Table 3.
Overview of health insurance managers’ perspectives on enablers and barriers for implementing high-quality hypertension care in a rural primary care facility, by theme and categorya,b,c
| Theme/category | Factors enabling high-quality hypertension care | Factors inhibiting high-quality hypertension care |
|---|---|---|
| 1. Necessary resources | ||
| 1.1 Health insurance | Health insurance makes CVD prevention and hypertension management affordable for enrolees. (IR1, IR2, IR3, IR4) If subsidy from third parties stops, resources in community will be found to sustain the programme. (IR1, IR2, IR4) |
Patients spend more than the annual premium on transport to clinic. (IR2) |
| Proactive care approach by insurance benefits population health and insurance. (IR1, IR2, IR3, IR4) | ||
| The insurance programme's quality improvement and education policy facilitates delivery of standardised CVD prevention care in contracted hospitals. (IR1, IR2, IR3) | Resource constraints experienced by healthcare providers hinder implementation of recommended improvements. (IR3, IR2) | |
| 1.2 Guideline and protocols | Insurance company uses guidelines to monitor and ensure high-quality care. (IR1, IR2, IR4) | Inconsistent and inadequate use of guidelines by healthcare professionals hinders care. (IR2, IR4) |
| 1.3 Equipment and supplies | Clinic upgrades and monitoring activities substantially minimised shortages of essential drugs, diagnostic tools, and materials. (IR3, IR2) | Some providers lack capacity/will to fund complementary acquisition of diagnostic tools and materials. (IR4, IR2) |
| 2. Financial incentives and disincentives | ||
| 2.1 Insurance claims management system | Quick claim settlement motivates providers. (IR1, IR2, IR3, IR4) | Claim verification process is time-consuming and intensive for insurance company. (IR2, IR1, IR4) |
| 2.2 Remuneration | A fixed extra fee on top of regular monthly capitation fee per patient promotes quality of CVD preventive care. (IR2) | Providers want capitation and ‘fee for service’ payments. (IR2, IR1) |
| 2.3 Benefits package of rural workers | Government and providers must improve welfare of rural health workers. (IR1) | Rural-based providers have no funds to improve welfare of health workers unilaterally. (IR1) |
| 3. Non-financial incentives and disincentives | ||
| 3.1 Provider–insurer relationship | M&E essential to ensure that hypertension/CVD preventive care is delivered according to standard. (IR1, IR2,IR2, IR4) Feedback, training, and teamwork will minimise credibility issues arising from monitoring of quality of care. (IR1) |
Some providers see M&E as a threat. (IR1, IR3) |
| 4. Information systems | ||
| 4.1 Information technology systems | A functional ICT system will facilitate efficient administration and promote quality of care. (IR1, IR2, IR3, IR4) | Dysfunctional information technology infrastructure hinders provider–insurer communication, leads to inefficient administration, and diminishes quality of care. (IR1, IR2, IR3, IR4) |
| 5. Quality assurance and patient safety systems | ||
| 5.1 Monitoring all aspects of treatment including patient satisfaction | Patient file checks to verify drugs, lifestyle advice, other treatment, BP outcomes, pharmacy stock, and quality reviews. (IR1, IR3, IR4) Laboratory checks. Certification of suppliers for drugs, laboratory reagents, and other materials. (IR1, IR2, IR2, IR4) Mystery shopping and surveys to investigate patient satisfaction. (IR1, IR2, IR4) |
|
| 6. Continuing professional education system | ||
| 6.1 Training for providers | Continuous skills improvement and update trainings made available for health professionals. (IR1, IR2, IR4) | High attrition of rural health workers means limited benefits of training to patients. (IR4) |
M&E, monitoring and evaluation; ICT, information communication technology; BP, blood pressure.
a
Theme refers to subdomains grouped under the TICD domain resources and incentives (26).
b
Category refers to inductively identified categories in interviews with health insurance managers in this study.
c
IR1, IR2, IR3, and IR4 refer to ID numbers given to respondents.