Determinants of Voluntary National Health Insurance Drop-Out in Eastern Sudan

Determinants of community-based health insurance membership renewal decision among rural households in Kellem Wollega zone, Oromia regional state, Ethiopia: a community-based cross-sectional study

Background

Despite the fact that community-based health insurance (CBHI) is a promising program to achieve the goal of universal health coverage (UHC), it faces challenges that are not only due to low enrollment but also due to membership renewal decision that impact its sustainability. Hence, the study aimed to identify the determinants of CBHI membership renewal decision among rural households in Kellem Wollega zone, Ethiopia.

Methods

The study was conducted in Kellem Wollega, Ethiopia, among rural households from March 30-April 30, 2022, using a community-based cross-sectional study design. An interviewer-administered structured questionnaire through face-to-face interviews was used. Using a systematic random sampling method, 551 households were selected making 540 (98%) response rates. The data was entered into EPI Data 3.1 and analyzed using SPSS 25 software. Descriptive statistics, binary, and multiple logistic regressions were performed. Using multiple logistic regressions, a significant association between the CBHI membership renewal decision and independent variables was identified, declaring the statistical significance level using a 95% confidence interval (CI) at p < 0.05.

Results

The overall rate of CBHI membership renewal decision among households was estimated to be 365 (67.6%, 95% CI = 63.7-71.5%). The factors that significantly influenced the households' membership renewal decision were family size (AOR = 0.46, 95% CI = 0.25-0.86), low literacy status (AOR = 0.28 95% CI = 0.12-0.64), lower than middle-level of wealth index (AOR = 9.80, 95% CI = 2.75-34.92), premium affordability (AOR = 4.34, 95% CI = 2.08-9.04), unavailability of services (AOR = 0.26, 95% CI = 0.12-0.55), trusting in health facilities (AOR = 5.81, 95% CI = 2.82-11.94), favorable providers' attitude toward members (AOR = 8.23, 95% CI = 3.96-19.64), good quality of service (AOR = 4.47, 95% CI = 2.28-8.85) and health care seeking behavior (AOR =3.25, 95% CI = 1.32-7.98).

Conclusion

The overall CBHI membership dropout decision rate among rural households was high, which could affect health service provision and utilization. Therefore, the insurance scheme and contracted health facilities should consider and work on family size and wealth status when membership premiums are calculated, the education level of households when creating awareness about the scheme, building trust in the contracted health facilities by providing all promised benefit packages of health services with good quality, and improving the attitude of health care providers towards the scheme members.

Dropout rate and associated factors of community-based health insurance beneficiaries in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Ethiopia aims to achieve universal healthcare using health insurance. To do so, it has been implementing community-based health insurance since 2011. However, the retention of members by the scheme has not yet been evaluated nationally. The systematic review and meta-analysis aimed to evaluate the dropout rate and associated factors among the scheme's beneficiaries in Ethiopia.

METHODS

On December 19, 2022, searches were conducted in Scopus, Hinari, PubMed, Semantic Scholar, and Google Scholar. Searches were also conducted on the general web and electronic repositories, including the Ethiopian Health Insurance Service, the International Institute for Primary Health Care-Ethiopia, and various higher education institutions. The Joanna Briggs Institute's tools and the "preferred reporting items for systematic reviews and meta-analyses 2020 statement" were used to evaluate bias and frame the review, respectively. Data were analyzed using Stata 17 and RevMan 5. To assess heterogeneity, we conducted subgroup analysis and used a random model to calculate odds ratios with a p value less than 0.05 and a 95% CI.

RESULTS

In total, 14 articles were included in the qualitative synthesis, of which 12 were selected for the quantitative analysis. The pooled estimate revealed that the dropout rate of beneficiaries from the scheme was 34.0% (95% CI: 23-44%), provided that the renewal rate was 66.0%, and was found to be influenced by socio-demographic, health status, length of enrolment, knowledge, attitude, the scheme, and health service-related variables. The southern and Oromia regions reported the lowest and highest dropout rates, with 27.0% (95% CI: 24-29%) and 48.0% (95% CI: 18-78%), respectively. The dropout rates increased from 12.3% in 2012-2015 to 34.4% in 2020-2021.

