The study aimed to identify factors associated with enrollment in Nepal's National Health Insurance Program (NHIP). A survey of 570 households in 2 municipalities was conducted, with equal numbers of enrolled and non-enrolled households. The results showed that enrollment was associated with ethnicity, socioeconomic status, past illness experience, and presence of chronic illness. Households from privileged ethnic groups and with higher socioeconomic status were more likely to enroll. Households experiencing acute illness or with a chronically ill member were also more likely to enroll. This suggests gaps in enrollment between rich and poor households, and privileged and underprivileged ethnic groups. Ensuring equitable enrollment across groups is needed to increase equity and universal coverage.
Paper presented at 'Nepal Development Conference: Views and Visions of Nepali Ph.D. Scholars Residing in the UK for the Development of Nepal' organised by Embassy of Nepal, London, 7 November 2020
discussion on Health Economics and Health Care in our country and abroad, and what resources are given by the private sectors and with the very scarce help from the DOH, national and local government, and from the support given by WHO.
The role of healthcare organizations in activating self-care systems and resp...AI Publications
Background: Self-care refers to the individuals’ ability to promote and maintain their health. The first requirement for self-care is raising awareness of healthcare issues. In this regard, healthcare non-governmental organizations can play a significant role. The present study was carried out in order to investigate the role of an active health organization in the Kurdistan Region of Iraq in activating self-care practices and responding to emergency situations. Methods: The study was a descriptive qualitative one that was carried out from July to December 2019 on 16 participants who were selected from doctors, nurses, managers, social researchers, employees, and patients in Zhian health organization. Unstructured in-depth interviews were carried out to collect required data. The collected data were analyzed through van Manen’s method, and the relevant themes and subthemes were extracted. Results: Analyzing the collected data led to emergence of two main theme which were labeled as “raising health awareness” and “providing emergency health care”. The first main theme had three subtheme, namely “raising public awareness of self-care”, “raising the pregnant women’s awareness of self-care”, and “raising the women’s awareness of gender-based violence”. The second main theme had two subtheme, namely “providing refugees with emergency health care” and “providing internally displaced persons with emergency health care”. Conclusion: Primary healthcare NGOs can play a significant role in raising health awareness, promoting self-care activities, and providing emergency health care. As a result, such NGOs need to be developed and supported by the government and the Ministry of Health.
Paper presented at 'Nepal Development Conference: Views and Visions of Nepali Ph.D. Scholars Residing in the UK for the Development of Nepal' organised by Embassy of Nepal, London, 7 November 2020
discussion on Health Economics and Health Care in our country and abroad, and what resources are given by the private sectors and with the very scarce help from the DOH, national and local government, and from the support given by WHO.
The role of healthcare organizations in activating self-care systems and resp...AI Publications
Background: Self-care refers to the individuals’ ability to promote and maintain their health. The first requirement for self-care is raising awareness of healthcare issues. In this regard, healthcare non-governmental organizations can play a significant role. The present study was carried out in order to investigate the role of an active health organization in the Kurdistan Region of Iraq in activating self-care practices and responding to emergency situations. Methods: The study was a descriptive qualitative one that was carried out from July to December 2019 on 16 participants who were selected from doctors, nurses, managers, social researchers, employees, and patients in Zhian health organization. Unstructured in-depth interviews were carried out to collect required data. The collected data were analyzed through van Manen’s method, and the relevant themes and subthemes were extracted. Results: Analyzing the collected data led to emergence of two main theme which were labeled as “raising health awareness” and “providing emergency health care”. The first main theme had three subtheme, namely “raising public awareness of self-care”, “raising the pregnant women’s awareness of self-care”, and “raising the women’s awareness of gender-based violence”. The second main theme had two subtheme, namely “providing refugees with emergency health care” and “providing internally displaced persons with emergency health care”. Conclusion: Primary healthcare NGOs can play a significant role in raising health awareness, promoting self-care activities, and providing emergency health care. As a result, such NGOs need to be developed and supported by the government and the Ministry of Health.
Standard treatment guideline bring everyone involved in medicines onto the same page. They are used by policy makers in the health ministries to set standards and regulate practices.
Research found that a lack of comprehensive sexual education in schools creates an increased risk for sexually transmitted diseases and unintended teenage pregnancy. The lack of access to sexual health resources not only raises the likelihood of young teenage parents to discontinue high school, but also multiplies the chances of abuse and neglect, and the possibilities of entering into the welfare system. The Illinois Caucus for Adolescent Health (ICAH) is an advocate for the Personal Responsibility Education Program (PREP) in Illinois, which implements comprehensive sexual health education curricula in school-based settings. Certified health education specialists facilitated ICAH’s skills-based training program that recruited educators and youth service providers from 29 school districts in Illinois. Selected for the trainings were counties that have statistically higher teenage birth rates and STDs. Results from a 3-to-6-month follow-up evaluation of the PREP curriculum-training revealed an estimated 95 percent of participants realize that professional development in PREP curricula is crucial to the overall goal in teaching youth the skills needed to develop healthy relationships, and to prevent unintended pregnancy and the acquisition of STDs/HIV. When developing recommendations for school board policy changes, studies point to the success of PREP as medically accurate, age-appropriate, and evidence-based curricula. Amid significant societal and financial costs of the lack of comprehensive sexual education, any progress in reducing these social concerns will not only sponsor the state and national economies, but will also develop the social, emotional, and physical wellbeing for current and subsequent generations of America.
"Dear Adler Community,
The posters presented today by our CSP students represented their reflections on their community work. The posters included themes about socially responsible practice, the connection between individual and community well-being, the systemic forces that marginalize whole communities, and the actions we can take to improve our society. Over 30 community partners joined faculty and staff to help students celebrate the completion of the Community Service Practicum.
It was difficult to do, but we did identify students whose posters excelled. These students will be awarded subsidies to a professional conference in the following amounts:
1st Place Winner: $500
2nd Place Winner: $400
3rd Place Winner: $300
Because we have so many students, this year we doubled the number of students who could win.
Our first place winners are Kulkiran Nakai and XX.
Our second place winners are XX and XX.
Our third place winners are XX and XX.
Many thanks to our judges, whose decisions were made so difficult by the excellent quality of students’ posters.
Nancy J. Bothne
Director of Community Engagement
Cecil Thomas
Associate Director of Community Engagement"
Recent Advances in Evidence Based Public Health PracticePrabesh Ghimire
This product is the result of compilation from various sources. I acknowledge all direct and indirect sources although they have not been mentioned explicitly in the document.
As the burden of NCDs increases, various countries have introduced new and innovative modes of managing them in primary healthcare setting. APO, in conjunction with Duke Kunshan University, China, conducted a 4-country study (Bangladesh, China, Nepal and Viet Nam) to understand the different approaches used in involving CHWs in preventing and managing NCDs. Access full publication here http://bit.ly/2XnWwcd
This describes the background problem, concept of health insurance, enrollment procedure, benefits,and implementation status of health insurance in Nepal, issues/concerns (discussion), take home message
The presentation gives a brief overview of the concept of the following :
1. what are user chargers
2. should we abolish them or not.
3. What could be the impact of either keeping them or abolishing them,
4. What role would the abolishment of User Charges play in achieving the goal of Universal Health Coverage?
National Health Policy Introduction, NHP 1983, NHP 2000, NHP 2002, NHP 2017, Seven Priority areas, Sustainable Developmental (SDGs), Public and Private health system in India, National Health Mission (NHM),Sustainable Development Goals (SDGs), International Pharmaceutical Federation Development Goal (FIP),
Vital statistics is accumulated data gathered on live births, deaths, migration, fetal deaths, marriages and divorces. The most common way of collecting information on these events is through civil registration, an administrative system used by governments to record vital events which occur in their populations.
Vital statistics is accumulated data gathered on live births, deaths, migration, fetal deaths, marriages and divorces. The most common way of collecting information on these events is through civil registration, an administrative system used by governments to record vital events which occur in their populations.
This presentation has made to health workers who have more than two decades of experience of managing/implementing public health programs in Nepal, especially at district level and below.
Patients' satisfaction towards doctors treatmentmustafa farooqi
The mood of the care recipient to see if the impression (expectations) of service are met by the patient may be defined as patient satisfaction. The current perspective on service efficiency tends to be that patient treatment meets public standards and requirements in terms of interpersonal support as well as professional assistance. (Hardy et al. 1996).
For various reasons, customer satisfactions in the healthcare industry have been investigated. First it was important to decide on the extent and the degree to which patient care seekers, the meeting of drugs criteria and the continuous use of these services have effect, satisfaction as a quality of service metric, as well as allowing doctors and health services to better appreciate and use the input of the patient. (Ong et al. 2000).
Consumer satisfaction with healthcare services is a multi-panel term that refers to the core facets of treatment and suppliers, while PS medical services with the quality enhancement systems from the patient context, full control of quality and the intended outcomes of services are considered to be of primary importance (Janicijevic et al. 2013).
The Pakistani health system is being changed somewhat and there are wonderful scope for applying standard of services to health care. Patients in Pakistan now have access to increased quality health care. Obviously, the staff and staff are the most important winners of a successful health care environment of every community sector framework (Bakari et al. 2019).
