This thesis examines the usefulness of voluntary health insurance (VHI) as a lever for improving health system performance. It posits that VHI may further health policy goals if it addresses gaps in statutory coverage, if it does not make those who rely on statutory coverage worse off, and if those who need VHI have access to it. The thesis presents four studies that analyse markets for VHI in the European Union; developments in public policy towards VHI, including the implications of the EUlevel regulatory framework for VHI; the impact of VHI on health system performance; the effects of allowing people to choose between statutory and voluntary health insurance; and VHI’s influence on consumer mobility where insurers compete to offer statutory benefits. The thesis finds that while VHI is critical to financial protection in some countries, it does not always address key gaps in statutory coverage or reach those who need it, and the depth of its coverage has declined over time, even in heavily regulated markets. VHI has a regressive effect on equity in health financing, lowers equity in the use of health services and does not seem to have a positive effect on efficiency, partly because insurers in many countries lack appropriate incentives. What is more, a failure to align incentives across VHI and statutory health insurance can undermine the efficiency of public spending on health. Many of VHI’s negative effects can be attributed to poor policy design. Policy makers can try and ensure VHI contributes to rather than undermines health system performance through the following mechanisms: better understanding of VHI’s interaction with the health system; stronger policy design, focusing on aligning incentives in pursuit of health policy goals and ensuring efficiency in the use of public resources; willingness and capacity to regulate the market to secure financial and consumer protection; and regular monitoring and evaluation.

In 2009 China launched an ambitious health care reform to ensure equal and affordable access to basic health care for all by 2020. The reform was not only a response to changing patterns of disease, rising health expenditures, and widening regional inequalities, but part of a wider strategy to improve the social security system covering residents in order to increase domestic consumption. Its success will be defined by the efficient use of funds in financing and delivering health care. Against this backdrop, this dissertation evaluates the importance of health insurance characteristics on measures of financial risk protection, household saving and consumption, and preference for health care providers. It uses an experimental design to study the effect of more generous outpatient coverage and a tiered reimbursement structure that sets rates higher at primary care facilities than tertiary hospitals. While middle income households benefitted most in terms of financial risk protection, poorer and sicker households increased utilization at primary care facilities and food consumption – two pathways by which health insurance can improve health outcomes. This suggests that as outpatient coverage improves those most vulnerable will increase their access to health care, where there was previous underutilization, but not necessarily see an improvement in financial risk protection. The increased cover would also offer greater protection for those already using healthcare, but on its own not necessarily change their utilization patterns or reduce household savings. Looking at the quality-price trade-off in choice of provider reveals that, while at lower levels of household consumption demand for outpatient care is elastic with respect to price, as living standards rise past subsistence, individuals begin to value other provider characteristics. Together, these findings highlight the importance of benefit design and quality improvements at lower levels of care to shift patterns of utilization and ensure health services are accessed cost-effectively.

The National Health Insurance Scheme (NHIS) in Ghana was introduced to alleviate the problem of citizens having to pay for healthcare at the point of delivery, given that many did not have the financial resources needed to do so, and as such were unable to adequately access healthcare services. The scheme is managed from the national headquarters in the capital Accra, through satellite offices located in districts right across the length and breadth of the country. It is the job of these offices to oversee the operations of the scheme within that particular district. Current literature however shows us that there is a digital divide that exists between the rural and urban areas of the country which has led to differences in the management of information within urban-based and rural-based districts. This thesis reviews the variables affecting the management of information within the scheme, and proposes an information management model to eliminate identified bottlenecks in the current information management model. The thesis begins by reviewing the theory of health insurance, information management and then finally the rural-urban digital divide. In addition to semi-structured interviews with key personnel within the scheme and observation, a survey questionnaire was also handed out to staff in nine different district schemes to obtain the raw data for this study. In identifying any issues with the current information management system, a comparative analysis was made between the current information management model and the real-world system in place to determine the changes needed to improve the current information management system in the NHIS. The changes discovered formed an input into developing the proposed information management system with the assistance of Natural Conceptual Modelling Language (NCML). The use of a mixed methodology in conducting the study, in addition to the employment of NCML was an innovation, and is the first of its kind in studying the NHIS in Ghana. This study is also the first to look at the differences in information management within the NHIS given the rural-urban digital divide.