Drop-out analysis of community-based health insurance membership at Nouna, Burkina Faso

From pilot to national roll-out of the improved Community Health Fund (iCHF) in Tanzania: lessons learnt and way forward

INTRODUCTION

Scaling up public health interventions in the health systems of resource poor settings come with technical and operational challenges. Little is documented on scaling up complex health financing interventions and their related outcomes, especially the voluntary health insurance schemes. This study aimed to analyse the scale-up steps, successes and challenges of the improved community health fund (iCHF), a voluntary health insurance scheme in Tanzania, METHODS: In this paper, guided by the Expand Net framework (a scale-up framework for health system interventions), we present a systematic analysis of countrywide scale-up of the iCHF that started in 2019 and implemented in partnership between the government and development partners. We systematically collected information on the scale-up steps and the success and challenges. The collected data was analysed using descriptive statistics.

RESULTS

The scale-up involved multiple steps and actions at different levels of the health system. The initial step involved gathering stakeholders' views on scale-up options and strategies. The subsequent steps focused on mobilizing resources for scale-up, advocacy and promotion of the scheme through media, community leaders and role models, capacity building to implementing organs, institutionalizing the scale-up processes, intensifying the scale-upscale-up activities for expansion and spontaneous scale-up and technical backstopping to lower levels of the health system on the scale-up process. We found success and challenges as the scale-upscale-up progressed to mature stages. The success included acceptability and institutionalization of the scale-up activities and growing enrolments and funds in the scheme. The challenges included: the costs to sustaining advocacy and enrolments, equity in scale-upscale-up activities across regions, relying on top-down scale-upscale-up approaches, influence of contextual factors and lack of implementation research alongside the scale-upscale-up process.

CONCLUSION

This paper underscores the scale up steps and success and challenges of scaling-up a voluntary health insurance scheme in a resource-constrained health system. Sustaining the scale-upscale-up gains will require utilizing program data and experiences to sustainably improve the scheme performance while also harnessing support from stakeholders. Further research is needed to assess equity and quality of outcomes of the scale up.

Spatial distribution and geographical heterogeneity factors associated with households' enrollment level in community-based health insurance

Background

Healthcare service utilization is unequal among different subpopulations in low-income countries. For healthcare access and utilization of healthcare services with partial or full support, households are recommended to be enrolled in a community-based health insurance system (CBHIS). However, many households in low-income countries incur catastrophic health expenditure. This study aimed to assess the spatial distribution and factors associated with households' enrollment level in CBHIS in Ethiopia.

Methods

A cross-sectional study design with two-stage sampling techniques was used. The 2019 Ethiopian Mini Demographic and Health Survey (EMDHS) data were used. STATA 15 software and Microsoft Office Excel were used for data management. ArcMap 10.7 and SaTScan 9.5 software were used for geographically weighted regression analysis and mapping the results. A multilevel fixed-effect regression was used to assess the association of variables. A variable with a p < 0.05 was considered significant with a 95% confidence interval.

Results

Nearly three out of 10 (28.6%) households were enrolled in a CBHIS. The spatial distribution of households' enrollment in the health insurance system was not random, and households in the Amhara and Tigray regions had good enrollment in community-based health insurance. A total of 126 significant clusters were detected, and households in the primary clusters were more likely to be enrolled in CBHIS. Primary education (AOR: 1.21, 95% CI: 1.05, 1.31), age of the head of the household >35 years (AOR: 2.47, 95% CI: 2.04, 3.02), poor wealth status (AOR: 0.31, 95% CI: 0.21, 1.31), media exposure (AOR: 1.35, 95% CI: 1.02, 2.27), and residing in Afar (AOR: 0.01, 95% CI: 0.003, 0.03), Gambela (AOR: 0.03, 95% CI: 0.01, 0.08), Harari (AOR: 0.06, 95% CI: 0.02, 0.18), and Dire Dawa (AOR: 0.02, 95% CI: 0.01, 0.06) regions were significant factors for households' enrollment in CBHIS. The secondary education status of household heads, poor wealth status, and media exposure had stationary significant positive and negative effects on the enrollment of households in CBHIS across the geographical areas of the country.

Conclusion

The majority of households did not enroll in the CBHIS. Effective CBHIS frameworks and packages are required to improve the households' enrollment level. Financial support and subsidizing the premiums are also critical to enhancing households' enrollment in CBHIS.

Effect of social capital on enrolment of informal sector occupational groups in the national health insurance scheme in Ghana: a cross-sectional survey

BACKGROUND

Enrolment of informal sector workers in Ghana's National Health Insurance Scheme (NHIS) is critical to achieving increased risk-pooling and attainment of Universal Health Coverage. However, the NHIS has struggled over the years to improve enrolment of this subpopulation. This study analysed effect of social capital on enrolment of informal sector workers in the NHIS.

METHODS

A cross-sectional survey was conducted among 528 members of hairdressers and beauticians, farmers, and commercial road transport drivers' groups. Descriptive statistics, principal component analysis, and multinomial logit regression model were used to analyse the data.

RESULTS

Social capital including membership in occupational group, trust, and collective action were significantly associated with enrolment in the NHIS, overall. Other factors such as household size, education, ethnicity, and usual source of health care were, however, correlated with both enrolment and dropout. Notwithstanding these factors, the chance of enrolling in the NHIS and staying active was 44.6% higher for the hairdressers and beauticians; the probability of dropping out of the scheme was 62.9% higher for the farmers; and the chance of never enrolling in the scheme was 22.3% higher for the commercial road transport drivers.

CONCLUSIONS

Social capital particularly collective action and predominantly female occupational groups are key determinants of informal sector workers' participation in the NHIS. Policy interventions to improve enrolment of this subpopulation should consider group enrolment, targeting female dominated informal sector occupational groups. Further studies should consider inclusion of mediating and moderating variables to provide a clearer picture of the relationship between occupational group social capital and enrolment in health insurance schemes.

Financing and provision of healthcare for two billion people in low-income nations: Is the cooperative healthcare model a solution?

The international consensus in support of universal health coverage (UHC), though commendable, thus far lacks a clear mechanism to finance and deliver accessible and effective basic healthcare to the two billion rural residents and informal workers of low- and lower-middle-income countries (LLMICs). Importantly, the two preferred financing modes for UHC, general tax revenue and social health insurance, are often infeasible for LLMICs. We identify from historical examples a community-based model that we argue shows promise as a solution to this problem. This model, which we call Cooperative Healthcare (CH), is characterized by community-based risk-pooling and governance and prioritizes primary care. CH leverages communities' existing social capital, such that even those for whom the private benefit of enrolling in a CH scheme is outweighed by the cost may choose to enroll (given sufficient social capital). For CH to be scalable, it needs to demonstrate that it can organize delivery of accessible and reasonable-quality primary healthcare that people value, with management accountable to the communities themselves through structures that people trust, combined with government legitimacy. Once LLMICs with CH programs have industrialized sufficiently to make universal social health insurance feasible, CH schemes can be rolled into such universal programs. We defend cooperative healthcare's suitability for this bridging role and urge LLMIC governments to launch experiments testing it out, with careful adaptation to local conditions.

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.