The medical clinic of today's study is the product of a long and complicated war of civilization to quantify produce and study and to give thought to the thoughtful (Fullman et al. 2017).
Regulatory changes, plus advances in cloud computing and analytic technologies, are making it possible for U.S. healthcare providers, payers and patients to connect, commmunicate and collaborate seamlessly, and ensure that the right care is provided at the right place, at the right time.
Standard treatment guideline bring everyone involved in medicines onto the same page. They are used by policy makers in the health ministries to set standards and regulate practices.
Research found that a lack of comprehensive sexual education in schools creates an increased risk for sexually transmitted diseases and unintended teenage pregnancy. The lack of access to sexual health resources not only raises the likelihood of young teenage parents to discontinue high school, but also multiplies the chances of abuse and neglect, and the possibilities of entering into the welfare system. The Illinois Caucus for Adolescent Health (ICAH) is an advocate for the Personal Responsibility Education Program (PREP) in Illinois, which implements comprehensive sexual health education curricula in school-based settings. Certified health education specialists facilitated ICAH’s skills-based training program that recruited educators and youth service providers from 29 school districts in Illinois. Selected for the trainings were counties that have statistically higher teenage birth rates and STDs. Results from a 3-to-6-month follow-up evaluation of the PREP curriculum-training revealed an estimated 95 percent of participants realize that professional development in PREP curricula is crucial to the overall goal in teaching youth the skills needed to develop healthy relationships, and to prevent unintended pregnancy and the acquisition of STDs/HIV. When developing recommendations for school board policy changes, studies point to the success of PREP as medically accurate, age-appropriate, and evidence-based curricula. Amid significant societal and financial costs of the lack of comprehensive sexual education, any progress in reducing these social concerns will not only sponsor the state and national economies, but will also develop the social, emotional, and physical wellbeing for current and subsequent generations of America.
"Dear Adler Community,
The posters presented today by our CSP students represented their reflections on their community work. The posters included themes about socially responsible practice, the connection between individual and community well-being, the systemic forces that marginalize whole communities, and the actions we can take to improve our society. Over 30 community partners joined faculty and staff to help students celebrate the completion of the Community Service Practicum.
It was difficult to do, but we did identify students whose posters excelled. These students will be awarded subsidies to a professional conference in the following amounts:
1st Place Winner: $500
2nd Place Winner: $400
3rd Place Winner: $300
Because we have so many students, this year we doubled the number of students who could win.
Our first place winners are Kulkiran Nakai and XX.
Our second place winners are XX and XX.
Our third place winners are XX and XX.
Many thanks to our judges, whose decisions were made so difficult by the excellent quality of students’ posters.
Nancy J. Bothne
Director of Community Engagement
Cecil Thomas
Associate Director of Community Engagement"
Recent Advances in Evidence Based Public Health PracticePrabesh Ghimire
This product is the result of compilation from various sources. I acknowledge all direct and indirect sources although they have not been mentioned explicitly in the document.
As the burden of NCDs increases, various countries have introduced new and innovative modes of managing them in primary healthcare setting. APO, in conjunction with Duke Kunshan University, China, conducted a 4-country study (Bangladesh, China, Nepal and Viet Nam) to understand the different approaches used in involving CHWs in preventing and managing NCDs. Access full publication here http://bit.ly/2XnWwcd
This describes the background problem, concept of health insurance, enrollment procedure, benefits,and implementation status of health insurance in Nepal, issues/concerns (discussion), take home message
The presentation gives a brief overview of the concept of the following :
1. what are user chargers
2. should we abolish them or not.
3. What could be the impact of either keeping them or abolishing them,
4. What role would the abolishment of User Charges play in achieving the goal of Universal Health Coverage?
National Health Policy Introduction, NHP 1983, NHP 2000, NHP 2002, NHP 2017, Seven Priority areas, Sustainable Developmental (SDGs), Public and Private health system in India, National Health Mission (NHM),Sustainable Development Goals (SDGs), International Pharmaceutical Federation Development Goal (FIP),
Vital statistics is accumulated data gathered on live births, deaths, migration, fetal deaths, marriages and divorces. The most common way of collecting information on these events is through civil registration, an administrative system used by governments to record vital events which occur in their populations.
Vital statistics is accumulated data gathered on live births, deaths, migration, fetal deaths, marriages and divorces. The most common way of collecting information on these events is through civil registration, an administrative system used by governments to record vital events which occur in their populations.
This presentation has made to health workers who have more than two decades of experience of managing/implementing public health programs in Nepal, especially at district level and below.
Patients' satisfaction towards doctors treatmentmustafa farooqi
The mood of the care recipient to see if the impression (expectations) of service are met by the patient may be defined as patient satisfaction. The current perspective on service efficiency tends to be that patient treatment meets public standards and requirements in terms of interpersonal support as well as professional assistance. (Hardy et al. 1996).
For various reasons, customer satisfactions in the healthcare industry have been investigated. First it was important to decide on the extent and the degree to which patient care seekers, the meeting of drugs criteria and the continuous use of these services have effect, satisfaction as a quality of service metric, as well as allowing doctors and health services to better appreciate and use the input of the patient. (Ong et al. 2000).
Consumer satisfaction with healthcare services is a multi-panel term that refers to the core facets of treatment and suppliers, while PS medical services with the quality enhancement systems from the patient context, full control of quality and the intended outcomes of services are considered to be of primary importance (Janicijevic et al. 2013).
The Pakistani health system is being changed somewhat and there are wonderful scope for applying standard of services to health care. Patients in Pakistan now have access to increased quality health care. Obviously, the staff and staff are the most important winners of a successful health care environment of every community sector framework (Bakari et al. 2019).
The medical clinic of today's study is the product of a long and complicated war of civilization to quantify produce and study and to give thought to the thoughtful (Fullman et al. 2017).
Regulatory changes, plus advances in cloud computing and analytic technologies, are making it possible for U.S. healthcare providers, payers and patients to connect, commmunicate and collaborate seamlessly, and ensure that the right care is provided at the right place, at the right time.
Essential Package of Health Services and Health Benefit Plans Mapping BriefHFG Project
Many governments are scaling up health benefit plans, such as social health insurance, to increase population health coverage. This brief presents findings from a mapping between the services covered under the country’s prominent health benefit plan(s) to the country’s Essential Package of Health Services. The mapping analyzes the extent to which the plan(s) cover essential services.
Essential Package of Health Services and Health Benefit Plans Mapping BriefHFG Project
Many governments are scaling up health benefit plans, such as social health insurance, to increase population health coverage. This brief presents findings from a mapping between the services covered under the country’s prominent health benefit plan(s) to the country’s Essential Package of Health Services. The mapping analyzes the extent to which the plan(s) cover essential services
Factors associated with Non Enrollment into Community Based Health Insurance ...Premier Publishers
The world has a growing attention on moving towards universal health coverage, and health insurance is instrumental in that endeavor. As a prepaid financing system, health insurance ensures collective pooling of risks and the redistribution of financial resources in a way that guarantees financial protection against the cost of illnesses. The main aim of the study was to determine the factors associated with Non enrollment into Community based health insurance schemes in the BHD. A community based cross-sectional study was carried-out among Parents in BHD. Multistage sampling technique was used to select participants and data collected using a structured interviewer administered questionnaire. Data collected was analysed using SPSS version 21. A total of 384 participants took part in the study. The rate of enrolment into CBHIS in BHD was 2.4% (95% CI: 0.9-3.9%). Salary employed individuals were 2.7 times more likely to be enrolled into CBHIS compared to those who were self-employed. (O.R: 2.70, 95%CI; 1.15-6.37: P = 0.023). Low level of education was also found to be significantly associated with non-enrollment into CBHIS (O.R: 0.455, CI: 0.212-0.976, P: 0.043). Unawareness of CBHIS (O.R: 0.025, CI: 0.006-0.113, P: <0.001), low income level (O.R: 0.305, CI: 0.134-0.697, P: 0.005) and age less than 40yrs (O.R: 0.255, CI: 0.103-0.631, P: 0.003) were found to be significantly associated with non-enrolment. There was low enrollment into CBHIS in the BHD (2.4%). Factors significantly associated with non-enrolment into CBHIS in BHD were; low level of education, low age group of less than 40yrs, non-salary employment, low income level and unawareness of existence of schemes.
NRHM Policies and Lacking in its ImplementationSupriya_1995
Survey was conducted to examine the impact of NRHM Policies in Rural and Urban Areas and its related implementation. To analyze the opinion and reaction towards the same, the general public from Rural and Urban areas of Bulandshahr were selected
Evolution of National Family Planning Programme (NFPP) and National Populatio...Dr Kumaravel
This presentation discuss the evolution of India's National Family Planning Program and National Population Policy 2000, significant impact of 1994 Cairo conference on country's Reproductive health approach.
Female Community Health Volunteers in Nepal: What We Know and Steps Going For...JSI
Presented by Leela Khanal, Project Director, JSI/Chlorhexidine Navi Care Program, at a USAID brown bag meeting on July 20, 2016.
