Community health insurance amidst abolition of user fees in Uganda: the view from policy makers and health service managers

Experiences of membership in munno mubulwadde (your friend indeed) - a novel community-based health insurance scheme in Luwero district in rural central Uganda

BACKGROUND

Community-Based Health Insurance (CBHI) schemes are recognized as an important health financing pathway to achieving universal health coverage (UHC). Although previous studies have documented CBHIs in low-income countries, the majority of these have been provider-based. Non-provider based schemes have received comparatively less empirical attention. We sought to describe a novel non-provider based CBHI munno mubulwadde (your friend indeed) comprising informal sector members in rural central Uganda to understand the structure of the scheme, the experiences of scheme members in terms of the perceived benefits and barriers to retention in the scheme.

METHODS

We report qualitative findings from a larger mixed-methods study. We conducted in-depth interviews with insured members (n = 18) and scheme administrators (n = 12). Four focus groups were conducted with insured members (38 participants). Data were inductively analyzed by thematic approach.

RESULTS

Munno mubulwadde is a union of ten CBHI schemes coordinated by one administrative structure. Members were predominantly low-income rural informal sector households who pay annual premiums ranging from $17 and $50 annually and received medical care at 13 scheme-contracted private health facilities in Luwero District in Central Uganda. Insured members reported that scheme membership protected them from catastrophic health expenditure during episodes of sickness among household members, and especially so among households with children under-five who were reported to fall sick frequently, the scheme enabled members to receive perceived better quality health care at private providers in the study district relative to the nearest public facilities. The identified barriers to retention in the scheme include inconvenient dates for premium payment that are misaligned with harvest periods for cash crops (e.g. maize corn) on which members depended for their agrarian livelihoods, long distances to insurance-contracted private providers, falling prices of cash crops which diminished real incomes and affordability of insurance premiums in successive years after initial enrolment.

CONCLUSION

Munno mubulwadde was perceived by as a valuable financial cushion during episodes of illness by rural informal sector households. Policy interventions for promoting price stability of cash crops in central Uganda could enhance retention of members in this non-provider CBHI which is worthy of further research as an additional funding pathway for realizing UHC in Uganda and other low-income settings.

A critical review of literature on health financing reforms in Uganda - progress, challenges and opportunities for achieving UHC

Background

Universal health coverage (UHC) is one of the sustainable development goals (SDG) targets. Progress towards UHC necessitates health financing reforms in many countries. Uganda has had reforms in its health financing, however, there has been no examination of how the reforms align with the principles of financing for UHC.

Objective

This review examines how health financing reforms in Uganda align with UHC principles and contribute to ongoing discussions on financing UHC.

Methods

We conducted a critical review of literature and utilized thematic framework for analysis. Results are presented narratively. The analysis focused on health financing during four health sector strategic plan (HSSP) periods.

Results

In HSSP I, the focus of health financing was on equity, while in HSSP II the focus was on mobilizing more funding. In HSSP III & IV the focus was on financial risk protection and UHC. The changes in focus in health financing objectives have been informed by low per capita expenditures, global level discussions on SDGs and UHC, and the ongoing health financing reform discussions. User fees was abolished in 2001, sector-wide approach was implemented during HSSP I&II, and pilots with results-based financing have occurred. These financing initiatives have not led to significant improvements in financial risk protection as indicated by the high out-of-pocket payments.

Conclusion

Health financing policy intentions were aligned with WHO guidance on reforms towards UHC, however actual outputs and outcomes in terms of improvement in health financing functions and financial risk protections remain far from the intentions.

Delays in emergency department intervention for patients with traumatic brain injury in Uganda

Background

In Sub-Saharan African countries, the incidence of traumatic brain injury (TBI) is estimated to be many folds higher than the global average and outcome is hugely impacted by access to healthcare services and quality of care. We conducted an analysis of the TBI registry data to determine the disparities and delays in treatment for patients presenting at a tertiary care hospital in Uganda and to identify factors predictive of delayed treatment initiation.

Methods

The study was conducted at the Mulago National Referral Hospital, Kampala. The study included all patients presenting to the emergency department (ED) with suspected or documented TBI. Early treatment was defined as first intervention within 4 hours of ED presentation-a cut-off determined using sensitivity analysis to injury severity. Descriptive statistics were generated and Pearson's χ² test was used to assess the sample distribution between treatment time categories. Univariable and multivariable logistic regression models with <0.05 level of significance were used to derive the associations between patient characteristics and early intervention for TBI.