Economic inequalities in health insurance subscription renewal: Evidence from Ghana's National Health Insurance Scheme

Ghana's national health insurance scheme (NHIS) is considered a major step towards achieving Universal Health Coverage (UHC) in the country. However, over the years the scheme has faced challenges, including subscription non-renewal, that threaten its sustenance. In this study, we estimate and analyse the nature of economic inequalities in NHIS subscription renewal and determine factors that contribute to the observed inequality. Data from the seventh round of the Ghana Living Standard Survey (GLSS) was used for the study. A sample of 40,170 ever insured individuals was included in the analysis comprising 18,066 males and 22,104 females. We computed concentration indices (CIs) and used linear regression techniques to decompose the CIs. The results show that NHIS renewal is pro-rich [CI = 0.126; P < 0.01] and favored males [CI = 0.110; P < 0.01] and urban dwellers [CI = 0.066; p < 0.01]. Major contributors to the observed inequality in subscription renewal include premium and processing fees payment, access to information, and economic wellbeing. The observed rural-urban and male-female differences in subscription renewal were explained by differences in premium and processing fee payments, education outcomes, employment status and access to information. The findings suggest that interventions that reduce cost barriers to NHIS subscription for the poor, improve physical access to healthcare and improve sensitization efforts should be encouraged.

Cognitive Patterns and Problematic Use of Video Games in Adolescents: A Cluster Analysis

BACKGROUND

Video game playing (VGP) is an increasingly common leisure activity among children and adolescents, although in some cases, it is accompanied by problems due to misuse.

METHOD

A sample of 2884 children and adolescents aged between 12 and 20, representative of the Community of Madrid (Spain), were studied using a cluster analysis to explore the existence of cognitive patterns associated with engagement, attitudes, and concurrent cognitions. We also explored the relationship between these patterns and problematic VGP, using the 2173 gamers as a reference.

RESULTS

The concurrent cognitions were not qualitatively different between the problematic users and the others. High engagement and high activation of concurrent cognitions (intensity and frequency) showed the greatest relationship with problematic VGP.

CONCLUSIONS

The results suggest the existence of different groups of gamers and the relevance to include psycho-educational aspects in intervention programs, as well as the training of specific skills, especially those related with the control of activation. Limitations related to the sample size and potential supplementary analyses are acknowledged.

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.

Household satisfaction and associated factors with community-based health insurance scheme in Ethiopia: systematic review and meta-analysis

BACKGROUND

Community-based health insurance (CBHI) schemes are crucial for households to avoid financial hardship, improve healthcare quality, and engage in health policies. Household satisfaction is a key indicator for assessing healthcare quality and identifying service gaps. However, research on household satisfaction with CBHI in Ethiopia is limited. Therefore, this study aimed to evaluate household satisfaction and associated factors with CBHI schemes in Ethiopia.

METHODS

A comprehensive search of relevant literature was conducted using multiple databases, including PubMed, Google Scholar, Africa Journal Online, and Ethiopian Universities' institutional open-access online repositories. The search was carried out between January 25, 2023, and February 28, 2023. Twelve primary studies, including eight published and four unpublished, were identified and included in the analysis with a total sample size of 5311 participants. A protocol with the registration number CRD20531345698 is recorded on the Prospero database. Two authors, DT and MK, independently extracted the required data using a standardized form. The extracted data were then analyzed using STATA version 17 software. Heterogeneity was assessed using the Cochrane Q-test and I2 tests. Finally, a random-effect model was employed to calculate the overall household satisfaction with CBHI and to determine the associated factors.

RESULTS

The meta-analysis showed that the overall household satisfaction with CBHI in Ethiopia was 62.26% (95% CI 53.25-71.21%). The study found regional variations in household satisfaction, with 63.40% in Oromia, 64.01% in Amhara, 49.58% in Addis Ababa, and 66.76% in SNNPs. The study identified several factors associated with household satisfaction and the CBHI scheme, including the availability of drugs (OR 2.13, 95% CI 1.47-2.78), friendly services (OR 3.85, 95% CI 1.60-6.10), affordability of premium (OR 2.80, 95% CI 1.97-3.63), and knowledge/awareness of CBHI (OR 2.52, 95% CI 1.73-3.33).

CONCLUSIONS

The study provides valuable insights into household satisfaction with CBHI in Ethiopia, with a considerable proportion of enrolees being satisfied. The finding highlights regional variations in household satisfaction and underscores the need for tailored interventions and monitoring to enhance CBHI sustainability and effectiveness. The results suggest that healthcare providers and policymakers should prioritize the availability of drugs, friendly services, affordable premiums, and education to improve household satisfaction with CBHI schemes.

Determinants of trust in healthcare facilities among community-based health insurance members in the Manna district of Ethiopia

BACKGROUND

Low-income countries, including Ethiopia, face substantial challenges in financing healthcare services to achieve universal health coverage. Consequently, millions of people suffer and die from health-related conditions. These can be efficiently managed in areas where community-based health insurance (CBHI) is properly implemented and communities have strong trust in healthcare facilities. However, the determinants of community trust in healthcare facilities have been under-researched in Ethiopia.

OBJECTIVE

To assess the determinants of trust in healthcare facilities among community-based health insurance members in the Manna District of Ethiopia.

METHODS

A community-based cross-sectional study was conducted from March 01 to 30, 2020 among 634 household heads. A multistage sampling technique was used to recruit the study participants. A structured interviewer-administered questionnaire was used to collect the data. Descriptive statistics were computed as necessary. Multivariable linear regression analyses were performed, and variables with a p-value < 0.05 were considered to have a significant association with households' trust in healthcare facilities.

RESULTS

In total, 617 households were included in the study, with a response rate of 97.0%. Household age (ß=0.01, 95% CI:0.001, 0.0013), satisfaction with past health services (ß=0.13, 95% CI:0.05, 0.22), perceived quality of services (ß= -0.47, 95% CI: -0.64, -0.29), perceived provider's attitude towards CBHI members (ß = -0.68, 95% CI: -0.88, -0.49), and waiting time (ß= -0.002, 95% CI:- 0.003, -0.001) were determinants of trust in healthcare facilities.

CONCLUSION

This study showed that respondents' satisfaction with past experiences, older household age, long waiting time, perceived poor quality of services, and perceived unfavorable attitudes of providers towards CBHI members were found to be determinants of trust in healthcare facilities. Thus, there is a need to improve the quality of health services, care providers' attitudes, and clients' satisfaction by reducing waiting time in order to increase clients' trust in healthcare facilities.

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.

Factors determining membership in community-based health insurance in West Africa: a scoping review

BACKGROUND

In many low-income countries, households bear most of the health care costs. Community-based health insurance (CBHI) schemes have multiplied since the 1990s in West Africa. They have significantly improved their members' access to health care. However, a large proportion of users are reluctant to subscribe to a local CBHI. Identifying the major factors affecting membership will be useful for improving CBHI coverage. The objective of this research is to obtain a general overview of existing evidence on the determinants of CBHI membership in West Africa.

METHODS

A review of studies reporting on the factors determining membership in CBHI schemes in West Africa was conducted using guidelines developed by the Joanna Briggs Institute. Several databases were searched (PubMed, ScienceDirect, Global Health database, Embase, EconLit, Cairn.info, BDPS, Cochrane database and Google Scholar) for relevant articles available by August 15, 2022, with no methodological or linguistic restrictions in electronic databases and grey literature.

RESULTS

The initial literature search resulted in 1611 studies, and 10 studies were identified by other sources. After eliminating duplicates, we reviewed the titles of the remaining 1275 studies and excluded 1080 irrelevant studies based on title and 124 studies based on abstracts. Of the 71 full texts assessed for eligibility, 32 additional papers were excluded (not relevant, outside West Africa, poorly described results) and finally 39 studies were included in the synthesis. Factors that negatively affect CBHI membership include advanced age, low education, low household income, poor quality of care, lack of trust in providers and remoteness, rules considered too strict or inappropriate, low trust in administrators and inadequate information campaign.