The presentation shows the results of the recent Nepal Female Community Health Volunteer (FCHV) National Survey which was funded by USAID, UNICEF, and Save the Children, and conducted by Advancing Partners & Communities in partnership with the Ministry of Health and Population. It collected updated information on FCHV work profiles, the services they provide, and the support they receive from different levels of the health system. In addition, the survey set out to understand FCHV motivational factors, and how FCHVs are perceived by the communities that they serve. The ultimate goal of the survey was to identify possible suggestions for policy change or other strategies to sustain the FCHV program in Nepal.
Factors Associated with Anemia among Pregnant Women of Underprivileged Ethnic...Prabesh Ghimire
Abstract
Background. This study aims at determining the factors associated with anemia among pregnant women of underprivileged ethnic groups attending antenatal care at the provincial level hospital of Province 2. Methods. A hospital-based cross-sectional study was carried out in Janakpur Provincial Hospital of Province 2, Southern Nepal. 287 pregnant women from underprivileged ethnic groups attending antenatal care were selected and interviewed. Face-to-face interviews using a structured questionnaire were undertaken. Anemia status was assessed based on hemoglobin levels determined at the hospital’s laboratory. Bivariate and multiple logistic regression analyses were used to identify the factors associated with anemia. Analyses were performed using IBM SPSS version 23 software. Results. The overall anemia prevalence in the study population was 66.9% (95% CI, 61.1–72.3). The women from most underprivileged ethnic groups (Terai Dalit, Terai Janajati, and Muslims) were twice more likely to be anemic than Madhesi women. Similarly, women having education lower than secondary level were about 3 times more likely to be anemic compared to those with secondary level or higher education. Women who had not completed four antenatal visits were twice more likely to be anemic than those completing all four visits. The odds of anemia were three times higher among pregnant women who had not taken deworming medication compared to their counterparts. Furthermore, women with inadequate dietary diversity were four times more likely to be anemic compared to women having adequate dietary diversity. Conclusions. The prevalence of anemia is a severe public health problem among pregnant women of underprivileged ethnic groups in Province 2. Being Dalit, Janajati, and Muslim, having lower education, less frequent antenatal visits, not receiving deworming medication, and having inadequate dietary diversity are found to be the significant factors. The present study highlights the need of improving the frequency of antenatal visits and coverage of deworming program in ethnic populations. Furthermore, promoting a dietary diversity at the household level would help lower the prevalence of anemia. The study findings also imply that the nutrition interventions to control anemia must target and reach pregnant women from the most-marginalized ethnic groups and those with lower education
Observational analytical study: Cross-sectional, Case-control and Cohort stu...Prabesh Ghimire
This presentation provides overview of three observational analytical studies: cross-sectional study design, case-control study design and cohort study design
Development of test instruments
Includes information about:
Methods of collecting information
Interview techniques and tools
Observation: concept and observation checklist
This is the product of compilation from various sources. I would like to acknowledge all direct and indirect sources although they have not been mentioned explicitly within the document.
This product is the result of compilation from various sources. I would like to acknowledge all direct and indirect sources, although they have not been explicitly mentioned within the document.
This product is the result of compilation from various sources. I acknowledge all direct and indirect sources although they have not been mentioned explicitly in the document.
New Organogram of Nepalese Health System (Please check the updated slides on ...Prabesh Ghimire
This slide has been updated to accommodate the recent changes. Please check the following link for the updated presentation:
https://www.slideshare.net/PrabeshGhimire/organogram-organization-structure-of-nepalese-health-system-updated-nov-2021
Bilateral and Multilateral Organizations in NepalPrabesh Ghimire
Declaration: The materials incorporated in this document have come from variety of sources and compiler bears no responsibilities for any information contained herein. The compiler acknowledges all the sources although references have not been explicitly cited for all the contents in this document.
Declaration: The materials incorporated in this document have come from variety of sources and compiler bears no responsibilities for any information contained herein. The compiler acknowledges all the sources although references have not been explicitly cited for all the contents in this document.
International Non Government Organizations (INGOs) in NepalPrabesh Ghimire
Declaration: The materials incorporated in this document have come from variety of sources and compiler bears no responsibilities for any information contained herein. The compiler acknowledges all the sources although references have not been explicitly cited for all the contents in this document.
Declaration: The materials incorporated in this document have come from variety of sources and compiler bears no responsibilities for any information contained herein. The compiler acknowledges all the sources although references have not been explicitly cited for all the contents in this document.
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
CHAPTER 1 SEMESTER V PREVENTIVE-PEDIATRICS.pdfSachin Sharma
This content provides an overview of preventive pediatrics. It defines preventive pediatrics as preventing disease and promoting children's physical, mental, and social well-being to achieve positive health. It discusses antenatal, postnatal, and social preventive pediatrics. It also covers various child health programs like immunization, breastfeeding, ICDS, and the roles of organizations like WHO, UNICEF, and nurses in preventive pediatrics.
The dimensions of healthcare quality refer to various attributes or aspects that define the standard of healthcare services. These dimensions are used to evaluate, measure, and improve the quality of care provided to patients. A comprehensive understanding of these dimensions ensures that healthcare systems can address various aspects of patient care effectively and holistically. Dimensions of Healthcare Quality and Performance of care include the following; Appropriateness, Availability, Competence, Continuity, Effectiveness, Efficiency, Efficacy, Prevention, Respect and Care, Safety as well as Timeliness.
Leading the Way in Nephrology: Dr. David Greene's Work with Stem Cells for Ki...Dr. David Greene Arizona
As we watch Dr. Greene's continued efforts and research in Arizona, it's clear that stem cell therapy holds a promising key to unlocking new doors in the treatment of kidney disease. With each study and trial, we step closer to a world where kidney disease is no longer a life sentence but a treatable condition, thanks to pioneers like Dr. David Greene.
Telehealth Psychology Building Trust with Clients.pptxThe Harvest Clinic
Telehealth psychology is a digital approach that offers psychological services and mental health care to clients remotely, using technologies like video conferencing, phone calls, text messaging, and mobile apps for communication.
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
ICH Guidelines for Pharmacovigilance.pdfNEHA GUPTA
The "ICH Guidelines for Pharmacovigilance" PDF provides a comprehensive overview of the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) guidelines related to pharmacovigilance. These guidelines aim to ensure that drugs are safe and effective for patients by monitoring and assessing adverse effects, ensuring proper reporting systems, and improving risk management practices. The document is essential for professionals in the pharmaceutical industry, regulatory authorities, and healthcare providers, offering detailed procedures and standards for pharmacovigilance activities to enhance drug safety and protect public health.
Health Education on prevention of hypertensionRadhika kulvi
Hypertension is a chronic condition of concern due to its role in the causation of coronary heart diseases. Hypertension is a worldwide epidemic and important risk factor for coronary artery disease, stroke and renal diseases. Blood pressure is the force exerted by the blood against the walls of the blood vessels and is sufficient to maintain tissue perfusion during activity and rest. Hypertension is sustained elevation of BP. In adults, HTN exists when systolic blood pressure is equal to or greater than 140mmHg or diastolic BP is equal to or greater than 90mmHg. The
CRISPR-Cas9, a revolutionary gene-editing tool, holds immense potential to reshape medicine, agriculture, and our understanding of life. But like any powerful tool, it comes with ethical considerations.
Unveiling CRISPR: This naturally occurring bacterial defense system (crRNA & Cas9 protein) fights viruses. Scientists repurposed it for precise gene editing (correction, deletion, insertion) by targeting specific DNA sequences.
The Promise: CRISPR offers exciting possibilities:
Gene Therapy: Correcting genetic diseases like cystic fibrosis.
Agriculture: Engineering crops resistant to pests and harsh environments.
Research: Studying gene function to unlock new knowledge.
The Peril: Ethical concerns demand attention:
Off-target Effects: Unintended DNA edits can have unforeseen consequences.
Eugenics: Misusing CRISPR for designer babies raises social and ethical questions.
Equity: High costs could limit access to this potentially life-saving technology.
The Path Forward: Responsible development is crucial:
International Collaboration: Clear guidelines are needed for research and human trials.
Public Education: Open discussions ensure informed decisions about CRISPR.
Prioritize Safety and Ethics: Safety and ethical principles must be paramount.
CRISPR offers a powerful tool for a better future, but responsible development and addressing ethical concerns are essential. By prioritizing safety, fostering open dialogue, and ensuring equitable access, we can harness CRISPR's power for the benefit of all. (2998 characters)
Global launch of the Healthy Ageing and Prevention Index 2nd wave – alongside...ILC- UK
The Healthy Ageing and Prevention Index is an online tool created by ILC that ranks countries on six metrics including, life span, health span, work span, income, environmental performance, and happiness. The Index helps us understand how well countries have adapted to longevity and inform decision makers on what must be done to maximise the economic benefits that comes with living well for longer.
Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
Professor Orazio Schillaci, Minister of Health, Italy
Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
Dr Karin Tegmark Wisell, Director General, Public Health Agency of Sweden
2. Ghimire et al
International Journal of Health Policy and Management, 2019, 8(11), 636–645 637
Background
In many developing countries, out-of-pocket health
expenditure of patients or their families constitute a large
proportion of amount spent on healthcare. This proportion
has been estimated to be the highest ie, 40.8% in the World
Health Organization (WHO) South East Asia Region.1
In
Nepal, household out-of-pocket health expenditure alone
contributes to 56.3% of current health expenditure.2
In
countries where out-of-pocket expenditure is the most
important source of healthcare financing, households can
experience financial catastrophe and often impoverishment
as a result of their out-of-pocket spending on healthcare.1,3
Over the past decades, many low- and middle-income
countries (LMICs) have faced severe challenges to sustain
sufficient financing for healthcare and to provide adequate
financial protection against impoverishing effects of
catastrophic illness.4
Because of these concerns, moving
away from out-of-pocket healthcare payments to prepayment
social health protection mechanisms has widely been argued
as an important step towards reducing risks from financial
hardship.Aresolutionpassedbyworldhealthassemblyin2005
called for countries to introduce prepayment mechanisms
in the health sector for sharing risk as well as to avoid
catastrophic healthcare expenditure and impoverishment of
individuals as a result of seeking care.5
World health report
2010 also advocated health insurance as one of the promising
means of subsidizing the entire population and achieving
universal healthcare coverage.6
Various countries in the
world responded to these calls by adopting different health
financing mechanisms including voluntary community-
based and social health insurance schemes.7
In Nepal, a variety of pre-paid healthcare financing schemes
have been launched in the past to strengthen the social health
protectionofNepalesecitizens.Despitehavingalonghistoryof
private, non-profit health insurance schemes,8,9
a government
funded community-based health insurance (CBHI) program
was initiated in 2003 at 2 districts and was expanded to an
additional 4 districts by 2006.10
Over the past several years,
Ministry of Health made remarkable efforts to expand social
health protection through health financing schemes such as
FreeBasicHealthcareProgram,Aamaprogram,Screeningand
Treatment of Uterine Prolapse and Poverty Stricken Citizens
Fund.10
Nevertheless several of these schemes experimented
in Nepal were often fragmented in resource allocation and
inefficient in securing a comprehensive financial protection
to its citizens.11,12
In this context, Government of Nepal
recently embarked on a path to universal coverage through
implementation of national social health insurance program.
Consequently in 2016, a National Health Insurance Program
(NHIP) was introduced in the country beginning its operation
at 3 districts (Kailali, Ilam, and Baglung). By the mid of 2017,
the program was operational in fifteen districts with gradual
expansion to other districts in a phased manner.13
Nepal’s NHIP is a family-based scheme characterized
by voluntary enrolment of households. In many LMICs,
voluntary health insurance schemes have often failed to cover
a large proportion of their target population.14
Even at national
level, the government’s experience with implementing CBHI
schemes in the past did not exhibit positive results. The
sustainability of CBHI scheme was threatened by limited
coverage of the population. The enrolment in public CBHI
schemes ranged from 1.6%-12% of the catchment area
population. The enrolment in private CBHI schemes was
also lower ie, 2.7% of the population.10
The initial reports
of NHIP also highlight difficulties in capturing its target
population. Within the first year of its operation, only 5% of
the population was covered by the scheme.13
Currently, there
have been wider concerns regarding the capacity of NHIP
to achieve adequate population coverage and remain viable.
Nevertheless, Government of Nepal considers this scheme as
a cornerstone for making progress towards universal coverage
and aims to expand to all 77 districts by 2020. Given low
enrolment in the scheme to date, achieving adequate coverage
of households requires understanding factors that influence
such enrolment.
Multitudes of factors are shown to have a variable influence
on health insurance enrolment, and these factors vary
between countries. Large body of literature from various
LMICs suggest that enrolment in health insurance program
is influenced by range of factors such as age, gender, and
education of the household head, household income,
household size, presence of children and elderly, place of
residence, distance to health facility and household illness
experience.14,15
However, only a limited number of studies in
Asia have explored these factors at household level.16,17
Given
a unique socio-economic context, health system status and
a unique family-based insurance modality of the NHIP, the
factors established at those countries are likely to vary in the
Nepalese context. Nonetheless, the evidence base for health
insurance programs in Nepal remains very weak. It is against
this background that the study aimed to identify the factors
associated with enrolment of households in the Nepal’s NHIP.
The evidence generated might inform policy-makers towards
addressing the problems of low enrolment in the NHIP.
Overview of Nepal’s National Health Insurance Program
In order to ensure universal coverage, the government of
Nepal adopted the National Health Insurance Policy in 2013.
The policy aims to ensure equitable and universal access for
all Nepalese citizens to necessary quality health services.18
Under this policy, a semi-autonomous Social Health Security
Development Committee was established in 2015 (after the
enactment of Health Insurance Act by the parliament of Nepal
in 2017, Social Health Security Development Committee has
been replaced by an autonomous Health Insurance Board)
and the NHIP was rolled out at Kailali district in April 2016.
The program was expanded to the 2 additional districts ie,
Baglung and Ilam in June 201619
and later the program was
gradually expanded in a phase-wise manner to other districts.
The government of Nepal aims to expand this program to all
77 districts by 2020.13
Premium for NHIP are collected from
households and the annual contribution amount depends
on the size of the family with Nepali Rupees (NPR) 2500 for
families up to 5 members and NPR 425 for each additional
member in the family. However, the payment of premium
by ultra-poor, poor and marginalized groups are subsidized
3. Ghimire et al
International Journal of Health Policy and Management, 2019, 8(11), 636–645
638
by the government.20
There is not any other cost sharing or
co-payments with the NHIP, except the premium paid. Each
family up to 5 members receives a benefit up to NPR 50 000.
Families with more than 5 members receive an additional
benefit of NPR 10
000 for each additional member of the
family not exceeding a maximum benefit ceiling of NRP
100
000 per family.13,20
The benefit package of the NHIP
consists of emergency services, outpatient consultations,
inpatient services, selected drugs and diagnostic services.
However, some services classified to be unnecessary or very
expensive are on the exclusion list. Among these are cosmetic
surgery, secondary equipment/machines such as artificial
organs, vision glasses (costing more than NPR 500), hearing
equipment, services relating to artificial insemination,
abortion services, dental services and treatment for injuries
resulting from fights or consumption of drugs or alcohol.20
NHIP is a cash-less system such that the members can receive
services and drugs covered by the program without having to
pay at any stage. The provider payments are made by Health
Insurance Board on the basis of claims made by providers
according to the agreed rates. The claim management process
is streamlined through Insurance Management Information
System (IMIS).21
Table 1 presents key features of the NHIP.
Methods
Settings for the Study
This study was purposively conducted in Ilam district which
was one of the first 3 districts (Kailali, Ilam, and Baglung) that
had completed its first year of enrolment cycle. Ilam is a hill
district of Eastern Nepal and 1 of the 14 districts of province
1. The district covers an area of 1707 km2
with population
of 287 916.23
It is administratively divided into 6 Palikas (4
municipalities and 6 rural municipalities). Ilam Municipality
and Sandakpur rural municipality were selected as study sites.
Ilam municipality is district headquarter located at about
600 km east from Kathmandu, the capital city. Sandakpur
rural municipality lies about 20 km north-east from district
headquarter. Both Ilam and Sandakpur have a population
of diverse ethnic groups comprising of privileged Brahmins,
Chhetris, Gurungs and Newars and underprivileged janajatis
(indigenouspeople)anddalits(theoppressed).24
Forcenturies,
these underprivileged groups are socially ascribed lower in the
caste/ethnicity hierarchy and face certain disparities in terms
of access to healthcare, education, economic opportunities as
well as political and social representation.25
Study Design and Sampling Procedure
This study was cross-sectional and comparative. 570
Table 1. Key Features of NHIP
Features Description
Roll out year - April 2016
Administration
- Currently administered by an autonomous Health Insurance Board (During the implementation of this study, the scheme was
administered by Social Health Security Development Committee, a semi-autonomous body)
- The board provides membership cards, makes decisions on contribution amounts, develops mechanisms for subsidies to
poor and disadvantaged groups, as well as negotiates with service providers on benefit package, their costs and deals with
provider payments
Membership - Voluntary scheme based on family contributions20
Sources of revenue
- Budget allocated by Government of Nepal
- Premium contributions from households where families with up to 5 members contribute NPR 2500 (US$21.59a
) per year
and NPR 425 (US$3.67) per additional member13,20
Exemptions - 100% exemption in annual premium for ultra-poor, 75% for poor and 50% for marginalized20
Service delivery
channels
- Public Health Facilities
- Private health facilities selected through contracting
Benefit Package
- Benefits of up to NPR 50 000 (US$431.70) per year are provided to insured families of up to 5 members with an additional
NPR 10 000 (US$86.34) covered for each additional member. The maximum amount of benefit available to a family per year
is NPR 100 00020
- Covers emergency services, outpatient consultations, selected inpatient services, drugs and diagnostic services
- Includes 928 types of medicines13
Co-payments - No co-payments or other cost sharing arrangements
Exclusion list
- Services considered to be unnecessary or very expensive are on the exclusion list
- Excludes cosmetic surgery, spectacles costing more than NPR 500 (US$4.32), hearing aids, artificial insemination, dental
services and treatment for injuries suffered in a drunken brawl20
Provider payment
mechanisms
- Case-based payment for outpatient and emergency services
- Fee for service for inpatient and diagnostic services
Claim management
- Service provider health institutions submit claim to Health Insurance Board through IMIS
- Health Insurance Board reviews and approves the claim for reimbursement to service provider health institutions
Information system
used
- Uses an internet-based IMIS. This system is used for registration of membership and renewal, claim management, feedback
and reporting
Abbreviations: NPR, Nepali Rupees; NHIP, National Health Insurance Program; IMIS, insurance management information system.
a
Note: 1 US dollar equivalent to 115.82 NPR based on exchange rate of Nepal Rastra Bank.22
4. Ghimire et al
International Journal of Health Policy and Management, 2019, 8(11), 636–645 639
households were studied by recruiting equal number of
enrolled (n
=
285) and non-enrolled (n
=
285) households.
