Operational

Capacityof

Insurers

inImplementing

Community-Based Health Insurance and Mandatory Health
Insurance in Low- and Middle- Income Countries in SubSaharan Africa : A Scoping Review1

一橋大学 国際・公共政策大学院
公共経済プログラム 修士 2 年

福嶋佳奈子

2020 年 1 月

1

本稿は、一橋大学国際・公共政策大学院公共経済プログラムにおけるコンサルティング・プロジェクトの成果物である。本稿の内容はすべて筆者の個人的見解であり、 本稿にあり得る誤りはすべて筆者個人の責任に帰するものである。

1

要約

本稿では、サブサハラアフリカ地域の低中所得国におけるコミュニティ医療保険及び強制医療保険の保険者の実務能力(資格管理・情報更新、保険料設定・徴収、給付範囲の設定、啓発、契約、支払審査、償還、モニタリングと評価)に関して、2010 年から 2018 年に発表された英語文献に対してスコーピング・レビューを行った。32 件の対象文献のうち、ガーナを対象にした文献は 17 件存在した。分析より次の点が明らかとなった。①支払審査以外の実務能力に関する量的調査が必要であること。②保険者人材の量的・質的な不足が保険料徴収、給付範囲の設定、支払審査、モニタリングと評価に影響を及ぼしていること。③最も文献が少なかったのは「契約」であること。
対象文献の半数を占めるガーナにおいては、国民健康保険を採用しているため購買契約は国単位で行っている。郡・州単位では効率的でない実務を明らかにし、適切な組織が実施するように業務調整することも有益であると示唆された。

謝辞

本稿は、一橋大学国際・公共政策大学院公共経済プログラムにおけるコンサルティング・プロジ
ェクトの一環として行われたものである。受入機関 として本プロジェクトにご協力いただいた一橋大学社会科学高等研究院医療政策・経済研究センターの中村良太准教授におかれては、多忙な中、貴重な時間を頂き、大変有益なご指導とご助言をいただき、心より感謝申し上げる。本田文子
准教授（上智大学）、戸辺誠専門員（国際協力機構）、野田信一郎先生（国立国際医療研究センター）におかれては、数々の有益なご指導とご助言をいただき、心より感謝申し上げる。この研究を完成させるにあたり、多くの方々から有益なコメントを頂戴した。指導教官である佐藤主光教授（一橋大学）からは、構成から分析、執筆の段階まで何度もご助言をいただいた。また、公共政策
大学院の先生方、そして公共経済プログラムの学生には、報告会の場で数多くの貴重なアドバイスをいただいた。
本プロジェクトを通して、貴重なご指導とご助言をいただいたすべての方 に、厚く御礼申し上げる。

2

Contents

Introduction ................................................................................................. 4
Methods ........................................................................................................ 8
Results......................................................................................................... 12
Discussion ................................................................................................... 20
References .................................................................................................. 23
Appendix .................................................................................................... 26

