National health insurance programs are increasingly being implemented in high burden TB countries. The impact of these insurance programs on use of TB services is unclear. NHI programs in high burden countries include a varying degree of integration of TB services, and there is a need to explore how the use of these mechanisms can increase universal coverage for TB patients. A study has been implemented by the USAID TB CARE II project to examine the package of services covered under NHI in the Philippines, India, Thailand, and Peru against the recommended TB services for diagnosis, treatment, and follow-up care. In the four countries, data collection teams conducted semi-structured interviews with national TB program managers, insurances providers, health providers, and TB-related community organizations. The study focused on large state-subsidized health insurance programs (including PhilHealth in the Philippines and the National Health Services Organization in Thailand). In India, the assessment focused on several insurance providers for different employment sectors in Rajasthan and Uttar Pradesh.
The findings revealed the impact of insurance programs on access to TB services, service quality, health seeking behaviour, coverage gaps, and health systems. Access to TB services increased for registered members in Thailand and Philippines, but not in India. Lack of information about the benefits of using in-program providers is a barrier in Peru and Philippines. Timely reimbursement is a key motivator for providers and delayed reimbursement to DOTS centers has been a barrier in the Philippines. Lack of coverage for indirect costs–transport, loss of wages, nutritional support needs – was a disincentive for seeking care in all countries, particularly for vulnerable populations. Coverage for MDR TB is a critical gap in all countries.
NHI programs have an overall positive impact on TB control when implemented in coordination with the NTP. Stronger emphasis is needed to design coverage packages to reinforce TB control objectives including closing coverage gaps and extending services to vulnerable populations.
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