The political economy of national health insurance schemes: evidence from Zambia.

IF 2.9 3区 医学 Q2 HEALTH CARE SCIENCES & SERVICES
Doris Osei Afriyie, Regina Titi-Ofei, Felix Masiye, Collins Chansa, Günther Fink
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Abstract

Governments in low and middle-income countries (LMICs) are increasingly considering the introduction of national health insurance scheme (NHIS) as a strategy to achieve universal health coverage (UHC) targets. The literature has widely documented the technical challenges associated with implementing UHC policies in LMICs but much less is known about the political process necessary to pass UHC legislation. In this article, we document the political economy issues surrounding the establishment of the Zambia NHIS in 2018. We adapted a political economy framework incorporating, semi-structured interviews with diverse stakeholders and document analysis of policies, operational reports, and legislatures from 1991 and 2018. Our findings show the 26-year journey towards the establishment of the NHIS in Zambia involved a long sequence of policy dialogue, technical review and stakeholder engagement. Our interviews with key stakeholders suggest that the act was eventually passed due to strong political will and dominant leadership of the Ministry of Health. Passing the law required trade-offs between choices influenced by stakeholder pressures and recommendations from research and actuarial studies. Another equally critical factor was the high public support and legacies of past policies, such as the removal of user fees that had created quality gaps and inequities in the health system. Furthermore, global ideas about UHC and initiatives implemented by other countries also generated support for Zambia's NHIS. Overall, this study highlights the complex set of political economy factors that need to align in order for governments to be able to adopt health insurance in low-income settings. We show that political leadership and commitment to getting reforms passed is crucial. We also highlight how certain narratives about countries in the global health sphere can shape policies in other countries.

国家医疗保险计划的政治经济学:来自赞比亚的证据。
中低收入国家(LMICs)的政府越来越多地考虑引入国家医疗保险计划(NHIS),将其作为实现全民医保(UHC)目标的一项战略。文献广泛记载了在中低收入国家实施全民医保政策所面临的技术挑战,但对通过全民医保立法所需的政治过程却知之甚少。在本文中,我们记录了围绕 2018 年赞比亚 NHIS 的建立所产生的政治经济问题。我们采用了一种政治经济学框架,其中包括对不同利益相关者的半结构式访谈,以及对 1991 年至 2018 年的政策、业务报告和立法机构的文件分析。我们的研究结果表明,在赞比亚建立 NHIS 的 26 年历程中,经历了政策对话、技术审查和利益相关者参与的漫长过程。我们对主要利益相关者的访谈表明,由于强烈的政治意愿和卫生部的主导领导,该法案最终获得通过。法律的通过需要在利益相关者的压力和调查与精算研究的建议之间做出权衡。另一个同样关键的因素是公众的大力支持和过去政策的遗留问题,如取消用户付费,这在医疗系统中造成了质量差距和不公平。此外,关于全民健康保险的全球理念和其他国家实施的举措也为赞比亚的 NHIS 带来了支持。总之,本研究强调了政府在低收入环境中采用医疗保险所需的一系列复杂的政治经济因素。我们表明,政治领导力和对通过改革的承诺至关重要。我们还强调了关于全球卫生领域国家的某些说法如何影响其他国家的政策。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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来源期刊
Health policy and planning
Health policy and planning 医学-卫生保健
CiteScore
6.00
自引率
3.10%
发文量
98
审稿时长
6 months
期刊介绍: Health Policy and Planning publishes health policy and systems research focusing on low- and middle-income countries. Our journal provides an international forum for publishing original and high-quality research that addresses questions pertinent to policy-makers, public health researchers and practitioners. Health Policy and Planning is published 10 times a year.
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