The sample size was estimated using Epi Info StatCalc
software assuming 90% power of the study and 95% level of
confidence. We assumed the percentage of households from
under-privileged group discontinuing the insurance scheme
at 56% with an odds ratio of 1.76.26
The sample size for each
Palika (municipality) was proportionate to the total number
of NHIP enrolled households. The selection of enrolled
households at each Palika was done using simple random
sampling. The list of enrolled households was obtained from
Social Health Security Development Committee (now Health
Insurance Board) through its IMIS. Enrolment assistants
(volunteers who are responsible to register and enrol families
to NHIP) and female community health volunteers helped
in locating the sampled households. For every enrolled
household recruited for the study, one comparison household
(not-enrolled to NHIP) was selected from the nearest
neighbour located in any direction. Non-enrolled households
living in the study area for less than 6 months were not
included in the study.
Data Collection
A structured questionnaire was developed based on study
objectives. A Nepal Demographic and Health Survey
questionnaire was adapted for measuring wealth index.27
In order to enhance the content validity of the tool, the
questionnaire was subjectively assessed by 2 health insurance
experts for its content, organization, appropriateness as
well as logical flow of the instrument. Contextualization
of the tool was done by reviewing national documents on
health insurance. The questionnaire was pretested among 44
households before application. The questionnaire included
4 sections; socio-demographic and economic information;
morbidity status, perceived health status of the family and
enrolment status of households. Household survey to collect
data was carried out from September to October 2017. The
tool was administered to household heads in Nepali language
using face to face interview. A written informed consent
was obtained from the participants before interview. One
enumerator with a university degree and prior field research
experience was trained and mobilized as interviewer.
Variables
Outcome Variable
The outcome variable for this study was the health insurance
enrolment status of households. Those enrolled in the NHIP
were coded as 1 and 0 otherwise.
Explanatory Variables
The choice of explanatory variables in this study was guided by
Anderson and Newman behavioural model of health service
utilization28,29
and the review of literature on the determinants
of enrolment in the health insurance schemes.30-35
The
behavioural model envisages that household’s decision to
enrol in health insurance scheme depends on 3 set of factors
namely; predisposing factors (demographic, and social
structures and health beliefs that predisposes households to
enrol in the NHIP), enabling factors (that facilitate or impede
households to enrol in the NHIP) and need factors (that
induce the need for households to enrol in the NHIP).
In this study, the predisposing factors included age of
household head classified into 3 categories (less than 40 years,
40-59 years and 60 years or older); gender of household head
(male or female); education of household head (no formal
education, up to secondary level education or post-secondary
education); household size (≤5 members or >5 members);
family type (nuclear or joint/extended); presence of children
aged 0-5 years (no children or at least one children);
presence of elderly above 60 years (no elderly or at least one
elderly); number of family members who had completed
their secondary education (none or at least one member)
and ethnicity (privileged or underprivileged). Privileged
ethnic group comprised of upper caste people (Brahmin
and Chhetri) and relatively advantaged janajatis (Newar and
Gurung) and underprivileged ethnic group comprised of
dalits and disadvantaged janajatis. The socio-economic status
of households was examined as a predisposing factor. This
was measured by constructing a wealth index using principal
component analysis based on data on household ownership
of durable assets. The components included were ownership
of house, electronic assets (television, refrigerator, computer/
laptop), mobile and non-mobile telephone, vehicles, animals,
types of fuel used for cooking and source of drinking water.
These components were converted into a weighted index
(factor score) and the households were then divided into 5
quintiles of wealth.36
The first quintile represented the poorest
segment of the population and fifth quintile, the least poor.
Needs factors in this study included morbidity conditions
of households and perceived health status of the family.
Morbidity conditions of households was assessed using 2
variables; past illness experience and presence of chronic
illness in the family. Past illness experience was a self-reported
response in which respondents were asked to recall if any
of their family members had experienced any acute illness
requiring health facility visit within 3 months preceding the
survey. The responses were recorded as “Yes” or “No.” The
presence of chronic illness was recorded as “Yes” if at least one
of members in family suffered from either of heart disease,
diabetes, chronic obstructive pulmonary disease, and cancer.
Perceived health status of family was rated as good, average,
or poor. Table 2 presents a summary of the study variables.
Data Management and Analysis
A digital questionnaire was prepared using Epi Info
application and data were collected using tablets. To prevent
the risk of data loss, the collected data was uploaded to cloud
storage on a daily basis. Compilation of data was done in
Epi InfoTM
7.2.1.0 and then exported to IBM SPSS Statistics
version 23.0 for cleaning and analysis. Descriptive statistics
were used to report the demographic and socio-economic
factors, morbidity characteristics and perception. The wealth
index was generated using principal component analysis.
Pearson’s chi-square test was performed to test the association
of independent variable with enrolment in NHIP. Multiple
logistic regression was used to investigate the effect of these
5. Ghimire et al
International Journal of Health Policy and Management, 2019, 8(11), 636–645
640
variables on the odds of enrolment in the NHIP. Multi-
collinearity of variables was tested before entering them in
the regression analysis. No problem of collinearity was seen
among the variables (the highest observed VIF was 1.937).
All variables significant at 15% significance level in bivariate
analyses were considered for multiple logistic regression.38
The goodness of fit of regression model was tested by the
application of Hosmer and Lemeshow chi-square test; the
model was found to be a good fit (P > .05).
The regression model was explained by the equation:
Log [Y/(1-Y)] = bo
+ b1
X1
+ b2
X2
+ b3
X3
.....bn
Xn
+ e
Where Y is the expected probability for the outcome
variable to occur, bo
is the constant/intercept, b1
through bn
are
the regression coefficients and the X1
through Xn
are distinct
independent variables and e is the error term.
Results
Characteristics of the Study Population
The mean age of respondents was 41.8 (standard deviation
[SD] = 13.5 years). Majority (87.4%) of the households were
headed by males. While more than one in 3 household heads
(35.3%) had completed their secondary level education, nearly
1 in 5 household heads (18.6%) had no formal education. The
average household size of the study population was 4.8 (SD
= 1.6).
More than half of the surveyed households belonged to
privileged ethnic group (56.1%). Majority households had
equal to or less than 5 members (74.4%) and lived in a nuclear
family(54.7%).Slightlylessthanone-thirdhouseholds(30.2%)
had children below 5 years of age and about 2 in 5 households
(39.6%) had elderly members above 60 years of age. Three in
4 households (76.3%) had at least 1 family member who had
completed their secondary education. Two in 5 households
(43.5%) had at least 1 family member with illness experience
in past 3 months. More than one-third households (36.1%)
had a family member suffering from chronic illness. Slightly
more than one in ten household heads (13.5%) perceived
health status of their family as poor (Table 3).
Factors Associated With Enrolment in NHIP
In the bivariate analyses of enrolment in NHIP with
demographic and socio-economic factors, morbidity
characteristics and perception, significant association
was found with education of household head (P = .001),
household size (P = .035), type of family (P < .001), ethnicity
(P < .001), presence of elderly (P = .001), number of members
with completed secondary education (P < .001), socio-
economic status (P
<
.001), illness experience in family
(P < .001), and presence of chronic illness (P < .001). Gender
of household head, presence of children and perceived health
status of family did not show any significant association with
enrolment of households in NHIP (Table 4).
Table 2. Summary of Study Variables
Variable Definition of Variables Measurements
Outcome Variable
Enrolment status Status of the household’s membership in the NHIP Enrolled (coded 1), not-enrolled (coded 0)
Explanatory Variables
Age
Age of household in completed years at the time of
household survey
Less than 40 years, 40-59 years, 60 years or older
Gender Gender of household head Male, female
Education
The highest level of education attained by household
head
No formal education, up to secondary level, post-
secondary education
Ethnicity Ethnicity of household members
Privileged (upper caste people and advantaged janajati),
under-privileged (dalits and disadvantaged janajati)
Household size
The number of family members living in the
household
Five or less members, more than 5 members
Family type Type and composition of family Nuclear, joint or extended
Presence of children aged 0-5 years
The number of children aged between 0 to 5 years
present in the household
None, at least 1 child
Presence of elderly above 60 year
The number of elderly members above 60 years
present in the household
None, at least 1 elderly
No. of members completed
secondary education
The number of family members who have completed
their secondary education
None, at least 1 member
Socio-economic status
Socio-economic position of households based on
wealth quintile
Richest, rich, middle, poor, poorest
Illness experience
Number of family members who experienced any
acute illness within 3 months prior to the survey
period
None, at least 1 member
Presence of chronic illness
Number of family members who have at least one
chronic illness
None, at least 1 member
Perceived health status of the
family
Health status of the family as rated by the household
head
Good, average, poor
Abbreviation: NHIP, National Health Insurance Program.