Results

Of 3944 patients, only 4.6% (n=182) received an intervention for TBI management within 1 hour of ED presentation, whereas 17.4% of patients (n=708) received some treatment within 4 hours of presentation. 19% of those with one or more serious injuries and 18% of those with moderate to severe head injury received care within 4 hours of arrival. Factors independently associated with early treatment included young age, severe head injury, and no known pre-existing conditions, whereas older or female patients had significantly less odds of receiving early treatment.

Discussion

With the increasing number of patients with TBI, ensuring early and appropriate management must be a priority for Ugandan hospitals. Delay in initiation of treatment may impact survival and functional outcome. Gender-related and age-related disparities in care should receive attention and targeted interventions.

Level of evidence

Prognostic and epidemiological study; level II evidence.

NATIONAL HEALTH INSURANCE SCHEME: PERCEPTION AND PARTICIPATION OF FEDERAL CIVIL SERVANTS IN IBADAN

Introduction

The National Health Insurance Scheme is a social health insurance programme designed by the Federal Government of Nigeria to complement sources of financing the health sector and to improve access to health care for the majority of Nigerians. Presently, the enrolment level on the Scheme is majorly among those in the formal sector and user experiences have been different. This study seeks to determine the perception and participation of Civil Servants regarding the National Health Insurance Scheme in Ibadan.

Methods

A descriptive cross-sectional study was conducted among 273 civil servants working at the Federal Secretariat, Ikolaba, between October and November 2015. An interviewer-administered questionnaire was used to collect information on socio-demographic characteristics, awareness, and membership of the NHIS, perception of NHIS, and health-seeking behaviour. Participation was defined as the number of civil servants registered or enrolled under the scheme, in other words, members of the scheme. Information on perceptions was sought using a 3-point Likert scale. Descriptive statistics and chi-square tests were used for data analysis at a 5% level of significance.

Results

About 60.1% of the respondents were males. The average age was 39.7±9.1 years, with 85.0% of the respondents being married. The majority (65.2%) of the respondents were mid-level cadre workers, 17.62% were working as senior-level workers and the remaining 17.6% were low cadre workers. The majority (88.9%) completed tertiary education, while just 11.1% completed basic education. The mean household size was 2.5±0.6. Awareness of the National Health Insurance Scheme was very high (95.2%) with 83.5% enrolled under the scheme. About (50%) of the respondents joined the scheme because it is cheap and affordable. There was a significant association between awareness, level of education, knowledge of NHIS, and registration into the scheme by respondents. The majority of the respondents (87.3%) claimed that NHIS is a better means of settling healthcare costs than Out-of-pocket-payment. The majority of the respondents thought that health insurance is a viable programme.

Conclusion

The perception of health insurance among civil servants was varied while participation was high. Relevant intervention should be introduced to remove bottlenecks to accessing and operating the scheme.

Do household perceptions influence enrolment decisions into community-based health insurance schemes in Tanzania?

BACKGROUND

Several countries including Tanzania, have established voluntary non-profit insurance schemes, commonly known as community-based health insurance schemes (CBHIs), that typically target rural populations and the informal sector. This paper considers the importance of household perceptions towards CBHIs in Tanzania and their role in explaining the enrolment decision of households.

METHODS

This was a cross-sectional household survey that involved 722 households located in Bahi and Chamwino districts in the Dodoma region. A three-stage sampling procedure was used, and the data were analyzed using both factor analysis (FA) and principal component analysis (PCA). Statistical tests such as Bartlett's test of sphericity, Kaiser-Meyer-Olkin (KMO) for sampling adequacy, and Cronbach's alpha test for internal consistency and scale reliability were performed to examine the suitability of the data for PCA and FA. Finally, multivariate logistic regressions were run to determine the associations between the identified factors and the insurance enrolment status.

