MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCE
DEPARTMENT OF COMMUNITY MEDICINE
RESEARCH PROPOSAL
TITLE: KNOWLEDGE, ATTIUDE AND CHALLENGES TOWARDS
HEALTH INSURANCE AMONG MEMBERS OF THE COMMUNITY IN
BAGAMOYO DISTRICT
FOURTH YEAR STUDENTS
MAY 2018
Contents
LIST OF ABBREVEATIONS..................................................................................3
ABSTRACT..............................................................................................................4
1.0 BACKGROUND.............................................................................................6
2.0 PROBLEM STATEMENT.................................................................................6
3.0 RATIONALE......................................................................................................7
4.0 RESEARCH QUESTIONS.................................................................................8
5.0 OBJECTIVES......................................................................................................8
5.1 Broad objective................................................................................................8
5.2 Specific objectives............................................................................................8
6.0 LITERATURE REVIEW....................................................................................9
6.1 Health Insurance coverage...............................................................................9
6.2 Knowledge on health insurance.....................................................................10
6.3 Attitude on the use of health insurance..........................................................10
6.4 Challenges on the use of health insurance.....................................................11
7.0 METHODOLOGY............................................................................................12
7.1 Study design...................................................................................................12
7.2 Study area.......................................................................................................12
7.3 Target population...........................................................................................13
7.4 Study population............................................................................................13
7.4.1 Inclusion criteria.......................................................................................13
7.4.2 Exclusion criteria.....................................................................................13
7.5 Study duration................................................................................................13
7.6 Sample size.....................................................................................................13
7.7 Sampling technique........................................................................................14
7.8 Data collection and Research instruments.....................................................14
7.9 Variables.........................................................................................................15
8.0 DATA COLLETION METHODS....................................................................15
8.1 Data analysis..................................................................................................15
8.2 Ethical consideration......................................................................................15
8.3 Limitations.....................................................................................................16
9.0 REFERENCES..................................................................................................16
LIST OF ABBREVEATIONS
CHF Community Health Fund
NHIF National Insurance Fund
MUHAS Muhimbili University of health and Allied Science
SPSS Statical Package for Social Services
WHO World Health Organization
LMIC Low and middle income countries
UHC Universal health coverage
ABSTRACT
Background:
Health insurance is one of the forms of health care financing methods. Can be
categorized into two basic groups, private health insurance such as Jubilee health
insurance fund and public (government based) health insurance such as national
health insurance fund (NHIF) and community health fund (CHF). The main aim
has been establishing universal health coverage, and thus various efforts has been
put forward in making it a success. The main goal being, by achieving universal
coverage will enhance better health services provision and thus better health for the
society. Thus this study target to add information that can be used in some way in
achieving universal health insurance coverage
Aim:
The main aim of this study is assessing Knowledge, attitude and challenges
towards the health insurance by taking Bagamoyo district in Pwani as a sample
Methodology:
A descriptive cross sectional study will be conducted in Bagamoyo district. Multi
stage cluster sampling technique is planned to be used and interviewer
administered questionnaire (interview schedule) will be used to obtain information
from study participants. And the data obtained on knowledge, attitude and
challenges toward the health insurance will be analyzed using SPSS version 20.0
software
1.0 BACKGROUND
Health insurance is insurance that covers the whole or a part of the risk of a person
incurring medical expenses, spreading the risk over a large number of persons. By
estimating the overall risk of health care and health system expenses over the risk
pool, an insurer can develop a routine finance structure such as a monthly premium
or payroll tax so as to provide the money to pay for the health care benefits
specified in the insurance agreement.
In Tanzania, there is growing commitment to the expansion of health insurance to
achieve a universal health coverage, whereby all those needing care can access
affordable services. There are mainly five types of health insurance schemes in
Tanzania, the largest scheme being the NHIF (National Health Insurance Fund)
which was setup in 2001 as a mandatory scheme. It offers a comprehensive benefit
package for public servants. The scheme is currently reaching out to members in
the formal sector. Other health insurance schemes includes National Social
Security Fund (NSSF), private insurance schemes such as AAR and micro scheme
insurance such as Chawana.(1)
Universal health coverage (UHC) is defined as access to needed health services to
all and protection against financial risks arising from paying for health services. It
is among the top priorities of reform agendas across many countries including
Tanzania. Provision of health services should be determined by individuals’ need
rather than their ability to pay and at the same time, utilization of services by those
seeking health care should not impose the risk of financial catastrophe.(2)
Only 15% of the population is covered by health insurance schemes. About 40% of
total health sector financing is from external sources while Out Of Pocket
payments account for about 30% of total health sector resources. The contribution
of prepayment health insurance schemes in total financing is insignificant.(2)
To achieve the goal of UHC, it is important for Tanzania to expand health
insurance coverage through mandatory contributions to health insurance pools.