CONCLUSIONS

This study shows many lessons to be learned from a variety of countries and initiatives that could make CBHI an effective tool for increasing access to quality health care in order to achieve universal health coverage. Coverage through CBHI schemes could be improved through communication, improved education and targeted financial support.

"Magnitude of community-based health insurance utilization and associated factors in Bassona Worena District, North Shoa Zone, Ethiopia: a community-based cross-sectional study"

INTRODUCTION

The health insurance system has been proven to offer effective and efficient health care for the community, particularly community-based health insurance is expected to ensure health care access for people with low economic status and vulnerable groups. Despite the significance of evidence-based systems and implementation, there is a limited report about the magnitude of CBHI utilization. Therefore, this study was done to assess factors associated with community-based health insurance utilization in Basona Worena District, North Shewa Zone, Ethiopia.

METHOD

A community-based cross-sectional study was employed. We have included 530 households from 6 randomly selected kebeles. The data was entered using Epi-Data V 3.1 and exported to SPSS version 20.0 for statistical analysis. Bi-variable and multivariable logistic regression analyses were computed to determine factors associated with community-based health insurance utilization.

RESULT

The study finding shows that 58.6% of the respondents were members of community-based health insurance. Respondents who had primary and secondary education levels were 2 times more likely to be members than those who had no formal education. As compared to those who had awareness, respondents who had no awareness about CBHI were 0.27 times less likely to be insured. Respondents who did not experience illness were 0.27 times less likely to be members than respondents who experienced illness.

CONCLUSION

Educational status, awareness about CBHI, perception of CBHI scheme and illness experience of family influence CBHI utilization. There is a need to strengthen awareness creation to improve the CBHI utilization.

Factors influencing drop-out of households from community based health insurance membership in rural districts of Gurage Zone, Southern Ethiopia: Community based case-control study

Background

Financial risk-sharing through community-based health insurance is a critical component of universal health coverage. However, its development is a great challenge, not only due to low enrollment but also due to the high dropout rate of members from the program, which threatens its sustainability. So far, the few existing studies in this area have focused on household enrollment into community-based health insurance, rather than on the number of members dropping out. This study aims to identify factors influencing households to drop out of community-based health insurance membership in rural districts of the Gurage Zone, Southern Ethiopia.

Methods

A community-based case-control study was carried out from May to July 2021. Supplemented by qualitative focus group discussions. Multi-stage sampling was employed. An interviewer-administered prearranged tool was used for collecting data. Epi-data version 3.1 and SPSS version 21 were used for data entry and analysis. The association between factor and outcome variable was determined using binary logistic regression analysis at p < 0.05 and 95% CI. Qualitative data were analyzed thematically and triangulated.

Results

From 525 (175 cases and 350 controls) rural household heads 171 cases and 342 controls responded, yielding a response rate of 97.7%. Of those, 73.1 and 69.0% were males in cases and controls, respectively. The statistically significant influencing factors associated with dropout from community-based health insurance were: highest wealth status (adjusted odds ratio [AOR] = 2.36, 95% confidence interval [CI]:1.14-4.87), unfavorable attitude toward CBHI (AOR: 1.81, 95% CI: 1.87-3.37), no illness experienced in the last 3 months (AOR: 5.21, 95% CI: 2.90-9.33). no frequent health facility visits (AOR:5.03, 95% CI:1.17-23.43), no exposure to indigenous community insurance (AOR:0.10, 95% CI: 0.03-0.37), not graduated in the model household (AOR: 3.20, 95% CI:1.75-5.83), being a member in the program for more than 3 years (AOR:0.55, 95% CI: 0.29-0.94), not trusting governing bodies (AOR:10.52, 95% CI:4.70-23.53), the ordered drug was not available in the contractual facility (AOR:14.62, 95% CI:5.37-39.83), waiting time was >3 h (AOR:4.26, 95% CI:1.70-10.66), and poor perception of service quality (AOR:12.38, 95%CI:2.46-62.24).

Conclusion

The findings of this study illustrated various factors which positively and negatively influenced households to drop out from CBHI: wealth status, attitude toward CBHI, perceived poor provider attitude toward CBHI members, illness experience in the household, the experience of frequent health facility visits, model household graduation status, trust on CBHI committee (governing bodies), availability of a prescribed drug in the contractual health facility, waiting time and perceived quality of health service from the contractual facility, exposure to any of the indigenous insurance (IDIR and/or IQUB) and length of membership in program. We strongly recommend all responsible stakeholders give strong attention to promoting the community, and for providers to project a favorable attitude toward community-based health insurance, to achieve model household graduation, and improve quality of service by addressing the basic quality-related areas like waiting time, and drug availability).

Community-Based Health Insurance Membership Renewal Rate and Associated Factors among Households in Gedeo Zone, Southern Ethiopia

Background

Community-based health insurance (CBHI) scheme is an emerging strategy to achieve universal health coverage and protect communities in developing countries from catastrophic financial expenditure at the service delivery point. However, high membership discontinuation from the CBHI scheme remained the challenge to progress toward universal financial protection in resource-constrained countries. Therefore, this study assessed the community-based health insurance membership renewal rate and associated factors in the Gedeo zone, Southern Ethiopia.

Methods

We conducted a community-based cross-sectional study among households in the Yirga Chafe district, Gedeo zone, Southern Ethiopia, from September 10 to 30, 2021. We used a multistage simple random sampling to recruit 537 respondents. We entered data into Epi-Info 7 and exported it to SPSS version 25 for analysis. We used a logistic regression model to determine factors associated with the CBHI scheme membership renewal. Variables with a P value of <0.05 and a 95% confidence level were considered to be significantly associated with the outcome variable.

Results

We found the respondents' CBHI membership renewal rate was 82.68%. Those who enrolled in the CBHI scheme >3years (AOR = 3.12; 95% CI: 1.40–6.97), having illnesses in the last three months (AOR = 2.97; 95% CI: 1.47–5.99), the CBHI premium affordability (AOR = 12.64; 95% CI: 3.25–49.38), good knowledge of the CBHI scheme (AOR = 21.11; 95% CI: 10.63–41.93), perceived quality of health service (AOR = 4.21; 95% CI: 1.52–11.68), and favorable attitude towards the CBHI scheme (AOR = 3.89, 95% CI: 1.67–9.04) were significantly associated with the CBHI program membership renewal rate.

Conclusion

In our study, we found the magnitude of CBHI members who discontinued their CBHI scheme membership was high. Besides, we found that the affordability of the CBHI premium, respondents' attitude, and knowledge of the CBHI program were predictor factors for dropout from the CBHI membership. Therefore, the government should consider the economic status of communities during setting the CBHI program contribution. Moreover, awareness creation through health education should be provided to improve participants' knowledge and perception of the CBHI program.

Exploring the role of social representations in micro-health insurance scheme enrolment and retainment in sub-Saharan Africa: a scoping review

Low enrolment in micro-health insurance (MHI) schemes is a recurring issue affecting the viability of such schemes. Beyond the efforts addressing low subscription and retention in these schemes, little is known on how social representations are related to micro-health insurance schemes enrolment and retention. This scoping review aimed at exploring the role of social representations in shaping enrollment and retention in MHI in sub-Saharan Africa. We reviewed qualitative, quantitative and mixed methods studies conducted between 2004 and 2019 in sub-Saharan Africa. We limited our search to peer-reviewed and grey literature in English and French reporting on social representations of MHI. We defined social representations as conventions, cultural and religious beliefs, local rules and norms, local solidarity practices, political landscape and social cohesion. We applied the framework developed by Arksey and O'Malley and modified by Levac et al. to identify and extract data from relevant studies. We extracted information from a total of 78 studies written in English (60%) and in French (40%) of which 56% were conducted in West Africa. More than half of all studies explored either cultural and religious beliefs (56%) or social conventions (55%) whereas only 37% focused on social cohesion (37%). Only six papers (8%) touched upon all six categories of social representation considered in this study whereas 25% of the papers studied more than three categories. We found that all the studied social representations influence enrollment and retention in MHI schemes. Our findings highlight the paucity of evidence on social representations in relation to MHI schemes. This initial attempt to compile evidence on social representations invites more research on the role those social representations play on the viability of MHI schemes. Our findings call for program design and implementation strategies to consider and adjust to local social representations in order to enhance scheme attractiveness.

