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3c. Economics: Health Insurance Coverage for Medicines in LMIC
Health Insurance Systems in Five Sub-Saharan African Countries: Medicines Benefits and Data for Decision-Making
1Northeastern University, United States of America; 2Harvard Medical School and Harvard Pilgrim Health Care Institute; 3World Health Organization, Regional Office for Africa
Problem statement: Medicines benefits through health insurance programs have the potential to improve access to and promote more effective use of affordable, high-quality medicines. Information is lacking about medicines benefits provided by health insurance programs in Sub-Saharan Africa.
Objectives: To describe the structure of medicines benefits and data routinely available for decision-making in 33 health insurance programs in Ghana, Kenya, Nigeria, Tanzania and Uganda
Design: Survey data of the program structure, characteristics of medicines benefits, and availability of routine data for decision-making in health insurance systems is described, by country, with tables and figures.
Setting and study population: A convenience sample of 82 health insurance programs in five Sub-Saharan African countries (Ghana, Kenya, Nigeria, Tanzania, and Uganda) were identified and surveyed, of which 33 (40% of total) submitted data complete enough to be analyzed.
Intervention: No intervention was applied and assessed.
Policy: No policy change was evaluated.
Outcome measure(s): Measures covered program structure, characteristics of medicines benefits, and data available for decision-making.
Results: Most programs surveyed were private, for-profit schemes covering voluntary enrollees, mostly in urban areas. Almost all provide both inpatient and outpatient medicines benefits, with members sharing the cost of medicines in all programs. Some programs use strategies that are common in high-income countries to manage the medicines benefit, such as formularies, generics policies, reimbursement limits, or price negotiation. Basic data to monitor performance in delivering medicines benefits are available in most programs, but key data elements and the resources needed to generate useful management information from the available data are typically missing.
Conclusion: Many questions remain unanswered about the design, implementation, and effects of specific medicines policies in the emerging and expanding health insurance programs in Sub-Saharan Africa. These include questions about the most effective medicines policy choices, given different corporate and organizational structures and resources; impacts of specific benefit designs on quality and affordability of care and health outcomes; and ways to facilitate the use of routine data for monitoring. Technical capacity building, strong government commitment, and international donor support will be needed to realize the benefits of medicines coverage in emerging and expanding health insurance programs in Sub-Saharan Africa.
Funding source(s): The WHO Department of Essential Medicines and Pharmaceutical Policies in Geneva funded the development of the survey. The WHO Regional Office for Africa organized and funded data collection and analysis.
Active Pharmaceutical Management Strategies of Health Insurance Systems to Improve Cost-Effective Use of Medicines in Low- and Middle-Income Countries: A Systematic Review of Current Evidence
Harvard Medical School and Harvard Pilgrim Health Care Institute, United States of America
Problem statement: Lack of access to essential medicines is a prominent public health problem that disproportionately affects populations in low- and middle-income countries (LMIC). WHO estimates that 30% of the world’s population, and over half of the population in the poorest areas of Asia and Africa, lack access to essential medicines. Experts at the 2004 International Conference on Improving Use of Medicines concluded that insurance systems have great potential to improve the use of medicines, which currently consume 25 to 65% of total public and private spending on health in developing countries, and recommended systematic work within insurance systems to leverage better provider prescribing, more cost-effective use by consumers, and lower prices from industry.
Objectives: Despite ample evidence from high-income countries, little is known about insurance system strategies targeting medicines in LMIC. This paper provides a critical literature review of these strategies and their impact in LMIC.
Design: We conducted a systematic review of published peer-review and gray literature, and organized the insurance system strategies into four categories: medicines selection, purchasing, contracting, and utilization management.
Setting: Low- and middle-income countries
Study population: Not applicable
Interventions and policies: Health insurance strategies to improve use of medicines
Outcome measure(s): Cost-effective use of medicines
Results: In 63 reviewed publications, we found reasonable evidence supporting the use of insurance as an overall strategy to improve access to pharmaceuticals and outcomes in LMIC. Beyond this, most of the literature focused on provider contracting strategies to influence prescribing. There was very little evidence on medicines selection, purchasing, or utilization management strategies.
Conclusions: There is a paucity of published evidence on the impact of insurance system strategies on improving the use of medicines in LMIC. The existing evidence is questionable since the majority of the published studies utilize weak study designs. This review highlights the need for well-designed studies to build an evidence base on the impact of medicines management strategies deployed by LMIC insurance programs.
