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

A Hierarchical Bayesian approach to small area estimation of health insurance coverage in Ethiopian administrative zones for better policies and programs

Sample surveys are extensively used to provide reliable direct estimates for large areas or domains with enough sample sizes at national and regional levels. However, zones are unplanned domains by the Demographic and Health Survey (DHS) program and need more sample sizes to produce direct survey estimates with adequate precision. Conducting surveys in small areas (like zones) is too expensive and time-consuming, making it unfeasible for developing countries like Ethiopia. Therefore, this study aims to use the Hierarchical Bayes (HB) Small Area Estimation (SAE) model to estimate the Community-Based Health Insurance (CBHI) coverage at the zone levels in Ethiopia. To achieve this, we combined the 2019 Ethiopia Mini-Demographic and Health Survey (EMDHS) data with the 2007 population census data. SAE has addressed the challenge of producing reliable parameter estimates for small or even zero sample sizes across Ethiopian zones by utilizing auxiliary information from the population census. The results show that model-based estimates generated by the SAE approach are more accurate than direct survey estimates of CBHI. A map of CBHI scheme coverage was also used to visualize the spatial variation in the distribution of CBHI scheme coverage. From the CBHI scheme coverage map, we noticed notable variations in CBHI scheme coverage across Ethiopian zones. Additionally, this research identified areas with high and low CBHI scheme coverage to improve decision-making and increase coverage in Ethiopia. One of the novelties of this paper is estimating the non-sampled zones; therefore, the policymakers will give equal attention similar to the sampled zones.

Barriers and Motivations for Health Insurance Subscription Among Health-Care Users in Cameroon

INTRODUCTION

Surgical care is a significant component of the overall health expenditure in low- and middle-income countries. In Cameroon, out-of-pocket payments for surgical service are very high with many patients declining potentially curative surgical procedures. Less than 2% of the population is enrolled in a health insurance scheme leading to a propensity for catastrophic health expenses when accessing care. To assess the perceived barriers and motivations for health insurance subscription among health-care users in Cameroon.

METHODS

This was a cross-sectional community-based qualitative study conducted in the Center Region of Cameroon. A total of 37 health-care users (health insurance subscribers and nonsubscribers) were purposively identified. Four focused group discussions and thirteen in-depth interviews were conducted. All anonymized transcripts were analyzed using a thematic analysis approach.

RESULTS

The six major themes identified as barriers to health insurance subscription were lack of trust in the existing health insurance schemes, inadequate knowledge on how health insurance works, premiums believed to be too expensive, the complexity of the claims processing system, minimal usage of health-care services and practice of self-medication. Motivational factors included the knowledge of having access to quality health services even without money in the event of an unforeseen illness and having a large family/household size. The importance of mass sensitization on the benefits of health insurance was noted.

CONCLUSION

Health insurance is still very underutilized in Cameroon. This results in significant out-of-pocket payment for health services by Cameroonians with catastrophic consequences to households. With most Cameroonians in the informal sector and underemployed, it is imperative to put in place a national strategic plan to overcome existing barriers and increase health insurance coverage especially among the poor. This has the potential to significantly increase access to safe, quality, timely and affordable surgical care.

Willingness to enroll and pay for community-based health insurance, decision motives, and associated factors among rural households in Enugu State, Southeast Nigeria

Background

Over 70% of Nigeria's population is poor and rural, and most lack financial risk protection against ill health. Community-based health insurance (CBHI) may be an essential intervention strategy for ensuring that quality healthcare reaches the informal and rural populations.

Aim

This article explores the willingness to enroll (WTE) and willingness to pay (WTP) for CBHI by community members, their decision considerations, and associated factors in Enugu State, Nigeria.

Materials and Methods

We adopted a cross-sectional survey design with a multi-stage sampling approach. A validated and pre-tested questionnaire was used to elicit information from the respondents. WTE and WTP for CBHI was determined using the bid contingent valuation method. A test of correlation/association (Chi-square and ordinary least square regression) was conducted to ascertain the relationship between WTP for CBHI and other variables at a 95% confidence interval. The socioeconomic status index was generated using principal component analysis. A test of association was conducted between the demographic characteristics and WTE and WTP variables.

Key Findings

A total of 501 household heads or their representatives were included in the study which yielded a return rate of 98.2%. The finding showed that most (92.4%) of the respondents indicated a WTE in CBHI. 86.6% indicated a willingness to pay cash for CBHI, while 84.4% indicated a willingness to pay other household members for CBHI. There was a significant association between gender, marital status, education, location, and willingness to pay. The study shows that 81.6% of the respondent stated that qualified staff availability motivates their WTE/WTP for CBHI, while 78.1% would be willing to enroll and pay for CBHI if services were provided free, and 324 (74.6%) stated that proximity to a health facility would encourage them to enroll and pay for the CBHI.

Conclusion

This community demand analysis shows that rural and peri-urban community members are open to using a contributory mechanism for their health care, raising the prospect of establishing CBHI. To achieve universal health coverage, policy measures need to be taken to promote participation, provide financial and non-financial incentives and ensure that the service delivery mechanism is affordable and accessible. Further studies are needed to explore ways to encourage participation and enrollment in CBHI and other contributory schemes among under-served populations and improve access to and utilization of healthcare services.

Association between women's household decision-making autonomy and health insurance enrollment in sub-saharan Africa

BACKGROUND

Out of pocket payment for healthcare remains a barrier to accessing health care services in sub-Saharan Africa (SSA). Women's decision-making autonomy may be a strategy for healthcare access and utilization in the region. There is a dearth of evidence on the link between women's decision-making autonomy and health insurance enrollment. We, therefore, investigated the association between married women's household decision making autonomy and health insurance enrollment in SSA.