6. Ghimire et al
International Journal of Health Policy and Management, 2019, 8(11), 636–645 641
Table 3. General Characteristics of the Study Population (n = 570)
Characteristics Number Percent 95% CI
Agea
Less than 40 years 275 48.2 44.1-52.4
40-59 years 224 39.3 35.3-43.4
60 years or older 71 12.5 9.9-15.5
Gender
Male 498 87.4 84.4-90.0
Female 72 12.6 10.0-15.6
Education of household head
No formal education 106 18.6 15.5-22.0
Up to secondary level (grade 1-10) 263 46.1 42.0-50.3
Post-secondary education (>grade 10) 201 35.3 31.3-39.3
Ethnicity
Privileged ethnic group 320 56.1 52.0-60.3
Underprivileged ethnic group 250 43.9 39.7-48.0
Household sizeb
Five or less members 424 74.4 70.6-77.9
More than 5 members 146 25.6 22.1-29.4
Family type
Nuclear 312 54.7 50.5-58.9
Joint or extended 258 45.3 41.1-49.5
Presence of children aged 0-5 years
None 398 69.8 65.9-73.6
At least 1 child 172 30.2 26.4-34.1
Presence of elderly above 60 years
None 344 60.4 56.2-64.4
At least one elderly 226 39.6 35.6-43.8
Illness experience (in past 3 months)
None 322 56.5 52.3-60.6
At least one member 248 43.5 39.4-47.7
Presence of chronic illness
None 364 63.9 59.8-67.8
At least one member 206 36.1 32.2-40.2
Perceived health status of family
Good 275 48.2 44.1-52.4
Average 218 38.2 34.2-42.4
Poor 77 13.5 10.8-16.6
a
Mean ± standard deviation [SD] = 41.8 ± 13.5.
b
Mean ± SD = 4.8 ± 1.6.
During the regression analysis, enrolment in NHIP showed
significant association with ethnicity, socio-economic status,
illness experience in family and presence of chronic illness.
The odds that households would enrol in NHIP were higher
among those with higher socio-economic status. Richest
householdswere4timesmorelikelytoenrolinNHIP(adjusted
odds ratio [AOR]: 4.08, 95% CI: 2.15-7.72) compared to those
in a poorest category. Similarly, households belonging to the
privileged ethnic group were 1.7 times more likely (AOR:
1.71, 95% CI: 1.18-2.48) to enrol in NHIP compared to ones
from underprivileged ethnic group. The households in which
at least one of their members experienced acute illness were
1.5 times more likely (AOR: 1.51, 95% CI: 1.04-2.19) to enrol
in NHIP compared to households that did not have such
illness experience. Similarly, households with chronically ill
members were 1.8 times more likely (AOR: 1.84, 95% CI:
1.23-2.73) to enrol in NHIP compared to households that did
not suffer a chronic illness (Table 5).
Discussion
Our study results showed that belonging to privileged ethnic
group, having a higher socio-economic status, having an
experience of acute illness by family member and presence
of chronic illness in the family are the potential factors that
influence the enrolment of households in NHIP.
This study confirmed an association between ethnicity
and household enrolment in the NHIP. The households from
privileged ethnic groups were more likely to enrol in NHIP
compared to those from underprivileged ethnic groups. This
might be explained by the fact that underprivileged ethnic
groups are more likely to be financially unstable and have
relatively less access to information and services. Hill janajati
and hill dalits represent significantly higher proportions
of the poor in Nepal.39
Paying for enrolment into the social
security schemes like NHIP might therefore be too difficult
for these groups. Previous studies have also confirmed the
role of ethnicity in determining the enrolment of households
in the health insurance schemes.32,40,41
Evidences from studies
in various LMICs have shown a positive association between
wealth or socio-economic status and health insurance
uptake.34,35,42,43
Bivariate and multivariate analyses in this study
also confirmed a similar association. The richest households
were 4 times more likely to enrol in NHIP as compared to
those in poorest category. One explanation for these findings
might be that richer and ethnically privileged families are
better connected to the government and enrol more in other
non-healthcare related government programs and services.
With greater interactions, they might have better exposure
to insurance information and knowledge on how to enrol.
In a study about United States Medicaid program, Saavedra
showed that those enrolled in other forms of government
programs are more likely to have health insurance coverage.44
Despite the policy provisions to subsidize the premium of
the poor and marginalized,20
NHIP does not seem to provide
financial protection to these segments of population. The
study results clearly show marked differences in enrolment
status between rich-poor and privileged-underprivileged
ethnic groups. These findings point out the issues of inequity
in enrolment. This might be because the pro-poor targeting
have not yet been realized in practice due to the delay in
distribution of poverty identification cards to these segments
of the population.13
Addressing these disparities in enrolment
of household in the NHIP across socio-economic and ethnic
group is necessary to accelerate the pace towards achieving
universal health coverage.
This study found an association between experience of
acute illness and enrolment in the NHIP. The presence
of chronically ill member in the household also showed
significant association with NHIP enrolment. Similar
7. Ghimire et al
International Journal of Health Policy and Management, 2019, 8(11), 636–645
642
Table 4. Association of Enrolment in NHIP With Various Characteristics
Demographic, Socio-economic, Morbidity
Characteristics and Perception
Enrolled (n = 285) Not-enrolled (n = 285)
P Value
No. (%) 95% CI No. (%) 95% CI
Gender of household head .313
Male 253 (50.8) 46.3-55.3 245 (49.2) 44.7-53.7
Female 32 (44.4) 32.7-56.6 40 (55.6) 43.4-67.3
Education of household head .001a
Secondary level and higher 120 (59.7) 52.6-66.5 81 (40.3) 33.5-47.4
Below secondary level 165 (44.7) 39.6-49.9 204 (55.3) 50.1-60.4
Household size .035a
More than 5 members 84 (57.5) 49.1-65.7 62 (42.5) 34.3-50.9
Five or less members 201 (47.4) 42.6-52.3 223 (52.6) 47.7-57.4
Family type <.001a
Joint/Extended 150 (58.1) 51.9-64.2 108 (41.9) 35.8-48.1
Nuclear 135 (43.3) 37.7-49.0 177 (56.7) 51.0-62.3
Ethnicity <.001a
Privileged ethnic group 191 (59.7) 54.1-65.1 129 (40.3) 34.9-45.9
Underprivileged ethnic group 94 (37.6) 31.6-43.9 156 (62.4) 56.1-68.4
Presence of children aged 0-5 years .584
At least 1 83 (48.3) 40.6-56.0 89 (51.7) 44.0-59.4
None 202 (50.8) 45.7-55.8 196 (49.2) 44.2-54.3
Presence of elderly above 60 years <.001a
At least 1 132 (58.4) 51.7-64.9 94 (41.6) 35.1-48.3
None 153 (44.5) 39.1-49.9 191 (55.5) 50.1-60.9
No. of members completed secondary education <.001a
At least 1 236 (54.3) 49.4-59.0 199 (45.7) 41.0-50.6
None 49 (36.3) 28.2-45.0 86 (63.7) 55.0-71.8
Socio-economic status <.001a
Q1-Poorest 39 (34.2) 25.6-43.7 75 (65.8) 56.3-74.4
Q2-Poor 61 (41.5) 33.4-49.9 86 (58.5) 50.1-66.6
Q3-Middle 32 (41.5) 31.8-55.3 42 (56.8) 44.7-68.2
Q4-Rich 62 (52.5) 43.1-61.8 56 (47.5) 38.2-56.9
Q5-Richest 91 (77.8) 69.2-84.9 26 (22.2) 15.1-30.8
Illness experience (in past 3 months) <.001a
At least 1 member 149 (60.1) 53.7-66.2 99 (39.9) 33.8-46.3
None 136 (42.2) 36.8-47.8 186 (57.8) 52.2-63.2
Number of members with chronic illness <.001a
At least 1 member 134 (65.0) 58.1-71.5 72 (35.0) 28.5-41.9
None 151 (41.5) 36.4-46.7 213 (58.5) 53.3-63.6
Perceived health status of family .214
Good 144 (52.4) 46.3-58.4 131 (47.6) 41.6-53.7
Average 99 (45.4) 38.7-52.3 119 (54.6) 47.7-61.3
Poor 42 (54.5) 42.8-65.9 35 (45.5) 34.1-57.2
Abbreviation: NHIP, National Health Insurance Program.
a
Statistically significant at P < .05.
findings have also been reported in several studies from other
LMICs.17,45,46
These findings support the notion that families
with pre-existing health conditions or more prone to being ill
have a greater tendency to enrol in a health insurance scheme.
