From the halls of the Health Systems Research Symposium in Nagasaki, this episode explores two vital health system challenges: improving contributory health insurance models in low- and middle-income countries and addressing fragmented care pathways for non-communicable diseases (NCDs) like diabetes and hypertension.

Agnes Gatome-Munyua highlights the shortcomings of contributory health insurance and suggests how better purchasing strategies can make these systems more effective. Dr. Sudha Ramani shares insights from Mumbai’s urban informal settlements, where patient journeys for NCD care are often convoluted and inequitable, pointing to systemic barriers and practical policy solutions.

Packed with actionable insights, this episode is essential for anyone working to build resilient and inclusive health systems globally.

For more information;

HSS Insights Series: PSI - To access Population Service International's blogs and policy briefs, visit our health systems insights website.

Health Systems Pathways is an SCL Agency Production.

Hi everyone, welcome back to Health Systems Pathways.

I'm Alex Ergo, PSI's Director of Health Systems.

And today I'm bringing you the fourth live episode recorded at the Health Systems Research Symposium in Nagasaki.

In this episode, we tackle two different topics that are not totally unrelated.

The challenges of implementing contributory health insurance in low and middle-income countries and the complexities of patient care journeys for non-communicable diseases such as diabetes and hypertension.

Let's get started.

Hi again, everyone.

I am now with Agnes, and we're going to talk about health insurance.

But let me first ask Agnes to introduce herself.

Agnes Gatome-Munyua: Hello, everyone.

My name is Agnes Gatome-Munyua.

I'm a program director at Results for Development, and I am based in Nairobi, Kenya.

Welcome to our podcast, Agnes.

And a few months ago, at PSI, we wrote this paper relating to health insurance, and basically what we were saying is that many countries, low and middle-income countries, tend to adopt a pathway towards universal health coverage that involves health insurance, but it doesn't always go as planned.

And in fact, in many countries, we see very low uptake of health insurance and that can be linked to poor design or poor implementation or any combination of those.

And a few days ago, Agnes presented some findings in a session that's related to exactly this same topic.

And so it would be great to hear from you, Agnes, what what some of your findings were and what some of the takeaways are.

Agnes Gatome-Munyua: Thank you for inviting me to be here.

Yes, you're right.

I think a lot has been said on contributory health insurance and in the past 10 years or more, it has been stated that there are shortcomings of contributory health insurance particularly for countries low and middle-income countries that are aiming to introduce these.

And so last year there was a paper released by very eminent colleagues in health financing, that contributory health insurance is a bad idea.

That paper really resonated with me.

I think from a perspective of giving advice to a country that is considering contributory health insurance, it was fantastic, but what nagged me is that my country in Kenya, as in other countries in Africa, there's some of these countries that have set up contributory health insurance for decades, and these have been going on, yes, with challenges, they're ongoing.

So, my question was, okay, the paper is great, but what happens to those who have the systems entrenched already and are very hard to turn back.

And so, from that perspective, I reached out to a number of colleagues to find out is there something we can provide in terms of reflections on what options there are for these countries?

And that really was the genesis of this paper on what happens to these countries who have this entrenched health insurance systems.

So, they can't turn back, they have to look forward.

What do they do?

And so based on that, I had a good, a fantastic actually set of co-authors in Cheryl Cashin and Joe Kutzin.

They are very well known in health financing circles.

Wonderful mentors to me as well.

And so when I brought this idea and I thought, okay, let's see what advice we can bring.

We thought of, what are the options?

What can these countries actually do?

And so we looked at, okay, what is a real pain point from this contributory health insurance systems, right?

And one of the biggest issues is that when these contributory health insurance systems were set up in many of these countries, there's a fallacy that they could generate sufficient revenue for the health system, and they've not been able to do that in many of these countries.

It has not been able to raise sufficient revenue, and it has largely provided coverage to the elites, those who are working in the formal sector, government workers in particular, who are able to contribute via the payroll system.

So, if you look at these schemes, like Kenya, for example, or Nigeria or Tanzania, you find that coverage of the formal sector is, almost at 100%, right?

But unfortunately, that is the minority of these countries.

And they are countries with a large informal sector who are relying on a daily income.

Or might be working in industries that do not provide them a salary at the end of the month.

Agriculture workers, we call them Jua Kali sector, people who work in informal sector in, in Kenya as an example.

So what happens to the majority in informal employment?

And so that's where social health insurance and compulsory health insurance has not been able to tap into these.

And we find that there are a lot of challenges where they have tried in terms of low coverage adverse selection, right?

So those who enroll are likely to need health services.

And if you look at the the particular group of these individuals who do enroll for this contributory health insurance programs, you find that utilization is very high and might not actually be commensurate with the contributions that they're making.

And once they've accessed the service they need, they're likely to drop off whether that's delivering a new baby or needing a surgery.

And there are just some things about contributory health insurance that are not working well.

And okay, we know that.

But are there other things that might not be too bad about these contributory health insurance schemes?