3

Introduction‘All people have access to services and do not suffer financial hardship paying
for them’, is the goal defined as universal health coverage (UHC) in the world healthreport 2010. The United Nations resolution on UHC was adopted in 2012 and became
Target 3.8 of the Sustainable Development Goal 3, Good Health and Well-Being (World
Health Organization, 2010).
In 2007, more than 50% of total health expenditure in 33 countries (mostly lowincome) was direct-out-of-pocket payments (World Health Organization, 2010). Study on
catastrophic payment incidences in 133 countries suggest that the proportion of the
population that is supposed to be covered by health insurance schemes or by national or
subnational health services is a poor indicator of financial protection. Increasing the shareof total health expenditure that is prepaid, particularly through taxes and mandatory
contributions, is required instead of increasing the share of GDP spent on health(Wagstaff A. , et al., 2018). Another study on impoverishing health spending in 122
countries shows that out-of-pocket spending on health can add to the poverty head countand the depth of poverty by diverting household spending from non-health budget items.
The scale of such impoverishment varies between countries and depends on the poverty
line but increasing the share of total health expenditure that is prepaid, especially throughtaxes and mandatory contributions, can help reduce impoverishment (Wagstaff A. , et al.,2018). To reduce reliance on direct payments, governments should encourage the riskpooling, prepayment approach, making the goal of UHC more realistic (World HealthOrganization, 2010). The financial commitment of each government is crucial forachieving UHC (Gottret, Schieber, & Waters, 2008) and, therefore, countries across Asia
4and Africa are currently reforming their health sectors to achieve UHC (Maeda, et al.,2014).
Strategies to achieve UHC are diverse and vary according to economic
conditions, geography, history or cultural context of each country (Maeda, et al., 2014)(McIntyre & Kutzin, Health financing country diagnostic: a foundation for national
stategy development, 2016). UHC schemes vary considerably in their revenue collection
strategy and most countries rely on mixed or hybrid sources of funding (Giedon, Alfonso,& Diaz, 2013). As developing an efficient tax-funded health system is a difficult task in
low-income countries, various health financing arrangements are expected to assist thecitizenry as financial protections for medical expenses (Habib, Perveen, & Khuwaja,2016).
In sub-Saharan Africa (SSA), several health schemes exist, for instancecommunity-based health insurance (CBHI) and Mandatory Health Insurance (MHI).
Most CBHI schemes in SSA are voluntary-based and have fewer than 500 members. The
number covered by CBHI schemes is still relatively small in most low-income countries.
There are exceptions, such as Rwanda, where the CBHI scheme covers 74 % of theinformal sector. However, evidence shows that most community-based schemes do notreach the very poor (Gottret, Schieber, & Waters, 2008) (Chemouni, 2018). The conceptof MHI is relatively new in SSA and lacks evidence regarding actual impact. Establishing
the MHI scheme is difficult in SSA, due to high poverty levels, large informal sector,
weak revenue collection mechanisms and alike. Kenya, Ghana, and Tanzania arecountries which have introduced MHI schemes (Chuma, Mulupi, & McIntyre, 2013),
despite their fragmented healthcare systems (McIntyre, et al., 2008).
Although various health insurance schemes are in place, weak managerial
5capacity of insurers has been detected in studies of CBHI (De Allegri, Sauerborn, Kouyate,& Flessa, 2009) (Schneider, 2005) (Carrin, Waelkens, & Criel, 2005) (Atim, 1998). De
Allegri et al. (2009) describe them as follows: ‘weak managerial capacity is reflected in
all fields of operation, from setting actuarially fair premiums to designing risk
management tools, from conducting social marketing campaigns to administering
everyday bookkeeping, from performing financial management to handling cash flow
control.’ (De Allegri, Sauerborn, Kouyate, & Flessa, 2009). A systematic review whichinvestigated the implementation, uptake and sustainability of CBHI schemes in low- andmiddle- income countries (LMIC) remarked that the management or administrative
structure has influence in their implementation and sustainability (Fadlallah, et al., 2018).
Several intuitive frameworks on capacity exists. Potter and Brough (2004) demonstrate
the systemic capacity building and capacity pyramid. Grindle and Hilderbrand (1995)
depict the dimensions of capacity. Certain studies on CBHI in Africa indicate that there
are several aspects of managerial capacity ensuring operation (De Allegri, Sauerborn,
Kouyate, & Flessa, 2009) (Carrin, Waelkens, & Criel, 2005) (Schneider, 2005) (Atim,
1998) (Tabor, 2005) (Baltussen, Bruce, Rhodes, Narh-Bana, & Agyepong, 2006)(Fadlallah, et al., 2018) (Ndiaye, Soors, & Criel, 2007):•

record keeping,•accounting or bookkeeping,•using management information system,•

reporting,•collecting premiums,•

setting premium rates,•

determining the benefits package,
6

•marketing and communication,•

contracting with providers,•pharmacies and clinics, and•claims verification

Additionally, ensuring sustainability of insurance via:•

Managing Fund,•

Considering appropriate investment strategies for the fund,•

Keeping separate accounts,•

Training,•

Holding regular meetings,•

Monitoring and evaluation

A central role in implementing health insurance is played by insurers. This includes:
efficient and effective administration, inevitable operational capacity, like deciding theeligibility and updating the information of each insured person, setting and collecting
premiums, setting the fee schedule, reviewing bills from medical institutions, andreimbursing medical fees (Shimazaki, 2013). The assessment of necessary capacity fordaily implementation of reforms in the health sector is inevitable (Mills, Bennett, &Russell, 2001), however, the description of operational capacity for insurers of MHI and
CBHI does not exist, which this paper addresses. Herein, operational capacity refers to:deciding the eligibility and updating the information of each insured person, setting andcollecting premiums, setting the fee schedule, reviewing bills from medical institutions,and reimbursing medical fees. We adopted the scoping review method to examine theextent, range and nature of the operational capacity of insurers and to identify researchgaps for the future studies (Anderson, Allen, Peckham, & Goodwin, 2008) (Levac,
7Colquhoun, & O’Brien, 2010).

