**3. Review on sub-Saharian Africa experiences**

This subsection presents a brief review of the operation, outcomes, experiences, and perceptions of users and partners in the social health insurance scheme in Sub-Saharan Africa. The snapshot review on different experiences across several Sub-Saharian Africa is next summarized.

Barasa et al. examined the perceptions and experiences of informal sector people living in two of Kenya's provinces with contributory National Hospital Insurance Fund (NHIF). The study was qualitative in design, making use of data from carefully

### *An Assessment of the Effect National Health Insurance Scheme Capitation Payment… DOI: http://dx.doi.org/10.5772/intechopen.102545*

selected informants in the provinces. Findings revealed poor perception and experiences related to inadequate and inconsistent information about registration and membership process, affordability issues, and discrimination against NHIF patients over those paying out-of-pocket [9].

The governments in Africa often partner with private healthcare providers for better coverage of their health insurance schemes. Against this background, Sieverding et al. examined the perspective and experiences of private health providers with the National Health Insurance Scheme (NHIS) in Ghana and the NHIF in Kenya. The study was an interview-based survey with a qualitative research design. Interview responses were coded and content-analyzed thematically. Poor communication of requirements for registration/accreditation and complex accreditation process was reportedly the major constraint in Kenya in line with the finding of Barasata et al. [9]. The accreditation experience in Ghana differs as it was found to be mostly straightforward. Private healthcare providers participating in health insurance schemes reportedly perceived the schemes to be worthwhile but identified poor engagement due to poor communication as barriers to active participation in the scheme.

Against the backdrop of low enrolment level in health insurance schemes in Ghana, Duku et al. analyzed the differences in perceptions between the insured and uninsured of the non-technical quality of healthcare and a possible association between insurance status and perception of healthcare quality with a view to ascertain whether insurance status matters in the perception of healthcare quality or not. The study was a primary survey, using quantitative research design. Results show that those insured had a more negative perception of the scheme compared to the uninsured, indicating the quality of service received. This finding appears to corroborate the discrimination against patients insured under social health insurance over those paying out-of-pockets by Barasa et al. [10].

Fenny et al. comparatively examined access to social health insurance schemes in five sub-Saharan African countries including Ghana, Rwanda, Tanzania, Ethiopia, and Kenya with a special focus on access by the poor. Access is key to experience, and experience informs perception. In Rwanda, both the poor were observed to have comparable lower inequality access unlike Ethiopia and Ghana with large access inequality between the poor and the rich. Only about 2% of the poor in Ghana and Ethiopia reportedly had access to the social health program. Fraudulent claims, difficulty in identifying who are actually the poor, poor funding, policy inconsistency, and enrolling the poor into social health insurance schemes were identified as barriers to widespread access to the schemes [11].

Amu et al., performed a quantitative secondary study using demographic and health surveys data and; assessed variations in health insurance coverage in four African countries including: Ghana, Kenya, Nigeria, and Tanzania. The data were analyzed using bivariate and multivariate techniques. Findings revealed that coverage was highest in Ghana (Females =62.4%, Males =49.1%) and lowest in Nigeria (Females =1.1%, Males =3.1%). Age, level of education, residence, wealth status, and occupation were the socio-economic factors influencing variations in health insurance coverage in the countries [12].

Erlangga et al., examined the public health insurance impact on health care utilization, financial protection, and health status in low- and middle-income countries based on a systematic literature review. Findings revealed that the public health insurance schemes generally appear to increase healthcare utilization, offer appreciable financial protection to their users, and have a positive effect on the health of the insured [13].

Adeniran et al. investigated cesarean delivery (CD) experience among out-of-pocket (OOP) and health insurance clients in Ilorin, Nigeria with a special focus on pregnancy events and financial transactions for the CD. The study was quantitative in design, using randomized sampling and inferential statistics. Findings revealed that OOP payers are prone to catastrophic spending on health. The waiting time before reimbursement to healthcare providers was found to be significantly prolonged; private insurers reportedly offered earlier and higher reimbursement compared to public insurers. Suboptimal referral and transportation of health-insured clients were found [14].

Adewole et al., examined enrollees' knowledge about the National Health Insurance Scheme (NHIS) and satisfaction with health services provided under the scheme in a cross-sectional questionnaire-based descriptive study. Findings revealed that 67% of the respondents had good knowledge about the NHIS. Majority of the respondents reportedly paid for drugs, laboratory tests, consultation fees, and X-ray out-of-pocket (81.2%) to supplement their health insurance cover. Slightly more than half (52.8%) of the respondents were found to be satisfied with service delivery, under the scheme with female respondents being significantly more satisfied than their male counterparts [15].

The foregoing review shows that there is a mixed outcome, experience, and perspectives on the impact of health insurance scheme in Sub-Saharian Africa. A common experience across the countries captured in the review is discrimination against and/or exploitation of enrollees in the health insurance schemes compared to those who pay out-of-pocket. Communication barriers, bureaucratic delay in paying partnering private healthcare providers, and policy inconsistencies via politics appear to be central issues militating against effective service delivery and good experience of the schemes by enrollees. Coverage appears to be low in the subregion except for Rwanda's experience. Particularly in Nigeria, going by the reform in the National Health Insurance Scheme there is significant improvement in the coverage of the various segments of the population through the introduction of Group Individual and Family Social Health Insurance Program.
