Explore publications.

This article employs a structured, theory-guided comparative policy analysis to examine the persistent deficits in community trust that undermine primary health care (PHC) service delivery in Nigeria. Despite numerous reforms targeting financing and administrative structures, PHC utilization remains low and citizen confidence fragile. Drawing on policy learning theory, this study argues that Nigeria’s PHC reforms have predominantly involved first-order, instrumental adjustments, failing to foster deeper shifts in governance philosophy or state-citizen relations essential for building trust. Using Rwanda as a contrasting case, the analysis illustrates how its post-genocide PHC reconstruction leveraged second- and third-order policy learning to embed community trust within governance through co-production, robust accountability mechanisms, and deliberate institutional design. The paper identifies context-sensitive policy lessons for Nigeria, emphasizing that trust must be recognized and actively governed as a strategic resource for legitimate, responsive, and sustainable PHC systems, rather than merely a residual outcome of service delivery.

The National Health Insurance (NHI) program in South Africa is a premier reform initiative aimed at attaining Universal Health Coverage. Nonetheless, its performance is largely contingent upon proficient management of project stakeholders throughout all stages of the program life cycle. Principal stakeholders express significant apprehensions over the policy revision and implementation procedure. This study aimed to identify program stakeholders and evaluate the degree to which the National Department of Health (NDoH) implemented project stakeholder management methods during the design and initial execution of the NHI. A qualitative, exploratory research design was utilised, utilising secondary data derived from document analysis. Primary data was obtained using a combination of semi-structured interviews and electronically distributed questionnaires with representatives from five principal stakeholder groups: private health insurers, professional organisations, regulators, and a governmental oversight agency. Despite the existence of a roadmap for NHI implementation, thematic analysis indicated that the stakeholder management strategy employed did not adhere to recognised project management standards. Findings reveal deficiencies in the NDoH stakeholder engagement strategy, including selective consultation, inconsistent response, inadequate openness, and ineffective communication and feedback systems, all of which erode confidence and hinder consensus-building. Comparative analyses from Nigeria and Thailand illustrate the significance of inclusive, partnership-oriented governance frameworks for the implementation of extensive health reform initiatives. The study indicates that enhancing stakeholder identification, analysis, and effective engagement tactics is crucial for the NHI's legitimacy and long-term viability. Utilising private sector knowledge is crucial throughout the whole program life cycle. The study is constrained by the lack of engagement from the NDoH, which hinders the triangulation of stakeholder perspectives.

South Africa is dedicated to attaining Universal Health Coverage via the National Health Insurance program, with the NHI Bill set to be enacted into law in 2024. The primary healthcare system, essential for Universal Health Coverage delivery, encounters ongoing challenges such as a shortage of healthcare professionals, insufficient infrastructure and medication shortages, financial limitations, and inadequate governance frameworks. The Johannesburg health district has experienced high turnover among trained primary healthcare nurses over the past two financial years, leading to staff shortages and decreased morale. This situation threatens the achievement of Universal Health Coverage. Additionally, patients were often turned away from primary health facilities due to early closures and staff shortages, limiting access to healthcare and hindering UHC goals. To achieve UHC, healthcare services must be available, accessible, affordable, and of high quality.To explore the experiences of professional nurses with regards to the implementation of Universal Health Coverage at Primary Health Care facilities in the Johannesburg health district, Gauteng. A qualitative, exploratory, descriptive methodology was employed. Eleven participants, comprising operational managers, professional nurses, and an area manager, were purposefully selected from eight primary healthcare facilities in Regions C and G of Johannesburg. Semi-structured interviews were performed, audio-recorded, and thematically evaluated using Braun & Clarke’s framework. Three themes emerged: (1) Hhuman resource limitations and professional erosion including staff shortages and high turnover, (2) healthcare system inadequacies  and patient accessibility such as poor infrastructure and medication stockouts; and (3) financial and policy constraints that impede effective UHC implementation. Nurses' experiences indicate structural obstacles hindering the implementation of UHC. It is essential to address personnel shortages, infrastructure deficiencies, and policy inefficiencies. Enhancing governance and prioritising nurse involvement in policymaking are crucial for attaining equitable, high-quality healthcare in South Africa.

