Mohammed Shafiu, Souares Aurélia, Bermejo Justo Lorenzo, Sauerborn Rainer, Dong Hengjin
Institute of Public Health, Medical Faculty Heidelberg, Heidelberg University, Im Neuenheimer Feld 324, 69120 Heidelberg, Germany.
BMC Health Serv Res. 2014 Mar 14;14:127. doi: 10.1186/1472-6963-14-127.
Performance measures are often neglected during the transition period of national health insurance scheme implementation in many low and middle income countries. These measurements evaluate the extent to which various aspects of the schemes meet their key objectives. This study assesses the implementation of a health insurance scheme using optimal resource use domains and examines possible factors that influence each domain, according to providers' perspectives.
A retrospective, cross-sectional survey was done between August and December 2010 in Kaduna state, and 466 health care provider personnel were interviewed. Optimal-resource-use was defined in four domains: provider payment mechanism (capitation and fee-for-service payment methods), benefit package, administrative efficiency, and active monitoring mechanism. Logistic regression analysis was used to identify provider factors that may influence each domain.
In the provider payment mechanism domain, capitation payment method (95%) performed better than fee-for-service payment method (62%). Benefit package domain performed strongly (97%), while active monitoring mechanism performed weakly (37%). In the administrative efficiency domain, both promptness of referral system (80%) and prompt arrival of funds (93%) performed well. At the individual level, providers with fewer enrolees encountered difficulties with reimbursement. Other factors significantly influenced each of the optimal-resource-use domains.
Fee-for-service payment method and claims review, in the provider payment and active monitoring mechanisms, respectively, performed weakly according to the providers' (at individual-level) perspectives. A short-fall on the supply-side of health insurance could lead to a direct or indirect adverse effect on the demand-side of the scheme. Capitation payment per enrolees should be revised to conform to economic circumstances. Performance indicators and providers' characteristics and experiences associated with resource use can assist policy makers to monitor and evaluate health insurance implementation.
在许多低收入和中等收入国家实施国家医疗保险计划的过渡时期，绩效衡量往往被忽视。这些衡量标准评估了该计划各方面在多大程度上实现其关键目标。本研究从提供者的角度，使用最佳资源利用领域评估医疗保险计划的实施情况，并考察影响每个领域的可能因素。
2010年8月至12月在卡杜纳州进行了一项回顾性横断面调查，对466名医疗保健提供者进行了访谈。最佳资源利用在四个领域进行定义：提供者支付机制（按人头支付和按服务收费支付方式）、福利包、行政效率和主动监测机制。采用逻辑回归分析来确定可能影响每个领域的提供者因素。
在提供者支付机制领域，按人头支付方式（95%）的表现优于按服务收费支付方式（62%）。福利包领域表现强劲（97%），而主动监测机制表现较弱（37%）。在行政效率领域，转诊系统的及时性（80%）和资金及时到位（93%）都表现良好。在个体层面，参保人数较少的提供者在报销方面遇到困难。其他因素对每个最佳资源利用领域都有显著影响。
从提供者（个体层面）的角度来看，按服务收费支付方式以及在提供者支付和主动监测机制中的理赔审核表现较弱。医疗保险供应方的不足可能会对该计划的需求方产生直接或间接的不利影响。应根据经济情况调整每位参保人的按人头支付金额。绩效指标以及与资源利用相关的提供者特征和经验可以帮助政策制定者监测和评估医疗保险的实施情况。