Objectives
This paper aims to describe the operational capacity of insurers of both MHI and
CBHI in implementing health insurance in SSA.
Research questions are as follows:
1) What are the operational capacities of insurers of MHI and CBHI in SSA?
Operational capacity refers to deciding the eligibility and updating theinformation of each insured person, to set premiums, to collect premiums and todesign benefit package, to conduct marketing and communication, to contract
with providers, pharmacies and clinics, to check the bills from medical
institutions to reimburse medical fees and to conduct monitoring and evaluation.
2) What are the research gaps in evidence underlying operational capacities of MHI
and CBHI insurers in SSA?

Methods
Types of studies
This study is a scoping review. Studies chosen included insurers of public healthinsurance in SSA. As per the research question, focusing on the process of insurers rather
than their effectiveness, this review includes qualitative research, survey and systematic
reviews (Petticrew & Roberts, 2006).

8

Sources
The search parameters were as follows: literature published between 2000 and2018, inclusive, was surveyed through the electronic databases of Medline and Google
Scholar, bolstered by certain grey literature. Our review considers studies published in
English only. Studies were included found via snowball searching, and thoserecommended by experts.

Data Collection and Analysis
Eligibility and inclusion criteria of surveyed studies:
1. Via Medline and Google Scholar database searches, grey literature with selectedcombinations of terms and keywords;
2. Published in English;
3. Published between 2000 and 2018, inclusive;
4. Including insurers of public health insurance in LMIC and SSA; and5. Quantitative and qualitative studies.

Exclusion criteria of surveyed studies:
1. Published in languages other than English;
2. Not focusing on LMIC or SSA contexts;
3. Health insurance schemes other than public health insurance;
4. Outside of the designated publishing years; and5. Not available with full text.

9

Search Strategy and Results
Please refer to the appendix for the search keywords utilised. Figure 1 below
outlines the systematic process followed to identify and select literature included in the
study.

Figure.1 Flowchart of Article Selection

Data Management
Microsoft Excel was used to manage and store the reviewed studies. A checklist
was developed according to the eligibility criteria of this review, following the PRISMAScR statement.

10Data Selection
We identified potentially relevant studies, analysed titles and abstracts andassessed their eligibility. If there was uncertainty of eligibility, the study was temporarily
included. Possible eligible studies were assessed in detail with their full text versions todetermine their relevance as per the eligibility and inclusion criteria. Studies selected wereused for the review and the results from each step were discussed and consensus reached.
For each study excluded, justification was documented.

Data Extraction
Investigators independently extracted all data items of each included study witha standardised data collection form.

Data Items
Please refer to the appendix for the Data Extraction Form. The descriptive items
collected were: (1) general information and characteristics of the study, country or place,and type of insurance scheme; (2) methodological characteristics, including the type of
method and how data or information was collected, components that were analysed; and(3) operational barriers for the insurer in implementation.

Data Synthesis and Analysis
Extracted data were analysed and summarized in order to answer the researchquestions. Data were summarized in a chart according to the operational barriers foundalong with gaps in evidence identified.

11

Results
Summary of Selected Literature
Thirty-two articles were identified (see Table 1). Twelve of them were publishedbetween 2000 and 2010. Twenty of them were published between 2011 and 2018. Six
articles were found in BMC, five articles are publications from The Partners for Health
Reform Project. More than half of the articles were focused on Ghana.

Geographic Focus
Articles are heavily focused on Ghana (n=18). Other countries included are
Rwanda (n=4), Senegal (n=2), Tanzania (n=2) and for each of the following areas, single
article was found (Asia, Africa, LMIC, Mauritania, South Africa, Uganda and West
Africa).

