Evasion of “mandatory” social health insurance for the formal sector: evidence from Lao PDR

Alkenbrack, Sarah; Hanson, Kara; Lindelöw, Magnus

doi:10.1186/s12913-015-1132-5

Cited by 16 publications

(13 citation statements)

References 14 publications

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“…Much of the inequities among government employees noted here would be averted should those who are uninsured join the scheme. Achieving that, however, would involve addressing the reasons for not enrolling, which centre around administrative complexities, lack of information about the scheme, and varying perceptions around the need for health insurance, as noted in other similar studies [ 22 ].…”

Section: Discussionmentioning

confidence: 99%

Social health insurance contributes to universal coverage in South Africa, but generates inequities: survey among members of a government employee insurance scheme

Goudge

Alaba

Govender

et al. 2018

Int J Equity Health

106

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BackgroundMany low- and middle-income countries are reforming their health financing mechanisms as part of broader strategies to achieve universal health coverage (UHC). Voluntary social health insurance, despite evidence of resulting inequities, is attractive to policy makers as it generates additional funds for health, and provides access to a greater range of benefits for the formally employed. The South African government introduced a voluntary health insurance scheme (GEMS) for government employees in 2005 with the aim of improving access to care and extending health coverage. In this paper we ask whether the new scheme has assisted in efforts to move towards UHC.MethodsUsing a cross-sectional survey across four of South Africa’s nine provinces, we interviewed 1329 government employees, from the education and health sectors. Data were collected on socio-demographics, insurance coverage, health status and utilisation of health care. Multivariate logistic regression was used to determine if service utilisation was associated with insurance status.ResultsA quarter of respondents remained uninsured, even higher among 20–29 year olds (46%) and lower-skilled employees (58%). In multivariate analysis, the odds of an outpatient visit and hospital admission for the uninsured was 0.3 fold that of the insured. Cross-subsidisation within the scheme has provided lower-paid civil servants with improved access to outpatient care at private facilities and chronic medication, where their outpatient (0.54 visits/month) and inpatient utilisation (10.1%/year) approximates that of the overall population (29.4/month and 12.2% respectively). The scheme, however, generated inequities in utilisation among its members due to its differential benefit packages, with, for example, those with the most benefits having 1.0 outpatient visits/month compared to 0.6/month with lowest benefits.ConclusionsBy introducing the scheme, the government chose to prioritise access to private sector care for government employees, over improving the availability and quality of public sector services available to all. Government has recently regained its focus on achieving UHC through the public system, but is unlikely to discontinue GEMS, which is now firmly established. The inequities generated by the scheme have thus been institutionalised within the country’s financing system, and warrant attention. Raising scheme uptake and reducing differentials between benefit packages will ameliorate inequities within civil servants, but not across the country as a whole.

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Section: Discussionmentioning

confidence: 99%

Social health insurance contributes to universal coverage in South Africa, but generates inequities: survey among members of a government employee insurance scheme

Goudge

Alaba

Govender

et al. 2018

Int J Equity Health

106

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“…Within this context, many countries without universal access are undertaking health financing reform to ensure households are protected from high OOP and are able to access the health services they need in a timely manner [2,8,[17][18][19][20][21]. As in other countries in the region such as Thailand and Vietnam [22,23], Lao PDR, in its efforts to achieve UHC, is shifting to a single-coverage NHI program as opposed to having multiple schemes for different sub-populations [8].…”

Section: Discussionmentioning

confidence: 99%

“…The study did not examine quality of care, which nevertheless remains a major challenge for Lao PDR despite steps towards improvement [ 21 , 33 – 35 ]. Quality of care however is of vital importance to the performance of health insurance schemes and enrolment.…”

Section: Discussionmentioning

confidence: 99%

“…Quality of care however is of vital importance to the performance of health insurance schemes and enrolment. For example, in Lao PDR, one study found the third most important reason for civil servants not enrolling in the earlier civil servants’ scheme was poor quality of government hospitals [ 21 ]. A study of an earlier voluntary community-based health insurance targeting for the informal sector and self-employed workers was also reported to be low due to poor quality of services [ 29 ].…”

Section: Discussionmentioning

confidence: 99%

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Factors associated with patient payments exceeding National Health Insurance fees and out-of-pocket payments in Lao PDR

