The challenge of ensuring elderly people can access their health insurance entitlements: a mixed methods study on the Republic of Srpska’s Protector of Patients’ Health Insurance Entitlements

Conceptual framework

To analyse the PPHIE accountability initiative, this study uses Molyneux et al’s accountability assessment framework,22 which suggests exploring the ‘context’, ‘content’ and ‘process’ of accountability initiatives to understand their functioning and their effectiveness. Applying this framework to the context of health insurance and the setting of the Republic of Srpska, we analysed: (1) content, meaning how the PPHIE accountability initiative is supposed to function based on policy documents and legal provisions; (2) process, understood in terms of how this initiative actually functions in practice; and (3) context, referring to the broader social and economic factors that shape how well the initiative functions. These three aspects explain the impact of this accountability initiative on the HIF’s responsiveness to community needs and concerns, and the reasons for the initiative’s level of performance. In the context of our research on health insurance, responsiveness is the ability of the HIF to meet citizen needs through ‘receptivity to the views, complaints and suggestions of service users by changing structure, culture and service delivery to make it more appropriate for users’.23 Empowerment in the context of health insurance is the citizens’ ability to exercise their entitlements.

Research design

We drew from both exploratory sequence and convergent mixed methods approaches24 to collect, analyse and interpret data from in-depth interviews (IDIs) with elderly rural people, PPHIEs, doctors, nurses and HIF managers, focus group discussions (FGDs) with elderly rural people and a household survey administered to elderly rural people (figure 1). The exploratory sequence enabled us to use our preliminary analysis of qualitative data to fine-tune the quantitative questionnaire. For example, after qualitative findings that showed low awareness of the PPHIE initiative, we added open-ended questions to the survey to ensure we would fully capture the experiences of the rare respondents who had heard of and engaged with PPHIE. We then used a convergent approach for final analysis wherein qualitative and quantitative data were triangulated, interrelated and integrated, in order to enrich and validate our interpretation of the data .

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The qualitative data informed all three domains of the Molyneux et al’s framework (content, process and context), while the survey results contributed to our understanding of the process and context domains.

To identify participants for IDIs and FGDs, we first randomly selected one rural PHC from each of the Republic of Srpska’s six areas (Banjaluka, Doboj, Zvornik, Foca, East Sarajevo and Trebinje). From each PHC, we then obtained a list of people registered with them and established a sublist of those who (1) are 65 or older in age; (2) live in rural areas; (3) had at least one disease diagnosed; and (4) had used healthcare services within the last 6 months. From this list, we randomly selected individuals to participate in the study. This purposive sampling ensured that our elderly rural respondents would have recent experience with the phenomena of interest: engaging with and navigation of healthcare and the HIF. The first contact with the selected elderly persons was realised by a PHC head nurse who explained the study purpose and objectives and invited potential respondents to participate either in an individual IDI or in an FGD, according to their preference. From each selected PHC, one doctor and one nurse were invited for individual interviews, as were the one or two PPHIEs and HIF management representatives for the municipality where the PHC was located. The first four interviews were conducted in March 2020 but, due to the COVID-19 pandemic, the remaining individual interviews and focus groups were postponed and finalised in June 2020.

We held a total of 39 individual IDIs with elderly people (aged 65 years and older) living in rural areas, doctors and nurses from family medical teams in rural PHCs, PPHIEs and HIF managers (table 1). The IDIs covered the following domains: (1) practice and experience of healthcare seeking (for patients) and healthcare provision (for practitioners), (2) knowledge of health insurance entitlements, grievance redressal mechanisms and cost sharing and (3) opinions about health insurance entitlements, health access, grievance redressal mechanism and cost-sharing. While the same domains were covered for all respondent types, the specific questions through which we elicited responses were adapted according to whether the respondent was an elderly rural resident, a healthcare provider, a PPHIE or an HIF manager. The interviews lasted an average of 60 min.