Insurance Schemes
Seventeen articles of the 32 focus on MHI, with 16 articles focusing on CBHI.
There is one article which focuses on both MHI and CBHI in Ghana, hence theduplication.

Types of Article and Study Design
Twenty-nine articles are research-based, employing various methodologies.
Three articles are government documents. Seventeen articles are of qualitative design(including five case study design), five were review articles, two were reports. Fourarticles were of mixed methodology (qualitative and quantitative). Four articles employed
quantitative methodologies. Of eight articles with mixed methodologies, five were12

investigating claims management; three utilised quantitative methodology to investigate
participants’ satisfaction, enrolment and financial sustainability.

13

Table1: Description and Analysis of Included Articles (in Alphabet order)#

Author and Year

Journal or Source

Title

Study Design

SettingType of Insurance (NHI,
CBHI etc.)

Study year
(1) decide theeligibility ofeach insured
person(2) update the (3) set(4) premiums
information of premium rates collection
each insured
person<Operational capacity>(5) design of (6) marketing (7) contract(8) claims(9) reimburse
benefitandwith providers, verification/
medical fees
packagecommunication pharmacies and check the bills
clinics
from medical
institutions

1

Adei et al.
(2012)

Current Research Journal of Social
Sciences

An Assessment of the Kwabre District Mutual Health Qualitative andInsurance Scheme in Ghana
quantitative

Ghana

CBHI

2008-2010✓✓

2

Agyepong et al.
(2016)BMC Health Services Research

The "Universal" in UHC and Ghana's National Health Mixed Mehod
Insurance Scheme: policy and implementation
challenges and dilemmas of a lower middle income
country.

Ghana

NHI

2010 – 2013

✓

✓

✓

✓

✓

3

Alhassan et al.
(2016)

Plos OneA Review of the National Health Insurance Scheme in Qualitative
Ghana: What Are the Sustainability Threats andProspects?

Ghana

NHI

2003-2016

✓

✓

✓

✓

✓

4

Atim et al.
(2000)The Partners for Health Reform Project, An External Evaluation of the Nkoranza Community
Abt Associates Inc.
Financing Health Insurance Scheme, Ghana.

Qualitative

Ghana

CBHI

1999

5

Atim et al.
(2001)The Partners for Health Reformplus
Project, Abt Associates Inc.

A Survey of Health Financing Schemes in Ghana.

Qualitative andquantitative

Ghana

NHI

2001

6

Baltussen et al.
(2006)

Tropical Medicine and International
HealthManagement of mutual health organizations in Ghana

Qualitative

Ghana

CBHI(MHO)

2004-2005

7

Borghi et al.
(2013)

Health Research Policy and Systems

Promoting universal financial protection: a case study Qualitativeof new management of community health insurance in (Case Study)
Tanzania.

Tanzania

CBHI

2011-2012✓✓8

Chee et al.
(2002)The Partners for Health Reformplus
Project, Abt Associates Inc.

Assessment of the community health fund in Hanang
District, Tanzania.

Tanzania

CBHI

2001-2002✓✓

9

Debpuur et al.
(2015)BMC Health Services Research

An exploration of moral hazard behaviors under the
Qualitative
national health insurance scheme in Northern Ghana: aqualitative study.

Ghana

NHI

2009-2010✓10

Derriennic et al.
(2005)The Partners for Health Reformplus
Project, Abt Associates Inc.

An Assessment of Community-Based Health
Financing Activities in Uganda.

Qualitative

Uganda

CBHI

2004

✓

11

Franco et al.
(2004)The Partners for Health Reformplus
Project, Abt Associates Inc.

Social Participation in the Development of Mutual
Health Organizations in Senegal.

Qualitative

Senegal

CBHI

2003

14

✓

✓

✓

✓

✓

✓

✓
✓

CBHI(MHO)

Qualitative✓(10) monitoringand evaluation

✓

✓

✓

✓
✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

Table1 (continued)#

Author and Year

Journal or Source

Title

Study Design

SettingType of Insurance (NHI,
CBHI etc.)

