Background
Methods
Study setting
Conceptual framework for developing attributes and attribute-levels
Study design
Initial literature review
Functions[46] | ||
---|---|---|
Policy attribute
|
Plausible levels definition (citations only provided for previous applications in DCEs)
| |
Revenue mobilization
|
Who pays the premium
| |
Unit of charging premium
| ||
Structure of premium
| ||
• Differential based on: income, employment, age, urban–rural
| ||
Premium price (level)
| • Based on real cost of healthcare
| |
Forms of premium payment
| ||
• Material (farm produce) or both
| ||
Premium payment mechanisms
| ||
• Pay through community agents
| ||
• Pay directly to insurance office
| ||
Premium collection modalities
| • Pay during wet, dry or all seasons
| |
Fund and risk pooling
|
Unit of enrolment
| |
Dependents eligibility
|
None, plus spouse, plus spouse and children[23] | |
Extent of pooling
|
Family/kin, community, Institutional(MFI) level, district, region, nation
| |
Nature of cross-subsidization
| • None
| |
• Based on income, employment, risk or geographical location status
| ||
• Exemptions for poor and indigents
| ||
Pooled fund Management and administration
|
Who manages the pooled funds
| |
• Community committees,
| ||
• Microfinance Institutions,
| ||
• NGOs, Health providers, Governmental organization
| ||
Quality of customer services
|
Good, bad[25] | |
Insurance information communication
| ||
Enrollment procedure (paper work involved)
| • No forms to complete, few forms, lots of forms[26] | |
Services purchasing
|
Benefit package
|
Comprehensive, medium, basic packages
|
Low cost vs. high cost events
| ||
Low risk vs. high risk events
| ||
Frequently occurring or rare events
| ||
a. Specific services coverage
| • Hospitalization due to medical treatment or surgery[26] | |
• Medical Consultation (by phone)[26] | ||
• Preventive care, wellness and education[27] | ||
• Emergency services[26] | ||
• Alcohol and substance abuse[26] | ||
• Treatment abroad or out of town emergency
| ||
• Laboratory, x-ray and imaging
| ||
• Maternal care
| ||
• Consultations of traditional healers
| ||
• Transportation
| ||
• Loss of income when ill
| ||
• Time loss of care giver
| ||
b. Cost sharing arrangements
|
Coverage ceiling (maximum liability)[28] |
benefits within specific facilities, communities, district, national, international
|
Co-payments levels
| • None
| |
• Out-of-pocket payment for first visit
| ||
• Insurance pays only at a certain quantum of cost
| ||
Benefit delivery
|
Cashless and re-imbursement
| |
Provision
|
Type of providers
|
Public, private, faith-based or all
|
Choice of provider (facility)
| ||
Location of contracted provider
| ||
• Defined setting: urban, rural
| ||
Quality of care
| ||
Reputation of affiliated providers
|
Outstanding, average, below average[23] | |
Waiting time for care
| ||
Opening hours of health facility
|
Only week days, weekends as well, nights and 24 hours[26] | |
Availability of providers
|
Yes/no[23] | |
Involvement in treatment decision making
|
Yes/no[25] |
Identification of context-specific attributes through the qualitative study
Study population and sampling
Data collection
Ethical approval
Data analysis
Expert opinion
Self-reflection and additional insights from a pilot study
Results
Qualitative analysis of the transcribed material and initial attribute identification
Attribute label | Lay terminology | Key quotations from qualitative data (mostly FGDs) | Labels of plausible levels | Final inclusion |
---|---|---|---|---|
Unit of enrollment | How many family members will benefit from enrollment into the MHI scheme | • “If everybody in my family will benefit from this basket… it will be a good idea, … but if I am the only person to benefit since I will be the one contributing into the basket, then it is not a good idea since I will still be paying hospital bills for my dependents” (Non-SACCO men)
| • Entire extended family
| Yes |
• “The head of the family should pay on behalf of the whole family” (SACCO women)
| • Core nuclear family
| |||
• “If it offers a package covering them and their children, they will be more than happy to go for it” (Health worker at district hospital)
| • Individual
| |||
Management | The managers of the common basket | • “Sometimes, just seeing the leaders who are managing this thing can make one to join or not” (SACCO men)
| • Community committee
| Yes |
• “There should be an elected committee to run the basket and trusted people” (SACCO women)
| • An external NGO
| |||
• “I will be happy if this basket is managed by the community for easy monitoring and accessibility” (Non-SACCO men)
| • Bvumbwe SACCO
| |||
• “If the basket can be managed by the NGOs it can be a good thing because if it is managed by people of this community…. if they buy chicken with their own money, people might think that they are misusing the money from the basket” (Non-SACCO men)
| ||||
• “I think the SACCCO can manage it but there should be a committee from the community …. linked to the SACCO, if it is managed by only SACCO there will be no trust” (SACCO-Men)
| ||||
Health service benefit package | The health services that the MHI will pay for | • “There are some drugs which cannot be found at public hospitals except private hospitals, so this basket should cover these situations” (non-SACCO men).