CONCLUSION

More than one-third of the scheme's beneficiaries were found to have dropped out, and this has been found to increase over time, dictating that a community-based strategy and intervention, from the supply, insurer, and demand sides, seem indispensable in minimizing this huge dropout rate.

Causes of dropout from health insurance program: An experience from Lumbini Province, Nepal

The Health Insurance Program (HIP) in Nepal is experiencing low enrolment and high dropout rates, but the causes of these issues have remained unknown. This study aimed to explore the causes of dropouts of the HIP implemented by the Health Insurance Board, Nepal. We employed an exploratory qualitative research design. We purposefully selected the informants for the data collection who had previously enrolled and currently not renewed their insurance scheme. We gathered qualitative information from 16 in-depth interviews, four key informant interviews, and four focus group discussion in Palpa and Bardia Districts of Lumbini Province, Nepal. The qualitative data were analyzed using thematic analysis. We identified two major themes and nine drop-out-related sub-themes. These were: unnecessary health insurance; negligence to renew; unable to pay the contribution amount; poor cooperation between institutions as well as insurees and insurers; limited coverage and ceiling amount; rigid processes to receive health services; health professionals' behaviors; poor quality healthcare services; inadequate information. Dropout-related factors were associated with personal or individual factors and institutional or policy-related (process-related) factors. The major causes/reasons for dropout include lengthy procedures, poor quality and unsatisfactory services, a lack of knowledge on health insurance norms and procedures, and health professionals' behavior towards insurees during treatment. Information, education, and communication programs related to health insurance are still necessary to make the insurees familiar with the insurance systems and its processes. These factors could be taken into account by policymakers while planning interventions to minimize the low enrollment and high dropout.

Determinants of household dropout from community-based health insurance program in northwest Ethiopia; A community-based case-control study

BACKGROUND

Community-Based Health Insurance (CBHI) is an evolving program for delivering financial protection against the cost of illness and enhancing access to quality health services for low-income informal households.

OBJECTIVE

The study aimed to identify determinants of household dropout from a CBHI program in Mecha district, North West Ethiopia, 2019.

METHODS

A community-based case-control study was conducted in the Mecha district from March 10 to June 10, 2018. The final sample was 634 (317 cases and 317 controls) determined by the two-population proportion formula, and these samples were selected using a multi-stage sampling technique. The collected data was entered into Epi-data version 3.1 and analyzed using R version 4.0 software. Descriptive statistics computed. A simple logistic analysis was run (at 95% CI and p-value < 0.05) to identify the determinants for the dropout from CBHI.

RESULTS

Poor perceived quality of care (AOR = 3.66; 95%CI: 2.35, 5.69), low knowledge of community-based health insurance (AOR = 6.02; 95%CI: 2.97, 12.26), no active community communication (AOR = 5.41; 95%CI: 3.29, 8.90) no chronic illness (AOR = 10.82; 95%CI: 5.52, 21.21) premium fee is not affordable (AOR = 2.35; 95%CI: 1.47, 3.77), and out of pocket money not reimbursed (AOR = 9.37; 95%CI: 4.44, 19.77) were the determinants for the dropout from CBHI.

CONCLUSIONS

Poor perceived quality of care, low knowledge of CBHI, no active community participation, no chronic illness, premium fees are not affordable, and out-of-pocket money not reimbursed were the determinants for the dropout from CBHI.

Dropout Analysis of a National Social Health Insurance Program at Pokhara Metropolitan City, Kaski, Nepal

BACKGROUND

Nepal's national social health insurance (SHI) program, which started in 2016, aims to achieve universal health coverage (UHC), but it faces severe challenges in achieving adequate population coverage. By 2018, enrolment and dropout rates for the scheme were 9% and 38% respectively. Despite government's efforts, retaining the members in SHI scheme remains a significant challenge. The current study therefore aimed to assess the factors associated with SHI program dropout in Pokhara, Nepal.

METHODS

A cross-sectional household survey of 355 households enrolled for at least one year in the national SHI program was conducted. Face-to-face interviews with household heads were conducted using a structured questionnaire. Data was entered in Epi-Data and analysed using SPSS. The factors associated with SHI program dropout were identified using bivariate and multiple logistic regression analyses.

