Episode 8
Rethinking Health Insurance and Patient Journeys for Better Care
From the halls of the Health Systems Research Symposium in Nagasaki, this episode explores two vital health system challenges: improving contributory health insurance models in low- and middle-income countries and addressing fragmented care pathways for non-communicable diseases (NCDs) like diabetes and hypertension.
Agnes Gatome-Munyua highlights the shortcomings of contributory health insurance and suggests how better purchasing strategies can make these systems more effective. Dr. Sudha Ramani shares insights from Mumbai’s urban informal settlements, where patient journeys for NCD care are often convoluted and inequitable, pointing to systemic barriers and practical policy solutions.
Packed with actionable insights, this episode is essential for anyone working to build resilient and inclusive health systems globally.
For more information;
HSS Insights Series: PSI - To access Population Service International's blogs and policy briefs, visit our health systems insights website.
Health Systems Pathways is an SCL Agency Production.
Transcript
Hi everyone, welcome back to Health Systems Pathways.
Alex Ergo:I'm Alex Ergo, PSI's Director of Health Systems.
Alex Ergo:And today I'm bringing you the fourth live episode recorded at the Health Systems Research Symposium in Nagasaki.
Alex Ergo:In this episode, we tackle two different topics that are not totally unrelated.
Alex Ergo:The challenges of implementing contributory health insurance in low and middle-income countries and the complexities of patient care journeys for non-communicable diseases such as diabetes and hypertension.
Alex Ergo:Let's get started.
Alex Ergo:Hi again, everyone.
Alex Ergo:I am now with Agnes, and we're going to talk about health insurance.
Alex Ergo:But let me first ask Agnes to introduce herself.
Alex Ergo:Agnes Gatome-Munyua: Hello, everyone.
Alex Ergo:My name is Agnes Gatome-Munyua.
Alex Ergo:I'm a program director at Results for Development, and I am based in Nairobi, Kenya.
Alex Ergo:Welcome to our podcast, Agnes.
Alex Ergo:And a few months ago, at PSI, we wrote this paper relating to health insurance, and basically what we were saying is that many countries, low and middle-income countries, tend to adopt a pathway towards universal health coverage that involves health insurance, but it doesn't always go as planned.
Alex Ergo:And in fact, in many countries, we see very low uptake of health insurance and that can be linked to poor design or poor implementation or any combination of those.
Alex Ergo:And a few days ago, Agnes presented some findings in a session that's related to exactly this same topic.
Alex Ergo:And so it would be great to hear from you, Agnes, what what some of your findings were and what some of the takeaways are.
Alex Ergo:Agnes Gatome-Munyua: Thank you for inviting me to be here.
Alex Ergo:Yes, you're right.
Alex Ergo:I think a lot has been said on contributory health insurance and in the past 10 years or more, it has been stated that there are shortcomings of contributory health insurance particularly for countries low and middle-income countries that are aiming to introduce these.
Alex Ergo:And so last year there was a paper released by very eminent colleagues in health financing, that contributory health insurance is a bad idea.
Alex Ergo:That paper really resonated with me.
Alex Ergo:I think from a perspective of giving advice to a country that is considering contributory health insurance, it was fantastic, but what nagged me is that my country in Kenya, as in other countries in Africa, there's some of these countries that have set up contributory health insurance for decades, and these have been going on, yes, with challenges, they're ongoing.
Alex Ergo:So, my question was, okay, the paper is great, but what happens to those who have the systems entrenched already and are very hard to turn back.
Alex Ergo:And so, from that perspective, I reached out to a number of colleagues to find out is there something we can provide in terms of reflections on what options there are for these countries?
Alex Ergo:And that really was the genesis of this paper on what happens to these countries who have this entrenched health insurance systems.
Alex Ergo:So, they can't turn back, they have to look forward.
Alex Ergo:What do they do?
Alex Ergo:And so based on that, I had a good, a fantastic actually set of co-authors in Cheryl Cashin and Joe Kutzin.
Alex Ergo:They are very well known in health financing circles.
Alex Ergo:Wonderful mentors to me as well.
Alex Ergo:And so when I brought this idea and I thought, okay, let's see what advice we can bring.
Alex Ergo:We thought of, what are the options?
Alex Ergo:What can these countries actually do?
Alex Ergo:And so we looked at, okay, what is a real pain point from this contributory health insurance systems, right?
Alex Ergo:And one of the biggest issues is that when these contributory health insurance systems were set up in many of these countries, there's a fallacy that they could generate sufficient revenue for the health system, and they've not been able to do that in many of these countries.
Alex Ergo:It has not been able to raise sufficient revenue, and it has largely provided coverage to the elites, those who are working in the formal sector, government workers in particular, who are able to contribute via the payroll system.