The five FGDs included 6–10 participants each, resulting in a total of 45 participants. They included participants ranging from 65 to 88 years in age and had a near equal balance of men and women. The focus groups included participants across the spectrum of educational attainment, from primary school to university. The focus groups lasted an average of 120 min and covered the same domains as the interviews. Both the IDI and FGD guides were developed a priori based on our research interests in understanding the content of the PPHIE policy.

The quantitative findings were derived from a face-to-face survey with elderly rural residents (N=715), which took place from September to November 2020. The sample for the household survey was developed in cooperation with the Statistical Office of the Republic of Srpska. The sampling frame was a subset of the master sample of census areas and households of the Republic of Srpska. The stratified two-stage random sampling first extracted all rural areas, and then randomly selected six PHCs within these rural areas, by listing all PHCs in these areas and then selecting six through the use of a random number generator. All elderly people registered with an FMT at these 6 PHCs who had a disease and used healthcare services in the last 6 months were identified, resulting in a list of 715 potential respondents. These potential respondents were approached, and all agreed to complete the survey. The survey took approximately 1 hour to complete and consisted of 55 questions covering 5 topics: (1) socio/demographic data, (2) health insurance status, (3) healthcare access and use, (4) the use of FMTs as navigators to access and (5) access to information on health insurance entitlements.

Quantitative survey respondents ranged in age from 65 to 98, with an average age of 74 years. Women composed 58% of the sample and men 42%. Almost a quarter (24%) did not finish primary school, while 34% and 33% completed primary and secondary school, respectively, and 8% completed higher education.

Patient and public involvement statement

There were no patients involved in this research. The elderly participants were recruited not as patients, but as stakeholders in health system, as service users and as citizens. Hence, the development of research question and outcome measures were not informed by the patients’ priorities, experiences and preferences. Patients were not involved in the design of the research. Further, this is not clinical research or randomised clinical trial.

Data analysis

All recorded interviews were transcribed verbatim, and hand-written detailed notes were typed-up. Analysis involved five steps: (1) reading and rereading transcripts and interview notes to generate an initial coding scheme, (2) adjustment of the initially created coding scheme based on the content from transcripts, (3) applying codes to the transcripts; (4) grouping together related codes and generating categories and themes and (5) interpretation of categories and themes. In order to ensure the reliability, credibility and validity of qualitative research findings and their unbiased interpretation, coding of the primary data was done by two research team members, who independently applied codes to the data, and later compared the level of agreement, discussing and adjusting where needed. Codes were grouped into four domains of analysis: (1) use of the internet to learn about health insurance entitlements and grievance redressal, (2) FMT as navigators to access health services, (3) PPHIEs as navigators to access services and (4) awareness of and engagement with grievance redressal mechanisms. Intercoder agreement was achieved for all codes and categories, and data interpretation of all researchers were convergent.

Survey answers were entered into MS Excel for preliminary analysis. To ensure data quality, a random check of 10% of the entered data was performed. SPSS V.22 (IBM 2013) was then used to generate descriptive statistics.

How are the PPHIE navigators supposed to work (‘content’)

PPHIEs are full-time employees of the HIF and, according to HIF policy guidelines,21 should be in direct contact with insured persons and health workers. They are mandated to spend at least half of their working hours in a PHC and the other half of their time within the HIF municipal office. PPHIEs are to serve as patient navigators through the health system and are obliged to undertake the following tasks: provide information to insured persons and health workers on health insurance entitlements; provide assistance to insured persons in accessing services; prevent denial of entitlements by healthcare institutions or the HIF; report potential violations of insured persons’ entitlements to the HIF’s management, analyse reasons for violation and suggest remedial measures to solve specific problems that individual patients face; and assess satisfaction of insured persons with health services provided.21

However, the policy on PPHIEs does not give PPHIEs the power to demand that the HIF provides case-specific information about individual insurance claims, nor does a PPHIE have the power to demand that the HIF respond to or change decisions as a result of citizen complaints on entitlements violation.21

When they [patients] get the decision on their complaints, we [PPHIE] can only read it to them and try to explain further action, but I cannot change any decision. (PPHIE 1)