RESULTS

The findings of the study revealed a dropout prevalence of 28.2% (95% CI: 23.6%-33.2%). Households having more than five members (adjusted odds ratio [aOR]: 2.19, 95% CI: 1.22-3.94), belonging to underprivileged ethnic groups (Dalit/Janajati) (aOR: 2.36, 95% CI: 1.08-5.17), living on rented homes (aOR: 4.53, 95% CI: 1.87-10.95), absence of chronic illness in family (aOR: 1.95, 95% CI: 1.07-3.59), perceived good health status of the family (aOR: 4.21, 95% CI: 1.21-14.65), having private health facility as first contact point (aOR: 3.75, 95% CI: 1.93-7.27), poor availability of drugs (aOR: 4.75, 95% CI: 1.19-18.95) and perceived unfriendly behaviour of service providers (aOR: 3.09, 95% CI: 1.01-9.49) were statistically significant factors associated with SHI dropout.

CONCLUSION

In Pokhara, more than one-fourth of households have dropped out of the SHI scheme, which is a significant number. Dropping out of SHI is most commonly associated with a lack of drugs, followed by rental housing, family members' reported good health status and unfriendly service provider behaviour. Efforts to reduce SHI dropout must focus on addressing drugs availability issues and improving providers' behaviour towards scheme holders. Increasing insurance awareness, including provisions to change first contact points, may help to reduce dropouts among rented households, which make up a sizable proportion of the Pokhara metropolitan area.

Perceived quality of care among households ever enrolled in a community-based health insurance scheme in two districts of northeast Ethiopia: a community-based, cross-sectional study

OBJECTIVES

To examine how clients perceived the quality of healthcare they received and identify associated factors both at the individual and facility levels.

DESIGN

A community-based, cross-sectional study.

SETTING

Two rural districts of northeast Ethiopia, Tehulederie and Kallu.

PARTICIPANTS

1081 rural households who had ever been enrolled in community-based health insurance and visited a health centre at least once in the previous 12 months. Furthermore, 194 healthcare providers participated in the study to provide cluster-level data.

OUTCOME MEASURES

The outcome variable of interest was the perceived quality of care, which was measured using a 17-item scale. Respondents were asked to rate the degree to which they agreed on 5-point response items relating to their experiences with healthcare in the outpatient departments of nearby health centres. A multilevel linear regression analysis was used to identify predictors of perceived quality of care.

RESULTS

The mean perceived quality of care was 70.28 (SD=8.39). Five dimensions of perceived quality of care were extracted from the factor analysis, with the patient-provider communication dimension having the highest mean score (M=77.84, SD=10.12), and information provision having the lowest (M=64.67, SD=13.87). Wealth status, current insurance status, perceived health status, presence of chronic illness and time to a recent health centre visit were individual-level variables that showed a significant association with the outcome variable. At the cluster level, the work experience of healthcare providers, patient volume and an interaction term between patient volume and staff job satisfaction also showed a significant association.

CONCLUSIONS

Much work remains to improve the quality of care, especially on information provision and access to care quality dimensions. A range of individual-level and cluster-level characteristics influence the perceived quality of care. For a better quality of care, it is vital to optimise the patient-provider ratio and enhance staff job satisfaction.

Continued adherence to community-based health insurance scheme in two districts of northeast Ethiopia: application of accelerated failure time shared frailty models

Background

The sustainability of a voluntary community-based health insurance scheme depends to a greater extent on its ability to retain members. In low- and middle-income countries, high rate of member dropout has been a great concern for such schemes. Although several studies have investigated the factors influencing dropout decisions, none of these looked into how long and why members adhere to the scheme. The purpose of this study was to determine the factors affecting time to drop out while accounting for the influence of cluster-level variables.

Methods

A community-based cross-sectional study was conducted among 1232 rural households who have ever been enrolled in two community-based health insurance schemes. Data were collected using an interviewer-administered questionnaire via a mobile data collection platform. The Kaplan–Meier estimates were used to compare the time to drop out among subgroups. To identify predictors of time to drop out, a multivariable analysis was done using the accelerated failure time shared frailty models. The degree of association was assessed using the acceleration factor (δ) and statistical significance was determined at 95% confidence interval.

