perspectives on financing population-based health care towards Universal Health Coverage among employed individuals in Ghanzi district, Botswana: A qualitative study

BMC Health Services Research, Volume 16, No. 1, Year 2016

Interpretation

Background: Globally, about 150 million people experience catastrophic healthcare expenditure services annually. Among low and middle income countries, out-of-pocket expenditure pushes about 100 million people into poverty annually. In Botswana, 83 % of the general population and 58 % of employed individuals do not have medical aid coverage. Moreover, inequity allocation of financial resources between health services suggests marginalization of population-based health care services (i.e. diseases prevention and health promotion). The purpose of the study is to explore perspectives on employed individuals regarding financing population based health care interventions towards Universal Health Coverage (UHC) in order to make recommendations to the Ministry of Health on health financing options to cover population-based health services. Methods: A qualitative design grounded in interpretivist epistemology through social constructivism lens was critical for exploring perspectives of employed individuals. Through purposive and snowballing sampling techniques, a total of 15 respondents including 8 males and 7 females were recruited and interviewed using a semi-structured format. Their age ranged from 23 to 59 years with a median of 36 years. Data was analyzed using Thematic Content Analysis technique. Results: Use of social constructivism lens enabled to classify emerging themes into population coverage, health services coverage and financial protection issues. Despite broad understanding of health coverage schemes among participants, knowledge appears insignificant in increasing enrolment. Participants indicated limited understanding of UHC concepts, however showed willingness to embrace UHC upon brief description. Main thematic issues raised include: exclusion of population-based health services from coverage scheme; disparity in financial protection and health services coverage among enrollees; inability to sustain contracted employees; and systematic exclusion of unemployed individuals and informal sector employees. Conclusion: Increasing enrolment in health coverage schemes requires targeted campaign for information dissemination through use of myriads mass media including: social networks, TV, Radio and others. Moreover, re-designing health insurance schemes is critical in order to include population-based interventions; expand uptake of unemployed and informal sector employees; flexibility in monthly premiums payment plan and use of technology to increase access to payment points. Further study need to evaluate the content of health financing policy in Botswana measured against the World Health Organization Universal Health Coverage conceptual requirements for Low and Middle Income Countries. Botswana is a land-locked country located in the Southern Africa region. It has an estimated population of 2,021,000 and GDP is US$ 14.79 per capita [41]. Life expectancy is estimated at 54.4 years; infant and under-five mortality rates are 54/1000 and 76/1000 live birth respectively; and maternal mortality ratio is 193/100,000 live births [42]. Botswana spends 17.7 % of annual budget for health services [43] which is above Abuja target of 15 % for African countries [44]. Health care expenditure in Botswana are highly subsidized and financed through government taxes (68 %); health insurance schemes (21 %); donors (12 %) and out-of-pocket expenditure (4.2 %) [45]. Nevertheless low out-of-pocket spending for health in Botswana at 4.2 % [45] suggests high risk of Catastrophic Health Expenditure amongst poor population group [46], thus illustrates gaps in the country’s health financing policy towards achieving UHC goals stipulated in the WHO three-dimensional cube. Alarming prevalence rates of HIV/AIDS at 21.9 % among adults aged 15 to 49 years [47]; high TB prevalence rates estimated at ≥ 300 cases per 100,000 populations [48]; increasing risk and prevalence of non-communicable diseases [49]; and advancing medical technology [50] collectively exerts enormous pressure on fiscal sustainability for UHC agenda in Botswana. Although about 84 % of the entire population in Botswana access health care within 5 km radius [51] thus suggests existence of the infrastructure for advancing UHC conceptual goals, only 17 % of the general population and 42 % of employed individuals have health insurance coverage [52]. Limited health insurance coverage among general population and employed individuals raises concerns on the design of health insurance scheme particularly with regards to efforts towards achieving UHC conceptual framework goals [13]. Most intriguing is the evident inequity of financial resources allocation between curative services and cost-effective public health interventions. For instance, during 2007/08 and 2009/10 fiscal years, hospital curative services were allocated 53 % of Total Health Expenditure (THE) whereas population-based services received only 9 % of THE [45]. Inequity in financial allocation deters efforts towards expanding health services coverage particularly expanding cost-containing strategies population-based health services geared towards disease prevention and health promotion interventions [53]. Inequity in financial allocation between curative and population-based health services further derails initiatives to tackle Social Determinants of Health [10, 11]. Globally to the best of researcher’s knowledge, there is no published study that explored population perspectives regarding financing population-based interventions through health coverage schemes in order to advance UHC goals. Despite most studies utilizing WHO Universal Health Coverage conceptual framework [13] to identify measurable indicators for UHC concepts [12], to the best of researcher’s knowledge there is no published study of similar nature conducted in Botswana. Most published studies on health coverage schemes investigated understanding and perspectives on financing curative intervention through health coverage schemes [30–36]. Nevertheless there is no study of similar nature which has been conducted in Botswana despite available indicators showing low enrollment in health coverage schemes [52]. Further to that, among Sub-Saharan Africa countries Botswana presents an exceptional commitment and surpassed Abuja declaration target of 15 % on healthcare spending for Africans countries by spending 17.7 % of Total Health Expenditure [43, 44]. However, only Ghana and Rwanda have developed financing system that advances the three-dimensional UHC conceptual goals by allocating 12.5 [15] and 16 % [16] respectively. Therefore literature is limited in explaining why and how Botswana does not have a health financing system that advances UHC goals as defined by the WHO three-dimensional conceptual framework. Therefore this study is set to fill the knowledge gap on health financing literature in Botswana by exploring perspectives of employed individuals on financing population-based interventions—i.e. health promotion and diseases prevention interventions—as the country gears-up towards achieving Universal Health Coverage goals.