Study year
(1) decide theeligibility ofeach insured
person12

Fusheini et al.
(2012)

Conference paper (62nd Political
The Implementation of the National Health InsuranceStudies Association Annual International Programme in Ghana - an Institutional Approach.
Conference in Defence of Politics)

Qualitative(Case Study)

Ghana

NHI

2011-201213

Fusheini et al.
(2016)BMC Health Services Research

Achieving universal health coverage in South Africa
through a district health system approach: conflicting
ideologies of health care provision.

ReviewSouth Africa

NHI

2014

14

Huber et al.
(2003)

GIZ - Deutsche Gesellschaft fürInternationale Zusammenarbeit GmbH

Mutual Health Insurance (MHO) – Five Years
Experience in West Africa.

Qualitative

WestAfrica

CBHI(MHO)

2001

15

Jakab et al.
(2001)

HNP Discussion Paper, World Bank

Community involvement in health care financing: A
Survey of the Literature on the Impact, strengths andweaknesses

Review

Asia & Africa

CBHI

1990-2001

16

Mbau et al.
(2018)

Global Health Action

Influence of organisational culture on theimplementation of health sector reforms in low-andmiddle-income countries: a qualitative interpretive
review

Qualitative

LMIC(incl. Ghana, Nigeria)

NHI

2000-2015

17

Ministry of Health,Ghana(2004)

National Health Insurance Policy Framework For
Ghana

Review

Ghana

NHI

18

(2016)The Development of Community-Based Health
Insurance in Rwanda: Experiences and Lessons

ReportRwandaCBHI

19

Mladovsky et al.
(2015)

Health Policy and Planning

The impact of stakeholder values and power relations Qualitative (Case Study) Senegalon community-based health insurance coverage:
qualitative evidence from three Senegalese casestudies.

CBHI

20

Musango et al.
(2013)

African Health Monitor

Strategies towards universal health coverage inRwanda : Lessons learned from extending coveragethrough mutual health organizations.

Review

RwandaCBHI

21

National Health
Insurance Authority,
Ghana(2011)

National Health Insurance Scheme, Annual Report
2011

Report

Ghana

NHI

2011

22

Nsiah-Boateng etal.
(2013)

Ghana

NHI

2007-2009

Value In Heatlh Regional Issues

Performance Assessment of Ga District Mutual Health Quantitative
insurance Scheme, Greater Accra Region, Ghana.

(2) update the (3) set(4) premiums
information of premium rates collection
each insured
person

✓

✓

✓

✓

✓

(10) monitoringand evaluation

✓

✓

✓

✓

✓

✓

✓

✓

✓

2009

15

<Operational capacity>(5) design of (6) marketing (7) contract(8) claims(9) reimburse
benefitandwith providers, verification/
medical fees
packagecommunication pharmacies and check the bills
clinics
from medical
institutions

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

Table1 (continued)#

Author and Year

Journal or Source

Title

Study Design

SettingType of Insurance (NHI,
CBHI etc.)

Study year
(1) decide theeligibility ofeach insured
person23

Nsiah-Boateng etal.
(2016)

Value In Heatlh Regional Issues

Value and Service Quality Assessment of the National Quantitative
Health Insurance Scheme in Ghana: Evidence from
Ashiedu Keteke District.

Ghana

NHI

2010-2014

24

Nsiah-Boateng etal.
(2017)BMC Health Services Research

Reducing medical claims cost to Ghana's National
Quantitative
Health Insurance scheme: a cross-sectional
comparative assessment of the paper- and electronicbased claims reviews.

Ghana

NHI

2014

25

Sakyi et al.
(2011)

Journal of Health Organization andManagement

Barriers to implementing health sector administrative
decentralisation in Ghana: a study of the Nkwanta
district healthmanagement team.

Ghana

NHI

2008

26

Sakyi et al.
(2008)

Leadership in Health Services

Implementing decentralised management in Ghana: the Qualitative (Case Study) Ghana
experience of the Sekyere West District healthadministration

NHI

2008

27

Schneider et al.
(2000)

International Affairs

Development and Implementation of Prepayment
Schemes in Rwanda.

Rwanda

CBHI

1999

28

Schneider P.
(2005)

Social Science & Medicine

Trust in micro-health insurance: an exploratory study in Qualitative (Case Study) Rwanda
Rwanda.