Results

Results of the multivariable analysis revealed that marital status of the respondents (δ = 1.610; 95% CI: 1.216, 2.130), household size (δ = 1.168; 95% CI: 1.013, 1.346), presence of chronic illness (δ = 1.424; 95% CI: 1.165, 1.740), hospitalization history (δ = 1.306; 95% CI: 1.118, 1.527), higher perceived quality of care (δ = 1.322; 95% CI: 1.100, 1.587), perceived risk protection (δ = 1.218; 95% CI: 1.027, 1.444), and higher trust in the scheme (δ = 1.731; 95% CI: 1.428, 2.098) were significant predictors of time to drop out. Contrary to the literature, wealth status did not show a significant correlation with the time to drop out.

Conclusions

The fact that larger households and those with chronic illness remained longer in the scheme is suggestive of adverse selection. It is needed to reconsider the premium level in line with household size to attract small size households. Resolving problems related to the quality of health care can be a cross-cutting area of ​​intervention to retain members by building trust in the scheme and enhancing the risk protection ability of the schemes.

Barriers to uptake of community-based health insurance in sub-Saharan Africa: a systematic review

In the past two decades, community-based Health Insurance (CBHI) is expanding in most of sub-Saharan African countries with the aim of improving equitable access to health services for the informal sector population. However, population enrolment into CBHI and membership renewals thereafter remains stubbornly low. The purpose of this systematic review is to generate an evidence to better understand barriers to uptake of CBHI in sub-Saharan African countries. We systematically searched for relevant studies from databases: PubMed, Scopus, Cumulative Index of Nursing and Allied Health Literature (CINAHL), PsychInfo, ProQest, Excerpta Medica dataBASE (EMBASE) and Africa-Wide Information. The search strategy combined detailed terms related to (i) CBHI, (ii) enrolment/renewal and (iii) sub-Saharan African countries. A narrative synthesis of findings was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The protocol for this systematic review was registered with International Prospective Register of Systematic Reviews (PROSPERO) (ref: CRD42020183959). The database search identified 4055 potential references from which 15 articles reporting on 17 studies met the eligibility criteria. The findings revealed that barriers to uptake of CBHI in sub-Saharan Africa were multidimensional in nature. Lack of awareness about the importance of health insurance, socio-economic factors, health beliefs, lack of trust towards scheme management, poor quality of health services, perceived health status and limited health benefit entitlements were reported as barriers that affect enrolments into CBHI and membership renewals. The methodological quality of studies included in this review has been found to be mostly suboptimal. The overall findings of this systematic review identified major barriers of CBHI uptake in sub-Saharan African countries which may help policymakers to make evidence-informed decisions. Findings of this review also highlighted that further research with a robust methodological quality, depth and breadth is needed to help better understand the factors that limit CBHI uptake at individual, societal and structural levels in sub-Saharan Africa.

Barriers and Facilitators of Community-Based Health Insurance Policy Renewal in Low- and Middle-Income Countries: A Systematic Review

PURPOSE

A growing number of low- and middle-income countries are implementing small-scale community-based health insurance schemes to tackle the burdens posed by direct out-of-pocket payments. Apart from a few successful experiences, such schemes suffer from the problem of persistent low membership which could be attributed to either initial low enrollment or low renewal rate. However, there is a lack of comprehensive information on the factors that influence subscribers' policy renewal decisions. Hence, we systematically synthesize information to answer the review question "what are the barriers and facilitators of community-based health insurance policy renewal in low and middle-income countries?".

METHODS

We searched PubMed, Scopus, and Hinari electronic databases in line with the PRISMA guidelines. Our search was limited to studies published from January 2005 to February 2020 in the English language. Additional studies and grey literature were searched using Google Scholar. We included quantitative, qualitative, and mixed-method studies in the review. We assessed the methodological quality of the studies using standardized appraisal tools. The findings were synthesized inductively using a thematic analysis approach.

RESULTS

Our searches retrieved 2386 records among which 27 were included in the review. The thematic synthesis identified six major themes that influence the decision to renew scheme policy: socio-demographic factors; scheme-related awareness and understanding; participation in scheme and other voluntary groupings, need and benefit factors; health-care quality; and scheme operation and policy.

