⒈ Private Health Insurance Case Study

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Private Health Insurance Case Study



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This led to significant difficulties and delays in establishing the NHIS policy and its passage through parliament. It also further polarised two sets of stakeholders and created a division that could have been prevented had the task force conducted a stakeholder analysis and used it to respond to the concerns of influential players. The Ghanaian case highlights the potential value of stakeholder analysis in guiding and managing health reform [ 2 ]. The experience in Ghana, as in Uganda, showed that high-level political commitment, popularity of the proposed reform, and sound technical analysis may be insufficient to avoid implementation difficulties.

In Ghana, the then ruling party and president also wanted to show the electorate that their party had fulfilled an election pledge before the next elections. Greater attention and focus needs to be placed on recognising, analysing, and managing the political interests of key stakeholders during the policy process. Indeed, only five countries—Botswana, Rwanda, Zambia, Madagascar, and Togo—have attained that target [ 67 ]. We recommend further research to elucidate additional details on the related technical, substantive, and operational factors towards clarifying the major reasons for preventing an NHI scheme from being established in Uganda—as compared with the East African countries that have advanced further in this area.

Such studies could provide greater information on the enabling and constraining factors, such as the scope of services included in insurance benefit packages, the level of private contributions, and the level of coverage provided to various sub-populations, particularly the poor, informal-sector workers, and other groups not covered by private insurance plans. Uganda provides an interesting case study for exploring how planning for NHI has evolved since and moved to the current phase of near-implementation. The design of the NHIS was characterised by small-scale, gradual changes and adjustments during all three phases of development.

Despite political will in government, resistance by various stakeholders played an important role in constraining the pace of the development process as well as in shaping the design of the proposed NHIS. Among other ways, the stakeholders influenced the policy makers in changing the design and name of the proposed health-financing reform from SHI to NHI. Stakeholders were also influential in changing the design from a single to multiple schemes and in the immediate incorporation of the informal sector in the early design and operation of the scheme.

In line with its neighbours, Uganda set out to establish an NHIS to provide for more equitable access to services as well as for a more durably financed health sector. The initial proposal received a low level of support, mainly because the plan was developed without taking into consideration key stakeholders and thus failed to meet their concerns. The preparation and planning for NHI in Uganda was overly concerned with policy content, and very little thought was given to stakeholder engagement.

Even the study tours to three East Asian countries failed to identify the general process by which policy reform was negotiated, stakeholders analysed, and political institutions engaged and managed. The initial phase had a limited knowledge base and minimal available research to provide guidance and practical examples for the political economy in establishing NHI. Lacking a good evidence base, the sponsors of the NHIS relied largely on technical solutions and past experience with other health reforms. It is vital to undertake a comprehensive stakeholder analysis as part of any substantive health-sector reform to identify, address, and overcome concerns before they harden into inflexible opposition.

An intensive, detailed stakeholder analysis during the design process could pinpoint rising issues or threats, minimise obstacles to passage, build coalitions, and channel information and resources to promote and sustain reform implementation [ 49 , 51 ]. The positions of stakeholders can be influenced to shape the direction in which they develop over time. Thus, policy makers and implementers need to consider periodic re-categorisation of stakeholders to capture emerging positions and shifting power dynamics as well as sustain their continued engagement. If stakeholder analysis is not re-evaluated at regular intervals, it can slow down or halt the policy design and development process—even when there is strong support from senior executive and legislative representatives.

The private sector represents an important stakeholder in health-financing reforms, and its role needs to be carefully considered. Comprehensive feasibility and actuarial studies of the health insurance scheme need to be complemented by broader political economy analyses and social impact assessments that specifically examine the potential effects of SHI on employment and investment in the private sector. A situational analysis of health-sector policies and recent health reforms may need to be conducted to identify potential conflicts with the proposed NHI plan. Launched after major political change and against the backdrop of abolition of user fees, the NHIS faces additional challenges that overlap with technical issues, stakeholder management, and the common apprehension that often surrounds major health reforms.

It is necessary to address these challenges. This will entail reconciling the views of two different sets of stakeholders on how to overcome the financial barriers to access: those advocating user fee abolition to achieve universal healthcare; and those advocating the imposition of some level of contribution for insurance coverage as the vehicle for universal healthcare. For example, Kenya and Tanzania had to reintroduce user fees before implementing their NHI schemes [ 4 , 64 , 68 ]. The government of Uganda may need to re-evaluate the impact on changes in the level of community financing of services in the current environment of abolishing user fees before pressing on with stakeholder discussions and NHIS implementation [ 6 , 64 ].

A growing body of literature supports the argument that an analysis of stakeholders and the policy arena is highly relevant to health-policy reform and represents an important first step in developing plans for NHI. This paper points out how policy making is a complex process with an unstable and rapidly changing context. The use of stakeholder analysis in predicting and managing the future is time limited, and it is desirable that it be supplemented by other policy analysis approaches, such as the Delphi method [ 69 ]. Our results from this Uganda case study add to the body of evidence and offer useful information to policy makers and those tasked with designing and implementing SHI in low- and middle-income countries or similar settings.

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The New Vision. World Health Forum. Schmeer K: Stakeholder analysis guidelines. Policy toolkit for strengthening health sector reform. World Bank: Stakeholder analysis. Walt G, Gilson L: Reforming the health sector in developing countries: the central role of policy analysis. Health Policy Plan. Chapter Google Scholar. A paper prepared for the DDM Symposium. Technical Briefs for Policy-Makers.

Ngilu CK: We have to make health the engine for economic development. S Afr Med J. PubMed Google Scholar. Chuma J, Okungu V: Viewing the Kenyan health system through an equity lens: implications for universal coverage. Gilson L: The lessons of user fee experience in Africa. Brugha R, Varvasovszky Z: Stakeholder analysis: a review. Download references. The authors wish to thank Dr. Julia Kim and Dr.

