospital). Direct medical costs accounted for 60% and 35% at those two facilities, respectively. Revolving drug funds as a provider payment method at tertiary hospitals were regressive. An uninsured patient faced higher outpatient costs than an insured patient. With the limited number of people currently insured in Lao PDR (8% of the total population in 2009), these results suggest the need to rapidly scale up effective risk protection schemes.
The Impact of a Policy on Universal Coverage on Equity in Health Care Finance in Thailand
2007
This paper exploited five different data sets of the national household survey in pre-(years 2000 and 2001) and post-(years 2002 and 2004) universal health care coverage (UC) periods to analyse trends and patterns of the distribution of utilisation and out-of-pocket (OOP) payments for public health care in relation to the distribution of household living standards. Benefit incidence of public health care spending, in general, has been progressive, in favour of the poor. The pro-poor subsidy was strongest for district health system (DHS) which included outpatient (OP) care provided by sub-district health centres (HC), and OP and inpatient (IP) care by district hospitals (DH). The pro-poor financing during the post-UC period in 2004 has been more pronounced for the public subsidies on OP care (Concentration Index-CI =-0.3326,-0.2921, and-0.1496 for HC, DH, and provincial hospitals-PH). Progressivity in the health care benefit incidence was weaker for IP care provided by PH (CI =-0.1104 and-0.1221 for 2001 and 2004, respectively). However, the Kakwani Index (KI) indicates that the public subsidy at every health care level has reduced inequality in the living standards of household members. Post-UC, 2004, comparisons of the benefit incidence across three public insurance schemes revealed that the progressivity of OP subsidies for HC and DH were consistent across all schemes. The OP subsidy from PH seemed to be pro-poor only for the Civil Servant Medical Benefit scheme (CSMBS) beneficiaries. The pro-poor subsidy of OP care in PH did not hold true among the UC beneficiaries, either UC exempted (UCE) members who were exempted from copayment or UC Pay (UCP) members who were required to co-pay at point of services, and for Social Security Scheme (SSS) beneficiaries. For those who were in the richest quintile, PH played a dominant role in subsidising IP care for all (CSMBS, UCP and UCE), except for the SSS enrolees. Distribution of the IP subsidy from PH seems to be regressive against the poorest quintile of UCE and UCP beneficiaries. The incidence of catastrophic health expenditure (defined as OOP payments for health care more than 10% of total household consumption expenditure), reduced from 5.4% in 2000 to 3.3% and 2.8% in 2002 and 2004, respectively for all households and from 4.7% to 3.2% and 2.6% during the same periods for members who previously belonged to the Low Income Scheme (LIC) and Voluntary Health Card Scheme (VHC) (who are currently UC) and UC groups. However, the catastrophe tended to be regressive against the poor households after the UC policy was implemented (CI = 0.0358 in 2000 and 0.2062-0.1712 in 2002-2004). Reduction in catastrophic incidence is a result of UC that provides a comprehensive coverage for ambulatory, admission and other high cost care with a very small nominal fee.
The health insurance system cannot achieve health systems goals of efficiency and equity. According to the decentralisation act, the majority of the public health service facilities may be devolved to the local authorities. The objective was to study the role of the local fund health security (LFHS) in local governments as a component of Thailand's universal coverage healthcare reforms in Thailand. This study using a mix method. A survey section used a cross-sectional approach within 190 samples in local governments. The qualitative data were focused on an After Action Review (AAR) of the LFHS. The LFHSs could manage healthcare services in different levels, 1) providing supports on the existing public health services, 2) establishing a new public health service system, and 3) purchasing of the existing public health services to be fully run at local level. The results suggest that the LFHS will be proposed to policy makers of the local government and the National Health Security...
PLOS ONE, 2019
We systematically review the health-financing mechanisms, revenue rising, pooling, purchasing, and benefits, in the Association of Southeast Asian Nations (ASEAN) and the People's Republic of China, and their impact on universal health coverage (UHC) goals in terms of universal financial protection, utilization/equity and quality. Two kinds of sources are reviewed: 1) academic articles, and 2) countries' health system reports. We synthesize the findings from ASEAN countries and China reporting on studies that are in the scope of our objective, and studies that focus on the system (macro level) rather than treatment/technology specific studies (micro level).The results of our review suggest that the main sources of revenues are direct/indirect taxes and out of pocket payments in all ASEAN countries and China except for Brunei where natural resource revenues are the main source of revenue collection. Brunei, Indonesia, Philippines, Malaysia, and Viet Nam have a single pool for revenue collection constituting a national health insurance. Cambodia, China, Lao, Singapore, and Thailand have implemented multiple pooling systems while Myanmar has no formal arrangement. Capitation, Fee-for-Service, DRGs, Fee schedules, Salary, and Global budget are the methods of purchasing in the studied countries. Each country has its own definition of the basic benefit package which includes the services that are perceived as essential for the population health. Although many studies provide evidence of an increase in financial protection after reforming the health-financing mechanisms in the studied countries, inequity in financial protection continue to exist. Overall, the utilization of health care among the poor has increased as a consequence of the implementation of government subsidized health insurance schemes which target the poor in most of the studied countries. Inappropriate policies and provider payment mechanisms impact on the quality of health care provision. We conclude that the most important factors to attain UHC are to prioritize and include vulnerable groups into the health insurance scheme. Government subsidization for this kind of
Health Policy, 2011
Objectives: To assess the impact on equity and effectiveness of introducing targeted subsidies for the poor into existing voluntary health insurance schemes in Low Income Countries with special reference to cross-subsidisation. Methods: A functional model was constructed using routine collected financial data to analyse changes in financial flows and resulting shifts in cross-subsidization between poor and non-poor. Data were collected from two sites, in Cambodia at Kampot operational health district and in the Lao People's Democratic Republic at Nambak district. Results: Six key variables were identified as determining the financial flows between the subsidy and the insurance schemes and with health providers: population coverage, premium rate, facility contact rate, capitation rate, cost of treatment and changes in administration costs. Negative cross-subsidization was revealed where capitation was used as the payment mechanism and where utilisation rates of the poor were significantly below the non-poor. The same level of access for the poor could have been achieved with a lower Health Equity Fund subsidy if used as a direct reimbursement of user charges by the Health Equity Fund to the provider rather than through the Community Based Health Insurance scheme. Conclusions: Purchasing premiums for the poor under these conditions is more costly than direct reimbursement to the provider for the same level of service delivery. Negative crosssubsidization is a serious risk that must be managed appropriately and the benefits of a larger risk pool (cross-subsidization of the poor) are not evident. Benefits from combined coverage may accrue in the longer term with an expanded base of voluntary payers or when those with subsidized premiums are lifted out of poverty.