Alex Ergo:So, if you look at these schemes, like Kenya, for example, or Nigeria or Tanzania, you find that coverage of the formal sector is, almost at 100%, right?
Alex Ergo:But unfortunately, that is the minority of these countries.
Alex Ergo:And they are countries with a large informal sector who are relying on a daily income.
Alex Ergo:Or might be working in industries that do not provide them a salary at the end of the month.
Alex Ergo:Agriculture workers, we call them Jua Kali sector, people who work in informal sector in, in Kenya as an example.
Alex Ergo:So what happens to the majority in informal employment?
Alex Ergo:And so that's where social health insurance and compulsory health insurance has not been able to tap into these.
Alex Ergo:And we find that there are a lot of challenges where they have tried in terms of low coverage adverse selection, right?
Alex Ergo:So those who enroll are likely to need health services.
Alex Ergo:And if you look at the the particular group of these individuals who do enroll for this contributory health insurance programs, you find that utilization is very high and might not actually be commensurate with the contributions that they're making.
Alex Ergo:And once they've accessed the service they need, they're likely to drop off whether that's delivering a new baby or needing a surgery.
Alex Ergo:And there are just some things about contributory health insurance that are not working well.
Alex Ergo:And okay, we know that.
Alex Ergo:But are there other things that might not be too bad about these contributory health insurance schemes?
Alex Ergo:And because we have a leaning towards purchasing, I do in particular, if you look at the ability of these systems in health insurance systems to channel the revenue that they have to define benefit packages, to develop formularies in terms of medicines to provide, to contract and accredit health providers, include the private sector, and then define output based benefit packages provider payment systems.
Alex Ergo:And you find that they're actually doing a little better than would be thought.
Alex Ergo:And based on, the positive elements in the purchasing, maybe that's where they should focus.
Alex Ergo:And that's the real premise of the paper, that the revenue generation doesn't seem to work.
Alex Ergo:We should be thinking of raising more public resources and channelling them through these systems.
Alex Ergo:Remove that revenue collection function from these health insurance agencies and let them focus on the purchasing function, how they define benefit packages, how they contract and accredit, how they set obligations for their providers, and then how they pay their providers with output-based payments.
Alex Ergo:And then, of course, using information to improve how they decide the what, the how, and the who of purchasing and I think that's the opportunity and that's what we speak about in the paper.
Alex Ergo:This is great, it resonates very much.
Alex Ergo:And I wonder if you think the authorities in Kenya are open to this and will be taking the advice that you've provided in your commentary.
Alex Ergo:Agnes Gatome-Munyua: I'm not very sure about that, possibly not.
Alex Ergo:Kenya is embarking on some big reforms right now.
Alex Ergo:We have set up a social health authority that is going to oversee three funds.
Alex Ergo:Social health insurance fund, the primary health care fund, and the chronic and emergency disease fund.
Alex Ergo:In terms of strengthening purchasing, maybe those are elements they can pick from the paper.
Alex Ergo:One of the points of contention is that they're still expected to collect revenue, and I'm not sure how well that's going to work, particularly from the large informal sector in Kenya.
Alex Ergo:Yes, because I imagine that they've set up entire functions to and institutions to fulfill those functions, right?
Alex Ergo:And so it's really hard to get rid of those.
Alex Ergo:So, what advice do you give in that respect?
Alex Ergo:Agnes Gatome-Munyua: One of the things we state is that over the years, one of the recommendations is we need to rely predominantly on public sources of health funding.
Alex Ergo:And so, what I'm hoping is that as we evolve and continue to implement under the Social Health Authority, that we see more public resources being channelled to the different funds.
Alex Ergo:The primary health care fund is supposed to be funded by the government, but commitments have been low, and so, if we can see more commitment from government to channel public resources so that the agency doesn't have to rely on trying to collect contributions, particularly for those that have been traditionally very hard to reach.
Alex Ergo:Great.
Alex Ergo:Thank you so much for sharing this Agnes and I hope you have a great rest of the conference.
Alex Ergo:Hi, everyone.
Alex Ergo:I'm now with Dr.
Alex Ergo:Sudha Ramani, who just presented interesting findings from a study conducted in Mumbai that involved journey mapping.
Alex Ergo:But let me first start by asking you, Sudha, if you could please introduce yourself.
Sudha Ramani:Hi, I'm Sudha.
Sudha Ramani:I live in India and I work mainly on health systems and health policy issues, mainly related to primary health care.
Alex Ergo:Great.
Alex Ergo:So maybe you can tell us a few words about the study that you conducted.
Alex Ergo:Maybe, a few words about the context and what you actually did and what the main findings were.
Sudha Ramani:Thanks Alex.
Sudha Ramani:This study was on care seeking journeys of people who live in urban informal settlements in Mumbai.