AI Digest

Study Justification:

– Globally, millions of people experience catastrophic healthcare expenditure and are pushed into poverty due to out-of-pocket expenses.
– In Botswana, a large percentage of the general population and employed individuals do not have medical aid coverage.
– There is inequitable allocation of financial resources between curative services and population-based health services.
– The study aims to explore perspectives of employed individuals on financing population-based health care interventions towards Universal Health Coverage (UHC) in Botswana.

Highlights:

– The study used a qualitative design to explore the perspectives of employed individuals.
– Themes emerged related to population coverage, health services coverage, and financial protection issues.
– Participants had limited understanding of UHC concepts but showed willingness to embrace UHC.
– Main issues raised include exclusion of population-based health services from coverage, disparity in financial protection and health services coverage, inability to sustain contracted employees, and systematic exclusion of unemployed individuals and informal sector employees.

Recommendations:

– Targeted campaigns for information dissemination through various mass media channels.
– Re-designing health insurance schemes to include population-based interventions.
– Expanding health coverage for unemployed and informal sector employees.
– Flexibility in monthly premiums payment plan and use of technology to increase access to payment points.
– Further study to evaluate the content of health financing policy in Botswana against WHO UHC conceptual requirements.

Key Role Players:

– Ministry of Health
– Health insurance providers
– Media organizations
– Community leaders and influencers
– Researchers and academics

Cost Items for Planning Recommendations:

– Advertising and marketing costs for targeted campaigns
– Costs for re-designing health insurance schemes
– Costs for expanding health coverage for unemployed and informal sector employees
– Costs for implementing flexible payment plans and technology solutions

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a qualitative study that explores perspectives of employed individuals regarding financing population-based health care interventions towards Universal Health Coverage (UHC) in Botswana. The study used a qualitative design grounded in interpretivist epistemology through social constructivism lens. The data was analyzed using Thematic Content Analysis technique. The abstract provides a clear description of the study design, methods, and results. However, the evidence is limited to the perspectives of a small sample size of 15 respondents and may not be representative of the entire population. To improve the strength of the evidence, future studies could consider increasing the sample size and using a mixed-methods approach to provide a more comprehensive understanding of the topic.