South Africa’s journey toward universal health coverage through the proposed National Health Insurance (NHI) scheme reflects a deeply contested terrain of political, economic, and institutional interests. At the heart of the debate lies the struggle to transform an inequitable, dual-tiered healthcare system into a unified platform for equitable access. This article examines the political economy underpinning the NHI discourse by critically unpacking the roles, incentives, and power dynamics of key stakeholder groups, including government institutions, private healthcare providers, civil society, trade unions, political parties, and international actors. Using a political economy analysis framework, the study explores how stakeholder preferences and alignments shape the pace, design, and legitimacy of NHI reforms. It interrogates the conflicting narratives of equity and efficiency, state capacity versus market reliance, and centralized control versus decentralized delivery. Drawing on diverse reports, policy analyses, public submissions, and academic critiques, the research highlights how divergent ideological, financial, and institutional positions influence both policy content and public perception. Evidence from the research indicates that health reform in South Africa is not merely a technical endeavor but a deeply political process. Stakeholders engage in strategic behavior to either support, contest, or reshape the NHI, with implications for policy coherence, implementation feasibility, and constitutional alignment. The article concludes that sustainable health reform depends not only on sound policy design but also on transparent negotiation, inclusive dialogue, and adaptive political strategy. A nuanced understanding of stakeholder dynamics is therefore essential to realizing South Africa’s vision of health equity and universal coverage.

Private health insurance is crucial for healthcare financing, but its uptake remains suboptimal, with many still relying on out-of-pocket expenses. Statistics indicate Kenya's informal sector comprises 83.3% of the population, with only 2% of employees having national hospital insurance and 20% having public health insurance. Therefore, this study investigated effect of strategic decision on uptake of private health insurance services, specifically, the study examined the effect of level of coverage, cost and affordability, network of health providers and quality of services on uptake of private health insurance services in Nairobi City County, Kenya. The study was anchored using the agency theory, dynamic capability theory and expected utility theory. The study embraced descriptive research design. The target population was sixteen private health insurance in Nairobi city county, Kenya. A sample size of eighty was utilized, employing census. Primary data was collected using a semi-structured questionnaire. The response rate was sixty eight percent. Level of coverage, cost and affordability, network of health providers and quality of services had a significant effect on uptake of private health insurance services. The study recommend, insurance providers should continue to offer diverse plans that cater to different needs and income brackets, ensuring that comprehensive coverage options remain accessible to a broad audience. Additionally, insurers should continue to develop and offer flexible payment plans that cater to different income levels. Introducing tiered pricing models, where customers can choose from a range of premium options based on their financial capacity, can make insurance more accessible. Moreover, the insurer should focus on maintaining a strong commitment to service quality and continually refining their offerings, which can build greater trust and satisfaction among customers, leading to increased adoption of private health insurance services.

Universal Health Coverage (UHC) aims to ensure access to quality healthcare services without financial hardship. This study compares the UHC models in Indonesia, Malaysia, and Thailand to identify their strengths, challenges, and opportunities for improvement. Using a comparative literature analysis, the research highlights significant differences in funding mechanisms, population coverage, service efficiency, and policy implementation. Malaysia successfully leverages its high per capita income to provide universal healthcare through tax-funded services, while Thailand demonstrates efficient resource management with the "30 Baht" scheme, ensuring universal access despite its moderate-income level. Although Indonesia faces challenges due to its large population and low per capita income, it has made significant progress, covering 86% of its population since the launch of the National Health Insurance (JKN) program in 2014. Based on the findings, policy recommendations include enhancing financing mechanisms, improving service efficiency, and ensuring broader access to healthcare services in all regions. For Malaysia and Thailand, further exploring sustainable financing models and addressing disparities in healthcare quality can help ensure long-term UHC sustainability. For Indonesia, increasing compliance with premium payments, improving healthcare infrastructure, and addressing funding deficits are key to achieving more inclusive healthcare access. These recommendations offer valuable insights for improving UHC implementation strategies in diverse economic and demographic contexts.