Funding source(s): WHO/HAI Medicines Prices Project
Impacts of Direct Fee-For-Service Payment Insurance on Access and Use of Drug: An Interrupted Time Series Study on Diabetic Care
1Faculty of Pharmacy,Silpakorn University, Thailand; 2Pharmacy division, Phramongkutklao Hospital, Thailand.
Problem Statement: Instead of advance payment by patients, the direct fee-for-service payment from the Thailand Ministry of Finance to hospitals for outpatient care has been implemented for beneficiaries of the Civil Servant Medical Benefit Scheme (CSMBS) since 2006. Consequently, the provision of care might be affected.
Objectives: To determine access and use of antidiabetic drugs before and after the implementation of direct fee-for-service payment for CSMBS beneficiaries to the hospital and to compare them with other health insurance.
Design: Longitudinal quasi-experimental analysis with an interrupted time series design.
Setting: A 1,200-bed public hospital with tertiary care services
Study Population: All diabetic outpatients with CSMBS who obtained antidiabetic drugs at the hospital between 2005 and 2009 were extracted from the hospital electronic prescription database.
Policy: The expenditure on health care for CSMBS beneficiaries had been dramatically and steadily increased every year. Many strategies were implemented for inpatient care but few for outpatient care. Health care utilization data is important for new policy formulation and development for cost-containment of outpatient care. This direct payment policy was implemented to reduce a burden of advance payment on beneficiaries and to obtain electronic health care utilization data submitted from hospitals for reimbursement. Diabetes was selected as a tracer chronic disease that could indicate the lifelong burden of outpatient healthcare costs. However, the more convenience for reimbursement might increase consumption of healthcare resources. This policy was implemented in the studied hospital in July 2006.
Outcome Measures: Levels and trends of number of patients accessed to antidiabetic drugs and average charge of antidiabetic drugs per patient per month before and after the direct payment policy implementation were examined by segmented regression analysis.
Results: The level and trend of number of diabetic outpatients with CSMBS who had access to antidiabetic drugs were not significantly changed from the baseline trend before the policy implementation (p>.05). The same findings were found for the beneficiary patients of Social Security Scheme (SSS) and out-of-pocket (OOP) patients, except for the patients in Universal Coverage (UC) project. For the average charge of antidiabetic drugs per patient per month after the policy changed, both the level and the trend were significantly higher than the baseline trend for CSMBS and OOP patients (p<.05). There was no change for SSS patients while the average charge was significantly decreased in level and trend for UC patients.
Conclusions: The direct fee-for-service payment to hospitals for CSMBS patients seems to extensively increase health care expenditure while the access to care was not changed.
Funding Source: No financial support.
The National Health Insurance Programme in Ghana and Household Access to Medicines
1Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Accra, Ghana; 2WHO Country Office, Accra, Ghana
Problem Statement: Lack of access to essential medicines in developing countries is one of the most pressing health issues. Health insurance is increasingly seen as an important alternative financing mechanism for health care. In Ghana, a National Health Insurance Scheme (NHIS) became operational in 2004 through an Act of Parliament. All people living in Ghana can become members through the payment of premiums, which cover 90% of medicines. Has health insurance in Ghana led to increased access to health? How does it affect utilization of medicines in general?
Objectives: Collect data on household expenditure on health for subscribers and non-subscribers of insurance schemes. Examine differences in health services utilization between insured and non-insured households and between subscribers to the national insurance and private health insurance.
Design: Policy evaluation to examine differences in household health care utilization and expenditure including medicines for the insured and non-insured of the NHIS and private insurance schemes.
Setting: A national population based survey using the standardized World Health Organization and the Medicines Transparency Alliance (MeTA) sampling approach for household surveys. The survey was conducted in six of the ten regions in Ghana systematically selected to represent varied socioeconomic profile and agro-ecological zones based on combination of purposive and random sampling.
Study Population: Data was collected from 30 households located in the vicinity of a reference public health facility. A third of sampled households were within 5 km, a third between 5 and 10 km, and another third farther than 10 km. Altogether, 1,020 households were interviewed by means of a questionnaire. Data entry was done with EpiData software and analysis with SPSS and Excel.
Policy evaluation: Survey explored the increase in access to health care following the introduction of health insurance in Ghana.
Outcome Measure(s): Health insurance coverage; household expenditure on health insurance, where household members sought outpatient treatment, admissions to a health facility, and expenditures for health services including medicines.
