Mobile money use and social health insurance enrolment among rural dwellers outside the formal employment sector: Evidence from Kenya

Barriers to rural women's participation in social insurance for farmers, villagers, and nomads: the case of Iran

Introduction

Since the enactment of the Law of Comprehensive Structure for Social Welfare and Security in Iran, only a small fraction of its target has been accomplished and a significant part of rural women have not been covered by the social insurance service yet. A few studies have been conducted on the social insurance of rural people. However, no study has ever addressed the issue of women with a focus on the theoretical aspects of sociology science, which is the contribution of the present research. Therefore, the present research aimed to explore the barriers to rural women's participation in social insurance.

Methods

The research adopted a qualitative approach and the grounded theory method. It was conducted among the brokers of social insurance for farmers, villagers, and nomads in Iran. Data were collected through interviews.

Results and Discussion

The results showed that the barriers to women's participation in social insurance were economic (e.g., women's economic dependence on the family head), social (e.g., low social trust, low literacy and awareness of rural women, and limitations imposed by religious doctrine), cultural (e.g., limited social communications, limited use of technology, and poor insurance culture), legal (e.g., poor legal support for rural women's insurance and non-satisfaction of expectations from the fund services), and institutional (e.g., inefficient advertisement methods and poor awareness-raising measures).

Effect of the COVID-19 Lockdown on Mobile Payments for Maternal Health: Regression Discontinuity Analysis

BACKGROUND

The COVID-19 pandemic resulted in the unprecedented popularity of digital financial services for contactless payments and government cash transfer programs to mitigate the economic effects of the pandemic. The effect of the pandemic on the use of digital financial services for health in low- and middle-income countries, however, is poorly understood.

OBJECTIVE

This study aimed to assess the effect of the first COVID-19 lockdown on the use of a mobile maternal health wallet, with a particular focus on delineating the age-dependent differential effects, and draw conclusions on the effect of lockdown measures on the use of digital health services.

METHODS

We analyzed 819,840 person-days of health wallet use data from 3416 women who used health care at 25 public sector primary care facilities and 4 hospitals in Antananarivo, Madagascar, between January 1 and August 27, 2020. We collected data on savings, payments, and voucher use at the point of care. To estimate the effects of the first COVID-19 lockdown in Madagascar, we used regression discontinuity analysis around the starting day of the first COVID-19 lockdown on March 23, 2020. We determined the bandwidth using a data-driven method for unbiased bandwidth selection and used modified Poisson regression for binary variables to estimate risk ratios as lockdown effect sizes.

RESULTS

We recorded 3719 saving events, 1572 payment events, and 3144 use events of electronic vouchers. The first COVID-19 lockdown in Madagascar reduced mobile money savings by 58.5% (P<.001), payments by 45.8% (P<.001), and voucher use by 49.6% (P<.001). Voucher use recovered to the extrapolated prelockdown counterfactual after 214 days, while savings and payments did not cross the extrapolated prelockdown counterfactual. The recovery duration after the lockdown differed by age group. Women aged >30 years recovered substantially faster, returning to prelockdown rates after 34, 226, and 77 days for savings, payments, and voucher use, respectively. Younger women aged <25 years did not return to baseline values. The results remained robust in sensitivity analyses using ±20 days of the optimal bandwidth.

CONCLUSIONS

The COVID-19 lockdown greatly reduced the use of mobile money in the health sector, affecting savings, payments, and voucher use. Savings were the most significantly reduced, implying that the lockdown affected women's expectations of future health care use. Declines in payments and voucher use indicated decreased actual health care use caused by the lockdown. These effects are crucial since many maternal and child health care services cannot be delayed, as the potential benefits will be lost or diminished. To mitigate the adverse impacts of lockdowns on maternal health service use, digital health services could be leveraged to provide access to telemedicine and enhance user communication with clear information on available health care access options and adherence to safety protocols.

Design Research to Embed mHealth into a Community-Led Blood Pressure Management System in Uganda: Protocol for a Mixed Methods Study

BACKGROUND

Uncontrolled hypertension is a leading risk factor for cardiovascular diseases. In Uganda, such diseases account for approximately 10% of all deaths, with 1 in 5 adults having hypertension (>90% of the hypertensive cases are uncontrolled). Although basic health care in the country is available free of cost at government facilities, regularly accessing medication to control hypertension is difficult because supply chain challenges impede availability. Clients therefore frequently suspend treatment or buy medication individually at private facilities or pharmacies (incurring significant costs). In recent years, mobile health (mHealth) interventions have shown increasing potential in addressing health system challenges in sub-Saharan Africa, but the acceptability, feasibility, and uptake conditions of mobile money approaches to chronic disease management remain understudied.

OBJECTIVE

This study aims to design and pilot-test a mobile money-based intervention to increase the availability of antihypertensive medication and lower clients' out-of-pocket payments. We will build on existing local approaches and assess the acceptability, feasibility, and uptake of the designed intervention. Furthermore, rather than entering the study setting with a ready-made intervention, this research will place emphasis on gathering applied ethnographic insights early, which can then inform the parameters of the intervention prototype and concurrent trial.

METHODS

We will conduct a mixed methods study following a human-centered design approach. We will begin by conducting extensive qualitative research with a range of stakeholders (clients; health care providers; religious, cultural, and community leaders; academics; and policy makers at district and national levels) on their perceptions of hypertension management, money-saving systems, and mobile money in the context of health care. Our results will inform the design, iterative adaptation, and implementation of an mHealth-facilitated pooled financing intervention prototype. At study conclusion, the finalized prototype will be evaluated quantitatively via a randomized controlled trial.