Factors Associated With Community Based Health Insurance Healthcare Service Utilization of Households in South Gondar Zone, Amhara, Ethiopia. A Community-Based Cross-Sectional Study

In Ethiopia, community-based health insurance was implemented to promote equitable access to sustainable quality health care and increase financial protection. The purpose of this study was to identify factors associated with community-based Health Insurance, Health Care Service Utilization of Households in the South Gondar Zone. A community-based cross-sectional study was employed. Data were collected among 619 randomly selected households in the south Gondar zone. Chi-square and binary logistic regression analyses with a P-Value of less than .05 were used to determine the association. Out of the total households, 511(82.6%) were using the CBHI scheme for health care service utilization. Residence, marital status, education level, occupation status, family size, presence of under-five children in the household, presence of elders in the households, nearest health institution, presence of chronic illness in the household's, time taken to reach health institution, an attitude of a household were the determinant factors of community-based health insurance scheme health care service utilization of households. It is recommended that the local, regional and national governments, policymakers on optimal actions, NGOs, and other supporting organizations shall improve or scale-up the scheme by providing awareness to the community based on these significant factors and the attitude of households.

Operational and Structural Factors Influencing Enrolment in Community-Based Health Insurance Schemes: An Observational Study Using 12 Waves of Nationwide Panel Data from Senegal

Community-based health insurance (CBHI) has been implemented in many low and middle-income countries to increase financial risk protection in populations without access to formal health insurance. While the design of such social programs is fundamental to ensuring equitable access to care, little is known about the operational and structural factors influencing enrolment in CBHI schemes. In this study, we took advantage of newly established data monitoring requirements in Senegal to explore the association between the operational capacity and structure of CBHI schemes-also termed 'mutual health organisations' (MHO) in francophone countries-and their enrolment levels. The dataset comprised 12 waves of quarterly data over 2017-2019 and covered all 676 MHOs registered in the country. Primary analyses were conducted using dynamic panel data regression analysis. We found that higher operational capacity significantly predicted higher performance: enrolment was positively associated with the presence of a salaried manager at the MHO level (12% more total enrollees, 23% more poor members) and with stronger cooperation between MHOs and local health posts (for each additional contract signed, total enrollees and poor members increased by 7% and 5%, respectively). However, higher operational capacity was only modestly associated with higher sustainability proxied by the proportion of enrollees up to date with premium payment. We also found that structural factors were influential, with MHOs located within a health facility enrolling fewer poor members (-16%). Sensitivity analyses showed that these associations were robust. Our findings suggest that policies aimed at professionalising and reinforcing the operational capacity of MHOs could accelerate the expansion of CBHI coverage, including in the most impoverished populations. However, they also suggest that increasing operational capacity alone may be insufficient to make CBHI schemes sustainable over time.

Factors affecting households' trust in the community based health insurance scheme in Ethiopia

The trust that potentially community-based health insurance (CBHI) members have in the actual health insurance scheme is a crucial determinant for members who decided to enroll and continue being members of the scheme. While the literature on health insurance in low-income countries mentions the importance of trust in consumers' decision to insure, to date the association between trust and trust-building factors has not been researched in the Ethiopian context. Therefore, the objective of this study was to assess the factors affecting households' trust in the CBHI scheme in Ethiopia. A community-based cross-sectional study design was employed to collect data from 617 household heads from March 1-30, 2020. A multistage sampling technique was carried out and interviewer-administered questionnaires were used to collect data. Descriptive statistics and multivariable linear regression analyses were performed, and variables with a P-value < 0.05 were considered to have a statistically significant association with trust in the CBHI scheme. A household survey resulted in 617 households being interviewed making a response rate of 97.3%. The mean age of the respondents was 44.7 (SD°11.2) years and the majority of the respondents were Oromo 528(85.6%). Holding other covariant fixed, educational level of household head (ß = 0.17, 95% CI:0.14-0.32), members' satisfaction with past experience (ß = 0.40, 95%CI:0.41-0.57), favorable attitude toward CBHI (ß = 0.31, 95%CI:0.12-0.49), perceived quality of service (ß = 0.15, 95% CI:0.02-0.29) and dropout from CBHI (ß = -0.23, 95%CI:- 0.41-- 0.05) were covariant that had an association with trust in the CBHI scheme. This study found that the educational level of the household head, members' satisfaction with past experience, members' attitude toward CBHI, perceived quality of services and dropout from CBHI were covariant that were affecting trust in the CBHI scheme. Therefore, if the scheme wants to build trust and maintain membership, great attention should be given toward the improvement of the quality of service and attitude of members towards the CBHI scheme. These findings suggest that CBHI managers, different health insurance agencies, providers and policymakers need to think systematically about a wide range of initiatives that enhance trust and caring, and to design trust-building structures and practices that sustain the CBHI scheme.

The sustainability of premium payment of national health insurance's self-enrolled members in Jakarta Greater Area

Background: The sustainability of the National Health Insurance (NHI) program heavily relies on the premium of its member. The negligence of a large number of members at pay the premium lead to the failure of the Social Security Agency for Health (SSAH) to deliver its services. This study aims at analyzing important factors that influence the sustainability of premium payment of NHI’s self-enrolled members in the Jakarta Greater Area.

Design and methods: This study performed an econometric analysis from the panel and the same respondent’s data in 2015 and 2017. The population of the study was NHI’s self-enrolled members who lived in the City of Jakarta, Bogor, Depok, Tangerang, Bekasi, (Jakarta Greater Area) and it represents the urban area of Indonesia. The ordinal logistic regression model was used to determine the type of sustainability NHI premium payment.

Results: The survey shows that around 28.3% of self-enrolled members do not pay the NHI insurance premium regularly. Applying ordered logit this study statistically confirms that age of household head, income per month, never experience economic hardship, 1^st/2^nd class registration, and benefits of SSAH are positively correlated with compliance rate to pay NHI insurance premium. Whereas tobacco consumption, health-seeking behavior, and the 2016 increase of premium are negatively correlated with regular premium payment.

Conclusions: This study calls for policy intervention to improve compliance of premium payment such as i) massive promotion of insurance literacy and benefits of insurance through a health professional, internet, and government officer; ii) expanding auto-debit and installment premium payment; iii) incentive for paying premium regularly and not smoking; and iv) improving access and quality of health services.

Linking poverty-targeted social protection and Community Based Health Insurance in Ethiopia: Enrolment, linkages, and gaps

BACKGROUND

Community-Based Health Insurance (CBHI) has received increasing attention in low and middle-income countries as a pathway toward universal health coverage. In 2011, the government of Ethiopia piloted CBHI and subsequently integrated CBHI with its flagship social protection programme, the Productive Safety Net Program (PSNP) which was established in 2005. We examined enrolment decisions by PSNP households, including, understanding of the programme, reasons for non-coverage, and factors associated with enrolment decisions.