CONCLUSION

Lower socioeconomic status, poor quality of health care, lack of benefit from the scheme, lack of trust in scheme management, and dissatisfaction with scheme services are important barriers for community-based health insurance policy renewal. Better education, understanding the principles of the scheme, active participation in the scheme, and long-term illness experience of member households facilitate renewal decisions. These are important areas of intervention for governments and other relevant stakeholders to retain members and maintain the sustainability of the schemes.

REGISTRATION

The review protocol was registered in PROSPERO international prospective register of systematic reviews (ID = CRD42020168971).

Who will drop out of voluntary social health insurance? Evidence from the New Cooperative Medical Scheme in China

Although public voluntary health insurance (VHI) has been adopted in many low- and middle-income countries to improve access to care for the population, a common issue with VHI is its high dropout rate. Using the New Cooperative Medical Scheme (NCMS)-a public VHI in China-as a case study, this article employs a fixed-effects negative binomial regression model combining the difference-in-difference-in-differences approach and multivariate distance matching to examine the factors associated with dropping out and the impact of dropout on outpatient care utilization among middle-aged and older people in rural China. Drawing data from the China Health and Retirement Longitudinal Study, our results showed that healthy people, vulnerable people and people who use less healthcare tended to drop out. Dropout had a significant negative impact on outpatient care utilization, especially for those with worse health statuses and those living in poorer provinces. We also found that the impact of dropout on outpatient utilization was more pronounced at secondary and tertiary hospitals than at primary care clinics. We urge policymakers to rethink the design of the NCMS by waiving premiums for the most vulnerable people.

Magnitude and Determinants of Dropout from Community-Based Health Insurance Among Households in Manna District, Jimma Zone, Southwest Ethiopia

Background

Community-based health insurance (CBHI) is a prepayment method of financial contributions for healthcare which aims to risk pooling, avoidance of catastrophic and impoverishing health expenditure. However, a high dropout from the scheme remains the biggest challenge to effective and sustainable progress towards universal financial protection in low- and middle-income countries. While large literature had examined initial enrollment and factors associated with it, only a few studies dealt with dropout. So the study aimed to assess the magnitude and determinants of dropout from community-based health insurance among households in Manna district, Jimma zone, Oromia Regional State, Ethiopia.

Methods

A community-based cross-sectional study design was employed to collect data from 634 household heads from March 1 to 30, 2020. A multistage sampling technique was carried out and interviewer-administered questionnaires were used to collect data. Descriptive statistics and multivariable logistic regression analyses were performed, and variables with a P-value<0.05 were considered as having a statistically significant association with the dropout from the CBHI.

Results

Magnitude of dropout from CBHI was 31.9% with 95% confidence interval (CI)=28.2–35.8% and relatively older age [adjusted odds ratio (AOR) (95% CI)=0.26 (0.10–0.78)], educational level [AOR (95% CI)=0.16 (0.06–0.41)], family size [AOR (95% CI)=0.36 (0.19–0.66)], poor perceived quality of service [AOR (95% CI)=5.7 (2.8–11.8)], trust in health facility [AOR (95% CI)=0.43 (0.3–0.61)], trust in the scheme [AOR (95% CI)=0.61 (0.45–0.84)], providers’ attitude [AOR (95% CI)=10 (4.0–25.4)], and benefit package [AOR (95% CI)=4.9 (2.4–9.9)] were statistically significant determinants associated with dropout.

Conclusion

Dropout from CBHI in this study area was high. Household heads’ age, educational level, family size, perceived quality of service, providers’ attitude, a benefits package, trust in the contracted health facility, and the scheme were the significant predictors of dropout. We strongly recommend that greater efforts should be made toward the providers’ attitude, promised benefit package, and quality of services.

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

BACKGROUND

The study set out to explore whether mobile money use (mobile phone-based financial services) increased the probability of rural dwellers outside the formal employment sector of being enrolled in Kenya's social health insurance, the National Hospital Insurance Fund (NHIF).

METHODS

We used data from the 2015 FinAccess Household Survey and analysed responses of 4282 rural individuals outside the formal employment sector. Probit and bivariate probit models were used and adjusted for mobile phone ownership, sex, age, age-squared, education, wealth quintile, bank account use, informal group membership, occupation, and health shocks.