Chaleunvong

Phoummalaysith²,

Phonvixay³

et al. 2020

Global Health Action

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Background: Attaining universal health coverage is a target in the Sustainable Development Goals. In Lao PDR, to achieve universal health coverage, the government is implementing a national insurance scheme, initially targeting the informal sector. Objective: The purpose was to assess: i) the percentage of NHI patients who paid above the scheduled amount, based on individual billing payment; and ii) the factors related to overpayment. Methods: Descriptive cross-sectional study based on a structured questionnaire administered at health facilities in face-to-face interviews with 1,850 patients in six provinces.e Results: All 1,850 participants worked in the informal sector. Of these, 78.8% of respondents (77.9% of in-patients; 79.5% of outpatients) made co-payments or were exempted from. Factors associated with in-patients paying above the scheduled fee were living in the province and district (OR = 2.8; 95%CI 1.2 to 6.3); not having documents with them (OR = 21.2; 95%CI 5.6 to 80.3); or not having documents (OR: 7.8; 95% CI 2.1 to 28.6). Significant factors associated with additional costs for outpatients were level of facility used at the provincial hospital (OR:1.4; 95% CI 1.1 to 1.9); older age (OR = 2.2; 95%CI 1.5 to 3.1); living in the province and district (OR = 2.3; 95%CI 1.5 to 3.7); living more than 5 km from the facility (OR = 1.4; 95%CI 1.1 to 1.9); buying medicine or supplies outside of the health facility (OR: 5.6; 95% CI 3.1 to 10.2); not bringing documents (OR:9.1; 95% CI 6.1 to 13.5), not having the right documents (OR: 8.9; 95% CI 5.4 to 14.8). Conclusions: A number of patients paid above scheduled fee rates, which may deter people from utilising services when needing them. There is a need for increased understanding of the benefits of the national insurance scheme among patients and healthcare staff.

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“…Cluster analysis I was based on a combination of all variables related to the last health care utilization in the past 12 months and payments reported by the respondents. These variables were then divided into three groups: [1] variables indicating the type of services used during the last episode of illness, and reasons for the choice of these services, [2] variables indicating the payment type, and [10] variables indicating the burden of OOPPs, such as size of OOPPs and coping strategies. Thus, cluster analysis II was based on the type of services and reasons of using these services; cluster analysis III was based on the type of payment for health care services used, e.g.…”

Section: Methodsmentioning

confidence: 99%

Patterns of health care use and out-of-pocket payments among general population and social security beneficiaries in Myanmar

Myint

Pavlova

Groot

2019

BMC Health Serv Res

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Background As a consequence of the low government expenditure and limited access to health insurance offered by the Social Security Scheme (SSS), out-of-pocket payments (OOPPs) have become the main source of payment for health care in Myanmar. This study aims to provide evidence on the patterns of health care use and OOPPs by the general population and SSS beneficiaries in Myanmar. Method Face-to-face interviews were conducted among two samples drawn independently of each other. The first sample, the general population sample of persons not insured by SSS, was drawn from the general population in the Yangon Region. The second sample, the SSS sample, was drawn from those possessing SSS insurance. The data were analyzed per sample. Mann-Whitney U tests were applied to compare ordinal variables and independent sample t-tests were applied to compare continuous variables between the two samples. Two-step cluster analysis was applied to identify clusters of respondents with similar patterns of health care use and OOPPs. After the clustering procedure, we used regression analysis to examine the association between socio-demographic characteristics and cluster membership (patterns of health care use and OOPPs) for the two samples separately. Results Only 23% of those who belonged to the SSS sample and sought health care during the past 12 months, report receiving health care from a SSS clinic during the last episode of illness. Close distance is the main reason for choosing a specific health facility in both samples. OOPPs for health care and pharmaceuticals, used during the last episode of illness are significantly higher in the general population sample. The regression analysis shows that the pattern of health care use is significantly associated with household income. In addition, respondents in the general population sample with a higher income pay higher amounts for their last health care used and were significantly more likely to have to borrow money or sell assets as a coping strategy to cover the payments. Conclusion Significantly higher OOPPs in the general population sample highlight the need of financial protection among this group. Myanmar needs to extend social protection for both coverage breadths and coverage depth. Electronic supplementary material The online version of this article (10.1186/s12913-019-4071-8) contains supplementary material, which is available to authorized users.

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Evasion of “mandatory” social health insurance for the formal sector: evidence from Lao PDR

Cited by 16 publications

References 14 publications

Social health insurance contributes to universal coverage in South Africa, but generates inequities: survey among members of a government employee insurance scheme

Social health insurance contributes to universal coverage in South Africa, but generates inequities: survey among members of a government employee insurance scheme

Factors associated with patient payments exceeding National Health Insurance fees and out-of-pocket payments in Lao PDR

Patterns of health care use and out-of-pocket payments among general population and social security beneficiaries in Myanmar

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