Sudha Ramani:And we looked at their journeys for two very common non communicable diseases, which are diabetes and hypertension.
Sudha Ramani:This study was sponsored by the Society for Nutrition, Education, and Health Action which is an NGO in Mumbai.
Sudha Ramani:The NGO basically works on maternal and child health issues.
Sudha Ramani:It's got a very strong presence in the urban informal settlements in Mumbai.
Sudha Ramani:And recently what they have been realizing is that non-communicable diseases like diabetes and hypertension are cropping up in their field everywhere.
Sudha Ramani:These diseases are no longer diseases of the rich as they used to be.
Sudha Ramani:So, what we did was we tried to get some deeper insights into what is really happening in these urban informal settlements when it comes to patients seeking care.
Sudha Ramani:Where do people seek diagnosis for these ailments?
Sudha Ramani:Where do people get treated for these two conditions, diabetes and hypertension?
Sudha Ramani:So, how we went about doing this study was we collected data from patients.
Sudha Ramani:We asked them to think about their life story on what they remembered of their journey of dealing with these two conditions.
Sudha Ramani:We also supplemented these with some interviews and discussions with private providers, public providers, and some focus group discussions in the community.
Sudha Ramani:I would like to talk now about our main findings from the study.
Sudha Ramani:What we really see in literature or when we look at it is we see these very linear kinds of mapping of patient journeys, especially when it comes to non-communicable diseases.
Sudha Ramani:So, if I look at a linear journey, it would involve, let's say screening for non-communicable diseases, or people think that something is wrong, then they go to a health practitioner, then they go get diagnosed, then they start some treatment, and after treatment, they do this disease management and follow up, and all is well and fine.
Sudha Ramani:So, this is great in an ideal world, but when we actually looked at our data, we found that this ideal sort of pathway that we had in mind does not apply in reality at all.
Sudha Ramani:In reality the journeys that people took were very messy.
Sudha Ramani:They were very convoluted and difficult for people to navigate.
Sudha Ramani:Also, in each step, let's say, from getting a diagnosis to get initiating treatment to getting a follow up between each of these steps, there was a lot of delay which was happening.
Sudha Ramani:Another point where I felt that we were really losing people was at the very first contact point.
Sudha Ramani:The initial care seeking in these urban informal settlements happens not in the formal private sector or even in the formal public sector.
Sudha Ramani:It all happens in the informal sector.
Sudha Ramani:In Hindi, they call them chota doctors or small doctors.
Sudha Ramani:These are doctors who, practice within the community.
Sudha Ramani:They sort of practice allopathic medicine, but they do not really have a formal qualification to practice.
Sudha Ramani:And what they can provide is symptomatic relief.
Sudha Ramani:So most often the patient goes in with these early symptoms like headache or frequent urination and they send them back with some paracetamol tablets.
Sudha Ramani:And people are stuck in this loop without a diagnosis for very long times, which is really a missed opportunity.
Sudha Ramani:It's only when things really get bad, really worsens or sometimes even in terms of emergencies like a heart attack, it is at that point that people are discovering that they have diabetes.
Sudha Ramani:A second point I would like to make which sort of really stood out in our findings was that people kept on switching providers, or hopping between providers.
Sudha Ramani:At least three to four times each patient journey we found that people hop providers.
Sudha Ramani:I think our maximum was about 13 providers before a patient could actually get on to diagnosis and treatment.
Sudha Ramani:People hopped between the small doctors and the more qualified doctors, between the allopathic sector and the ayurvedic sector between the public sector and the private sector.
Sudha Ramani:So, there was a lot of hopping going on.
Sudha Ramani:And this hopping is challenging because very often the second provider they go to, they do not know what the first provider has prescribed to the patient, which makes the whole treatment journey even more complex than than it should have been.
Sudha Ramani:I think the third most important finding of our study was that this study was conducted in a vulnerable population, so people are very poor, they live a day-to-day existence, so they were constantly making a tradeoff between the need for relief and the need for lowering the cost of care that is needed.
Sudha Ramani:So let's say during times when the symptoms were really troubling people, it was then that they sought care from the big doctors.
Sudha Ramani:They spent a lot of money, they would get themselves diagnosed and they would start treatment.
Sudha Ramani:Once they started treatment, as the symptoms started to go in remission, they were more under control.
Sudha Ramani:People started feeling, why should I spend so much money on this and so people stop treatment and seek relief in other ways.
Sudha Ramani:Saying I can manage my symptoms using home remedies or I can manage it using some herbal treatment, and other things.
Sudha Ramani:This was constantly happening in people's life.
Sudha Ramani:It was not a one-time thing, there was a constant seeking of balance between the need for relief and lowering care.
Sudha Ramani:Maybe I should just summarize here by saying that care seeking journeys for diabetes and hypertension, they're not easy, linear journeys.