METHODS

Cross-sectional data for this study come from an Integrated Safety Net Program (ISNP) baseline survey implemented in four rural woredas in Amhara region, Ethiopia between December 2018 and February 2019. We collected data from 5398 PSNP beneficiary households, categorized as either Public Work (PW) or Permanent Direct Support (PDS) types. We used descriptive methods to characterize sample households and fitted binary logistic regression to identify factors associated with households' CBHI enrolment decisions.

RESULTS

Current CBHI enrolment is higher among PW households (70.1 %) than PDS clients (50.3 %). The most common reason for not enrolling in both PW and PDS households is cost. Results further show that the following characteristics are positively associated with CBHI enrolment: the number of children and working-age adults in the household, older household head, female household head, married household head, having been food insecure in the previous 12 months, heads having experienced illness in the past month, and increasing household wealth status.

CONCLUSION

While demographic factors are important in households' decisions to enrol in CBHI, various mechanisms could be used to increase enrolment among vulnerable households such as PDS clients. In this regard, while better communication about CBHI could increase enrolment for some households, other poor and vulnerable households will need fee waivers to induce enrolment.

Dropping out of voluntary community-based health insurance in rural Uganda: Evidence from a cross-sectional study in rural south-western Uganda

AIM

Community Based Health Insurance (CBHI) schemes have become central to health systems financing as avenues of achieving universal health coverage in developing countries. Yet, while emphasis in research and policy has mainly concentrated on enrolment, very little has been apportioned to high rates of dropping out after initial enrolment. The main aim of this study is to understand the factors behind CBHI dropping out through a cross-sectional quantitative research design to gain insights into curtailing the drop out of CBHI in Uganda.

METHODS

The survey for the quantitative research component took place between August 2015 and March 2016 covering 464 households with under-5 children in south-western Uganda. To understand the factors associated with dropping out of CBHI, we employ a multivariate logistic regression on a subsample of 251 households who were either currently enrolled or had enrolled at one time and later dropped out.

RESULTS

Overall, we find that 25.1 percent of the households that had ever enrolled in insurance reported dropping out. Household socioeconomic status (wealth) was one of the key factors that associated with dropping out. Larger household sizes and distance from the hospital were significantly associated with dropping out. More socially connected households were less likely to drop out revealing the influence of community social capital in keeping households insured.

CONCLUSION

The findings have implications for addressing equity and inclusion concerns in community-based health insurance programmes such as one in south-western Uganda. Even when community based informal system aim for inclusion of the poorest, they are not enough and often the poorest of the poor slip into the cracks and remain uninsured or drop out. Moreover, policy interventions toward curtailing high dropout rates should be considered to ensure financial sustainability of CBHI schemes.

Non-fatal injuries in rural Burkina Faso amongst older adults, disease burden and health system responsiveness: a cross-sectional household survey

OBJECTIVES

This study aimed to evaluate the epidemiology of injury as well as patient-reported health system responsiveness following injury and how this compares with non-injured patient experience, in older individuals in rural Burkina Faso.

DESIGN

Cross-sectional household survey. Secondary analysis of the CRSN Heidelberg Ageing Study dataset.

SETTING

Rural Burkina Faso.

PARTICIPANTS

3028 adults, over 40, from multiple ethnic groups, were randomly sampled from the 2015 Nouna Health and Demographic Surveillance Site census.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome was incidence of injury. Secondary outcomes were incidence of injury related disability and patient-reported health system responsiveness following injury.

RESULTS

7.7% (232/3028) of the population reported injury in the preceding 12 months. In multivariable analyses, younger age, male sex, highest wealth quintile, an abnormal Generalised Anxiety Disorder score and lower Quality of Life score were all associated with injury. The most common mechanism of injury was being struck or hit by an object, 32.8%. In multivariable analysis, only education was significantly negatively associated with odds of disability (OR 0.407, 95% CI 0.17 to 0.997). Across all survey participants, 3.9% (119/3028) reported their most recent care seeking episode was following injury, rather than for another condition. Positive experience and satisfaction with care were reported following injury, with shorter median wait times (10 vs 20 min, p=0.002) and longer consultation times (20 vs 15 min, p=0.002) than care for another reason. Injured patients were also asked to return to health facilities more often than those seeking care for another reason, 81.4% (95% CI 73.1% to 87.9%) vs 54.8% (95% CI 49.9% to 53.6%).

CONCLUSIONS

Injury is an important disease burden in this older adult rural low-income and middle-income country population. Further research could inform preventative strategies, including safer rural farming methods, explore the association between adverse mental health and injury, and strengthen health system readiness to provide quality care.

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.

Education and Experience as Determinants of Micro Health Insurance Enrolment

BACKGROUND

India faces a formidable challenge of providing universal health coverage to its uninsured population in the informal sector of the economy. Numerous micro health insurance (MHI) schemes have emerged as health financing mechanisms to reduce medical-illness-induced poverty. Existing research shows that the purchase of health insurance is most likely to be determined by health status, expected healthcare expenditure, and past health experiences in addition to socio-economic variables. We add to the understanding of various factors influencing enrolment in MHI from an Indian perspective.

METHODS

A survey was carried out to collect quantitative data in three districts in the state of Karnataka, India.

RESULTS

We show that education does not matter as significantly as experience does, in the determination of new insurance purchases. In other words, the importance of new insurance is not understood by those who are merely educated, but by those who have either fallen ill, or have previously seen the hazards of usurious borrowing.

CONCLUSION

Our study provides deeper insights into the role of usurious borrowing and past illness in determining insurance purchases and highlights the formidable challenge of financial sustainability in the MHI market of India.

Factors influencing variation in implementation outcomes of the redesigned community health fund in the Dodoma region of Tanzania: a mixed-methods study

Introduction

Micro-health insurance (MHI) has been identified as a possible interim solution to foster progress towards Universal Health Coverage (UHC) in low- and middle- income countries (LMICs). Still, MHI schemes suffer from chronically low penetration rates, especially in sub-Saharan Africa. Initiatives to promote and sustain enrolment have yielded limited effect, yet little effort has been channelled towards understanding how such initiatives are implemented. We aimed to fill this gap in knowledge by examining heterogeneity in implementation outcomes and their moderating factors within the context of the Redesigned Community Health Fund in the Dodoma region in Tanzania.

Methods

We adopted a mixed-methods design to examine implementation outcomes, defined as adoption and fidelity of implementation (FOI) as well as their moderating factors. A survey questionnaire collected individual level data and a document review checklist and in-depth interview guide collected district level data. We relied on descriptive statistics, a chi square test and thematic analysis to analyse our data.

Results

A review of district level data revealed high adoption (78%) and FOI (77%) supported also by qualitative interviews. In contrast, survey participants reported relatively low adoption (55%) and FOI (58%). Heterogeneity in adoption and FOI was observed across the districts and was attributed to organisational weakness or strengths, communication and facilitation strategies, resource availability (fiscal capacity, human resources and materials), reward systems, the number of stakeholders, leadership engagement, and implementer’s skills.

At an individual level, heterogeneity in adoption and FOI of scheme components was explained by the survey participant’s level of education, occupation, years of stay in the district and duration of working in the scheme. For example, the adoption of job description was statistically associated with occupation (p = 0.001) and wworking in the scheme for more than 20 months had marginal significant association with FOI (p = 0.04).

Conclusion

The study demonstrates that assessing the implementation processes helps to detect implementation weaknesses and therefore address such weaknesses as the interventions are implemented or rolled out to other settings. Attention to contextual and individual implementer elements should be paid in advance to adjust implementation strategies and ensure greater adoption and fidelity of implementation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-10013-y.

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.