PPHIEs are not envisioned as outreach workers beyond healthcare facilities, that is, they are not mandated or financed to visit the many outreach health posts (ambulanta) where elderly people often receive healthcare, nor are they mandated to develop informational material to teach the broader population about their health insurance entitlements or to perform surveys to assess patient satisfaction. Mass media communication about health insurance and quality assessment of services fall under the purview of other departments of the HIF. Instead, PPHIEs are envisioned to perform one-to-one patient support for those coming to the healthcare facilities or HIF office, or for patients contacting them through their phone number. This support is to include explaining the HIF benefits and helping patients access these benefits (eg, helping patients request reimbursement for transportation costs to tertiary facilities) and lodge complaints to the HIF service-in-charge. Notably, there is no guideline or mandate in the policy documents setting out the number of PPHIEs that should be hired, their distribution, and the qualifications they should have.

How well does the PPHIE navigation mechanism work (‘process’)

The face-to-face survey revealed a low level of awareness of health insurance entitlements among the elderly in the Republic of Srpska. Only 2% of elderly respondents surveyed reported that they knew their health insurance enlistments well and 36% reported being partially aware of their health insurance entitlements. A significant majority (62%) reported that they did not have any information about their health insurance entitlements.

These figures demonstrate a clear need for information provision among insurance beneficiaries, a gap that PPHIEs are mandated to fill. However, there is a very low awareness of the existence of the PPHIE initiative, with only 4% of the elderly respondents surveyed aware of this initiative. Among elderly participants in interviews and focus groups, only one person had heard of the PPHIEs. This respondent, an elderly man, reported learning about the programme from a poster.

In our waiting room [in the healthcare facility] there is a phone number, which one can call if dissatisfied with the physician, nurse… I called once, just in curiosity to learn what is there. (FG5)

This lack of familiarity extends to those working within the health system. Out of six doctors and five nurses interviewed, a majority (seven) were also unfamiliar with the PPHIE initiative.

PPHIE respondents felt that efforts to publicise their existence were insufficient and that this was a key reason for the lack of public awareness. Basic information (name, work address and phone number) on the PPHIEs was mentioned on the HIF website and in posters, although key aspects of this information, such as the phone number to contact PPHIEs, were generally out of date. Even though posters were initially displayed in some HIF offices and health institutions to inform visitors about the PPHIE initiative, many were taken down over time. Posters were not uniformly displayed at all hospitals, PHCs, private facilities and outreach health posts. Moreover, these posters did not provide any information about the PPHIE’s role and tasks, diminishing their impact.

Out of 10 PPHIEs interviewed, 9 reported that they worked exclusively from HIF offices, and spent no time in facilities interacting with patients. They further mentioned that they had no designated office space at PHCs. Several PPHIEs reported that they had been assigned administrative duties at the HIF office, which took them away from health facilities, or were reassigned to quality control in healthcare institutions, which left them unavailable to work as patient navigators. Since they were not physically present in the waiting rooms of health facilities, and since posters or other forms of publicity about their existence were neither widespread nor particularly informative, their opportunities to educate and support patients in the tasks that they are mandated to carry out were severely compromised.

Among those surveyed who knew about PPHIEs 4%, 21% reported that they had sought to use PPHIE services. These respondents stated that they had needed administrative assistance (eg, for filling forms) or had used the PPHIEs as an avenue to complain about inadequate provision of health insurance entitlements. While none of the elderly respondents in the IDIs and FGDs had filed complaints, they identified many problems with healthcare provision and insurance coverage, including the persistence of out-of-pocket payments for health services or medication that should be fully covered, being refused rehabilitation care in specialised health institutions, unfriendly behaviour by health staff, long waiting lists for medical check-ups, and administratively complicated and time-consuming reimbursement of travel costs (that is covered by the HIF). Moreover, survey respondents assumed that grievance redressal processes would be cumbersome and likely futile, a key reason for them choosing not to try file a complaint, as indicated in the quotes below.

No, no. I didn’t intend to complain now. You complain to the one who rejected you and if the commission makes a negative decision, you should not complain. (elderly respondent, interview SL 2)

Oh, gosh, I don’t know where to go. Wherever I came, I felt as if I was hitting a wall. I didn’t ask for much, but what to say? (elderly respondents, FGD 3)

Some also expressed concern that complaining about their healthcare providers would cause tension and potentially result in poorer quality care in the future.