CBHI

2000

29

Sodzi-Tettey et al.
(2012)

Ghana Medical Journal

Challenges in provider payment under the Ghana
National Health Insurance Scheme: a case study ofclaims management in two districts.

Ghana

NHI

2008, 200930

Waelkens et al.
(2017)BMC Health Services Research

An in-depth investigation of the causes of persistent
Qualitative
low membership of community-based health insurance:a case study of the mutual health organisation of DarNaïm, Mauritania.

Mauritania

CBHI (MHO)

2003-2012

31

Wang et al.
(2017)

World bankGhana National Health Insurance SchemeImproving Quantitative
Financial Sustainability Based on Expenditure Review

Ghana

NHI

2008, 201432

Witter et al.
(2009)BMC International Health and Human
RightsSomething old or something new? Social healthinsurance in Ghana.

Ghana

NHI

2005-2009

Qualitative

Review

Qualitative andquantitative

Qualitative

16(2) update the (3) set(4) premiums
information of premium rates collection
each insured
person<Operational capacity>(5) design of (6) marketing (7) contract(8) claims(9) reimburse
benefitandwith providers, verification/
medical fees
packagecommunication pharmacies and check the bills
clinics
from medical
institutions(10) monitoringand evaluation

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

Operational Capacity
Considering the identified study variables to investigate operational capacity:
16 articles (50%) referred to ‘decide the eligibility of each insured person’, 16 articles(50%) referred to ‘set premiums rates’, 16 articles (50%) referred to ‘design of benefit
package’, 15 articles (47%) referred to ‘marketing and communication’, 13 articles (41%)
referred to ‘claims verification/ check the bills from medical institutions’, nine articles(28%) referred to ‘premium collection’, nine articles (28%) referred to ‘reimburse
medical fees’, eight articles (25%) referred to ‘update the information of each insured
person’, eight articles (25%) referred to ‘monitoring and evaluation’, five articles (16%)
referred to ‘contract with providers, pharmacies and clinics’. (see Table 2)

Table 2

Number of articles by each operational capacity

Operational capacity

number of articles

decide the eligibility of each insured person

16/32

update the information of each insured person

08/32

set premiums rates

16/32

premium collection

09/32

design of benefit package

16/32

marketing and communication

15/32

contract with providers, pharmacies and clinics

05/32

claims verification/ check the bills from medical institutions

13/32

reimburse medical fees

09/32

monitoring and evaluation

08/32

Regarding, ‘decide the eligibility of each insured person’, six articles refer to thedecision making of indigent people or exemption (as per Table 1: #2, #3, #8, #20, #27 and#32). Two articles find the abuse of membership card (#9 and #18).
Regarding, ‘update the information of each insured person’, two articles refer todelays in issuing membership cards (#2 and #3). Two articles indicate that the schemes17adopt some measure to avoid membership card fraud (#6 and #9). Insurers find that people
are unaware of expiry dates of insurance cards (#2) and think it unnecessary when they
did not use the insurance the previous year (#18). Three articles suggest the lack ofadequate databases for insurance members, which cause miscommunication among
stakeholders regarding expiry dates, undetected forgery of membership cards, andcomplicated entitlement procedures (#18, #29 and #30).
Regarding, ‘set premiums rates’, four articles mentioned the actual premium
rates according to the category of people (#1, #18, #30 and #31). Six articles refer to thedecision-making process of premium rates (#7, #10, #11, #12, #19 and #28). In Ghana,high premiums and registration fees are thought to be the barrier of enrolment (#2),
conversely, there is a need for policy reforms on low premiums and the generous broad
benefits package (#3).
Regarding, ‘premium collection’, three articles refer to the responsible personfor premiums collection (#19, #24 and #30). Low revenue is mentioned in two articles(#3 and #8), however, figures on the collection rate is available from one article (#3). The
schemes, which are run by volunteers, the premiums collection is a challenging task, due
to the shortage of time and travel costs (#19 and #30).
Regarding, ‘design of benefit package’, four articles discuss the content ofbenefit package (#5,#27,#31 and #32); two articles focus on autonomy of benefit
packages (#2 and #6); two articles focus on considerations of designing benefit packages
by local context or by health facility level (#12 and #18); and one article on the processof deciding benefit packages (#28). One article mentions that actuarial methods are rarely
used to set premiums and define the benefit package (#6).
Regarding, ‘marketing and communication’, nine articles refer to the lack of18