METHODS

Demographic and Health Survey data of 29 countries in SSA conducted between 2010 and 2020 were analyzed. Both bivariate and multilevel logistic regression analyses were carried out to investigate the relationship between women's household decision-making autonomy and health insurance enrollment among married women. The results were presented as an adjusted odds ratio (AOR) and the 95% confidence interval (CI).

RESULTS

The overall coverage of health insurance among married women was 21.3% (95% CI; 19.9-22.7%), with the highest and lowest coverage in Ghana (66.7%) and Burkina Faso (0.5%), respectively. The odds of health insurance enrollment was higher among women who had household decision-making autonomy (AOR = 1.33, 95% CI; 1.03-1.72) compared to women who had no household decision-making autonomy. Other covariates such as women's age, women's educational level, husband's educational level, wealth status, employment status, media exposure, and community socioeconomic status were found to be significantly associated with health insurance enrollment among married women.

CONCLUSION

Health insurance coverage is commonly low among married women in SSA. Women's household decision-making autonomy was found to be significantly associated with health insurance enrollment. Health-related policies to improve health insurance coverage should emphasize socioeconomic empowerment of married women in SSA.

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.

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.

The effects of individual and community-level factors on community-based health insurance enrollment of households in Ethiopia

Introduction

Community-based health insurance (CBHI) is a type of volunteer health insurance that has been adopted all over the world in which people of the community pool funds to protect themselves from the high costs of seeking medical care and treatment for the disease. In Ethiopia, healthcare services are underutilized due to a lack of resources in the healthcare system. The study aims to identify the individual and community level factors associated with community-based health insurance enrollment of households in Ethiopia.

Methods

Data from the Ethiopian mini demographic and health survey 2019 were used to identify factors associated with community-based health insurance enrollment of households in Ethiopia. Multilevel logistic regression analysis was used on a nationally representative sample of 8,663 households nested within 305 communities, considering the data’s layered structure. We used a p-value<0.05 with a 95% confidence interval for the results.

Result

The prevalence of community-based health insurance enrollment in Ethiopia was 20.2%. The enrollment rate of households in the scheme was high in both Amhara (57.9), and Tigray (57.9%) regions and low (3.0%) in the Afar region. At the individual level; the age of household heads, number of children 5 and under, number of household members, has land for agriculture, has a mobile telephone, receiving cash of food from the safety Net Program, Owning livestock, and herds of farm animals, wealth index, and at the community level; the region had a significant association with community-based health insurance enrollment.

Conclusion

Both individual and community-level characteristics were significant predictors of community-based health insurance enrollment in households. Furthermore, the ministry of health, health bureaus, and other concerning bodies prioritize clusters with low health insurance coverage to strengthen health system financing and intervene in factors that negatively affect the CBHI enrollment of households.

Spatial distribution and associated factors of community based health insurance coverage in Ethiopia: further analysis of Ethiopian demography and health survey, 2019

Background

Community-Based Health Insurance is an emerging concept for providing financial protection against the cost of illness and improving access to quality health services for low-income households excluded from formal insurance and taken as a soft option by many countries. Therefore, exploring the spatial distribution of health insurance is crucial to prioritizing and designing targeted intervention policies in the country.

Methods

A total of 8,663 households aged 15–95 years old were included in this study. The Bernoulli model was used by applying Kulldorff methods using the SaTScan software to analyze the purely spatial clusters of community based health insurance. ArcGIS version 10.3 was used to visualize the distribution of community-based health insurance coverage across the country. Mixed-effect logistic regression analysis was also used to identify predictors of community-based health insurance coverage.

Results

Community based health insurance coverage among households had spatial variations across the country by regions (Moran’s I: 0.252, p < 0.0001). Community based health insurance in Amhara (p < 0.0001) and Tigray (p < 0.0001) regions clustered spatially. Age from 15–29 and 30–39 years (Adjusted Odds Ratio 0.46(AOR = 0.46, CI: 0.36,0.60) and 0.77(AOR = 0.77, CI: 0.63,0.96), primary education level 1.57(AOR = 1.57, CI: 1.15,2.15), wealth index of middle and richer (1.71(AOR = 1.71, CI: 1.30,2.24) and 1.79(AOR = 1.79, CI: 1.34,2.41), family size > 5, 0.82(AOR = 0.82, CI: 0.69,0.96),respectively and regions Afar, Oromia, Somali, Benishangul Gumuz, SNNPR, Gambella, Harari, Addis Ababa and Dire Dawa was 0.002(AOR = 0.002, CI: 0.006,0.04), 0.11(AOR = 0.11, CI: 0.06,0.21) 0.02(AOR = 0.02, CI: 0.007,0.04), 0.04(AOR = 0.04, CI: 0.02,0.08), 0.09(AOR = 0.09, CI: 0.05,0.18),0.004(AOR = 0.004,CI:0.02,0.08),0.06(AOR = 0.06,CI:0.03,0.14), 0.07(AOR = 0.07, CI: 0.03,0.16) and 0.03(AOR = 0.03, CI: 0.02,0.07) times less likely utilize community based health insurance than the Amhara region respectively in Ethiopia.

Conclusion

Community based health insurance coverage among households in Ethiopia was found very low still. The government needs to develop consistent financial and technical support and create awareness for regions with lower health insurance coverage.