And because we have a leaning towards purchasing, I do in particular, if you look at the ability of these systems in health insurance systems to channel the revenue that they have to define benefit packages, to develop formularies in terms of medicines to provide, to contract and accredit health providers, include the private sector, and then define output based benefit packages provider payment systems.

And you find that they're actually doing a little better than would be thought.

And based on, the positive elements in the purchasing, maybe that's where they should focus.

And that's the real premise of the paper, that the revenue generation doesn't seem to work.

We should be thinking of raising more public resources and channelling them through these systems.

Remove that revenue collection function from these health insurance agencies and let them focus on the purchasing function, how they define benefit packages, how they contract and accredit, how they set obligations for their providers, and then how they pay their providers with output-based payments.

And then, of course, using information to improve how they decide the what, the how, and the who of purchasing and I think that's the opportunity and that's what we speak about in the paper.

This is great, it resonates very much.

And I wonder if you think the authorities in Kenya are open to this and will be taking the advice that you've provided in your commentary.

Agnes Gatome-Munyua: I'm not very sure about that, possibly not.

Kenya is embarking on some big reforms right now.

We have set up a social health authority that is going to oversee three funds.

Social health insurance fund, the primary health care fund, and the chronic and emergency disease fund.

In terms of strengthening purchasing, maybe those are elements they can pick from the paper.

One of the points of contention is that they're still expected to collect revenue, and I'm not sure how well that's going to work, particularly from the large informal sector in Kenya.

Yes, because I imagine that they've set up entire functions to and institutions to fulfill those functions, right?

And so it's really hard to get rid of those.

So, what advice do you give in that respect?

Agnes Gatome-Munyua: One of the things we state is that over the years, one of the recommendations is we need to rely predominantly on public sources of health funding.

And so, what I'm hoping is that as we evolve and continue to implement under the Social Health Authority, that we see more public resources being channelled to the different funds.

The primary health care fund is supposed to be funded by the government, but commitments have been low, and so, if we can see more commitment from government to channel public resources so that the agency doesn't have to rely on trying to collect contributions, particularly for those that have been traditionally very hard to reach.

Great.

Thank you so much for sharing this Agnes and I hope you have a great rest of the conference.

Hi, everyone.

I'm now with Dr.

Sudha Ramani, who just presented interesting findings from a study conducted in Mumbai that involved journey mapping.

But let me first start by asking you, Sudha, if you could please introduce yourself.

Hi, I'm Sudha.

I live in India and I work mainly on health systems and health policy issues, mainly related to primary health care.

Great.

So maybe you can tell us a few words about the study that you conducted.

Maybe, a few words about the context and what you actually did and what the main findings were.

Thanks Alex.

This study was on care seeking journeys of people who live in urban informal settlements in Mumbai.

And we looked at their journeys for two very common non communicable diseases, which are diabetes and hypertension.

This study was sponsored by the Society for Nutrition, Education, and Health Action which is an NGO in Mumbai.

The NGO basically works on maternal and child health issues.

It's got a very strong presence in the urban informal settlements in Mumbai.

And recently what they have been realizing is that non-communicable diseases like diabetes and hypertension are cropping up in their field everywhere.

These diseases are no longer diseases of the rich as they used to be.

So, what we did was we tried to get some deeper insights into what is really happening in these urban informal settlements when it comes to patients seeking care.

Where do people seek diagnosis for these ailments?

Where do people get treated for these two conditions, diabetes and hypertension?

So, how we went about doing this study was we collected data from patients.

We asked them to think about their life story on what they remembered of their journey of dealing with these two conditions.

We also supplemented these with some interviews and discussions with private providers, public providers, and some focus group discussions in the community.

I would like to talk now about our main findings from the study.

What we really see in literature or when we look at it is we see these very linear kinds of mapping of patient journeys, especially when it comes to non-communicable diseases.

So, if I look at a linear journey, it would involve, let's say screening for non-communicable diseases, or people think that something is wrong, then they go to a health practitioner, then they go get diagnosed, then they start some treatment, and after treatment, they do this disease management and follow up, and all is well and fine.

So, this is great in an ideal world, but when we actually looked at our data, we found that this ideal sort of pathway that we had in mind does not apply in reality at all.

In reality the journeys that people took were very messy.

They were very convoluted and difficult for people to navigate.

Also, in each step, let's say, from getting a diagnosis to get initiating treatment to getting a follow up between each of these steps, there was a lot of delay which was happening.

Another point where I felt that we were really losing people was at the very first contact point.

The initial care seeking in these urban informal settlements happens not in the formal private sector or even in the formal public sector.

It all happens in the informal sector.

In Hindi, they call them chota doctors or small doctors.

These are doctors who, practice within the community.

They sort of practice allopathic medicine, but they do not really have a formal qualification to practice.

And what they can provide is symptomatic relief.

So most often the patient goes in with these early symptoms like headache or frequent urination and they send them back with some paracetamol tablets.

And people are stuck in this loop without a diagnosis for very long times, which is really a missed opportunity.

It's only when things really get bad, really worsens or sometimes even in terms of emergencies like a heart attack, it is at that point that people are discovering that they have diabetes.

