Seeking care in the context of social health insurance in Kenya and Ghana

Abstract

Background Social Health Insurance (SHI) is widely used by countries attempting to move toward Universal Health Coverage (UHC). While evidence suggests that SHI is a promising strategy for achieving UHC, low-income countries often struggle to implement and sustain SHI systems. It is therefore important to understand how SHI enrollees use health insurance and how it affects their health-seeking behavior. This paper examines how SHI affects patient decision-making regarding when and where to seek care in Kenya and Ghana, two countries with established SHI systems in sub-Saharan Africa. Methods This paper draws from two datasets collected under the African Health Markets for Equity (AHME) program. One dataset, collected in 2013 and 2017 as part of the AHME qualitative evaluation, consists of 106 semi-structured clinic exit interviews conducted with patients in Ghana and Kenya. This data was analyzed using an inductive, thematic approach. The second dataset was collected internally by the AHME partner organizations. It derives from a cross-sectional survey of social franchise clients at three social franchise networks supported by AHME. Data collection took place from February – May 2018 and in December 2018. Results Many clients appreciated that insurance coverage made healthcare more affordable, reported seeking care more frequently when covered with SHI. Clients also noted that the coverage gave them access to a wider variety of providers, but rarely sought out SHI-accredited providers specifically. However, clients sometimes were charged for services that should have been covered by insurance. Due to a lack of understanding of SHI benefits, clients rarely knew they had been charged inappropriately. Conclusions Clients and providers would benefit from education on what is included in the SHI package. Providers should be monitored and held accountable for charging clients inappropriately; in Ghana this should be accompanied by reforms to make government financing for SHI sustainable. Since clients valued provider proximity and both Kenya and Ghana have a dearth of providers in rural areas, both countries should incentivize providers to work in these areas and prioritize accrediting rural facilities into SHI schemes to increase accessibility and reach.

Strengthening the Health System as a Strategy to Achieving a Universal Health Coverage in Underprivileged Communities in Africa: A Scoping Review

“…Household members [ 25 , 28 , 31 , 33 , 48 ]; people with access to a private subsidized health insurance program [ 34 ]; community members [ 46 ]; HIV+ pregnant women [ 36 ]; pregnant women [ 37 ]; poor women who had given birth [ 38 ]; community residents [ 39 ]; males and females aged 23 to 59 years [ 45 ]; patients exiting healthcare facilities [ 40 ].…”

“…This scoping review reports the different strategies (derived from the included studies) to strengthen the health system for attaining UHC in Africa. These strategies include those that fall under capacity building in health facilities, as well as developing and improving health infrastructure (e.g., training, supervising, and retaining healthcare workers, developing healthcare facilities) [ 19 , 24 , 27 , 30 , 35 , 42 , 49 ]; health information systems (health technology assessment) [ 29 , 41 ]; access to essential medicines (access to medicines and introducing African traditional medicine and traditional health practitioners into health systems) [ 23 , 26 ]; and health financing [ 17 , 18 , 20 , 21 , 22 , 25 , 28 , 31 , 32 , 33 , 34 , 36 , 37 , 38 , 39 , 40 , 43 , 44 , 45 , 46 , 47 , 48 , 50 ].…”

“…Of the 34 studies included, 23 focused on assessing the role of health financing, as a health system strengthening strategy in Botswana, Egypt, Ethiopia, Democratic Republic of Congo, Gabon, Ghana, Kenya, Malawi Nigeria Rwanda, South Africa, Tanzania, Zambia, and Zimbabwe [ 17 , 18 , 20 , 21 , 22 , 25 , 28 , 31 , 32 , 33 , 34 , 36 , 37 , 38 , 39 , 40 , 43 , 44 , 45 , 46 , 47 , 48 , 50 ]. These studies investigated and reported various ways in which finances could be enhanced, i.e., through household out-of-pocket payments, health insurance, and attracting donors and taxes.…”

Successes and obstacles in implementing social health insurance in developing and middle-income countries: A scoping review of 5-year recent literatures

“…However, many enrollees had to make co-payments because they were unaware of the accreditation status of the provider's full benefits of SHI. The coverage should expand access to primary healthcare, both to public and private providers, as there seemed to be more confidence in the private sector ( 39 ). Another study in Ghana demonstrated that the NHIS resulted in increased health-seeking behavior from informal to formal providers.…”

Gender Differences in Insurance, Surgical Admissions and Outcomes at a Kenyan Referral Hospital

“…For women, one common reason was due to lack of access to the enrollment card or card number, as the husband was the principal cardholder. Furthermore, coverage of healthcare centers by NHIF is not uniform and women limited in travel may not have convenient access to providers who ac-cept NHIF, 33 which may highlight why women in our cohort were more likely to present in a delayed fashion and directly to MTRH. The act of enrolling in NHIF is also a challenge for women.…”