Sudha Ramani:There are multiple providers involved, people are always making very hard choices, and they're not making these choices because they're not aware of things; aware of, say, what is diabetes or what is hypertension, but because in the kind of context that they come from, this is what is possible for them to do.
Sudha Ramani:And also, when we did the study one, one of our big expectations was that for ailments which are as common as diabetes and hypertension, the pathway should be reasonably easy, but we did not find the case.
Sudha Ramani:So, for other NCDs, which are less common and more complex like cancers, we do not even know how very messy the treatment journey would be like.
Alex Ergo:I can imagine that's true in many cases and for many types of conditions.
Alex Ergo:What are the policy recommendations that came out of your study?
Sudha Ramani:The first thought that everybody starts with is, yes, we have to spread awareness in the community.
Sudha Ramani:The minute we say patients are not able to navigate the health system, we say yes, we have to teach them how to navigate the health system.
Sudha Ramani:We have to spread awareness, and there should be mass counselling and individual counselling and other things.
Sudha Ramani:And our study did show that there is a need for all these things.
Sudha Ramani:But in addition to that, I think our patient journeys also point to several things that the health system itself has to do so that it can make these patient journeys much less messy for them.
Sudha Ramani:For example, one thing that these systems have to do is engage our public systems and our private systems do have to engage better with each other.
Sudha Ramani:We do have prior examples from the tuberculosis program in India where this program has worked with informal providers in urban informal settlements and help them get people into the system so that they can receive tuberculosis care.
Sudha Ramani:And this study did tell us that maybe this kind of model might work for non-communicable diseases as well in this setting.
Sudha Ramani:The other thing that was recommended was patient support groups.
Sudha Ramani:These are long patient journeys.
Sudha Ramani:So, you start medication you're not supposed to stop them for life.
Sudha Ramani:So having these support groups, having other patients tell them that, yes, you need to do this for life.
Sudha Ramani:These are the implications of it and this is how this journey is going to be might be of more of words to the community rather than just having awareness campaign.
Sudha Ramani:And I think lastly, the public sector we do have an emerging non-communicable diseases program in India.
Sudha Ramani:The government is giving priority to it, but the scale of population we have in urban areas is huge.
Sudha Ramani:Definitely, we need to expand more screening in these areas, more early reaching out and strengthening of the public sector is required.
Alex Ergo:So an interesting point you raise that basically the TB program already came to the similar conclusions a while back.
Alex Ergo:And it's interesting that those findings didn't basically make it to the other health areas.
Alex Ergo:And yeah, that's basically another argument for strengthening primary health care, right?
Alex Ergo:And then integration.
Sudha Ramani:Yes, definitely.
Sudha Ramani:Those are long standing debates, I think, in health systems on how much easier it is to do things in vertical programs which are under the control of one ministry and take that approach to move things forward.
Sudha Ramani:And you're absolutely right in saying the, these lessons need to be transferred to the general health system and it's overall the foundation of PHC is something that we really need to improve in India.
Alex Ergo:Thank you so much for sharing these findings.
Alex Ergo:Very interesting, and I'm sure they apply to many other settings, and possibly also to many other conditions.
Alex Ergo:Maybe a last question before we wrap up.
Alex Ergo:What are you taking with you back to Mumbai from this conference?
Alex Ergo:What are some of the things that stood out and that you were surprised about?
Sudha Ramani:I must confess, I do love this conference.
Sudha Ramani:This is one of those communities which is very warm and welcoming.
Sudha Ramani:So I, I really try to make it to almost every conference of HSGs that that has happened so far.
Sudha Ramani:This time particularly today, related to the research that we are talking about, I was very happy and very excited also to see that there are many patient journey studies that are happening.
Sudha Ramani:When I went down to look at the posters, I found one poster from Ghana, one from Burkina Faso, one from Guatemala, all of them looking at patient journeys and looking at patient journeys for non-communicable diseases.
Sudha Ramani:So, clearly people are pursuing these these to fine tune policies and work towards more more patient centered health system and that's always a good thing to see.
Alex Ergo:Wonderful.
Alex Ergo:Thank you so much for joining us.
Sudha Ramani:Thank you again.
Sudha Ramani:And looking forward to doing more work in this area.
Alex Ergo:A big thank you to Agnes and Sudha for sharing their insights into some of the challenges of health insurance and the complexities of patients journeys through the health system in resource constrained settings.
Alex Ergo:Thank you for tuning into Health Systems Pathways.
Alex Ergo:If you enjoyed this episode, be sure to subscribe or follow us for more stories and lessons from the halls of the HSR Symposium in Nagasaki.
Alex Ergo:Until next time, I'm Alex Ergo, let's keep working together to build stronger health systems that work for people.
