Towards universal health coverage: evidence generation to inform national health insurance scheme implementation in The Gambia

Abstract

Introduction Universal health coverage (UHC) aims to provide all people with access to needed healthcare without financial hardship. Many Low- and Middle-Income Countries, including The Gambia, explore innovative financing mechanisms like the national health insurance scheme (NHIS) to finance their health systems. Aim and Objectives This thesis contributes evidence for NHIS implementation in The Gambia. Objectives include assessing population willingness to pay (WTP), healthcare worker (HCW) preferences for payment systems, procedural fairness in NHIS financing, and policy processes influencing the NHIS. The aim is to provide insights for successful NHIS implementation and contribute to achieving UHC. Methods and Materials This research uses cross-sectional surveys and case studies with probability, purposive, and snowballing sampling techniques. Data, collected through questionnaires and interviews, were analyzed using IBM SPSS Statistics and StataSE version 17, along with analytic coding. Results Paper I reveal an average population WTP of US$23 (GMD 1,120). Demographic and socio-economic factors were associated with the population’s WTP. Paper II shows HCW preferences in the NHIS were influenced by demographic, facility, and regional characteristics. Papers III highlight shortcomings in the NHIS Bill legislation process, lacking greater inclusiveness, active participation, and transparency. Paper IV identifies centralized oversight and decision-making in NHIS policy processes, raising concerns about transparency and stakeholder involvement. Conclusion This thesis explores NHIS implementation in The Gambia, offering valuable insights and recommendation. Findings emphasize the complexities of NHIS processes, including population’s WTP and HCW preferences in NHIS, procedural fairness, and the need for an informed, inclusive and active participatory approach. Lessons learned can guide evidence-informed decision-making during NHIS implementation and efforts to achieve UHC.