Health Insurance Component of the Social Package: a Qualitative Assessment

Abstract

Background: Armenia implemented several major health care reforms in the last 20 years. The main reform efforts aimed to establish a balance between hospital and primary care and to make those services accessible and reduce informal payments. During the past decade, the Ministry of Health of the Republic of Armenia and international organizations implemented a number of projects to improve the performance of the Armenian healthcare system. The Government of Armenia introduced the Social Package (SP) in January 2012, for public employees of educational, cultural institutions, and civil servants in Armenia which covered about 120,000 people. Mandatory health insurance was one of the components of the package, giving each beneficiary a voucher with a value of 132,000 AMD out of which 52,000 AMD must be dedicated to obtaining basic health insurance package from private insurance companies. There are no evaluation studies for this program. Objectives: This study aimed to evaluate the health insurance component of the Social Package program for evidence based decision and policy making in Armenia. The specific objectives of the study included exploring attitudes, practices, and experiences in terms of how the health insurance component (HIC) of the SP program influenced access to healthcare services, out-of-pocket payments, and overall satisfaction of different stakeholder groups with the mandatory and voluntary parts of the HIC of the Social Package. Methods: The research team used a qualitative study design with semi-structured in-depth interviews and focus group discussions to address the research questions. The directed content analysis using the SWOT approach helped to emphasize the strengths, weaknesses, opportunities and threats of the health insurance component of the Social Package program. The study took place in Yerevan (the capital city) and Shirak marz (Gyumri city) to understand the challenges of implementing the HIC of the SP program. Five groups of participants took part in the study: policy makers/experts, healthcare providers, insurance company officers, SP beneficiaries and non-beneficiaries. The study included 75 participants (65 female and 10 male). Results: All participants had a positive opinion about the HIC of the SP program; it improved affordability and utilization of inpatient surgical care for its beneficiaries. The participants highlighted the following weaknesses of HIC of the SP program: limited coverage and long list of exclusions; reported episodes of informal payments, particularly in marzes; limited understanding of the HIC among some stakeholder groups; and informal pressures to choose a specific insurance company or health provider. The participants suggested the following opportunities to improve the HIC of the SP program: improving management of financial and human recourses in insurance companies and health facilities, expanding coverage of services and number of people, and strengthening monitoring of the program. The following threats to sustainability of the program were mentioned: unequal opportunities to use the HIC in marzes due to poor quality of services and lack of specialists, lack of treatment and diagnostic guidelines, inappropriate allocation of financial resources for primary and hospital care, very high administrative expenses, and unnecessary use of hospital services. Conclusion: The implementation of the health insurance component of the SP was a step forward in reducing informal payments for healthcare services in Armenia and improving utilization of vi hospital care. However, the HIC of the SP program introduced motivations for unnecessary hospitalizations leading to inefficiencies in the health system and increased health expenditures for the country. The current study makes recommendations to make the health component of the SP program more effective, efficient, and equitable: reconsider organization of HIC of the SP program moving away from the current multi-payer one through a non-profit public agency; redesign the basic health package of the SP program to motivate utilization of preventive and primary care; strengthen the capacity of a strategic purchaser establishing mechanisms for continuous monitoring and evaluation of financial flows; consider establishment of mandatory health insurance (single-payer) as a complementary source of financing health care system; improve facility level financial management practices to increase transparency and effectiveness; develop standard treatment and diagnosis guidelines; continuously work with the general public to increase awareness of the health insurance component of the SP Program.