RESULTS

The PCA identified seven perception factors while FA identified four factors. The quality of healthcare services, preferences (social beliefs), and accessibility to insurance scheme administration (convenience) were the most important factors identified by the two methods. Multivariate logistic regressions showed that the factors identified from the two methods differed somewhat in importance when considered as independent predictors of the enrollment status. The most important perception factors in terms of strength of association (odds ratio) and statistical significance were accessibility to insurance scheme administration (convenience), preferences (beliefs), and the quality of health care services. However, age and income were the only socio-demographic characteristics that were statistically significant.

CONCLUSION

Household perceptions were found to influence households' decisions to enroll in CBHIs. Policymakers should recognize and consider these perceptions when designing policies and programs that aim to increase the enrolment into CBHIs.

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.

Willingness to pay for Community Health Insurance among taxi drivers in Kampala City, Uganda: a contingent evaluation

BACKGROUND

Community Health Insurance (CHI) schemes have improved the utilization of health services by reducing out-of-pocket payments (OOP). This study assessed income quintiles for taxi drivers and the minimum amount of premium a driver would be willing to pay for a CHI scheme in Kampala City, Uganda.

METHODS

A cross-sectional study design using contingent evaluation was employed to gather primary data on willingness to pay (WTP). The respondents were 312 randomly and 9 purposively selected key informants. Qualitative data were analyzed using conceptual content analysis while quantitative data were analyzed using MS Excel 2016 to generate the relationship of socio-demographic variables and WTP.

RESULTS

Close to a half (47.9%) of the respondents earn above UGX 500,000 per month (fifth quintile), followed by 24.5% earning a monthly average of UGX 300,001-500,000 and the rest (27.5%) earn less. Households in the fourth and fifth quintiles (38.4% and 20%, respectively) are more willing to join and pay for CHI. A majority of the respondents (29.9%) are willing to pay UGX, 6,001-10,000 while 22.3% are willing to pay between UGX 11,001 and UGX 20,000 and 23.2% reported willing to pay between UGX 20,001 and UGX 50,000 per person per month. Only 18.8% of the respondents recorded WTP at least UGX 5,000 and 5.8% reported being able to pay above UGX 50,000 per month (1 USD=UGX 3,500). Reasons expressed for WTP included perceived benefits such as development of health care infrastructure, risk protection, and reduced household expenditures. Reasons for not willing to pay included corruption, mistrust, inadequate information about the scheme, and low involvement of the members.

CONCLUSION

There is a possibility of embracing the scheme by the taxi drivers and the rest of the informal sector of Uganda if the health sector creates adequate awareness.

Universal Health Coverage in Marginalized Populations: A Qualitative Evaluation of a Health Reform Implementation in Rural Ecuador

In 2008, Ecuador underwent a major health reform with the aim of universal coverage. Little is known about the implementation of the reform and its perceived effects in rural parts of the country. The aim of this study was to explore the perceived effects of the 2008 health reform implementation, on rural primary health care services and financial access of the rural poor. A qualitative study using focus group discussions was conducted in a rural region in Ecuador, involving health staff, local health committee members, village leaders, and community health workers. Qualitative content analysis focusing on the manifest content was applied. Three categories emerged from the texts: (1) the prereform situation, which was described as difficult in terms of financial access and quality of care; (2) the reform process, which was perceived as top-down and lacking in communication by the involved actors; lack of interest among the population was reported; (3) the effects of the reform, which were mainly perceived as positive. However, testimonies about understaffing, drug shortages, and access problems for those living furthest away from the health units show that the reform has not fully achieved its intended effects. New problems are a challenging health information system and people without genuine care needs overusing the health services. The results indicate that the Ecuadorean reform has improved rural primary health care services. Still, the reform faces challenges that need continued attention to secure its current achievements and advance the health system further.

Barriers and facilitators to implementation, uptake and sustainability of community-based health insurance schemes in low- and middle-income countries: a systematic review

BACKGROUND

Community-based health insurance (CBHI) has evolved as an alternative health financing mechanism to out of pocket payments in low- and middle-income countries (LMICs), particularly in areas where government or employer-based health insurance is minimal. This systematic review aimed to assess the barriers and facilitators to implementation, uptake and sustainability of CHBI schemes in LMICs.

METHODS

We searched six electronic databases and grey literature. We included both quantitative and qualitative studies written in English language and published after year 1992. Two reviewers worked in duplicate and independently to complete study selection, data abstraction, and assessment of methodological features. We synthesized the findings based on thematic analysis and categorized according to the ecological model into individual, interpersonal, community and systems levels.