RESULTS

We found that 16.26% (95% CI, 14.58% to 18.10%) of mobile money users had NHIF cover as compared with 2.44% (95% CI, 1.83% to 3.23%) of nonusers. Importantly, mobile money use increased the probability of being enrolled in NHIF by 4.6% (95% CI, 2.1% to 7.1%) after controlling for confounders. Access to mobile money was associated with reduced travel time and lower transport costs, which are likely to be key mechanisms for increasing NHIF enrolment.

CONCLUSION

By lowering transport costs and saving travel time, mobile money provides an easy means to pay social health insurance premiums thus incentivising its uptake among rural people outside of formal employment.

Determinants of Enrolment and Renewing of Community-Based Health Insurance in Households With Under-5 Children in Rural South-Western Uganda

Background: The desire for universal health coverage in developing countries has brought attention to communitybased health insurance (CBHI) schemes in developing countries. The government of Uganda is currently debating policy for the national health insurance programme, targeting the integration of existing CBHI schemes into a larger national risk pool. However, while enrolment has been largely studied in other countries, it remains a generally under-covered issue from a Ugandan perspective. Using a large CBHI scheme, this study, therefore, aims at shedding more light on the determinants of households’ decisions to enrol and renew membership in these schemes.

Methods: We collected household data from 464 households in 14 villages served by a large CBHI scheme in southwestern Uganda. We then estimated logistic and zero-inflated negative binomial (ZINB) regressions to understand the determinants of enrolment and renewing membership in CBHI, respectively.

Results: Results revealed that household’s socioeconomic status, husband’s employment in rural casual work (odds ratio [OR]: 2.581, CI: 1.104-6.032) and knowledge of health insurance premiums (OR: 17.072, CI: 7.027-41.477) were significant predictors of enrolment. Social capital and connectivity, assessed by the number of voluntary groups a household belonged to, was also positively associated with CBHI participation (OR: 5.664, CI: 2.927-10.963). More positive perceptions on insurance (OR: 2.991, CI: 1.273-7.029), access to information were also associated with enrolment and renewing among others. Burial group size and number of burial groups in a village, were all significantly associated with increased the likelihood of renewing CBHI.

Conclusion: While socioeconomic factors remain important predictors of participation in insurance, mechanisms to promote inclusion should be devised. Improving the participation of communities can enhance trust in insurance and eventual coverage. Moreover, for households already insured, access to correct information and strengthening their social network information pathways enhances their chances of renewing.

Household satisfaction with community-based health insurance scheme and associated factors in piloted Sheko district; Southwest Ethiopia

BACKGROUND

Community-based health insurance (CBHI) scheme is an emerging strategy for providing financial protection against health-related poverty. It is being piloted in the Sheko district, but community satisfaction with the scheme has not yet studied. Therefore, this study aimed to assess the level of household's satisfaction to CBHI scheme and associated factors in a piloted Sheko district; southwest Ethiopia.

METHODS

A community-based cross-sectional study was conducted in Sheko district from March to April 2018. Data was collected on 528 households by using simple random sampling method. Trained data collectors gathered the data using a pre-tested and structured questionnaire. Descriptive statistics, bivariate and multivariable logistic regression analyses were performed. To determine the independent predictors of household's satisfaction to CBHI, a cut point of p values < 0.05 were used.

RESULTS

This study showed that more than half (54.7%) of the households were satisfied with the CBHI scheme. Satisfaction to CBHI was positively associated with adequate knowledge of CBHI benefit packages (AOR = 2.29, 95% CI = 1.55-3.38), type of health facility visit (AOR = 1.93, 95% CI = 1.09-3.39), laboratory service provision (AOR = 2.07, 95% CI = 1.15-373) and length of enrollment (AOR = 1.53, 95% CI = 1.01-2.32).

CONCLUSIONS

Household's satisfaction to CBHI scheme was moderate. Modifiable factors, including adequate knowledge of CBHI benefit packages, type of health facility visit, laboratory service provision, and length of enrollment were independent determinants of satisfaction. In order to augment enrollee's satisfaction to CBHI, efforts should be given to improving their knowledge of CBHI benefit packages through education and information campaigns. Furthermore, due consideration should also be given to improving the quality of health services.