A new series of BMJ Global Health brings together a first set of country case studies about better engaging citizens in insurance programmes. While publicly funded health insurance programmes in low- and middle-income countries have reported impressive increases in populations covered, there exist several barriers that prevent beneficiaries from effectively exercising their entitlements. These include a lack of information on programmes, challenges in navigating health care facilities as well as power asymmetries that make it difficult for those covered to hold providers and insurers to account.
To address this, governments and civil society organizations have implemented a range of initiatives – including those providing information to beneficiaries on their health insurance entitlements, initiatives to support beneficiaries to navigate the health care system and initiatives to engage citizens in benefit package design and insurance oversight. However, relatively little is known on how these initiatives have performed in achieving their stated objectives and the factors that underlie their performance. Filling this knowledge gap, the Alliance in partnership with the WHO Department of Health Governance and Financing, developed a programme of work in this area. This rolling series of articles, with new articles added as they are accepted, will bring together these country case studies with cross-national learning and reflections towards improving the performance of these initiatives.
The first paper from Bosnia and Herzegovina by Stojisavljevic et al. examines the role of government supported navigators known as the Protector of Patients’ Health Insurance Entitlements (PPHIE) in information provision, facilitating access to health services and grievance redressal among the elderly within the context of the Health Insurance Fund (HIF). The authors found low awareness of the initiative among the elderly population. This was on account of the initiative being poorly publicized and PPHIE workers not spending much time in health care facilities, offering them limited opportunities to engage with beneficiaries. Health care providers filled much of the gap in information provision and navigation, but this was something that they did not feel equipped to do. However, the grievance redressal role remained unfulfilled, and the study recommended policy changes to enable the PPHIEs to carry out this function.
In contrast to the first paper that focuses on an initiative established by the government, Raharja et al. examine three informal nongovernmental patient navigation initiatives that support patients to access their entitlements under Indonesia’s JKN national health insurance programme. The study finds that informal navigation initiatives – many of which had roots in the labour movement – often emerged organically to fill the gaps in formal initiatives established by the government. These formal initiatives were often perceived by beneficiaries as slow to respond, bureaucratic and distant from patients. By contrast, these informal initiatives were seen to play a crucial enabling role in facilitating patient access to health facilities including through advocating for individual patients with facility management and enforcing people’s rights to health care.
Thomas et al. then illustrate the role of community-based resource centres in Gujarat, India, in enhancing women’s access to health care and utilization of publicly funded health insurance programmes. The paper identifies three factors that contribute to the effectiveness of these resource centres established by the Self-Employed Women’s Association (SEWA), a long-standing trade union of informal sector women workers. These include: active local leadership, the establishment and maintenance of strong partnerships with the government and the broad mandate of the resource centres to support women in exercising entitlements across a wide range of government schemes and programmes beyond health insurance.
Finally, Bolivar et al. examine the functioning of user associations within the context of Colombia’s health insurance programme. These associations are envisioned to serve as platforms for citizens to participate in the decision-making and oversight of health insurance companies. The study finds that, while many user associations have been created as mandated under the insurance programme, they are largely non-functional and only play a tokenistic role. This is mainly down to an absence of resources dedicated to the association’s functioning, low public awareness about these associations and the inherent contradiction of leaving health insurance companies responsible for setting up user associations to oversee their functioning. The authors call for reform of existing rules and regulations that would enable user associations to play their initially envisaged role towards genuine community empowerment.