This study aimed to examine the correlation between health-risk behaviour patterns, health lifestyle practices, and self-monitoring and care, in connection to the increasing costs of health insurance premiums. The research utilised a cross-sectional design and applied Linear Regression via SPSS software to analyse data collected from 385 public servants and college students in Mwanza, constituting 68.84% of the NHIF membership share. The analysis reveals that hazardous behaviours, including Alcohol Consumption (AC), Tobacco Use (TU), and Exposure to Harmful Chemicals (ETHC), are directly correlated with an increase in insurance costs. Nonetheless, the use of painkillers is unwarrantedly associated with the development of non-communicable diseases. Healthy lifestyle practices, including the consumption of processed foods (PFC), adherence to a balanced diet (UBD), and participation in physical activity (PA), are positively correlated with the likelihood of acquiring non-communicable diseases (NCD). In the near term, patients undergoing regular medical checks (MCP) exhibited elevated medical expenses. Ultimately, they decreased long-term medical costs by mitigating the likelihood of an individual developing non-communicable diseases (NCDs). The study emphasises policy recommendations aimed at reducing the likelihood of non-communicable disease (NCD) development and enhancing the financial stability of health insurance schemes in Tanzania. These include the creation of media and electronic campaigns to inform both members and non-members about effective strategies to prevent NCDs, the establishment of incentive packages to encourage members to cease or abandon risky behaviours, the provision of discounted premium pricing, the offering of mental health counselling and therapy programs, and the development or acquisition of health-related applications to modify member behaviour.

Access to health insurance is vital for achieving Universal Health Coverage, yet barriers such as high costs, inadequate coverage, and systemic inefficiencies often impede access to necessary health care. This study evaluated access to the National Health Insurance Scheme-provided services among enrollees at the outpatient department (OPD) of Levy Mwanawasa University Teaching Hospital (LMUTH) in Lusaka, Zambia, chosen for its role as a pioneering NHIS-accredited facility and its significance as a major publicly funded referral hospital. Data were collected in May 2024 from 270 systematically sampled NHIS enrollees at the OPD of LMUTH using an interviewer-administered questionnaire. Descriptive analysis revealed a balanced gender distribution, with most respondents aged 35 and above, married, holding tertiary education, and earning a monthly Zambian Kwacha (ZMW) of 20,000 or less. The thematic analysis using NVivo uncovered positive and negative experiences with NHIS services, highlighting issues such as medical service availability, drug shortages, service delays, technological problems, communication challenges, equity in service delivery, and coverage gaps. The key policy implications for improving access to NHIS services include enhancing supply chains, digital infrastructure, coverage to rural areas, staff training, public awareness of the NHIS, and information technology systems.

This paper aims to analyse the behaviours and practices of health care service providers that constitute supply-side abuse of the medical health insurance schemes premised on the notion that patients visit doctors precisely to learn what amount and type of care is medically necessary. Using qualitative methods, individual in-depth interviews were carried on private health service practitioners and thematic analysis via SPSS. The study identifies systemic abuses like overcharging, billing for services not provided, and over prescription. Implication of these findings show that Fee-for-Service Payment Models incentivize providers to deliver more services, leading to potential over-utilization and increased costs in Botswana’s healthcare; due to information asymmetry providers may prioritize quantity over quality of care exploiting patients’ lack of knowledge to recommend unnecessary tests or treatments to maximize on revenue but also costs. On how to minimize supply side moral hazards, the propositions is for pursuance of cost containment strategies to ensure the smooth operation of the schemes like price listings, educate beneficiaries on cost implications and sustainability threats. These propositions can be instituted through an industry led bench-marking, on nationally through regulatory frameworks since moral hazards are an economic cost as inefficiencies brings mis-allocation of resources to enhance the sustainability of medical aid-based health care provisioning.