Community-Based Health Insurance Membership Dropout Rate and Associated Factors in Dera District, Northwest Ethiopia

Background

Community-based health insurance is an emerging strategy for providing financial protection against health-related poverty. They have developed into alternative health financing mechanisms for out-of-pocket expenses in low- and middle-income countries. Hence, the aim of this study was to assess the drop-out rate of community-based health insurance membership and associated factors in Dera district, Northwest Ethiopia, 2020.

Methods

Through systematic random sampling techniques, a community-based cross-sectional study was conducted on 584 participants. A structured interviewer-based administered questionnaire was used for data collection. EpI data is used for data entry, while SPSS 20 version is used for analysis. P-value <0.2 binary logistic regression was entered into multivariable logistic regression. Variables with a P-value of <0.05 and a 95% confidence level were considered to be significantly associated with the outcome variable.

Results

The CBHI dropout rate in the district is calculated to be 37.3% (95% CI: 34, 41%) in the district. Length of enrollment, ≥4 years in the CBHI program (AOR=0.39, 95% CI: 0.26, 0.59), households visit the health facilities 4–6 times a year (AOR=1.92, 95% CI: 1.10, 3.32), have no access to the hospital (AOR=1.68, 95% CI: 1.02, 2.77), knowledge of CBHI (AOR=1.93, 95% CI: 1.32, 2.82) and official position holder for decision-making in the households (AOR=2.07, 95% CI: 1.33, 3.23) were factors associated with CBHI dropout rate in the scheme.

Conclusion

This finding confirmed that the CBHI dropout rate in the district was high. Length of enrollment, health facility visit, hospital accessibility, knowledge of CBHI, and official position holders used for decision-making are significantly associated with the CBHI dropout rate. Therefore, emphasis should be given on improving members’ understanding of the CBHI package of benefits; increasing access to hospitals and empowering women will increase the utilization of CBHI. In addition, the quality of care for CBHI patients can be improved when they had access to health services.

Perceived Quality of Healthcare and Availability of Supplies Determine Household-Level Willingness to Join a Community-Based Health Insurance Scheme in Amhara Region, Ethiopia

Purpose

The Ethiopian health system has been challenged by a shortage of funds and is heavily reliant on foreign donation. However, voluntary community-based health insurance (CBHI) has been implemented to reach and cover the very large agricultural sector since 2010. Thus, the level of acceptability of the scheme needs to be regularly assessed through households’ willingness to join before the nationwide rollout of the scheme. This study was intended to assess the level of willingness to join in community-based health insurance and associated factors in northwest Ethiopia.

Patients and Methods

Using a pretested structured questionnaire, a cross-sectional community-based study was conducted in 2017 in Amhara Region, northwest Ethiopia. Using a multi-stage sampling method, from 15 clusters in which CBHI was implemented, 1,179 households without CBHI membership were included as a sample for the study. Bivariable and multivariable logistic regression was fitted to assess the association between predictor variables and the outcome of interest.

Results

Out of the total (1,179) participants, 60.5% (713) were willing to join the scheme. Households’ occupation (AOR=2.26; 95% CI:=1.12–5.07), perceived good (AOR=2.21; 95% CI:=1.53−3.21), and medium (AOR=1.44; 95% CI=1.22–2.0) healthcare quality and richer wealth status (AOR=1.72; 95% CI=1.08–2.73) were associated with higher odds of willingness to join the scheme.

Conclusion

As The study revealed that level of willingness to join is lower compared to other studies. Therefore, social protection activities for the low-income population and enhancement of the capacity of health facilities are crucial.

The Effect of Ethiopia's Community-Based Health Insurance Scheme on Revenues and Quality of Care

Ethiopia's Community-Based Health Insurance (CBHI) scheme was established with the objectives of enhancing access to health care, reducing out-of-pocket expenditure (OOP), mobilizing financial resources and enhancing the quality of health care. Previous analyses have shown that the scheme has enhanced health care access and led to reductions in OOP. This paper examines the impact of the scheme on health facility revenues and quality of care. This paper relies on a difference-in-differences approach applied to both panel and cross-section data. We find that CBHI-affiliated facilities experience a 111% increase in annual outpatient visits and annual revenues increase by 47%. Increased revenues are used to ameliorate drug shortages. These increases have translated into enhanced patient satisfaction. Patient satisfaction increased by 11 percentage points. Despite the increase in patient volume, there is no discernible increase in waiting time to see medical professionals. These results and the relatively high levels of CBHI enrollment suggest that the Ethiopian CBHI has been able to successfully negotiate the main stumbling block-that is, the poor quality of care-which has plagued similar CBHI schemes in Sub-Saharan Africa.

Economic valuation of setting up a social health enterprise in urban poor-resource setting in Kenya

The failure of the market and government to provide quality healthcare services have been the motivation to set up social health enterprise. However, the value for money associated with setting up a social health enterprise in sub-Sahara African countries has been relatively unexplored in the literature. The study presents the first empirical estimates of the mean willingness-to-pay (WTP) for setting up a social health enterprise that will simultaneously run a health center and provide health insurance scheme in an urban resource-poor setting and explores whether the benefits outweigh the costs. The contingent valuation method is used to estimate the mean WTP for the health insurance scheme proposed by the social health enterprise in Viwandani slum (Nairobi, Kenya). The survey was conducted between June and July 2018 on 300 households. We find that the feasibility of setting up a social health enterprise could be promising with 97 percent of respondents willing to pay about US$ 2 per person per month for a scheme that would provide quality healthcare services. More importantly, setting up the social health enterprise will yield a positive net profit, and investors could expect US$ 1.11 in benefits for each US$ 1 of costs of investment in setting up the social health enterprise. We, therefore, conclude that this health policy in this urban resource-poor setting could be a viable solution to reach the neglected urban households in the Kenyan slums.

Examining purchasing reforms towards universal health coverage by the National Hospital Insurance Fund in Kenya

BACKGROUND

Kenya has prioritized the attainment of universal health coverage (UHC) through the expansion of health insurance coverage by the National Hospital Insurance Fund (NHIF). In 2015, the NHIF introduced reforms in premium contribution rates, benefit packages, and provider payment methods. We examined the influence of these reforms on NHIF's purchasing practices and their implications for strategic purchasing and health system goals of equity, efficiency and quality.

METHODS

We conducted an embedded case study with the NHIF as the case and the reforms as embedded units of analysis. We collected data at the national level and in two purposively selected counties through 41 in-depth interviews with health financing stakeholders, facility managers and frontline providers; 4 focus group discussions with 51 NHIF members; and, document reviews. We analysed the data using a Framework approach.

RESULTS

The new NHIF reforms were characterized by weak purchasing actions. Firstly, the new premium contribution rates were inadequately communicated and unaffordable for certain citizen groups. Secondly, while the new benefit packages were reported to be based on service needs, preferences and values of the population, they were inadequately communicated and unequally distributed across different citizen groups. In addition, the presence of service delivery infrastructure gaps in public healthcare facilities and the pro-urban and pro-private distribution of contracted health facilities compromised delivery of, and access to, these new services. Lastly, the new provider payment methods and rates were considered inadequate, with delayed payments and weak links to financial accountability mechanisms which compromised their ability to incentivize equity, efficiency and quality of healthcare delivery.

CONCLUSION

While NHIF sought to expand population and service coverage and reduce out-of-pocket payments with the new reforms, weaknesses in the reforms' design and implementation limited NHIF's purchasing actions with negative implications for the health system goals of equity, efficiency and quality. For the reforms to accelerate the country's progress towards UHC, policy makers at the NHIF and, national and county government should make deliberate efforts to align the design and implementation of such reforms with strategic purchasing actions that are aimed at improving health system goals.