We are also grateful to Rebecca K. Contributions by Dr. Francis Runumi and Mrs. Box , Kampala, Uganda. You can also search for this author in PubMed Google Scholar. This article is published under license to BioMed Central Ltd. Reprints and Permissions. Basaza, R. Players and processes behind the national health insurance scheme: a case study of Uganda. Download citation. One addressed the issue of minimum necessary information in telephone message content. Employees were trained to provide only the minimum necessary information in messages, and were given specific direction as to what information could be left in a message. Employees also were trained to review registration information for patient contact directives regarding leaving messages.

The new procedures were incorporated into the standard staff privacy training, both as part of a refresher series and mandatory yearly compliance training. A mental health center did not provide a notice of privacy practices notice to a father or his minor daughter, a patient at the center. To resolve this matter, the mental health center revised its intake assessment policy and procedures to specify that the notice will be provided and the clinician will attempt to obtain a signed acknowledgement of receipt of the notice prior to the intake assessment.

The acknowledgement form is now included in the intake package of forms. A patient alleged that a covered entity failed to provide him access to his medical records. The Privacy Rule permits the imposition of a reasonable cost-based fee that includes only the cost of copying and postage and preparing an explanation or summary if agreed to by the individual. Among other corrective actions to resolve the specific issues in the case, OCR required the hospital to develop and implement a policy regarding disclosures related to serious threats to health and safety, and to train all members of the hospital staff on the new policy.

A staff member of a medical practice discussed HIV testing procedures with a patient in the waiting room, thereby disclosing PHI to several other individuals. Also, computer screens displaying patient information were easily visible to patients. Among other corrective actions to resolve the specific issues in the case, OCR required the provider to develop and implement policies and procedures regarding appropriate administrative and physical safeguards related to the communication of PHI.

The practice trained all staff on the newly developed policies and procedures. In addition, OCR required the practice to reposition its computer monitors to prevent patients from viewing information on the screens, and the practice installed computer monitor privacy screens to prevent impermissible disclosures. A complaint alleged that a law firm working on behalf of a pharmacy chain in an administrative proceeding impermissibly disclosed the PHI of a customer of the pharmacy chain. However, the investigation revealed that the pharmacy chain and the law firm had not entered into a Business Associate Agreement, as required by the Privacy Rule to ensure that PHI is appropriately safeguarded.

Without a properly executed agreement, a covered entity may not disclose PHI to its law firm. To resolve the matter, OCR required the pharmacy chain and the law firm to enter into a business associate agreement. A grocery store based pharmacy chain maintained pseudoephedrine log books containing protected health information in a manner so that individual protected health information was visible to the public at the pharmacy counter. Initially, the pharmacy chain refused to acknowledge that the log books contained protected health information.

OCR issued a written analysis and a demand for compliance. Among other corrective actions to resolve the specific issues in the case, OCR required that the pharmacy chain implement national policies and procedures to safeguard the log books. Moreover, the entity was required to train of all staff on the revised policy. The chain acknowledged that log books contained protected health information and implemented the required changes. A chain pharmacy disclosed protected health information to municipal law enforcement officials in a manner that did not conform to the provisions of the Privacy Rule.

Among other corrective actions to resolve the specific issues in the case, OCR required this chain to revise its national policy regarding law enforcement's access to patient protected health information to comply with the Privacy Rule requirements, including that disclosures of protected health information to law enforcement only be made in response to written requests from law enforcement officials, unless state law requires otherwise. The revised policy was implemented in the chains' stores nationwide. A municipal social service agency disclosed protected health information while processing Medicaid applications by sending consolidated data to computer vendors that were not business associates.

Among other corrective actions to resolve the specific issues in the case, OCR required that the social service agency develop procedures for properly disclosing protected health information only to its valid business associates and to train its staff on the new processes. The new procedures were instituted in Medicaid offices and independent health care programs under the jurisdiction of the municipal social service agency. A national health maintenance organization sent explanation of benefits EOB by mail to a complainant's unauthorized family member. OCR's investigation determined that a flaw in the health plan's computer system put the protected health information of approximately 2, families at risk of disclosure in violation of the Rule.

Among the corrective actions required to resolve this case, OCR required the insurer to correct the flaw in its computer system, review all transactions for a six month period and correct all corrupted patient information. A state health sciences center disclosed protected health information to a complainant's employer without authorization. Among other corrective actions to resolve the specific issues in the case, including mitigation of harm to the complainant, OCR required the Center to revise its procedures regarding patient authorization prior to release of protected health information to an employer. All staff was trained on the revised procedures.

A pharmacy employee placed a customer's insurance card in another customer's prescription bag. The pharmacy did not consider the customer's insurance card to be protected health information PHI. OCR clarified that an individual's health insurance card meets the statutory definition of PHI and, as such, needs to be safeguarded. Discussion Papers. Samantha Smith, Wiley, Kanika Kapur, Hobbins, Anna P. You can help correct errors and omissions. When requesting a correction, please mention this item's handle: RePEc:oec:elsaaden. See general information about how to correct material in RePEc. For technical questions regarding this item, or to correct its authors, title, abstract, bibliographic or download information, contact:.

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Private Health Insurance Case Study policies. For Private Health Insurance Case Study questions regarding this item, or to correct its authors, Essay On Reincarnation, abstract, bibliographic or download information, contact:. An employee of a major health insurer impermissibly disclosed the protected health information of one of its members without The Birthmark Theme Private Health Insurance Case Study insurer's authorization and verification Private Health Insurance Case Study. There is Private Health Insurance Case Study of potential spread to her kidneys as well.

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