Expansion of health insurance coverage will enhance financial protection among
those who use services and also increase access to needed services, thereby
translating into improved health status.(3)
2.0 PROBLEM STATEMENT
The use of health insurance as one of the mode of health care financing has been
facing challenge particularly in attaining universal health coverage. Universal
health coverage is firmly based on WHO constitution of 1948 declaring health as
the fundamental human right. Hence countries need to track the progress in
provision of health services not just across the nation but also within the different
groups.(1)
Most of developing countries are facing increasing difficulties in sustained
sufficient funding in health care.(2) In Tanzania out-of-pocket (OOP) payments
account for about 2% of people’s income. About 2% of the population incurs
catastrophic health care expenditures and 1% becomes impoverished because of
OOP payments.(2)
In Tanzania, health insurance coverage is still low. According to the population
based census report of 2012 the estimated coverage of both NHIF and CHIF was
about 15% (3) .Initiatives have been taken to improves the coverage such as
extension of services to the dispensary level, inclusion of primary health care
services (consultation and medications) however by the end of the year 2016 only
about 30% of the population were insured.(4)
Increasing knowledge on health insurance in the community is one of the
fundamental methods that could be used to increase the coverage of service to
community. To attain this goal, it is of paramount importance to assess the current
level of knowledge and attitude of the community.
Therefore, the aims of our study are to address level of knowledge, attitude
towards the use of health insurance and reason for low health insurance coverage.
This may help the community to improve the public level of knowledge and
willingness of people join in any health insurance financing mechanism.
3.0 RATIONALE
Carrying out this study shall provide results with useful information and
knowledge regarding health insurance. This will help to improve health insurance
coverage and address challenges the community face on joining and the use of
health insurance.
Also this study will help other stakeholders to plan on improvement of health
insurance coverage and health packages provided by health insurance.
This study will also help healthcare providers in the community to know the
challenges facing the community members in using and accessing health care
services offered through the national health insurance schemes.
This study will also help us to asses if the society has appropriate information
concerning health insurance and their attitudes toward the use of health insurance
services.
More over this study will be part of our learning and will help in improving our
research skills on preparation of a research proposal.
4.0 RESEARCH QUESTIONS
1) What is the level of knowledge on health insurance in Bagamoyo district?
2) What are the attitudes on health insurance Bagamoyo district?
3) What are the challenges facing adult population that are covered with health
insurance in Bagamoyo district?
4) What are the factors that hinder in joining the various health insurance
schemes in Bagamoyo district?
5) What are the reasons for Bagamoyo district members who were previously
health insurance beneficiary to become no longer beneficiary?
5.0 OBJECTIVES
5.1 Broad objective
To assess knowledge, attitude and challenge toward health insurance among
community members in Bagamoyo district
5.2 Specific objectives
1) To assess knowledge towards health insurance in Bagamoyo district
2) To assess altitude towards health insurance in Bagamoyo district
3) To determine challenges towards health insurance in Bagamoyo district
4) To determine the coverage of health insurance in Bagamoyo district
5) To determine the association between demographic characteristics and level
of knowledge on health insurance in Bagamoyo district
6.0 LITERATURE REVIEW
6.1 Health Insurance coverage
Access to affordable and effective health care is a major problem in low and
middle income countries (LMIC) and out-of-pocket expenditure for health care a
major cause of impoverishment. One way to facilitate access and overcome
catastrophic expenditure is through a health insurance mechanism.(5)
In 2008, 87% of the total Chinese population was covered by various social health
insurance schemes. In that year nearly 90% of the rural population was covered by
the social health insurance scheme, while 65% of the urban residents were covered
by urban health insurance schemes. After the NCMS was set up in 2003, its
coverage of the population expanded rapidly, jumping from 8 million of the rural
population in 2003-2004, to 179 million in 2005, 815 million in 2008, and 833
million in 2009 (MoH) —representing an expansion from 3% to 90% in five years.
(6)
In Nigeria 12years after launching of the national health insurance scheme, only
4% of its population has been covered.(7). In 2006, the Cameroon government
adopted a national strategy aimed at creating at least one community based health
insurance scheme in each health district and covering at least 40% of the
population with this scheme by 2015. By 2013 only 4% of respondents had health
insurance, and specifically 1% were involved in the scheme. The coverage is still
low.(8)
Rwanda has made impressive strides towards universal health coverage, mainly by
providing health insurance to the poor in the informal sector through its
community-based health insurance (CBHI). The scheme has made Rwanda the
country with the highest health insurance enrolment in Sub-Saharan Africa. In
2015/2016, the scheme covered 81.6 percent of Rwandese according to the
Rwandan Social Security Board.(9).