RESULTS

As of August 2023, qualitative data collection, which started in November 2022, is ongoing, with data analysis of the first qualitative interviews underway to inform platform and implementation design. Recruitment for the quantitative part of this study began in August 2023.

CONCLUSIONS

Our results aim to inform the ongoing discourse on novel and sustainable pathways to facilitate access to medication for the management of hypertension in resource-constrained settings.

TRIAL REGISTRATION

German registry of clinical trials DRKS00030922; https://drks.de/search/en/trial/DRKS00030922.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/46614.

Effect of mobile phone-based health insurance contribution payment system on retention of coverage in the National Health Insurance Scheme in Ghana: an evaluation study

BACKGROUND

Ghana introduced a mobile phone-based contribution payment system in its national health insurance scheme (NHIS) in December 2018 to improve the process of enrolment. We evaluated the effect of this digital health intervention on retention of coverage in the Scheme, one year after its implementation.

METHODS

We used NHIS enrolment data for the period, 1 December 2018-31 December 2019. Descriptive statistics and propensity-score matching method were performed to examine a sample of 57,993 members' data.

RESULTS

Proportion of members who renewed their membership in the NHIS via the mobile phone-based contribution payment system increased from 0% to 8.5% whilst those who did so through the office-based system only grew from 4.7% to 6.4% over the study period. The chance of renewing membership was higher by 17.4 percentage points for users of the mobile phone-based contribution payment system, compared to those who used the office-based contribution payment system. The effect was greater for the informal sector workers, males and the unmarried.

CONCLUSIONS

The mobile phone-based health insurance renewal system is improving coverage in the NHIS particularly for members who hitherto were less likely to renew their membership. Policy makers need to devise an innovative way for new members and all member categories to enrol using this payment system to accelerate progress towards attainment of universal health coverage. Further study needs to be conducted using mixed-method design with inclusion of more variables.

Usability and acceptance of a mobile health wallet for pregnancy-related healthcare: A mixed methods study on stakeholders' perceptions in central Madagascar

BACKGROUND

Several sub-Saharan African countries use digital financial services to improve health financing, especially for maternal and child health. In cooperation with the Malagasy Ministry of Health, the NGO Doctors for Madagascar is implementing a mobile health wallet for maternal health care in public-sector health facilities in Madagascar. Our aim was to explore the enabling and limiting factors related to the usability and acceptance of the Mobile Maternal Health Wallet (MMHW) intervention during its implementation.

METHODS

We conducted a cross-sectional, mixed methods study with mothers and pregnant women and facility- (FBHWs) and community-based (CHWs) health workers from public-sector health facilities in three districts of the Analamanga region in Madagascar. We used a convergent design in collecting and analyzing quantitative and qualitative data. We performed one-stage proportional sampling of women who had signed up for the MMHW. All FBHWs and CHWs at primary care facilities in the intervention area were eligible to participate.

RESULTS AND SIGNIFICANCE

314 women, 76 FBHWs, and 52 CHWs were included in the quantitative survey. Qualitative data were extracted from in-depth interviews with 12 women and 12 FBHWs and from six focus group discussions with 39 CHWSs. The MMHW intervention was accepted and used by health workers and women from different socioeconomic backgrounds. Main motivations for women to enroll in the intervention were the opportunity to save money for health (30.6%), electronic vouchers for antenatal ultrasound (30.2%), and bonus payments upon reaching a savings goal (27.9%). Main motivation for health workers was enabling pregnant women to save for health, thus encouraging facility-based deliveries (57.9%). Performance-based payments had low motivational value for health workers. Key facilitators were community sensitization, strong women-health worker relationship, decision making at the household level, and repetitive training on the use of the MMHW. Key barriers included limited phone ownership, low level of digital literacy, disinformation concerning the effects of the intervention, and technical problems like slow payout processes.

The resilience of two departmental health insurance units during the COVID-19 pandemic in Senegal

BACKGROUND

In its pursuit of solutions for universal health coverage (UHC), Senegal has set up two departmental health insurance units (UDAMs) since 2014. Few studies on the resilience of health systems in Africa have examined health insurance organisations. This article aims to understand how these two UDAMs have been resilient during the COVID-19 pandemic and the restrictive measures imposed by the State to maintain services to their members and reimbursements to healthcare providers.

METHODS

This study was a multicase study with multiple levels of analysis using a conceptual framework of resilience and analysis of organisational configurations. Empirical data are derived from document analysis, observations for 6 months and 17 qualitative in-depth interviews.

RESULTS

The results identified three main configurations concerning (1) safety and hygiene, (2) organisation and planning and (3) communication for sustainable payment. The UDAM faced the pandemic with resilience processes to absorb the shock and maintain service to their members. The UDAM learnt positive lessons from crisis management, such as remote work or the ability to support members in their care in hospitals away from their headquarters. They have innovated (transformative resilience) with the organisation of electronic payment and the use of social networks to raise funds and communicate with members. Strengthening their effectiveness after the shock of the departure of the donors in 2017 contributed to the adaptation and even transformation from the pandemic shock of 2020 and 2021. The study shows that leadership, team dynamics and adaptation to contexts are drivers of resilience processes.

CONCLUSION

Both UDAMs adapted to the shocks of the pandemic and government measures to maintain the services of their members and their organisational routine. This resilience confirms that UDAMs are one of the possible solutions for UHC in the Sahel.