From a public health perspective, this is very encouraging as
it enhances healthcare access for those with poor health.17,47
The observed association also indicates the possibility of
adverse selection taking place in a NHIP which is critical
from a sustainability point of view. Adverse selection
results when high-risk or sick individuals enrol more in the
health insurance schemes compared to low-risk or healthy
individuals. Adverse selection might limit potential for
cross-subsidies and can affect the sustainability and financial
viability of the scheme.17,48
In the case of Nepal’s NHIP, entire households are enrolled
as unit. Household enrolment is ideally believed to lessen the
problems of adverse selection by bringing into the insurance
pool all healthier family members those who would not
otherwise enrol.49
Nevertheless, the financial viability of the
scheme can be threatened if the provisions for household
8. Ghimire et al
International Journal of Health Policy and Management, 2019, 8(11), 636–645 643
enrolment are not strictly enforced. In a study of rural mutual
healthcare health insurance scheme in China, Wang et al
found significant adverse selection among partially enrolled
households because the policy to enrol households as a unit
was not fully enforced.50
Similar situation in Nepal’s NHIP
therefore cannot be ruled out where there are also possibilities
for larger size households to partially enrol their sickest
member. Since the partial enrolment status of households was
not examined by our study, we recommend detailed studies
to substantiate the presence of adverse selection and to assess
whether it would threaten the financial viability of the scheme.
Considering the patriarchal nature of Nepalese society,
men are conventionally considered responsible for major
financial decisions within the households. In contrast to
this presumption, gender of household head in this study
showed no association with enrolment in NHIP. The available
evidence however is mixed regarding association between
gender of household head and enrolment in health insurance
scheme. While some studies suggested that female headed
households are more likely to purchase health insurance,31,34,40
Table 5. Odds of Enrolment in NHIP Due to Various Characteristics
Demographic, Socio-economic and
Morbidity Characteristics
Enrolment in NHIP
OR 95% CI
Education of household head
Secondary level and higher 1.37 0.90-2.07
Below Secondary level 1 1
Household Size
More than 5 0.97 0.58-1.62
Less than or equal to 5 1 1
Family type
Joint/extended 1.41 0.86-2.31
Nuclear - 1
Ethnicity
Privileged group 1.71a
1.18-2.48
Underprivileged group 1 1
No. of elderly above 60 years
At least 1 1.11 0.71-1.74
None 1 1
No. of members completed secondary education
At least 1 1.18 0.73-1.92
None 1 1
Socio-economic status
Richest 4.08a
2.15-7.72
Rich 1.53 0.86-2.75
Middle 1.27 0.67-2.40
Poor 1.08 0.63-1.86
Poorest 1 1
Illness experience (in last 3 months)
At least 1 member ill 1.51a
1.04-2.19
None 1 1
Presence of chronic illness
At least 1 member chronically ill 1.84a
1.23-2.73
None - 1
Abbreviations: OR, odds ratio; NHIP, National Health Insurance Program.
a
Statistically significant at P < .05.
others have shown that male headed households are more
likely to enrol in health insurance program,35,51
and yet other
studies reported no significant association in enrolment in
health insurance schemes between male and female headed
households.32,52
Although factor such as education of household head was
significantly associated in bivariate analysis, this relationship
was not significant after adjustments using regression
analysis. However, the role of education of household head in
enrolling their families into health insurance schemes cannot
be ruled out. Studies from Bangladesh, Ghana, Burkina Faso,
and Zimbabwe have shown positive associations between
health insurance uptake and higher education of household
head.32,33,35,46,53
Also our study did not find any significant
association between poor perceived health status and
increased uptake of health insurance although other studies
have established such association.34,54
The findings of this study might be relevant to policy and
decision-makers interested in increasing the NHIP enrolment
rates for households. First, the policy-makers should consider
the fact that poor socio-economic households are less enrolled
to NHIP than households with higher socio-economic status.
Simply proclaiming subsidies for poor and marginalized
households may not be enough to induce these households
to enrol into the NHIP. Robust and timely measures might
be necessary in order to put the pro-poor targeting policy
into practice. Second, policy-makers may wish to ensure
that households from underprivileged ethnic groups have
as much access to health insurance program as families
from privileged ethnic groups. Health Insurance Board and
policy-makers need to design policies and interventions that
will ensure equitable enrolment of unreached marginalized
ethnic groups. At the meantime, local governments and other
community stakeholders could play a significant role to raise
insurance awareness, engender community trust and increase
the connectedness of households to government programs
and schemes.
To the best of our knowledge, this study provides an early
evidence on the factors associated with household enrolment
in the newly implemented health insurance program of
Nepal. Although the findings of this study are consistent with
large body of literatures from various LMICs, we could not
relate these findings to our national context owing to the
limited number of literatures available for Nepal. The results
of this study might be affected by the purposive selection of
the study sites. Furthermore, the selection of neighbours of
enrolled households for comparison might have introduced a
selection bias. Due to the cross-sectional nature of our data,
it was not possible to demonstrate a temporal relationship
between enrolment in NHIP and explanatory variables.
Despite these limitations, the results of the study will add to
the knowledge base on the NHIP and generally be useful to
policy- and decision-makers at the government and health
insurance board and those in academia.
Conclusion
Belonging to the privileged ethnic group, having a higher
socio-economic status, experiencing an acute illness and
9. Ghimire et al
International Journal of Health Policy and Management, 2019, 8(11), 636–645
644
presence of chronically ill member in the family are the
factors associated with enrolment of households in NHIP.
Our study revealed gaps in enrolment between rich-poor
households and privileged-underprivileged ethnic groups.
Despite the stated pro-poor targeting of the NHIP, there is a
clear gap between the policy and its practice. Extending health
insurance coverage to poor and marginalized households is
therefore needed to increase equity and accelerate the pace
towards achieving universal health coverage.
Acknowledgements
This study was funded by the University Grants Commission
under it Masters Research Support Program to the first author
(Award no. MRS/74_75/HS-6). Department of Community
Medicine and Public Health, Maharajgunj Medical Campus
provided an institutional support to complete this study. The
authors also acknowledge the support of Health Insurance
Board. We thank Keshab Sanjel and Narayan Budhathoki
for their editorial assistance. We are grateful to the study
participants, field enumerator who contributed to data
collection and enrolment assistants and female community
health volunteers who helped in locating the sampled
households.
Ethical issues
The research protocol was approved by Institutional Review Board at Institute
of Medicine, Tribhuwan University, Kathmandu, Nepal.
Competing interests
Authors declare that they have no competing interests.
Authors’ contributions
PG designed the study, acquired data, performed data analysis and drafted the
manuscript. Both VPS and AKP participated in the conception and design of the
study and provided important critical revisions of the manuscript for important
intellectual content. AKP provided critical inputs during statistical analysis. All
authors read and approved the final manuscript.
References
1. WHO. World health statistics 2016: monitoring health for the
SDGs sustainable development goals: Geneva: World Health
Organization; 2016.
2. Pandey J, Karna R, Shrestha D, Neupane G, Bajracharya B. Nepal
national health accounts, 2009/2010–2011/2012. Kathmandu,
Nepal: Ministry of Health, Government of Nepal; 2016.
3. Saito E, Gilmour S, Rahman MM, Gautam GS, Shrestha PK,
Shibuya K. Catastrophic household expenditure on health in Nepal:
a cross-sectional survey. Bull World Health Organ. 2014;92(10):760-
767. doi:10.2471/BLT.13.126615
4. Gottret P, Schieber G. Health financing revisited: a practitioner’s
guide. The World Bank; 2006.
5. WHO. Sustainable health financing, universal coverage and social
health insurance, Resolution WHA58.33. Geneva: World Health
Organization; 2005.
6. WHO. The world health report 2010: health systems financing: the
path to universal coverage. Geneva: World Health Organization;
2010.
7. Giedion U, Andrés Alfonso E, Díaz Y. The impact of universal
coverage schemes in the developing world: a review of the existing
evidence. 2013.
8. Ghimire R. Community based health insurance practices in Nepal.
International Research and Reviews. 2013;2(4).
9. An inventory of micro-insurance schemes in Nepal. Kathmandu:
International Labour Office in Nepal, International Labour
Organization; 2003.
10. Stoermer M, Fuerst F, Rijal K, et al. Review of community-based
health insurance initiatives in Nepal. Deutsche Gesellschaft fur
internationale Zusammenarbeit (GIZ) Gmbh; 2012.
11. Pokharel R, Silwal PR. Social health insurance in Nepal: A health
system departure toward the universal health coverage. Int J Health
Plann Manage. 2018. doi:10.1002/hpm.2530
12. Torres LV, Gautam GS, Fuerst F. Assessment of the government
health financing system in Nepal: suggestions for reform. Deutsche
Gesellschaft für Internationale Zusammenarbeit; 2011.
13. Annual Report for FY 2073/74. Kathmandu: Social Health Security
Development Committee; 2017.