In Tanzania out-of-pocket (OOP) payments account for about 2% of people’s
income. About 2% of the population incurs catastrophic health care expenditures
and 1% becomes impoverished because of OOP payments. Only 15% of the total
populations are covered by the health insurance schemes, 40% of the health care
financing is from the external sources while out pocket sources accounts for 30%.
(2).
In 2013 the study was conducted in Liwale district in Lindi. Most participants
(347, 90%) were poor subsistence farmers and 229 (60%) had never subscribed to
any form of health insurance scheme. The idea of a Community health fund was
accepted by 221 (57%) survey participants.(10).
6.2 Knowledge on health insurance
Demand for health insurance are influenced by knowledge of the full costs of
health care and experience or knowledge of how and when health care costs
become ‘catastrophic.’(11). In 2013the study done in South Africa found that
slightly less than half (50%) of the respondents did not have knowledge of how the
NHI works. The knowledge of what the NHI would pay for was poor and 48%
knew that the NHI Fund would pay for medical expenses if a person got sick and
46% knew that with health insurance, basic health requirement is ensured and that
if one becomes ill, medical treatment would be paid for by the NHI Fund, 51% of
respondents did not understand how the NHI Fund will pay for health care
received, only 45% understood how the NHI will pay for health care services
received.(12).
A study was conducted in district of Douala Cameroon in 2013 in order to assess
the community based health insurance knowledge. The study showed that there is a
very low participation in community based health insurance schemes among the
informal sector workers. This is mainly due to the lack of awareness and limited
knowledge on the basic concepts of a community based insurance fund by this
target population.(8).
In 2015 the study done in Addis Ababa Ethiopia, the findings suggest that there is
little knowledge about the concept and elements of health insurance. Some
concepts such as, risk pooling and sharing are not well understood. The
participants of the study considered health insurance as only a prepayment
mechanism without risk sharing among members of the scheme.(13)
6.3 Attitude on the use of health insurance
The study was done in developed countries, from the People’s Republic of China,
Germany, and the United States to measures the basic attitude toward social health
insurance. German respondents have the most favorable attitude toward social
health insurance, followed by China, and then the United States. Chinese
respondents have the most favorable attitude toward government responsibility in
health insurance.(14).
In 2014 the survey done in developing countries reveal negative attitudes toward
the idea of health insurance are influenced by multiple factors and have their roots
in financial, cultural, traditional, religious, cognitive, experiential and
psychological cause.(15).
The study conducted 2008 in kilosa, kigoma rural and [Link] result show that
most of participants think that health insurance are for wealth group. Each wealth
group was between 1-12% more likely to enrol in the CHF relative to the poorest
group. However, the least poor were no more likely to join than the poorest.
Christian’s were 7% more likely to be members than those from other religious
groups. Poor understanding of risk pooling deterred people from joining the
scheme and was the main reason for not renewing membership..(16)
6.4 Challenges on the use of health insurance
The challenges on accessibility to health care services facing health insurance
schemes members in developed countries are higher cost-sharing, some services
are not covered (e.g. dental care, eye care), some covered services are not
provided, poor health care services in rural areas, long waiting time for high-tech
interventions, providers discriminate clients based on health insurance schemes
and inadequate 24-hours health centres.(17).
Other survey conducted in kigoma rural in 2008 reveal that on the supply side,
poor quality of public care services, the limited benefit package and a lack of
provider choice were the main factors for low enrolment.(16).
NHIF as one of the health insurance operating in Tanzania, it has improved the
health care financing system in the country and also has increased the public
awareness towards the importance of health insurance. But still the services
provided are of poor quality, there is a long-prolonged registration process. Also,
some of the NHIF benefits and packages services which are to be provided to the
members are not provided and most of the health facilities do favor much on
clients who have cash at hand.
From the case study done in Dar es salaam, 2015 shown over 70% (72%) of
NHIF members strongly agreed that non-members who pay cash directly are
attended first before them. While only 27% of them responded that they are not
sure if the ones who pay directly by cash are attended first before them. Also 64%
of respondents strongly agree that there is better relationship between non-
members of NHIF and health care providers and the rest just agree that
there are always better relationship between non-members and health care
providers .Also all of the respondents, strongly agreed that there is better
access to health services to non-members of NHIF than NHIF members.
Furthermore 81% of respondents strongly agreed that people paying the cash
directly perceive a better attitude from health care providers than NHIF
members while the rest were not sure if non- members One of the contributory
factor is the delaying time of reimbursement of NHIF bills to health care
providers which is contrary to the reimbursement policy ( 60 working days).(18)
7.0 METHODOLOGY
7.1 Study design.
This study will be a community based cross sectional descriptive study. Because it
is quick, cheap, easily to analyze and many variables will be included.