A second point I would like to make which sort of really stood out in our findings was that people kept on switching providers, or hopping between providers.

At least three to four times each patient journey we found that people hop providers.

I think our maximum was about 13 providers before a patient could actually get on to diagnosis and treatment.

People hopped between the small doctors and the more qualified doctors, between the allopathic sector and the ayurvedic sector between the public sector and the private sector.

So, there was a lot of hopping going on.

And this hopping is challenging because very often the second provider they go to, they do not know what the first provider has prescribed to the patient, which makes the whole treatment journey even more complex than than it should have been.

I think the third most important finding of our study was that this study was conducted in a vulnerable population, so people are very poor, they live a day-to-day existence, so they were constantly making a tradeoff between the need for relief and the need for lowering the cost of care that is needed.

So let's say during times when the symptoms were really troubling people, it was then that they sought care from the big doctors.

They spent a lot of money, they would get themselves diagnosed and they would start treatment.

Once they started treatment, as the symptoms started to go in remission, they were more under control.

People started feeling, why should I spend so much money on this and so people stop treatment and seek relief in other ways.

Saying I can manage my symptoms using home remedies or I can manage it using some herbal treatment, and other things.

This was constantly happening in people's life.

It was not a one-time thing, there was a constant seeking of balance between the need for relief and lowering care.

Maybe I should just summarize here by saying that care seeking journeys for diabetes and hypertension, they're not easy, linear journeys.

There are multiple providers involved, people are always making very hard choices, and they're not making these choices because they're not aware of things; aware of, say, what is diabetes or what is hypertension, but because in the kind of context that they come from, this is what is possible for them to do.

And also, when we did the study one, one of our big expectations was that for ailments which are as common as diabetes and hypertension, the pathway should be reasonably easy, but we did not find the case.

So, for other NCDs, which are less common and more complex like cancers, we do not even know how very messy the treatment journey would be like.

I can imagine that's true in many cases and for many types of conditions.

What are the policy recommendations that came out of your study?

The first thought that everybody starts with is, yes, we have to spread awareness in the community.

The minute we say patients are not able to navigate the health system, we say yes, we have to teach them how to navigate the health system.

We have to spread awareness, and there should be mass counselling and individual counselling and other things.

And our study did show that there is a need for all these things.

But in addition to that, I think our patient journeys also point to several things that the health system itself has to do so that it can make these patient journeys much less messy for them.

For example, one thing that these systems have to do is engage our public systems and our private systems do have to engage better with each other.

We do have prior examples from the tuberculosis program in India where this program has worked with informal providers in urban informal settlements and help them get people into the system so that they can receive tuberculosis care.

And this study did tell us that maybe this kind of model might work for non-communicable diseases as well in this setting.

The other thing that was recommended was patient support groups.

These are long patient journeys.

So, you start medication you're not supposed to stop them for life.

So having these support groups, having other patients tell them that, yes, you need to do this for life.

These are the implications of it and this is how this journey is going to be might be of more of words to the community rather than just having awareness campaign.

And I think lastly, the public sector we do have an emerging non-communicable diseases program in India.

The government is giving priority to it, but the scale of population we have in urban areas is huge.

Definitely, we need to expand more screening in these areas, more early reaching out and strengthening of the public sector is required.

So an interesting point you raise that basically the TB program already came to the similar conclusions a while back.

And it's interesting that those findings didn't basically make it to the other health areas.

And yeah, that's basically another argument for strengthening primary health care, right?

And then integration.

Yes, definitely.

Those are long standing debates, I think, in health systems on how much easier it is to do things in vertical programs which are under the control of one ministry and take that approach to move things forward.

And you're absolutely right in saying the, these lessons need to be transferred to the general health system and it's overall the foundation of PHC is something that we really need to improve in India.

Thank you so much for sharing these findings.

Very interesting, and I'm sure they apply to many other settings, and possibly also to many other conditions.

Maybe a last question before we wrap up.

What are you taking with you back to Mumbai from this conference?

What are some of the things that stood out and that you were surprised about?

I must confess, I do love this conference.

This is one of those communities which is very warm and welcoming.

So I, I really try to make it to almost every conference of HSGs that that has happened so far.

This time particularly today, related to the research that we are talking about, I was very happy and very excited also to see that there are many patient journey studies that are happening.

When I went down to look at the posters, I found one poster from Ghana, one from Burkina Faso, one from Guatemala, all of them looking at patient journeys and looking at patient journeys for non-communicable diseases.

So, clearly people are pursuing these these to fine tune policies and work towards more more patient centered health system and that's always a good thing to see.

Wonderful.

Thank you so much for joining us.

Thank you again.

And looking forward to doing more work in this area.

A big thank you to Agnes and Sudha for sharing their insights into some of the challenges of health insurance and the complexities of patients journeys through the health system in resource constrained settings.

Thank you for tuning into Health Systems Pathways.

If you enjoyed this episode, be sure to subscribe or follow us for more stories and lessons from the halls of the HSR Symposium in Nagasaki.

Until next time, I'm Alex Ergo, let's keep working together to build stronger health systems that work for people.