communication within the insurers or between the insurers and the local community, due
to the lack of marketing strategy, communication skills, human resources or sometimes
the sensitisation policy not being shared (#2, #4, #6, #7, #8, #10, #16, #30 and #31). Threearticles describe the strategies of marketing utilised (#1, #20 and #27).
Regarding, ‘contract with providers, pharmacies and clinics’, there is only one
article which took place in Ghana (#29). Other articles mention the number of contracts(#13), and the process behind securing contracts (#15, #19, #30).
Regarding, ‘claims verification/check the bills from medical institutions’, six
articles describe procedures (#5, #6, #7, #13, #24 and #32). These articles show that there
are several reasons for ineffective procedures being, the lack of skills to verify claims (#8,
#18 and #29), shortage of personnel (#22, #29 and #31), and ineffective equipment (#22
and #31). Certain articles show figures on rejection rates (#29), claims processing rates(#22), and claims adjustment rates (#23).
Regarding, ‘reimburse medical fees’, six articles refer to the reimbursement
procedure (#2, #3, #18, #24, #28 and #29). Five articles refer to the delay inreimbursements (#1, #2, #3, #18 and #29) and point out that such delay leads to the deficitof medical supplies or salaries (#1).
Lastly, regarding ‘monitoring and evaluation’, two articles describe the content
of monitoring (#7, #20 and #27), one article mentions the lack of skills in monitoring (#4),
and one article refers the inadequate use of data for monitoring (#31).

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Discussion
Key Findings
Our findings suggest that the operational capacity of insurers is not always
focused as a main topic of health insurance. Although the deficit of management capacity
is noted in many articles, few studies focused on the achievement of operational capacity.
Considering the volume of literature focused on Ghana, there seems to be a wide gap ininsurers between countries and within countries. Few articles apply the quantitative
methods only found in the ‘claim verification’ category—the key function of the insurer.
It shows that common problems exist behind several operational capacities. The
shortage of personnel problem is found in both ‘premium collection’ and ‘claims
verification’. The lack of adequate skills problem is found in the categories of ‘design ofbenefit package’, ‘claims verification’ and ‘monitoring and evaluation’. The problem of
the inadequate use of data is found in both categories of ‘update the information of each
insured person’ and ‘monitoring and evaluation’. Lack of communication is a major
problem found in the ‘marketing and communication’ category.
Articles analysed are scarce in the ‘contract with providers, pharmacies andclinics’ category. Purchasing is one of the three core health financing functions (Kutzin,2001), and within five articles there is only one article on Ghana. In Ghana, the District
Mutual Health Insurance Schemes is a provider of health insurance and the National
Health Insurance Authority (NHIA) is responsible for entering into purchase agreementswith providers and reimbursing them (Sodzi-Tettey, Aikins, Awoonor-Williams, &Agyepong, 2012).

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Gaps and Potential for the Future Research
There are limited quantitative studies on categories other than ‘claim
verification’. Depending on the availability of data, the capacity of ‘monitoring andevaluation’, for example, can accumulate data using the monitoring sheet. The articles
analysed mostly focus on Ghana, since it has a long tradition of national health insurance.
Considering the context of SSA, we recommended including articles written in French.
The geographic focus was narrow, and to generalise the operational capacity of the insurer,
widening the area will be inevitable. Gaps in specific skills are indicated from the
supporting factors, however, it might need further investigation since the specific skills
for each insurance organization might be different considering the background of eachcountry and district.

Implications
Our findings suggest that there is a need for personnel with a review from quality
and quantity. The lack of insurers simply delays many operations and insurers withinadequate skills leads to stifling the whole procedure. Certain operations could be
integrated with the superior institution, for example the purchasing of health insurance in
Ghana was transferred from the district level to the national level, which can profit fromthe larger scale of benefits and efficacy of operations. There seems to be a deficit inadequate skill of insurers, which is a crucial factor in operation. Therefore, it is suggested
to assess the specific skill of insurers, to decide the strategy to fill the gap of operational
deficit by training or by task shifting, before implementing the insurance.

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Limitations
A limitation of this review is the exclusion of articles not published in English.
Although using Google Scholar and Medline platforms, and the direct search, someliterature may have been missed and publication bias cannot be excluded.