Examining purchasing reforms towards universal health coverage by the National Hospital Insurance Fund in Kenya

BACKGROUND

Kenya has prioritized the attainment of universal health coverage (UHC) through the expansion of health insurance coverage by the National Hospital Insurance Fund (NHIF). In 2015, the NHIF introduced reforms in premium contribution rates, benefit packages, and provider payment methods. We examined the influence of these reforms on NHIF's purchasing practices and their implications for strategic purchasing and health system goals of equity, efficiency and quality.

METHODS

We conducted an embedded case study with the NHIF as the case and the reforms as embedded units of analysis. We collected data at the national level and in two purposively selected counties through 41 in-depth interviews with health financing stakeholders, facility managers and frontline providers; 4 focus group discussions with 51 NHIF members; and, document reviews. We analysed the data using a Framework approach.

RESULTS

The new NHIF reforms were characterized by weak purchasing actions. Firstly, the new premium contribution rates were inadequately communicated and unaffordable for certain citizen groups. Secondly, while the new benefit packages were reported to be based on service needs, preferences and values of the population, they were inadequately communicated and unequally distributed across different citizen groups. In addition, the presence of service delivery infrastructure gaps in public healthcare facilities and the pro-urban and pro-private distribution of contracted health facilities compromised delivery of, and access to, these new services. Lastly, the new provider payment methods and rates were considered inadequate, with delayed payments and weak links to financial accountability mechanisms which compromised their ability to incentivize equity, efficiency and quality of healthcare delivery.

CONCLUSION

While NHIF sought to expand population and service coverage and reduce out-of-pocket payments with the new reforms, weaknesses in the reforms' design and implementation limited NHIF's purchasing actions with negative implications for the health system goals of equity, efficiency and quality. For the reforms to accelerate the country's progress towards UHC, policy makers at the NHIF and, national and county government should make deliberate efforts to align the design and implementation of such reforms with strategic purchasing actions that are aimed at improving health system goals.

Why Do Informal Sector Workers Not Pay the Premium Regularly? Evidence from the National Health Insurance System in Indonesia

BACKGROUND

The challenges of universal health coverage (UHC) in developing countries with a significant proportion of the labor force that works in the informal sector include administrative difficulties in recruiting, registering and collecting regular contributions in a cost-effective way. As most developing countries have a limited fiscal space to support the program in the long run, the fiscal sustainability of UHC, such as that in Indonesia, relies heavily on the contributions of its members. The failure of a large proportion of voluntary enrollees/self-enrolled members/informal sector workers (Peserta Mandiri/Pekerja Bukan Penerima Upah [PBPU] members) to pay their premiums may lead to the National Health Insurance System (NHIS) in Indonesia being unable to effectively deliver its services.

OBJECTIVE

This study aims at exploring the important factors that affect the compliance behavior of informal sector workers (PBPU members) in regularly paying their insurance premium. This analysis may be a basis for designing effective measures to encourage payment sustainability in informal sector workers in the NHIS.

METHOD

This study utilizes the survey data collected from three regional offices of the Indonesian Social Security Agency for Health (SSAH), which cover approximately 1210 PBPU members, to understand the relationship between members' characteristics and their compliance behavior regarding the premium payment. We applied an econometric analysis of a logit regression to statistically estimate which factors most affect their compliance behavior in paying the insurance premium.

RESULTS

This study reveals that almost 28% of PBPU members do not pay their insurance premiums in a sustainable way. Our logistic regression statistically confirms that the number of household members, financial hardship, membership in other social protection arrangements, and the utilization of health services are negatively correlated with the compliance rate of informal sector workers in paying their insurance premium. For instance, people who experience financial hardship tend to have a 7.7 percentage point lower probability of routinely paying the premium. In contrast, households that work in agricultural sectors and have income stability, the cost of inpatient care incurred before joining the NHIS, a comprehensive knowledge of the SSAH's services, and the availability of health professionals are all positively correlated with regular premium payment.

CONCLUSION

Although there is no single policy that can ensure that informal sector workers (PBPU members) regularly pay their premiums, this study recommends some policy interventions, including (1) flexibility in applying for a government subsidy for premiums (Penerima Bantuan Iuran [PBI]), especially for people who have financial hardship; (2) an intensive promotion of insurance literacy; (3) expanding the quantity and quality of healthcare services; and (4) tailor-made policies for ensuring the sustainability of premium payments for each regional division.

Determinants of enrollment decision in the community-based health insurance, North West Ethiopia: a case-control study

OBJECTIVE

To identify the determinants for enrollment decision in the community-based health insurance program among informal economic sector-engaged societies, North West Ethiopia.

METHOD

Unmatched case-control study was conducted on 148 cases (member-to-insurance) and 148 controls (not-member-to-insurance program) from September 1 to October 30,2016. To select the villages and households, stratified then simple random sampling method was employed respectively. The data were entered in to Epi-info version 7 and exported to SPSS version 20 for analysis. Descriptive statistics, bi-variable, and multi-variable logistic regression analyses were computed to describe the study objectives and identify the determinants of enrolment decision for the insurance program. Odds ratio at 95% CI was used to describe the association between the independent and outcome variables.

RESULTS

A total of 296 respondents (148 cases and 148 controls) were employed. The mean age for both cases and controls were 42 ± 11.73 and 40 ± 11.37 years respectively. Majority of respondents were males (87.2% for cases and 79% for controls). Family size between 4 and 6 (AOR = 2.26; 95% CI: 1.04, 4.89), history of illness by household (AOR = 3.24; 95% CI: 1.68, 6.24), perceived amount of membership contribution was medium (AOR = 2.3; 95% CI: 1.23, 4.26), being married (AOR = 6; 95% CI:1.43, 10.18) and trust on program (AOR = 4.79; 95% CI: 2.40, 9.55) were independent determinants for increased enrollment decision in the community-based health insurance. While, being merchant (AOR = 0.07; 95% CI: 0.09, 0.6) decreased the enrollment decision.

CONCLUSION

Societies' enrollment decision to community-based health insurance program was determined by demographic, social, economic and political factors. Households with large family sizes and farmers in the informal sector should be given maximal attention for intensifying enrollment decision in the insurance program.

Impact of voluntary community-based health insurance on child stunting: Evidence from rural Uganda

While community-based health insurance increasingly becomes part of the health financing landscape in developing countries, there is still limited research about its impacts on health outcomes. Using cross-sectional data from rural south-western Uganda, we apply a two-stage residual inclusion instrumental variables method to study the impact of insurance participation on child stunting in under-five children. We find that one year of a household's participation in community-based health insurance was associated with a 4.3 percentage point less probability of stunting. Children of two years or less dominated the effect but there were also statistically significant benefits of enrolling in insurance after a child's birth. The expansion of community-based health insurance might have more dividends to improving health, in addition to financial protection and service utilisation in rural developing countries.

Healthcare Financing in Rural Cameroon

In the global South, low-income populations are faced with frequent health shocks. Formal mechanisms to protect them against these shocks are absent or limited. Thus, what are the mechanisms used by low-income rural populations to finance healthcare? This paper draws on a qualitative study to examine the healthcare financing mechanisms of low-income rural populations in Cameroon. The findings suggest that low-income populations use 13 mechanisms to finance healthcare. Depending on several factors, people may use more than one of these mechanisms. In addition, social factors shape people’s patterns of usage of these mechanisms. Patterns of usage of these mechanisms are embedded in the principle of reciprocity. The notion of reciprocity does seem to discourage people from enrolling in the limited voluntary health insurance programmes which exist in various communities. Newly insured people were more likely to drop out if they did not receive a payout.

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.