RESULTS

Of 15,510 citations, 51 met the eligibility criteria. Individual factors included awareness and understanding of the concept of CBHI, trust in scheme and scheme managers, perceived service quality, and demographic characteristics, which influenced enrollment and sustainability. Interpersonal factors such as household dynamics, other family members enrolled in the scheme, and social solidarity influenced enrollment and renewal of membership. Community-level factors such as culture and community involvement in scheme development influenced enrollment and sustainability of scheme. Systems-level factors encompassed governance, financial and delivery arrangement. Government involvement, accountability of scheme management, and strong policymaker-implementer relation facilitated implementation and sustainability of scheme. Packages that covered outpatient and inpatient care and those tailored to community needs contributed to increased enrollment. Amount and timing of premium collection was reported to negatively influence enrollment while factors reported as threats to sustainability included facility bankruptcy, operating on small budgets, rising healthcare costs, small risk pool, irregular contributions, and overutilization of services. At the delivery level, accessibility of facilities, facility environment, and health personnel influenced enrollment, service utilization and dropout rates.

CONCLUSION

There are a multitude of interrelated factors at the individual, interpersonal, community and systems levels that drive the implementation, uptake and sustainability of CBHI schemes. We discuss the implications of the findings at the policy and research level.

TRIAL REGISTRATION

The review protocol is registered in PROSPERO International prospective register of systematic reviews (ID =  CRD42015019812 ).

What Factors Affect Voluntary Uptake of Community-Based Health Insurance Schemes in Low- and Middle-Income Countries? A Systematic Review and Meta-Analysis

INTRODUCTION

This research article reports on factors influencing initial voluntary uptake of community-based health insurance (CBHI) schemes in low- and middle-income countries (LMIC), and renewal decisions.

METHODS

Following PRISMA protocol, we conducted a comprehensive search of academic and gray literature, including academic databases in social science, economics and medical sciences (e.g., Econlit, Global health, Medline, Proquest) and other electronic resources (e.g., Eldis and Google scholar). Search strategies were developed using the thesaurus or index terms (e.g., MeSH) specific to the databases, combined with free text terms related to CBHI or health insurance. Searches were conducted from May 2013 to November 2013 in English, French, German, and Spanish. From the initial search yield of 15,770 hits, 54 relevant studies were retained for analysis of factors influencing enrolment and renewal decisions. The quantitative synthesis (informed by meta-analysis) and the qualitative analysis (informed by thematic synthesis) were compared to gain insight for an overall synthesis of findings/statements.

RESULTS

Meta-analysis suggests that enrolments in CBHI were positively associated with household income, education and age of the household head (HHH), household size, female-headed household, married HHH and chronic illness episodes in the household. The thematic synthesis suggests the following factors as enablers for enrolment: (a) knowledge and understanding of insurance and CBHI, (b) quality of healthcare, (c) trust in scheme management. Factors found to be barriers to enrolment include: (a) inappropriate benefits package, (b) cultural beliefs, (c) affordability, (d) distance to healthcare facility, (e) lack of adequate legal and policy frameworks to support CBHI, and (f) stringent rules of some CBHI schemes. HHH education, household size and trust in the scheme management were positively associated with member renewal decisions. Other motivators were: (a) knowledge and understanding of insurance and CBHI, (b) healthcare quality, (c) trust in scheme management, and (d) receipt of an insurance payout the previous year. The barriers to renewal decisions were: (a) stringent rules of some CBHI schemes, (b) inadequate legal and policy frameworks to support CBHI and (c) inappropriate benefits package.

CONCLUSION AND POLICY IMPLICATIONS

The demand-side factors positively affecting enrolment in CBHI include education, age, female household heads, and the socioeconomic status of households. Moreover, when individuals understand how their CBHI functions they are more likely to enroll and when people have a positive claims experience, they are more likely to renew. A higher prevalence of chronic conditions or the perception that healthcare is of good quality and nearby act as factors enhancing enrolment. The perception that services are distant or deficient leads to lower enrolments. The second insight is that trust in the scheme enables enrolment. Thirdly, clarity about the legal or policy framework acts as a factor influencing enrolments. This is significant, as it points to hitherto unpublished evidence that governments can effectively broaden their outreach to grassroots groups that are excluded from social protection by formulating supportive regulatory and policy provisions even if they cannot fund such schemes in full, by leveraging people's willingness to exercise voluntary and contributory enrolment in a community-based health insurance.

