Study setting
The study will be conducted in the Kalihati Upazila under Tangail district where the SSK is currently being implemented. A total of 89,351 households (including 35,740 BPL households) of the Upazila will be the study population. The Kalihati Upazila Health Complex, the first contact point of the SSK beneficiaries, and Tangail District Hospital, the referral facility, will also be within the jurisdiction of this study.
Design & Methods
This study will be a concurrent process documentation using mixed-method approach that includes both quantitative and qualitative assessments. The integrated approaches will provide the flexibility to fill in gaps in the available information, strengthen the validity of the assessment and provide different perspectives on contextual and multi-dimensional phenomena. The study will have 6 different phases. The different research activities planned to be implemented at different phases are shown in Table 2.
Review and validate the selection process of BPL population for SSK
To understand the pitfall in existing BPL population identification we will review the method applied and tools used in this process. In addition, the problems in applying the selection criteria will be recorded through process documentation and key-informant interviews of the program personnel. Using appropriate quantitative approach targeted beneficiaries’ perspectives will also be collected to record the challenges in selection of the BPL population.
Validation study
To validate the selection process of BPL population, we will estimate positive predictive value. Both SSK member and non-member households will be interviewed. For member household, a sampling frame will be collected from SSK project and from that frame the required number of samples will be selected randomly. For non-member, closest adjacent household of SSK member will be selected. If the closest adjacent household is found a member household of SSK project the next closest will be selected for interview. The heads of the selected households will be interviewed with a structured questionnaire on household characteristics, BPL selection criteria of the SSK, and detailed consumption expenditure information [see Additional file 1]. To identify the poor household, the average monthly consumption expenditure of each household will be compared with the poverty line defined by Bangladesh Bureau of Statistics (BBS) for Dhaka Division using cost-of-basic needs (CBN) approach [8]. This poverty line will be used as a gold standard for poverty identification in this study.
Community survey
The community survey will be conducted to assess the knowledge of the card holders about SSK services as well as to document the barriers in utilization of such services. From the sampling frame of the SSK card holders, the respondents will be randomly selected. In this survey, the card holders will be asked whether they know about the benefit package of the SSK. They will also be asked whether they face any difficulties while receiving SSK services such as negligence of provider, unavailability of listed services, shortage of prescribed medicines, long waiting time, and unofficial tips. An instrument for assessing knowledge level is developed to gather this information which will be piloted before finalization. Focus Group Discussions (FGD) will be applied for understanding the experience, perception of beneficiaries about the SSK services, and barrier to utilize these services. Beneficiaries who utilized healthcare in last 3 months will be included in FGDs. FGDs will be held in an independent place away from the health facility. In each FGD, 8–10 participants from same level will participate. Initially, a number of 5 FGDs is planned. If the research team feels that additional knowledge can be extracted from more FGDs, then additional sessions will be organized.
Facility record review for service utilization
From computer based record managed by the SSK project, numbers of different services utilized by the card holders will be retrieved. Facility record review will be done in 3 phases. In each phase, last 3 months patient's records will be gathered. Trend analysis will be done. Number of patients treated by disease, types of diagnostic services offered, type of drugs provided, and number of patient referred by disease along with compliance will be estimated.
Key-informant interviews (KIIs)
The rationale of choosing key-informant interviews (KIIs) for this study is to understand the systems that affect barriers in implementation of SSK project activities as per plan and gather their suggestions. This will include delay in project implementation, problem in selection process of BPL population, availability of necessary equipments, drugs, logistics for providing services, scarcity of manpower, workload related issues, problem in referrals, problem related to SSK fund management, and barriers in claim management.
KIIs will be conducted face-to-face by experienced qualitative researchers. The interviewer would schedule a convenient time and place for the interview. The interview will be digitally recorded after having permission from the key-informant personnel. Another researcher will also take simultaneous verbatim notes. The duration of a KII will be at least 45 minutes to one-hour.
Process documentation
The process documentation will be undertaken to review the progress in SSK project implementation activities, identify barriers for possible delays in implementation, scheme operator’s oversight, and how well the outputs of the SSK project are aligned to achieve outcomes and impacts. The areas of process documentation include number of services under benefit package, enrollment of the beneficiaries, service provision steps, claim management and payment process to the provider. Multiple methods will be used for capturing information in process documentation (e.g. document review and synthesis of secondary data). Through process documentation timely feedback will be provided to the SSK project personnel.
Cost analysis
The additional cost of scaling-up the SSK project at national level will be estimated from program perspective. Cost will be estimated for all parties involved with the SSK project implementation namely, service delivery cost for health facilities, overall monitoring and supervision cost for HEU, and scheme management cost for insurance company. To estimate cost, all inputs to be used in SSK project will be identified, quantified and valued. The project and the hospital management personnel will be interviewed for collecting these cost related information. Semi-structured questionnaires will be used for this interview. The inputs will be separated by capital (e.g. Buildings) and recurrent costs (e.g. staff salary). The capital costs will be annualized using their lifetime and 3% discount rate [9, 10]. Total project cost will be estimated by summing up the capital and recurrent costs. The nationwide scale-up cost of the SSK project will be estimated by applying economic modeling and projections technique. The economic modeling of cost will be performed considering the existing utilization of services and unit cost of producing such services. For nation-wide implementation, a hypothetical scenario for cost input (e.g. number of healthcare facilities, additional manpower required) will be prepared in consultation with the experts (e.g. HEU, DGHS personnel and insurance providers). The unit cost information collected from the health facility will be used to estimate cost for this scenario using OneHealth Tool software. A sensitivity analysis of nationwide scale-up cost will be performed considering 5 to 10% increase in utilization of services to realize the situation during full implementation of the project.