7.2 Study area.
Pwani is a coastal region located in the eastern part of [Link] region is
bordered to the North by Tanga region, to the east by Dar es salaam region and the
Indian ocean to the south by lindi and to the west by morogoro region.
The region is administratively divided into six districts namely Bagamoyo,
Mkuranga , Rufiji ,Kibaha ,Kisarawe, , and [Link] to the 2012
population census the total population of the region is 1,098,668. Bagamoyo
District has a total population of 311,740 which occupies the area of 9,842 km2.
The District contains 7 Divisions, 22 Wards and 97 villages.
It has one District Hospital, four government health centers and one missionary
health [Link] district also has a total of 59 dispensaries and 4 clinics.
The major ethnic groups are Zigua, Kwere, Doe, Zaramo and Masai. Major socio-
economic activities in Bagamoyo include small holder farming, subsistence
fishing, Mariculture (sea weed and prawn farming), livestock keeping, salt
production, trade and tourism. Major health problems in Bagamoyo include
Malaria and Malnutrition.
7.3 Target population.
All people above 18 years of age in Bagamoyo district
7.4 Study population.
The study shall involve all adults aged 18 years old and above. The population
distribution of males and females in Bagamoyo is 154,198 and 157,542
respectively.
7.4.1 Inclusion criteria.
- All adults above the age of 18 years, available and willing to participate.
7.4.2 Exclusion criteria.
- People who can’t communicate by using either Swahili or English language.
- People with cognitive problems, hearing or language difficulties.
- The ones that are seriously sick
- Refusal to participate in the study
7.5 Study duration.
The study will be done in three weeks.
7.6 Sample size.
Sample size will be calculated as follows,
Z 2× P× Q
n= ×D
e2
Where by ,
n= sample size.
Z= standard normal deviation of 95% corresponding to 1.96 confidence
interval.
P= is the proportion of adults who are using health insurance,30%
corresponding to 0.3(18).
Q=is the proportion of adults who are not using the health insurance, 70%
corresponding to 0.7.
D=is the design effect, which is 2.
e=margin of error which is 5% corresponding to 0.05.
Hence,
2
1.96 × 0.3 ×0.7
n= 2
×2.
0.05
=323×2
=646.
The sample size for this study will be 646 people.
7.7 Sampling technique.
Cluster sampling technique will be used.
7.8 Data collection and Research instruments.
Questionnaire (interview schedule) will be used to collect the data. The
information regarding the knowledge, attitude and challenges towards health
insurance will be collected.
The questionnaire will be divided into four sections, comprising of four section A,
B, C and D.
Section A will have demographic characteristics of the respondents.
Section B will have questions to asses on knowledge
Section C will contain questions to assess attitude.
Section D challenges towards health services.
The questionnaire will be developed in English, then translated into Swahili
version and back translated into English. Data collection will be done by students
with supervision from the field supervisors (lecturers)
7.9 Variables.
In this study the independent variables used will be the age, sex, marital status and
level of education, while the dependent variables will be knowledge, attitude and
coverage of health insurance services.
8.0 DATA COLLETION METHODS
8.1 Data analysis.
1. Knowledge will be analyzed by running the frequencies of people who have
scored higher or lower than the predetermined scale
2. Attitude will be analyzed by running the frequencies of responses on the specific
attitude.
3. Challenges will be analyzed by frequencies of the response given by the
participants on the specific challenges.
4. The coverage of health insurance will be analyzed by running the frequency of
the participants who will report to be using the different health insurance schemes.
8.2 Ethical consideration.
Ethical permission will be sought from the department of community medicine,
also permission will be sought from the village authorities.
Participation will be voluntary and informed consent will be obtained before data
collection.
Confidentiality and privacy will observed. Participant’s identification such as
names was not included in the questionnaire.
Storage of the questionnaire after completion of the research activity was in
archives in such a way that unauthorized people was not to have access to them.
8.3 Limitations.
1. Unreliability of the given information from participants by giving out desired
answers rather than telling the truth. This will be minimized by encouraging
participants to give out reliable information as well as using structured and
standardized questions to reduce bias.
2. Some interviewers and respondents may not be fluent in language particularly in
understanding some of the terms used in the questionnaire. This will be minimized
by using very simple, clear and non-technical language in the questions.
3. Since the study will be conducted by the group, some data collectors have their
own technique of getting the information from the respondents. This will be
minimized by giving to the group instructions before so as to insure that all the
data are collected in the same manner.
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