The future of financing for HIV services in Uganda and the wider sub-Saharan Africa region: should we ask patients to contribute to the cost of their care?

Whilst multi-lateral funding for HIV/AIDS dramatically increased from 2004 to 2008, it has largely plateaued in the last 8 years. Across sub-Saharan Africa, up to 20 % of total spending on health is used for HIV services, and of this over 85 % is estimated to come from international funding rather than in-country sources. In Uganda, the fiscal liability to maintain services for all those who are currently receiving it is estimated to be as much as 3 % of Gross Domestic Product (GDP). In order to meet the growing need of increased patient numbers and further ART coverage the projected costs of comprehensive HIV care and treatment services will increase substantially. Current access to HIV care includes free at point of delivery (provided by Ministry of Health clinics), as well as out-of-pocket financing and health insurance provided care at private for- and not for- profit facilities. The HIV response is funded through Ugandan Ministry of Health national budget allocations, as well as multilateral donations such as the President's Emergency Plan for AIDS in Africa (PEPFAR) and Global Fund (GF) and other international funders. We are concerned that current funding mechanism for HIV programs in Uganda may be difficult to sustain and as service providers we are keen to explore ways in which provide lifelong HIV care to as many people living with HIV (PLHIV) as possible. Until such time as the Ugandan economy can support universal, state-supported, comprehensive healthcare, bridging alternatives must be considered. We suggest that offering patients with the sufficient means to assume some of the financial burden for their care in return for more convenient services could be one component of increasing coverage and sustaining services for those living with HIV.

Determinants of community health fund membership in Tanzania: a mixed methods analysis

Background

In many developing countries, initiatives are underway to strengthen voluntary community based health insurance as a means of expanding access to affordable care among the informal sector. However, increasing coverage with voluntary health insurance in low income settings can prove challenging. There are limited studies on determinants of enrolling in these schemes using mixed methods. This study aims to shed light on the characteristics of those joining a community health fund, a type of community based health insurance, in Tanzania and the reasons for their membership and subsequent drop out using mixed methods.

Methods

A cross sectional survey of households in four rural districts was conducted in 2008, covering a total of 1,225 (524 members of CHF and 701 non-insured) households and 7,959 individuals. In addition, 12 focus group discussions were carried out with CHF members, non-scheme members and members of health facility governing committees in two rural districts. Logistic regression was used to assess the determinants of CHF membership while thematic analysis was done to analyse qualitative data.

Results

The quantitative analysis revealed that the three middle income quintiles were more likely to enrol in the CHF than the poorest and the richest. CHF member households were more likely to be large, and headed by a male than uninsured households from the same areas. The qualitative data supported the finding that the poor rather than the poorest were more likely to join as were large families and of greater risk of illness, with disabilities or persons with chronic diseases. Households with elderly members or children under-five years were also more likely to enrol. Poor understanding of risk pooling deterred people from joining the scheme and was the main reason for not renewing membership. On the supply side, poor quality of public care services, the limited benefit package and a lack of provider choice were the main factors for low enrolment.

Conclusions

Determinants of CHF membership are diverse and improving the quality of health services and expanding the benefit package should be prioritised to expand voluntary health insurance coverage.

Community-based health insurance programmes and the National Health Insurance Scheme of Nigeria: challenges to uptake and integration

BACKGROUND

Nigeria has included a regulated community-based health insurance (CBHI) model within its National Health Insurance Scheme (NHIS). Uptake to date has been disappointing, however. The aim of this study is to review the present status of CBHI in SSA in general to highlight the issues that affect its successful integration within the NHIS of Nigeria and more widely in developing countries.

METHODS

A literature survey using PubMed and EconLit was carried out to identify and review studies that report factors affecting implementation of CBHI in SSA with a focus on Nigeria.