Abstract

Botswana is a land-locked country located in the Southern Africa region. It has an estimated population of 2,021,000 and GDP is US$ 14.79 per capita [41]. Life expectancy is estimated at 54.4 years; infant and under-five mortality rates are 54/1000 and 76/1000 live birth respectively; and maternal mortality ratio is 193/100,000 live births [42]. Botswana spends 17.7 % of annual budget for health services [43] which is above Abuja target of 15 % for African countries [44]. Health care expenditure in Botswana are highly subsidized and financed through government taxes (68 %); health insurance schemes (21 %); donors (12 %) and out-of-pocket expenditure (4.2 %) [45]. Nevertheless low out-of-pocket spending for health in Botswana at 4.2 % [45] suggests high risk of Catastrophic Health Expenditure amongst poor population group [46], thus illustrates gaps in the country’s health financing policy towards achieving UHC goals stipulated in the WHO three-dimensional cube. Alarming prevalence rates of HIV/AIDS at 21.9 % among adults aged 15 to 49 years [47]; high TB prevalence rates estimated at ≥ 300 cases per 100,000 populations [48]; increasing risk and prevalence of non-communicable diseases [49]; and advancing medical technology [50] collectively exerts enormous pressure on fiscal sustainability for UHC agenda in Botswana. Although about 84 % of the entire population in Botswana access health care within 5 km radius [51] thus suggests existence of the infrastructure for advancing UHC conceptual goals, only 17 % of the general population and 42 % of employed individuals have health insurance coverage [52]. Limited health insurance coverage among general population and employed individuals raises concerns on the design of health insurance scheme particularly with regards to efforts towards achieving UHC conceptual framework goals [13]. Most intriguing is the evident inequity of financial resources allocation between curative services and cost-effective public health interventions. For instance, during 2007/08 and 2009/10 fiscal years, hospital curative services were allocated 53 % of Total Health Expenditure (THE) whereas population-based services received only 9 % of THE [45]. Inequity in financial allocation deters efforts towards expanding health services coverage particularly expanding cost-containing strategies population-based health services geared towards disease prevention and health promotion interventions [53]. Inequity in financial allocation between curative and population-based health services further derails initiatives to tackle Social Determinants of Health [10, 11]. Globally to the best of researcher’s knowledge, there is no published study that explored population perspectives regarding financing population-based interventions through health coverage schemes in order to advance UHC goals. Despite most studies utilizing WHO Universal Health Coverage conceptual framework [13] to identify measurable indicators for UHC concepts [12], to the best of researcher’s knowledge there is no published study of similar nature conducted in Botswana. Most published studies on health coverage schemes investigated understanding and perspectives on financing curative intervention through health coverage schemes [30–36]. Nevertheless there is no study of similar nature which has been conducted in Botswana despite available indicators showing low enrollment in health coverage schemes [52]. Further to that, among Sub-Saharan Africa countries Botswana presents an exceptional commitment and surpassed Abuja declaration target of 15 % on healthcare spending for Africans countries by spending 17.7 % of Total Health Expenditure [43, 44]. However, only Ghana and Rwanda have developed financing system that advances the three-dimensional UHC conceptual goals by allocating 12.5 [15] and 16 % [16] respectively. Therefore literature is limited in explaining why and how Botswana does not have a health financing system that advances UHC goals as defined by the WHO three-dimensional conceptual framework. Therefore this study is set to fill the knowledge gap on health financing literature in Botswana by exploring perspectives of employed individuals on financing population-based interventions—i.e. health promotion and diseases prevention interventions—as the country gears-up towards achieving Universal Health Coverage goals.

Materials

https://efashare.b-cdn.net/materials/a2de6983d8881d6bc1c85325d071142a316b5cd779c9a6758af68dafb13b4b34/12913_2016_1657_MOESM1_ESM.doc

Innovations

Based on the provided information, here are some potential innovations that could be recommended to improve access to maternal health in Botswana:

1. Mobile Health (mHealth) Solutions: Develop and implement mobile health applications that provide pregnant women with access to information, resources, and support for prenatal care, childbirth, and postnatal care. These applications can provide reminders for appointments, educational materials, and communication channels with healthcare providers.

2. Telemedicine Services: Establish telemedicine services that allow pregnant women in remote areas to consult with healthcare professionals through video conferencing or phone calls. This would enable them to receive medical advice, guidance, and monitoring without the need for travel.

3. Community Health Workers: Train and deploy community health workers who can provide basic prenatal and postnatal care services to pregnant women in underserved areas. These workers can conduct regular check-ups, provide health education, and refer women to healthcare facilities when necessary.

4. Maternal Health Vouchers: Introduce a voucher system that provides pregnant women with financial assistance to access maternal health services. These vouchers can cover the cost of antenatal care, delivery, and postnatal care, ensuring that women can afford and access the necessary healthcare services.

5. Public-Private Partnerships: Foster collaborations between the government, private healthcare providers, and non-profit organizations to improve access to maternal health services. This can involve subsidizing private healthcare services for pregnant women, establishing referral systems, and leveraging the resources and expertise of different stakeholders.

6. Health Education Campaigns: Launch comprehensive health education campaigns that target pregnant women and their families. These campaigns can raise awareness about the importance of prenatal care, childbirth preparedness, and postnatal care, as well as promote healthy behaviors and practices.