So what to do? Complain about the one who I have to see tomorrow? And yes, you are told you are too old to seek justice. (elderly respondent, interview SL 1)

While the PPHIEs and HIF management reported that PPHIEs were very helpful to patients, they did not have any information on the proportion of complaints and appeals filed by beneficiaries being resolved in favour of the complainants. They also had no information of the commission’s decision or the extent of satisfaction of those who had complained with the help of a PPHIE.

In the absence of a functioning PPHIE mechanism, another mechanism is used by elderly rural patients to get information about their healthcare entitlements: doctors and nurses on FMTs. While these clinicians have taken on the information provision and navigation roles envisioned for PPHIEs, there has been no mechanism filling the grievance redressal gap. Family medical team staff were reported to be the most frequent source of information on health insurance (43%) for elderly respondents living in rural areas, followed by TV (41%), and then family members, such as adult children (4%). When elderly people asked their doctors and nurses for information about health insurance entitlements, 95% reported that doctors and nurses provided all of the requested information or even more information than required. On the specific topic of drug coverage (in terms of which medicines were fully covered by HIF and which required a copayment) pharmacists also served as an important source of information for 48% elderly respondents, with 39% receiving this information from their doctor or nurse and 11% from their children.

Despite high patient satisfaction with receiving information from their FMTs, doctors and nurses expressed frustration that they were not mandated, trained or remunerated for this patient navigation role. They noted that the rules about entitlements were complex and difficult for elderly patients to understand. Thus, health workers had to engage in long conversations with their patients about health insurance related concerns, such as the circumstances under which transportation to a tertiary hospital was covered by the HIF or why a specific medicine is covered for some diagnoses but not others. They explained that it took time away from their clinical duties:

…To provide information takes a lot of time. It takes a quarter of working hours per day. […] Especially in rural areas where [the patient] is not aware. (Health care provider from FMT 2)

While these conversations were time-consuming, doctors and nurses pointed out that some information provision about health insurance entitlements and how to access those entitlements is integral to healthcare provision and cannot be fully separated from the treatment of patients. The doctors and nurses not only wanted the PPHIE mechanism to be strengthened so that a portion of this patient navigation could be shifted to the PPHIE but also noted that, ideally, FMTs would also be given training and resources to support their inevitable role in patient navigation. All doctors and nurses were clear that the current arrangement—without active PPHIEs—was exhausting and time-consuming, and that it has caused them to reduce time spent on medical checkups and diagnostics.

I do not run away from information provision. We have to be aware of that, by definition, family medicine is the entry point. But it is not the same to work daily with 40 to 45 people: that’s how many [patients] I have [each day]. And 30 patients is how many I should have. (Health care provider from FMT 3)

Doctors and nurses reported struggling to stay up to date on legal terminology used in the health insurance coverage rulebook due to its frequent modification. While changes in the HIF rulebook were often conveyed to doctors by HIF representatives and discussed at internal medical professionals’ meetings, doctors and nurses still found their information was sometimes out of date and often had to phone HIF staff to clarify questions from patients. Doctors and nurses also reported sometimes needing further clarification and consultations with their superiors, the Legal Department of the Health Center or the HIF employees, as indicated in the quote below:

There are things I can understand, and the ones I cannot understand. You know, I am not a lawyer (…) I think they are not adapted to health professionals. There are so many terms we simply do not understand (…) I did not graduate at the Faculty of Law. (healthcare worker from FMT 9)

If PPHIEs were active in their patient navigation role, the doctor or nurse could have these technical questions about coverage easily addressed by a PPHIE. Further, temporary placements for doctors at rural health facilities were common, with two-thirds of outreach health posts (ambulanta) reporting frequent doctor turnover. The elderly respondents in the IDIs and FGDs indicated that doctors in temporary posts were usually less proactive in informing elderly patients about their HIF entitlements. As a consequence, a large part of the rural population is disadvantaged in terms of benefiting from their guidance.

