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Health insurance and health system (un) responsiveness: a qualitative study with elderly in rural Tanzania
Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa. Department of Health Systems Management, School of Public Administration and Management, Mzumbe University, Morogoro, Tanzania.
Umeå universitet, Medicinska fakulteten, Institutionen för epidemiologi och global hälsa.ORCID-id: 0000-0001-7087-1467
Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
Department of Development Studies, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
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2021 (Engelska)Ingår i: BMC Health Services Research, E-ISSN 1472-6963, Vol. 21, nr 1, artikel-id 1140Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

BACKGROUND: Health insurance (HI) has increasingly been accepted as a mechanism to facilitate access to healthcare in low and middle-income countries. However, health insurance members, especially those in Sub-Saharan Africa, have reported a low responsiveness in health systems. This study aimed to explore the experiences and perceptions of healthcare services from the perspective of insured and uninsured elderly in rural Tanzania.

METHOD: An explanatory qualitative study was conducted in the rural districts of Igunga and Nzega, located in western-central Tanzania. Eight focus group discussions were carried out with 78 insured and uninsured elderly men and women who were purposely selected because they were 60 years of age or older and had utilised healthcare services in the past 12 months prior to the study. The interview questions were inspired by the domains of health systems' responsiveness. Qualitative content analysis was used to analyse the data.

RESULTS: Elderly participants appreciated that HI had facilitated the access to healthcare and protected them from certain costs. But they also complained that HI had failed to provide equitable access due to limited service benefits and restricted use of services within schemes. Although elderly perspectives varied widely across the domains of responsiveness, insured individuals generally expressed dissatisfaction with their healthcare.

CONCLUSIONS: The national health insurance policy should be revisited in order to improve its implementation and expand the scope of service coverage. Strategic decisions are required to improve the healthcare infrastructure, increase the number of healthcare workers, ensure the availability of medicines and testing facilities at healthcare centers, and reduce long administrative procedures related to HI. A continuous training plan for healthcare workers focused on patients' communication skills and care rights is highly recommended.

Ort, förlag, år, upplaga, sidor
BioMed Central, 2021. Vol. 21, nr 1, artikel-id 1140
Nyckelord [en]
Tanzania, elderly, health insurance, healthcare use, responsiveness
Nationell ämneskategori
Folkhälsovetenskap, global hälsa och socialmedicin
Identifikatorer
URN: urn:nbn:se:umu:diva-188848DOI: 10.1186/s12913-021-07144-2ISI: 000710127200002PubMedID: 34686182Scopus ID: 2-s2.0-85117712520OAI: oai:DiVA.org:umu-188848DiVA, id: diva2:1605605
Tillgänglig från: 2021-10-25 Skapad: 2021-10-25 Senast uppdaterad: 2025-02-20Bibliografiskt granskad
Ingår i avhandling
1. Does health insurance contribute to improving responsiveness of the health system?: the case of elderly in rural Tanzania
Öppna denna publikation i ny flik eller fönster >>Does health insurance contribute to improving responsiveness of the health system?: the case of elderly in rural Tanzania
2022 (Engelska)Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)
Alternativ titel[sv]
Bidrar sjukförsäkringen till att förbättra hälso- och sjukvårdssystemets lyhördhet? : fallet med äldre på landsbygden i Tanzania
Abstract [en]

Background: Financing healthcare in Tanzania has for years depended on out-of-pocket payments. This mechanism has been criticized as being inefficient, contributing to inequity and high cost as well as denying access to healthcare to those most in need, including the elderly in rural areas. Health insurance (HI) was recently introduced as an instrument to enable equitable access to healthcare and thus to improve the responsiveness of the health system. Even though health insurance is expected to bring benefits to those who are insured, there is a lack of specific studies in the country looking at the role of HI in facilitating the health system responsiveness among vulnerable populations of remote areas.

Aim: The aim of this thesis is to understand if and how health insurance contributes to improving the responsiveness of the healthcare system among the elderly in rural Tanzania. 

Methods: Four interrelated sub-studies (2 quantitative and 2 qualitative) were conducted in Igunga and Nzega districts of Tabora region between July 2017 and December 2018. The first two sub-studies are based on a household survey using an adapted version of the World Health Organization’s Study on Global Ageing and Adult Health questionnaire. Elderly people aged 60 years and above who had used both outpatient and inpatient healthcare three and twelve months prior to the study, respectively, were interviewed. Whereas in sub-study 1 the focus was to investigate the role of health insurance status on facilitating access to healthcare, sub-study 2 assessed the relationship between health insurance and the health system responsiveness domains. In sub-study 3, interviews with healthcare providers were carried out to capture their perspective regarding the functioning of the health insurance. In the final sub-study 4, focus group discussions with elderly were conducted in order to explore their experience of healthcare, depending on their health insurance status. Crude and adjusted logistic and quantile regression models were applied to analyse the association between health insurance and access to healthcare (sub-study 1) and responsiveness (sub-study 2), respectively. For both sub-studies 3 and 4, qualitative content analysis was used to analyse the data.

Results: Sub-studies 1 and 2 involved a total of 1899 insured and uninsured elderly, while sub-studies 3 and 4 included 8 health providers and 78 elderlies respectively. Sub-study 1 showed that about 45% of the elderly were insured and HI ownership improved access and utilization of healthcare, both outpatient and inpatient services. In sub-study two, however, health insurance was associated with a lower responsiveness of the healthcare system. In general, all six domains: cleanliness, access, confidentiality, autonomy, communication, and prompt attention were rated high, but three were of concern: waiting time; cleanliness; and communication. Sub-study 3 uncovered several challenges coexisting alongside the provision of insurance benefits and thus contributing to a lower responsiveness. These included shortage of human resources and medical supplies, as well as operational issues related to delays in funding reimbursement. In sub-study 4, the elderly revealed that HI did not meet their expectations, it failed to promote equitable access, provided limited-service benefits and restricted use of services within residential areas. 

Conclusion: While HI seems to increase the access to and use of healthcare services by the elderly in rural Tanzania, a lower responsiveness by the healthcare system among the insured elderly was reported. Long waiting times, limited-service benefits, restricted use of services within schemes, lack of health workforce in both numbers and skills as well as shortage of medical supplies were important explanations for the lower responsiveness. The results of this thesis, while supporting the national aim of expanding HI in rural areas, also exposed several weaknesses that require immediate attention. There is a need to, first, review the insurance policy to improve its implementation, expand the scope of services coverage, and where possible, to introduce cross-subsidization between the publicly owned schemes; additionally, improvements in the healthcare infrastructure, increasing the number of qualified health workforce and the availability of essential medicines and laboratory services, especially at the primary healthcare facilities, should be prioritized and further investments allocated.

Ort, förlag, år, upplaga, sidor
Umeå: Umeå University, 2022. s. 83
Serie
Umeå University medical dissertations, ISSN 0346-6612 ; 2190
Nyckelord
SAGE, health insurance, healthcare use, older people, community health fund, rural, responsiveness, Tanzania
Nationell ämneskategori
Folkhälsovetenskap, global hälsa och socialmedicin
Identifikatorer
urn:nbn:se:umu:diva-194699 (URN)978-91-7855-825-4 (ISBN)978-91-7855-826-1 (ISBN)
Disputation
2022-06-10, Sal Q0 Bergasalen / Zoom, Norrlands universitetssjukhus, Umeå, 13:00 (Engelska)
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Handledare
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Zoom Meeting ID: 681 2716 1861, Passcode: 650584

Tillgänglig från: 2022-05-20 Skapad: 2022-05-13 Senast uppdaterad: 2025-02-20Bibliografiskt granskad

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