| • Comprehensive: Drugs, lab test/ x-ray, and surgical operations
| Yes |
• “(It should cover) x-ray and drugs, no more things (services) because we can’t manage to pay” (Non-SACCO men)
| • Medium: Drugs, lab tests/x-rays
| |||
• “We have all agreed that medicine should be included in this basket” (SACCO women).
| • Basic: Drugs only
| |||
• “They have to be sure that once they are putting money into this insurance, they are going to be covered properly” (health worker at private clinic)
| ||||
Copayment | The proportion of health service bill that a MHI member is expected to pay out-of-pocket | • “The basket should be assisting with half of the bill not the whole bill” (SACCO women)
| • None
| Yes |
• “25% (from the patient) is fair ….. because we should think of others who will also need the basket” (non-SACCO men)
| • 25% (quarter)
| |||
• “It can happen that you are sick but you don’t have a single coin … the committee is telling you, you will only get 50% of your charge from the basket, the other half will be paid by yourself…it will mean the basket will be of no use” (Non-SACCO men )
| • 50% (half)
| |||
Transport | Transport | • “I will join …… if I fall sick and this basket will cover transport to the hospital“ (SACCO Men).
| • Always from home to the health facility any time sic
| Yes |
• “Private hospitals are very far from here so we need transport from this community to these private hospitals” (SACCO women)
| ||||
• “Transport, because we have problems mainly in times of referral to Thyolo hospital” (district hospital) (Non-SACCO Men)
| • Only during referral and emergencies
| |||
• “If they package involves offering transport to people from where ever they are to here, they will be more than happy to join” (health worker in public health center)
| • none
| |||
Premium per person per month | Membership contributions | • “If the contributions will be unaffordable then I cannot join” (SACCO women)
| • MWK100
| Yes |
• “We will manage MWK100 per month, if they charge more than that; people will not be able to pay” (Non-SACCO-women)
| • MWK300
| |||
• ”We should agree on MWK500 per month” (Non-SACCO men)
| • MWK500
| |||
• “The amount of money to be contributed whether is it monthly or how often” (health worker, private clinic)
| ||||
Premium payment modalities | Frequency of premium contribution | • “Here, most of us find money on a seasonal basis, so I think it would be ideal if we contribute at the beginning of each and every year” (SACCO women)
| • Once-off annual payment
| No |
• Monthly payment
| ||||
• “Monthly contribution will help to have more money in the basket than annually” (non-SACCO men).
| ||||
Provider network | Contracted healthcare facilities for service provision by the MHI | • “When a person falls sick and goes to private hospital, he should use the money from the basket to settle the bills because there is a difference between public and private hospitals in terms of treatment“ (non-Sacco men)
| • Private –for-profit
| No |
• Faith-based (CHAM )facilities
| ||||
• “They will like to go to private facilities” (Health worker, public facility)
| • Public health facilities
| |||
Pooling level | Extent of geographical pooling | • “Each and every village has to have its own basket” (non-SACCO Women)
| • Community level
| No |
• “I cannot be happy with district level” (non-SACCO Men) ”… there will be no trust and some will benefit from it while others will not benefit ……. unless it is at district level and managed by NGOs” (Non SACCO men)
| • Traditional Authority
| |||
• District
| ||||
Premium structure | Extent of dependency of contributions on earnings | • “It should be one figure because everyone whether one earns more or less can fall sick so it should be one figure” (SACCO Men).
| • Flat rate contributions
| No |
• Contributions based on earnings
|