RESULTS

CBHI schemes with a variety of designs have been introduced across SSA but with generally disappointing results so far. Two exceptions are Ghana and Rwanda, both of which have introduced schemes with effective government control and support coupled with intensive implementation programmes. Poor support for CBHI is repeatedly linked elsewhere with failure to engage and account for the 'real world' needs of beneficiaries, lack of clear legislative and regulatory frameworks, inadequate financial support, and unrealistic enrolment requirements. Nigeria's CBHI-type schemes for the informal sectors of its NHIS have been set up under an appropriate legislative framework, but work is needed to eliminate regressive financing, to involve scheme members in the setting up and management of programmes, to inform and educate more effectively, to eliminate lack of confidence in the schemes, and to address inequity in provision. Targeted subsidies should also be considered.

CONCLUSIONS

Disappointing uptake of CBHI-type NHIS elements in Nigeria can be addressed through closer integration of informal and formal programmes under the NHIS umbrella, with increasing involvement of beneficiaries in scheme design and management, improved communication and education, and targeted financial assistance.

Players and processes behind the national health insurance scheme: a case study of Uganda

Background

Uganda is the last East African country to adopt a National Health Insurance Scheme (NHIS). To lessen the inequitable burden of healthcare spending, health financing reform has focused on the establishment of national health insurance. The objective of this research is to depict how stakeholders and their power and interests have shaped the process of agenda setting and policy formulation for Uganda’s proposed NHIS. The study provides a contextual analysis of the development of NHIS policy within the context of national policies and processes.

Methods

The methodology is a single case study of agenda setting and policy formulation related to the proposed NHIS in Uganda. It involves an analysis of the real-life context, the content of proposals, the process, and a retrospective stakeholder analysis in terms of policy development. Data collection comprised a literature review of published documents, technical reports, policy briefs, and memos obtained from Uganda’s Ministry of Health and other unpublished sources. Formal discussions were held with ministry staff involved in the design of the scheme and some members of the task force to obtain clarification, verify events, and gain additional information.

Results

The process of developing the NHIS has been an incremental one, characterised by small-scale, gradual changes and repeated adjustments through various stakeholder engagements during the three phases of development: from 1995 to 1999; 2000 to 2005; and 2006 to 2011. Despite political will in the government, progress with the NHIS has been slow, and it has yet to be implemented. Stakeholders, notably the private sector, played an important role in influencing the pace of the development process and the currently proposed design of the scheme.

Conclusions

This study underscores the importance of stakeholder analysis in major health reforms. Early use of stakeholder analysis combined with an ongoing review and revision of NHIS policy proposals during stakeholder discussions would be an effective strategy for avoiding potential pitfalls and obstacles in policy implementation. Given the private sector’s influence on negotiations over health insurance design in Uganda, this paper also reviews the experience of two countries with similar stakeholder dynamics.

Mapping of initiatives to increase membership in mutual health organizations in Benin

INTRODUCTION

Mutual health organizations (MHO) have been implemented across Africa to increase access to healthcare and improve financial protection. Despite efforts to develop MHOs, low levels of both initial enrolment and membership renewals continue to threaten their financial viability. The purpose of this study was to map initiatives implemented to increase the pool of MHO members in Benin.

METHODS

A multiple case study was conducted to assess MHOs supported by five major promoters in Benin. Three months of fieldwork resulted in 23 semi-structured interviews and two focus groups with MHO promoters, technicians, elected members, and health professionals affiliated with the MHOs. Fifteen non-structured interviews provided additional information and a valuable source of triangulation.

RESULTS

MHOs have adopted a wide range of initiatives targeting different entry points and involving a variety of stakeholders. Initiatives have included new types of collective health insurance packages and efforts to raise awareness by going door-to-door and organizing health education workshops. Different types of partnerships have been established to strengthen relationships with healthcare professionals and political leaders. However, the selection and implementation of these initiatives have been limited by insufficient financial and human resources.

CONCLUSIONS

The study highlights the importance of prioritizing sustainable strategies to increase MHO membership. No single MHO initiative has been able to resolve the issue of low membership on its own. If combined, existing initiatives could provide a comprehensive and inclusive approach that would target all entry points and include key stakeholders such as household decision-makers, MHO elected members, healthcare professionals, community leaders, governmental authorities, medical advisors, and promoters. There is a need to evaluate empirically the implementation of these interventions. Mechanisms to promote dialogue between MHO stakeholders would be useful to devise innovative strategies, avoid repeating unsuccessful ones, and develop a coordinated plan to promote MHOs.