The South African national department of the health system is piloting the National Health Insurance (NHI). This is in preparation for the overhaul of healthcare services so that they are efficient and equitable to all citizens immaterial of their socio-economic status. This article aims to evaluate healthcare providers' perceptions of improved service delivery by the government’s health department during the first piloting phases of the NHI. The context of the study is a health district center in a rural area of KwaZulu-Natal province in South Africa. The article is interdisciplinary in that it interrogates governance issues in the health sector. A quantitative research methodology was utilized to collect data from 30 participants who were the center’s staff. The findings indicate that the significant areas of concern are lack of improvement in response rate to emergencies, ambulances, provision of resources, and specialized staff. The implication is that the government’s health department working with provincial departments, still has major healthcare reforms to address if the NHI program contributes effectively to healthcare service delivery.

The system implemented by the Health Social Security Administering Agency (BPJS) Samarinda is to carry out the Socialization program of the National Health Insurance for Healthy Indonesia Card (JKN-KIS) program to the Business Entity Wage Recipient Workers segment, the program to increase membership by conducting Telemarketing, Mapping, Canvasing, O.S.X. & O.S.S., and synergizing with the relevant District Attorney providing administrative sanctions based on Presidential Regulation number 86 the year 2013. This study aims to identify obstacles and strategies implemented by Health Insurance-BPJS Samarinda to increase membership in the Business Entity Wage Recipient Workers segment. The method used in this study is a qualitative approach by analyzing the data descriptively. Data collection techniques were by conducting observations, interviews, and questionnaires to business entities in the city of Samarinda; as many as 60 respondents were to find out that the business entity had registered its workers in the J.K.N.'s program. This study found obstacles such as a lack of awareness of health insurance, workers registered in the non-wage and unemployees, high turnover of workers, and administrative sanctions that have not been implemented according to the applicable law.

The objective of the study was to assess the factors that motivate or demotivate households to choose among the three healthcare facilities, public healthcare, private health care and traditional healthcare facilities in South Africa as revealed by Statistics South Africa . The utilisation of healthcare facilities in South Africa is such that more households prefer public healthcare facilities more than other healthcare facilities. The multinomial logit model was used, with traditional/self-medication category as the reference or baseline category. The results indicated that gender, income and access to grants were significant in influencing the probability of a household choosing a public healthcare facility, while age, income, grants, salaries/wages/commission and pensions were significant in influencing the choice of private healthcare institutions. Therefore the study recommends that due to a large portion of households that are using public health facilities compared to private and traditional facilities, the government must invest more in public healthcare facilities in South Africa.

The main aim of this article is to explore how performance-based budgeting has an effect on primary health care service delivery in the Eastern Cape. This article assessed the performance-based budgeting system in the Eastern Cape Department of Health in an attempt to advocate for effective and efficient health service delivery. The Eastern Cape Province is succumbing to insufficient funding at the provincial level and this has a clear-cut reflection on the administration of services within respective departments. The article is premised on a constructivist paradigm that adopts a qualitative approach where document analysis was employed for collecting data. The Eastern Cape Province is succumbing to insufficient funding at the provincial level and this has a clear-cut reflection on the administration of services within respective departments. The article employed the Public Choice Theory and the Concept of New Public Management. Three main findings emerged from the article of the crippled funds in the province, the human resources crisis, poor public finance management, and shortage of health equipment. Data were analyzed using thematic analysis to examine the distinctive themes and sub-themes identified from within the reviewed literature. Recommendations were thus given based on the discussed and derived themes to ensure that there is an appropriate budgeting system to ensure efficient and effective provision of health care services in the Eastern Cape Department of Health.