Finally, although doctors, nurses, pharmacists and other actors were to a large extent filling the patient navigation gap left by the absence of PPHIEs, the grievance redressal mechanism allocated to PPHIEs remained void. While any citizen can file a grievance with HIF service-in-charge, and take forward a legal challenge in the court system, actually engaging in these grievance mechanisms was far beyond the scope of most rural elderly people. PPHIEs would be vital to informing rural elderly people if indeed their complaint represented a potential violation of healthcare entitlements (as opposed to a misunderstanding). They could tell elderly people about their right to complain, help them complete and submit the grievance paperwork and follow-up on their case.

They come to us saying, ‘I got this, I don't know why this is so. Nothing is clear to me in the explanation.’ […] These older people, they do not understand. When I look at the explanation, [sometimes] I write an appeal against the decision and they submit it to the protocol and then they have the right to appeal to the court. But mostly if there is an omission or if they are not understanding something, I am telling them, ‘You are missing this and that, let’s find it,’ so we will find a solution within 15 days. (PPHIE 2)

What contextual factors influence how the PPHIE navigation mechanism works?

The PPHIEs limited effectiveness is grounded in resource limitations within the Republic of Srpska’s health system, programme design flaws in relation to the rural health system, and social norms in rural areas whereby the elderly have low expectations and low willingness to complain. Resource shortages resulted in family medical teams taking on far more patients than they could handle, making it extremely difficult for doctors and nurses to find the time to explain health entitlements to elderly patients.

I’m sure that colleagues all over the Republic will answer you the same; we have too many patients, they are a huge burden for us, so we absolutely need to change something to reduce the number of patients so that our service become better, without doctors and nurses burning out at work, and to do much more prevention and have less administrative work. (Health care provider from FMT 1)

Moreover, resource shortages caused HIF managers to shift PPHIEs from their mandated role as patient supports located in health facilities to administrative roles in HIF offices or quality control workers in hospitals. However, even if the 55 PPHIEs remained situated in waiting areas at PHCs and private clinics, the PPHIE programme’s design still made it unlikely to meet the needs of rural elderly people. Rural healthcare is primarily provided away from the PHCs, at outreach clinics, thus most elderly people would never meet their PPHIE.

Further, this study found that rural elderly people were highly satisfied with the current situation, wherein they received information and help accessing their HIF entitlements from their FMT staff. The elderly respondents felt that their family medicine staff are proactive healthcare navigators, who help patients use healthcare services. The quantitative survey found that nearly all elderly people are registered in a family health team (99%) with 96% of them having confidence in the FMT that they had chosen. This high patient satisfaction initially appears somewhat at odds with doctor and nurse reports that they lacked the time, resources and training to adequately counsel their elderly patients about HIF entitlements. However, social norms among the rural elderly population suggest that patients had low expectations of the health system and high trust in their doctors and nurses. The elderly respondents expressed a sense that they had lived through a lot of upheaval and suffering and were now satisfied with basic healthcare and whatever information about their HIF entitlements that their doctors and nurses were able to provide. They seemed very disinterested in grievance redressal, expressing a sense of satisfaction with whatever care they received and fear that complaining would be futile and potentially mark them out as ‘troublemakers’ resulting in some unspecified reprisal.

Study limitations

The study was conducted in rural areas of six municipalities in the Republic of Srpska ensuring wide geographical coverage. However, the random sampling of study areas did not consider environmental and socioeconomic variations across the different areas and less developed areas may have been left out. It would be beneficial to replicate the study in rural areas belonging to less developed municipalities, to ensure a larger representation of the elderly population. Although the patient sample was randomly selected, only the elderly who had a diagnosed disease and who used FMT services in the year preceding the study were included. Those without any diagnosed disease and who are not registered at an FMT might have different health information seeking behaviour and health access. Finally, the study was conducted during the time of the COVID-19 pandemic. COVID-19 may have reduced elderly people’s engagement with the health system due to fear of contagion, thereby reducing their need for information about how to navigate health services, and also reducing their access to information since they had fewer interactions with FMTs.