Potential demand for voluntary community-based health insurance improvement in rural Lao People's Democratic Republic: A randomized conjoint experiment

INTRODUCTION

In Lao People's Democratic Republic (PDR), community-based health insurance (CBHI) is the only voluntary insurance scheme; it typically targets self-employed people, most of whom reside in rural areas and are dependent on agricultural activities for subsistence. However, until very recently, the enrollment rate has fallen short and failed to reach a large percentage of the target group. To promote the CBHI scheme and increase demand, some supporting components should be considered for inclusion together with the health infrastructure component.

OBJECTIVES

This paper provides empirical evidence that the benefit package components of hypothetical CBHI schemes have causal effects on enrollment probabilities. Furthermore, we examine the distribution of willingness to pay (WTP) in response to policy changes based on a sample of 5,800 observations.

METHODS

A randomized conjoint experiment is conducted in rural villages in Savannakhet Province, Lao PDR, to elicit stated preference data. Each respondent ranks three options-two hypothetical alternatives and the CBHI status quo scheme. The levels of seven attributes-insurance coverage for medical consultations, hospitalizations, traffic accidents, pharmaceuticals and transportation; premiums; and prepaid discounts-are randomly and simultaneously assigned to the two alternatives.

RESULTS

The findings suggest that the average WTP is at least as large as 10.9% of the per capita income of those who live in rural areas, which is higher than the WTP for health insurance averaged across low- and middle-income countries (LMICs) in the literature. The component of round-trip transportation insurance coverage has a significant effect on WTP distribution, particularly increasing the share of the highest bin.

CONCLUSION

Therefore, the low CBHI scheme enrollment rate in Lao PDR does not necessarily imply low demand among the targeted population, as the finding from the WTP analysis illustrates potential demand for the CBHI scheme. Specifically, if transportation is addressed, enrollment is likely to significantly increase.

Factors Contributing to Low Adherence to Community-Based Health Insurance in Rural Nyanza District, Southern Rwanda

Background

Community-based health insurance (CBHI) schemes are an emerging mechanism for providing financial protection against health-related poverty. In Rwanda, CBHI is being implemented across the country, and it is based on four socioeconomic categories of the “Ubudehe system”: the premiums of the first category are fully subsidized by government, the second and third category members pay 3000 frw, and the fourth category members pay 7000 frw as premium. However, low adherence of community to the scheme since 2011 has not been sufficiently studied.

Objective

This study aimed at determining the factors contributing to low adherence to the CBHI in rural Nyanza district, southern Rwanda.

Methodology

A cross-sectional study was conducted in nine health centers in rural Nyanza district from May 2017 to June 2017. A sample size of 495 outpatients enrolled in CBHI or not enrolled in the CBHI scheme was calculated based on 5% margin of error and a 95% confidence interval. Logistic regression was used to identify the determinants of low adherence to CBHI.

Results

The study revealed that there was a significant association between long waiting time to be seen by a medical care provider and between health care service provision and low adherence to the CBHI scheme (P value < 0.019) (CI: 0.09107 to 0.80323). The estimates showed that premium not affordable (P value < 0.050) (CI: 0.94119 to 9.8788) and inconvenient model of premium payment (P value < 0.001) (CI: 0.16814 to 0.59828) are significantly associated with low adherence to the CBHI scheme. There was evidence that the socioeconomic status as measured by the category of Ubudehe (P value < 0.005) (CI: 1.4685 to 8.93406) increases low adherence to the CBHI scheme.

Conclusion

This study concludes that belonging to the second category of the Ubudehe system, long waiting time to be seen by a medical care provider and between services, premium not affordable, and inconvenient model of premium payment were significant predictors of low adherence to CBHI scheme.

Predictors of Health Care Service Quality among Women Insured Under Ghana's National Health Insurance Scheme

Background:

Insured women in Ghana are more likely to use maternity care services than their uninsured counterparts. To improve service quality among insured women in Ghana, better understanding of the factors that predict quality standards of primary health care services is essential.

Objective:

To examine predictors of health care service quality among insured women under the National Health Insurance Scheme (NHIS) in Ghana.

Methods:

Data from the 2014 Ghana Demographic Health Survey was analysed. Cluster analysis was applied to construct a dependent variable; service care quality. Socio-demographic/background characteristics were used as independent variables. Descriptive and inferential analyses were performed followed by multiple regression to predict service quality among the insured population of women aged 15–49 years. SPSS version 21 was used during the clustering while STATA version 14 was used to perform the inferential and regression analyses.

Findings:

A total of 5,457 women with valid health insurance were included in the analysis. Overall, geographical region of respondents was significant to expressions of insured service quality (χ² = 495.4, p ≤ 0.001). Literacy levels were significant at χ² = 69.232 and p < 0.001 for service quality. On place of residence, the estimation showed urban residency to be more positively correlated with indicating quality ratings of health services compared to rural residency (χ² = 70.29, p < 0.001). Highest educational level had the highest predictive influence (coefficient = 0.15) on women’s views about the quality of health care services.

Conclusions:

A health insurance system that shifts towards introducing valued-based care models for patients, insurers, and health care providers could be supportive in improving the quality of healthcare delivered to Ghanaians.

Predictors of Health Care Service Quality among Women Insured Under Ghana's National Health Insurance Scheme

BACKGROUND

Insured women in Ghana are more likely to use maternity care services than their uninsured counterparts. To improve service quality among insured women in Ghana, better understanding of the factors that predict quality standards of primary health care services is essential.

OBJECTIVE

To examine predictors of health care service quality among insured women under the National Health Insurance Scheme (NHIS) in Ghana.

METHODS

Data from the 2014 Ghana Demographic Health Survey was analysed. Cluster analysis was applied to construct a dependent variable; service care quality. Socio-demographic/background characteristics were used as independent variables. Descriptive and inferential analyses were performed followed by multiple regression to predict service quality among the insured population of women aged 15-49 years. SPSS version 21 was used during the clustering while STATA version 14 was used to perform the inferential and regression analyses.

FINDINGS

Overall, geographical region of respondents was significant to expressions of insured service quality (χ2=495.4, p ≤ 0.001). Literacy levels were significant at χ2=69.232 and p ≤ 0.001 for service quality. On place of residence, the estimation show urban residency was more positively correlated with indicating quality ratings of health services compared to rural residency (χ2=70.29, p ≤ 0.001). Highest educational level had the highest predictive influence with a coefficient of 0.15.

CONCLUSIONS

A more supportive health insurance system approach that shifts towards introducing valued-based care models for patients, insurers and health care providers could be supportive in improving quality standards among insured population groups in Ghana.

Can information increase the understanding and uptake of insurance? Lessons from a randomized experiment in rural Burkina Faso

Community Based Health Insurance Schemes are often confronted to very low uptake. We analyze the impact of a randomized information package on the understanding and adoption of Community Based Health Insurance in Burkina Faso. The sample consists of about 2000 households in the rural community of Ziniaré which we interviewed several times between 2013 and 2016. In contrast to previous studies in the literature, we assess the effects of an intensive information intervention combining tools and repeated interaction instead of only a single event of information provisioning. The information package combines three tools to present different types of information - a brochure presenting factual information, a video presenting a hypothetical health episode and a personalized phone call reminder. The brochure and video are delivered through home visits by specially trained agents. Despite the repeated interaction and the comprehensiveness of the information package, we find only modest improvements in the understanding of insurance principles following our intervention. Investigating treatment heterogeneity, we observe an increase in understanding in poorer households and in households with literate heads. Given the small improvements in insurance knowledge we do not see a significant effect on insurance uptake either. We conclude that information is not enough to increase insurance uptake and discuss the role of other factors that might matter including the political context in which our experiment was implemented.