Results: Some 72% of households had at least one member covered by health insurance in the past 12 months of the study. 51.8% made an expenditure of 20 Ghana cedi (GHC) on administrative cost and premium for NHIS. Of insured households, 1.9% reported a median of GHC 12 for private health insurance premium. 10.78% reported some spending on insecticide treated nets (ITNs) and 37.16% utilized various sources of treatments. 53.56% sought complementary treatments and drug outlets were popular sources for the non-insured.
Conclusions: Introduction of health insurance has led to greater access to health care and health security. Proximity or geographical access to health facility is a likely key determinant to household enrollment but additional analysis need to be carried out to determine that.
Funding Source(s): WHO, Accra, Ghana, MoH, Ghana
Evaluation of the New Rural Cooperative Medical Scheme Outpatient Capitation Payment Reform in Qianjiang
1Chongqing Health Bureau, P.R.China; 2National Institute of Hospital Administration, MoH, P.R.China; 3Chongqing Medical University, P.R.China; 4Qianjiang District Health Bureau, Chongqing, P.R.China
Problem Statement: The funding level of New Rural Cooperative Medical Scheme (NRCMS) is low, there has been an increasing cost containment pressure for NRCMS. The fee-for-service payment and other factors created perverse incentives, which drive the irrational provider behaviours. Capitation payment reform was piloted in Qianjiang district of Chongqing (Qianjiang) with the expectations of containing the cost and rationalizing provider behaviours.
Objectives: To evaluate if the reform contained the cost, and rationalized the providers’ behaviour , and if such changes caused health workers and facilities to lose income.
Design: The effect of the policy is measured with changes of cost per visit, quality of care, and income of facilities and health workers before and after the reform in Qianjiang. 4 prescription indicators help to show if medicines are rationally used; referral and hospitalization rates, and proportions of appropriate referrals show if patients are selected and shifted from outpatient to inpatient. The cost and hospitalization data of Qianjiang are compared with that of Southeast Chongqing (SEC) with similar social and economical development situations.
Setting: In 2009, there are 30 township/community health centers (THC/CHC) and 169 village clinics (VC) in Qianjiang. SEC covers Qianjiang and other 5 neighbour counties/districts, comprises 200 THC/CHC and 1,431 VC.
Study Population: The cost and hospitalization data of Qianjiang and SEC are obtained from the NRCMS management database of Chongqing and Qianjiang ; the quality of care and income data in Qianjiang are collected from sample facilities (6 VC and 3 THC/CHC). The qualitative data are obtained from the key informants interviews and group discussions.
Policy: The capitation payment reform for NRCMS designated primary outpatient services started from two VC in July 2007 and expanded to all facilities by Jan. 2009. A performance assessment was developed as a base for payment within the annual limit, which was set to appropriately reflect the ongoing situation. No compensation to overruns and the balance could be kept by facilities.
Outcome Measure: Cost is measured with annual average value of all facilities of Qianjiang and compared with SEC during 2006-9. Annual median costs of all and sample facilities in Qianjiang during 2007-9 are also calculated. Both compare with the prescription caps. Quality of care and income data are collected from sample facilities. Interviews provided complementary information.
Results: The average costs per visit of all THC/CHC and VC in Qianjiang are at the same level with that in SEC in 2006, but much lower in 2009. The median cost per visit of all THC/CHC and sample THC/CHC in Qianjiang are both with an increasing trend during 2007-9, which are statistically significant (Ⅹ² = 851.7614, P<0.0001 and Ⅹ² =1078.8001, P<0.0001). Both average and median cost of Qianjiang kept within the prescription caps during 2007-9, when costs of SEC far exceed. There are no significant changes of referral and prescription data in Qianjiang during 2007-9 (Ⅹ² test, P>0.05), except that of the proportion of essential medicines used in THC/CHC (Ⅹ² test, P<0.05). The qualitative interviews and group discussions show, doctors are more likely to adopt less costly alternative treatments, and are more willing to provide outreach services for preventive care. There are no significant differences between the average hospitalization rates of sample THC/CHC of Qianjiang and SEC in 2006 and 2009 (Ⅹ²test, P>0.05). The monthly income of the health workers and the outpatient revenue of facilities in Qianjiang keep growing during 2007-9. There are no overruns in all the sample facilities in Qianjiang.
Conclusions: The cost containment objective is achieved. Provider behaviours are partially improved but with limited affect on prescriptions. Careful consideration of supporting policies is critical to address the unexpected side effects of the reform. The reform does not bring financial loss to both the facilities and the individuals, but creates incentive for less costly alternative treatments and more attention to prevention.
Funding Source: WHO