Conclusions
This scoping review provides a descriptive map of the academic literature on theoperational capacity and supporting factors of health insurers. Since many countries arereforming their health sectors to reduce out-of-pocket expense, focus on the operating
capacity of health insurers is increasingly important. More research is needed to address
the gap in operational capacity and clarify the competency of health insurers and thedemarcation of operation at different levels.

Conflict of Interest
None.

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Appendix
Search Keywords
Google Scholar(“low* middle* incom* countr*” OR “low* incom* countr*” OR “middle* incom* countr*” OR“underdevelop* countr*” OR “developing countr*” OR “low* middle* income* nation*” OR“third*world* nation*” OR “underdevelop* nation*” OR “less* developed nation*” OR “low*income nation*” OR “developing nation*” OR “least* developed countr*” OR “less-developed
countr*” OR “developing world*” OR “undeveloped world*” OR Africa OR Angola OR Benin OR
Botswana OR “Burkina Faso” OR Burundi OR “Cabo Verde” OR Cameroon OR “Central African
Republic” OR Chad OR Comoros OR “Congo, Dem* Rep*” OR “Congo, Rep*” OR “Cote d'Ivoire”
OR Djibouti OR “Equatorial Guinea” OR Eritrea OR Ethiopia OR Gabon OR Gambia OR Ghana OR
Guinea OR “Guinea-Bissau” OR Kenya OR Lesotho OR Liberia OR Madagascar OR Malawi OR
Mali OR Mauritania OR Mauritius OR Mozambique OR Namibia OR Niger OR Nigeria OR Reunion
OR Rwanda OR “Sao Tome and Principe” OR Senegal OR Seychelles OR “Sierra Leone” OR
Somalia OR “South Africa” OR “South Sudan” OR Swaziland OR Tanzania OR Togo OR Uganda
OR Zambia OR Zimbabwe)
AND(CBHI OR “community based health insurance” OR “community based health” OR “community
based insurance” OR ”community financing” OR “compulsory health insurance” OR “mandatory
health insurance” OR “micro*credit” OR microfinance OR “micro health insurance” OR“micro*savings” OR “mutual health” OR “mutual health organization” OR “mutuelles de santé” OR“national health insurance”)
AND(access OR account* OR admin* OR authority OR barrier OR “benefit package” OR bookkeeping
OR catastrophic OR challenges OR “claims verification” OR communication OR community OR
compliance OR contribution OR corruption OR coverage OR cooperation OR culture OR
determinants OR difficulties OR “drop out" OR economic OR eligib* OR empowerment OR equity
OR emergence OR enrol* OR equipment OR evaluation OR evidence OR exemption OR expenditure
OR facilitator OR facility OR financ* OR “formal sector” OR fragmentation OR funding OR “global
health” OR govern* OR health OR “human resources” OR impact OR implement* OR impoverishing
OR inclusion OR “informal sector” OR information OR invest* OR insurance OR legislation OR
marketing OR manag* OR membership OR mobilization OR monitoring OR obstacles OR operation
OR outcome OR participation OR perceptions OR performance OR policy OR politic* OR pooling
OR poverty OR premium OR “public sector” OR purchasing OR quality OR role OR record OR
regulation OR relevance OR remuneration OR report OR resource OR risk OR stewardship OR skill
OR social OR sustainab* OR social OR strateg* OR strength OR technical OR trust OR universal
coverage OR “universal health coverage” OR UHC OR uptake OR value OR weakness)

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Data Extraction Sheet

1. General Information and Characteristics of the studies
Author’s name
Title
Journal or Source
Year of publication
Setting (district, region/state, country)
Study Design
2. Insurer
Type of Insurance (NHI, CBHI etc.)
Membership
Characteristics of insurance organization(level, body of insurer, etc.)
Operational capacity of insurer- decide the eligibility of each insured person- update the information of each insured person- set premium rates- premiums collection- design of benefit package- marketing and communication- contract with providers, pharmacies and clinics-claims verification/ check the bills frommedical institutions-reimburse medical fees
- monitoring and evaluation- others
OthersRecognized barriers in implementing insurance
Recognized promoting factors in implementing
insurance

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