7. Maternal Health Clinics: Establish dedicated maternal health clinics that provide comprehensive and specialized care for pregnant women. These clinics can offer a range of services, including antenatal care, ultrasound scans, prenatal classes, and postnatal support, all in one location.

8. Strengthening Health Insurance Coverage: Work towards expanding health insurance coverage to include maternal health services. This can involve advocating for policy changes, increasing funding for health insurance programs, and ensuring that pregnant women are eligible for coverage.

It is important to note that the implementation of these innovations would require careful planning, coordination, and evaluation to ensure their effectiveness and sustainability. Additionally, addressing the underlying issues of financial resources allocation and inequity in healthcare financing would be crucial for achieving universal health coverage and improving access to maternal health services in Botswana.

AI Innovations Description

Based on the description provided, the study aims to explore perspectives on financing population-based health care interventions towards Universal Health Coverage (UHC) in Botswana, specifically focusing on employed individuals. The study identifies several issues related to access to maternal health and makes recommendations to the Ministry of Health on health financing options to cover population-based health services.

The main recommendation to improve access to maternal health is to increase enrollment in health coverage schemes. This can be achieved through targeted campaigns for information dissemination using various mass media platforms such as social networks, TV, radio, and others. The study also suggests re-designing health insurance schemes to include population-based interventions, expanding coverage to unemployed and informal sector employees, providing flexibility in monthly premium payment plans, and using technology to increase access to payment points.

Additionally, the study highlights the need for further evaluation of the content of health financing policy in Botswana, measured against the World Health Organization’s Universal Health Coverage conceptual requirements for Low and Middle Income Countries. This evaluation will help identify gaps and areas for improvement in the country’s health financing system towards achieving UHC goals.

AI Innovations Methodology

Based on the provided information, here are some potential recommendations to improve access to maternal health in Botswana:

1. Strengthen Health Insurance Coverage: Expand health insurance coverage to include maternal health services, ensuring that pregnant women have access to prenatal care, skilled birth attendants, and postnatal care without facing financial barriers.

2. Increase Awareness and Education: Launch targeted campaigns to raise awareness about the importance of maternal health and the available services. This can be done through various channels such as social networks, TV, radio, and community outreach programs.

3. Improve Infrastructure and Facilities: Invest in upgrading healthcare facilities, particularly in rural areas, to ensure that they are equipped to provide quality maternal health services. This includes improving access to emergency obstetric care and ensuring the availability of essential medical supplies and equipment.

4. Strengthen Health Workforce: Increase the number of skilled healthcare professionals, such as midwives and obstetricians, and ensure their deployment in areas with limited access to maternal health services. This can be achieved through targeted recruitment and training programs.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Data Collection: Gather baseline data on the current state of maternal health access in Botswana, including indicators such as maternal mortality ratio, antenatal care coverage, and skilled birth attendance rates.

2. Modeling: Develop a simulation model that incorporates the recommended interventions and their potential impact on improving access to maternal health. This could involve using mathematical equations and statistical techniques to estimate the expected changes in key indicators.

3. Sensitivity Analysis: Conduct sensitivity analysis to assess the robustness of the model and explore the potential variations in outcomes under different scenarios. This could involve varying parameters such as the coverage of health insurance, the effectiveness of awareness campaigns, and the availability of healthcare facilities.

4. Impact Assessment: Evaluate the simulated impact of the recommendations on improving access to maternal health by comparing the projected outcomes with the baseline data. This could include assessing changes in maternal mortality rates, antenatal care coverage, and other relevant indicators.

5. Policy Recommendations: Based on the simulation results, provide evidence-based policy recommendations to the Ministry of Health in Botswana on the most effective interventions to improve access to maternal health. This could include prioritizing certain interventions, allocating resources, and implementing targeted strategies.

It is important to note that the methodology described above is a general framework and may need to be adapted based on the specific context and available data in Botswana.

Author

Dima Health

Statistics:

Citations: 5

Identifiers:

DOI: 10.1186/s12913-016-1657-2

Research Areas:

Community Interventions, Disparities, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Noncommunicable Diseases, Quality of Care, Social Determinants, Technology and Innovations

Study Countries:

Botswana, Ghana, Multi-Countries, Rwanda

Study Design:

Cross Sectional Study, randomised-control-trial

Study Approach:

Qualitative

Participants Gender:

Female