14. Acharya A, Vellakkal S, Taylor F, et al. Impact of national health
insurance for the poor and the informal sector in low- and middle-
income countries. London: The EPPI-Centre; 2012.
15. Dror DM, Hossain SS, Majumdar A, Koehlmoos TLP, John D,
Panda PK. What factors affect voluntary uptake of community-
based health insurance schemes in low- and middle-income
countries? a systematic review and meta-analysis. PLoS One.
2016;11(8):e0160479. doi:10.1093/heapol/czh014
16. Kamath R, Sanah N, Machado LM, Sekaran VC. Determinants of
enrolment and experiences of Rashtriya Swasthya Bima Yojana
(RSBY) beneficiaries in Udupi district, India. Int J Med Public Health.
2014;4(1). doi:10.4103/2230-8598.127164
17. Alkenbrack S, Jacobs B, Lindelow M. Achieving universal health
coverage through voluntary insurance: what can we learn from the
experience of Lao PDR? BMC Health Serv Res. 2013;13(1):521.
doi:10.1186/1472-6963-13-521
18. Government of Nepal. National health insurance policy. Kathmandu:
Ministry of Health and Population; 2013.
19. Ministry of Health. Annual Report for 2015/2016. Kathmandu:
Department of Health Services; 2017.
20. Social health security program operation rules (second amendment).
Kathmandu: Social Health Security Deveopment Committee; 2017.
21. Government of Nepal. Social health security programme: Standard
operating procedures. Kathmandu: Social Health Security
Development Committee; 2016.
22. Foreign exchange rates. https://www.nrb.org.np/fxmexchangerate.
php. Accessed September, 2018.
23. Brief introduction of rural municipality and municipality. Kathmandu:
Ministry of Federal Affairs and Local Development; 2017.
24. National population and housing census 2011 (National report).
Kathmandu, Nepal: National Planning Commission Secretariat,
Central Bureau of Statistics; 2012.
25. Bennet L, Dahal D, Govindasamy P. Caste, ethnic and regional
identity in Nepal: further analysis of the 2006 Demographic and
Health Surveys. Calverton, Maryland, USA: Macro International Inc;
2008.
26. Mainali D. Community based health insurance practices in
Mangalbare primary health care centre, Morang district [Thesis].
Kathmandu: Tribhuwan University, Institute of Medicine; 2011.
27. MOHP. Nepal demographic and health survey 2011. Kathmandu,
Nepal: Ministry of Health and Population, New ERA, and ICF
International; 2012.
28. Andersen R, Newman JF. Societal and individual determinants of
medical care utilization in the United States. Milbank Q. 2005;83(4).
doi:10.1111/j.1468-0009.2005.00428.x
29. Andersen RM. Revisiting the behavioral model and access to
medical care: does it matter? J Health Soc Behav. 1995;36(1):1-10.
doi:10.2307/2137284
30. Aregbeshola BS, Khan SM. Predictors of enrolment in the National
Health Insurance Scheme among women of reproductive age in
Nigeria. Int J Health Policy Manag. 2018;7(11):1015. doi:10.15171/
ijhpm.2018.68
31. Jehu-Appiah C, Aryeetey G, Spaan E, de Hoop T, Agyepong I,
Baltussen R. Equity aspects of the National Health Insurance
Scheme in Ghana: who is enrolling, who is not and why? Soc Sci
Med. 2011;72(2):157-165. doi:10.1016/j.socscimed.2010.10.025
32. De Allegri M, Kouyaté B, Becher H, et al. Understanding enrolment
in community health insurance in sub-Saharan Africa: a population-
based case-control study in rural Burkina Faso. Bull World Health
Organ. 2006;84(11):852-858.
33. Manortey S, Alder S, Crookston B, Dickerson T, VanDerslice J,
10. Ghimire et al
International Journal of Health Policy and Management, 2019, 8(11), 636–645 645
Benson S. Social deterministic factors to participation in the National
Health Insurance Scheme in the context of rural Ghanaian setting. J
Public Health Afr. 2014;5(1). doi:10.4081/jphia.2014.352
34. Kusi A, Enemark U, Hansen KS, Asante FA. Refusal to enrol in
Ghana’s National Health Insurance Scheme: is affordability the
problem? Int J Equity Health. 2015;14(1):2. doi:10.1186/s12939-
014-0130-2
35. Alatinga KA, Williams JJ. Towards universal health coverage:
exploring the determinants of household enrolment into National
Health Insurance in the Kassena Nankana District, Ghana. Ghana
Journal of Development Studies. 2015;12(1-2):88-105. doi:10.4314/
gjds.v12i1-2.6
36. Vyas S, Kumaranayake L. Constructing socio-economic status
indices: how to use principal components analysis. Health Policy
Plan. 2006;21(6):459-468. doi:10.1093/heapol/czl029
37. Filmer D, Pritchett LH. Estimating wealth effects without expenditure
data—or tears: an application to educational enrollments in
states of India. Demography. 2001;38(1):115-132. doi:10.1353/
dem.2001.0003
38. Bursac Z, Gauss CH, Williams DK, Hosmer DW. Purposeful
selection of variables in logistic regression. Source Code Biol Med.
2008;3(1):17. doi:10.1186/1751-0473-3-17
39. Poverty in Nepal 2010-11. Kathmandu: Central Bureau of Statistics;
2011.
40. Adhikari N, Wagle RR, Adhikari DR, Thapa P, Adhikari M. Factors
affecting enrolment in the community based health insurance
scheme of Chandranigahapur hospital of Rautahat district. J Nepal
Health Res Counc. 2018;16(41):378-384. doi:10.33314/jnhrc.1581
41. Badu E, Agyei-Baffour P, Ofori Acheampong I, Preprah Opoku
M, Addai-Donkor K. Households sociodemographic profile as
predictors of health insurance uptake and service utilization: a
cross-sectional study in a municipality of Ghana. Adv Public Health.
2018;2018. doi:10.1155/2018/7814206
42. Chankova S, Sulzbach S, Diop F. Impact of mutual health
organizations: evidence from West Africa. Health Policy Plan.
2008;23(4):264-276. doi:10.1093/heapol/czn011
43. Vellakkal S. Determinants of enrolment in voluntary health insurance:
evidences from a mixed method study, Kerala, India. International
Journal of Financial Research. 2013;4(2). doi:10.5430/ijfr.v4n2p99
44. Saavedra M. Children’s health insurance, family income, and welfare
enrollment. Child Youth Serv Rev. 2017;73:182-186. doi:10.1016/j.
childyouth.2016.12.014
45. Aggarwal A. Achieving equity in health through community-based
health insurance: India’s experience with a large CBHI programme.
J Dev Stud. 2011;47(11):1657-1676. doi:10.1080/00220388.2011.6
09586
46. Mhere F. Health insurance determinants in Zimbabwe: case of
Gweru urban. J Appl Bus Econ. 2013;14(2):62.
47. Parmar D, Souares A, De Allegri M, Savadogo G, Sauerborn R.
Adverse selection in a community-based health insurance scheme
in rural Africa: implications for introducing targeted subsidies. BMC
Health Serv Res. 2012;12(1):181. doi:10.1186/1472-6963-12-181
48. McIntyre D. Learning from experience: Health care financing in
low-and middle-income countries. Geneva: Global forum for health
research Geneva; 2007.
49. Rajkotia Y, Frick K. Does household enrolment reduce adverse
selection in a voluntary health insurance system? Evidence from the
Ghanaian National Health Insurance System. Health Policy Plan.
2012;27(5):429-437. doi:10.1093/heapol/czr057
50. Wang H, Zhang L, Yip W, Hsiao W. Adverse selection in a voluntary
Rural Mutual Health Care health insurance scheme in China. Soc Sci
Med.2006;63(5):1236-1245. doi:10.1016/j.socscimed.2006.03.008
51. Dong H, Kouyate B, Cairns J, Sauerborn R. Differential willingness
of household heads to pay community-based health insurance
premia for themselves and other household members. Health Policy
Plan. 2004;19(2):120-126. doi:10.1093/heapol/czh014
52. Kapologwe NA, Kagaruki GB, Kalolo A, et al. Barriers and facilitators
to enrollment and re-enrollment into the community health funds/
Tiba Kwa Kadi (CHF/TIKA) in Tanzania: a cross-sectional inquiry
on the effects of socio-demographic factors and social marketing
strategies. BMC Health Serv Res. 2017;17(1):308. doi:10.1186/
s12913-017-2250-z
53. Iqbal M, Chowdhury AH, Mahmood SS, Mia MN, Hanifi S, Bhuiya
A. Socioeconomic and programmatic determinants of renewal
of membership in a voluntary micro health insurance scheme:
evidence from Chakaria, Bangladesh. Glob Health Action.
2017;10(1):1287398. doi:10.1080/16549716.2017.1287398
54. Boateng D, Awunyor-Vitor D. Health insurance in Ghana: evaluation
of policy holders’ perceptions and factors influencing policy
renewal in the Volta region. Int J Equity Health. 2013;12(1):50.
doi:10.1186/1475-9276-12-50