Is giving the subsidy in the implementation of national health care security in line with the purpose of arrangement of Law of Republic of Indonesia Number 40 of 2004 on System of National Social Security? Health care security is a basic right of all citizens of Indonesia as regulated in Article 28 H paragraph (3) and Article 34 Article (3) of the Constitution of the Republic of Indonesia. This writing makes an analysis of the arrangement of subsidy of implementation of national health care security. Argumentation in this writing gives an analysis in doing reformulation of an arrangement of giving subsidy in implementation of national health care security as regulated in Article 14 paragraph (2) of Law of Republic of Indonesia Number 40 of 2004 on System of National social security, the program of national health care security is a program in the form of security done by the government, but in the implementation, it is done by using social insurance method. Premiums of poor people and deprived citizens are guaranteed by the state, formal premium is paid by the worker and employer while the informal worker pays the premium independently, by this system it makes injustice in the society. All costs of National health care security should be covered by the state as the aim of implementation of the Law of System of National Health Care Security and the government should use the method of system of security and not social insurance system.

Under capitation health scheme, a member freely selects a health facility from which to seek health services. There is no restriction of the number of times a member seeks health services from the facility within the contract period. This has affected delivery of health service under capitation contracting. This paper documents a quantitative analysis of the effect of health seeking behaviour on effective delivery of health services. Since human behaviour is assumed to be a natural phenomena, a philosophical view of positivism w?s ?dopted in this research. Accordingly, a scientific approach was used to deduce the influence of health seeking behaviour on the metrics of effectiveness. Out of 1152 health facilities accredited to offer primary healthcare in Kenya, data was collected from a sample of 297 health units using closed ended questionnaires. Logit regression analysis on the data revealed that congestion in out-patient department had a negative effect on quality of health services delivered but a positive effect on accessibility and affordability of the services. Increased frequency of consultation had a negative effect on all the three measures of effectiveness; quality, accessibility and affordability of health service delivery. Corresponding odds ratios were 0.173, 1.105 and 1.295 respectively.

Co-payment is an out-of-pocket payment collected by the service provider from members capitated by a health scheme for the purpose of gatekeeping against the misuse of the services. This paper documents an assessment of the effect of copayment on the effectiveness of health services delivered under the capitation scheme in Kenya. The unit of analysis was the 1152 health facilities capitated by the National Hospital Insurance Fund to provide outpatient primary healthcare in Kenya as of July 2015. logit regression was used to analyze the data collected from a sample of 297 capitated health facilities. The Effectiveness of the delivery of health services was evaluated using three metrics; quality, accessibility, and affordability. The regression model for each of the metrics was constructed in order to examine the effect of copayment on the delivery of services. The results revealed that an increment of one unit on copayment increased the index of delivery of quality, accessible and affordable health services by .073, 4.349 and 79.4 respectively. The optimal amount of copayment is determined from the models using theories of calculus.

Equity is one of the basic principles of health systems and features explicitly in the Nigerian health financing policy. Despiteacclaimed commitment to the implementation of this policy through various pro-poor health programmes and interventions,the level of inequity in health status and access to basic health care interventions remain high. This paper examines theequity of health care expenditure by individuals in Nigeria. The paper evaluated equity in out-of-pocket spending (OOP) forthe country and separately for the six geopolitical zones of the country. The methodological framework rests on KakwaniProgressivity Indices (KPIs), Reynold-Smolensky indices and concentration indices (CIs) using data from the 2004 Nigerian National Living Standard Survey (NLSS) collected by the National Bureau of Statistic. The results reveal that health financing is regressive with the incidence disproportionately resting on poor households with about 70% of the total expenditure on health being financed through out-of-pocket payments by households. Poor households are prone to bear most of the expenses in the event of any health shock. The catastrophic consequences thus push some into poverty, and aggravate the poverty of others. The paper therefore suggests that the country’s health financing systems must be such that allows people to access services when they are needed, but must also protect household, from financial catastrophe, by reducing OOP spending through risk pooling and prepayment schemes within the health system.