Sample size
Quantitative
We use the following formula for estimating sample size to validate the selection process of BPL population and assess knowledge level of SSK card holders, \( \mathrm{Sample}\ \mathrm{size}\ \left(\mathrm{n}\right)=\frac{{\mathrm{Z}}_{\left(1-\upalpha \right)/2}^2\times \mathrm{P}\times \left(1-\mathrm{P}\right)}{{\mathrm{L}}^2} \)
Where,
n = required sample size,
P = anticipated proportion (positive predictive value/BPL card holders are knowledgeable about the benefit package).
α = size of the critical region (1 – α is the confidence level),
Z(1-α)/2 = standard normal deviate corresponding to the specified size of the critical region (α),
L = absolute precision desired on either side (half-width of the confidence interval) of positive predictive value.
We used 95% confidence interval, 5% error level, and 10% non-response for estimating the sample size. Therefore, for validating the selection process of BPL population, an estimated 270 SSK card holders and an equal number of non-card holders will be required to interview assuming positive predictive value at 80%. In total, 540 households (card holders and non card holders) will be interviewed. Similarly, to assess knowledge level of SSK card holders about benefit package, a minimum of 423 BPL card holders will be required to interview assuming 50% of them are knowledgeable.
Qualitative
The key-informants will be selected from different level of the project implementation, e.g. the SSK Cell members, scheme operators and service providers. Semi-structured guidelines will be developed based on informants’ characteristics [see Additional file 1]. In phase II and IV of the study, 7 to 9 key-informants will be interviewed. However, actual number will be determined based on data saturation and availability of informants.
Data analysis
Quantitative
Both descriptive and advance analysis will be performed using quantitative data. The positive predictive value will be estimated for validation of BPL population. A 2 × 2 table will be constructed for the poor and non-poor households and the SSK members and non-members households by comparing the poverty line with the household consumption expenditure data. From the table, the probability that a ‘poor’ among those with the BPL population are enrolled in the SSK project (positive predictive value) will be estimated [11].
Factor analysis will be used for ranking the knowledge level of the card holders. Earlier studies have used this technique for assessment of knowledge level [12, 13]. Principle component analysis will be performed to generate the factor score. We will estimate one main factor (namely, knowledge level for SSK benefit package) with items loading on this factor [14]. Using the factor score we will rank household from low to high level of knowledge. Multivariate regression model will be used to assess the association of demographic and socioeconomic characteristics of the respondent with their level of knowledge. In this analysis, level of knowledge will be the dependent variable and age, sex, education level and monthly income will be the explanatory variables.
To understand the service utilization pattern, trend analysis will be performed using project record. Average number of outpatient and inpatient services utilized per 1000 card holders will be estimated for three time points (Table 2). This utilization information will be presented by patient characteristics available in the project record (e.g. age, sex) and cause of illness. This analysis will provide evolving nature of healthcare utilization among the SSK card holders.
Economic modeling and projections will be performed for nationwide cost estimation. Cost per service delivery and cost per beneficiary of SSK project will be estimated considering cost of all parties involved in the project. OneHealth Tool software will be used for nationwide implementation cost estimation.
Qualitative
After completion of a KII, a verbatim transcription and translation will be performed immediately using the audiotapes and interview notes. A systematic framework approach will be employed for systematic generation of themes and codes and for analyzing the qualitative data. The Framework Method support thematic analysis in a systematic manner for organization and mapping the qualitative interview data which is appropriate for interdisciplinary and collaborative scheme projects [15]. The research team will become familiar with the whole interview by repeatedly listening the audio recording or by reading the transcript for interpretation. After familiarization with the interview, the researcher will apply ‘code’ that illustrates the interpreted information from the interview for systematic comparison with other components of the dataset. By using the categories and codes, the analytical framework will be applied by indexing subsequent transcripts. For the analysis process, a framework matrix will be generated using spreadsheet and data will be summarized and charting into the matrix by category. Charting ensures data summarization and careful explanation of participant’s own opinion and expressions prior to interpretation by the research team. The interpreted findings under each main theme or category will be presented for the identification of key implementation barriers and possible solution to overcome such barriers. Triangulation of information will be done for findings from different sources.
Ethical assurance for protection of human rights
This study will involve human subjects hence ethical approval have been obtained from the Research Review Committee and Ethical Review Committee of icddr,b. All respondents of the study will be interviewed after giving written informed consent. Their participation will be voluntary. Efforts will be made to ensure that they are properly informed about the study objectives and thoroughly understand what their participation in the study involves. All collected information will be kept confidential and will be used only for research purposes.
