How does membership in local savings groups influence the determinants of national health insurance demand? A cross-sectional study in Kisumu, Kenya

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.

Can Informal Savings Groups Promote Food Security and Social, Economic and Health Transformations, Especially among Women in Urban Sub-Saharan Africa: A Narrative Systematic Review

This narrative review aimed to identify if roles of common informal savings groups known as Accumulating Savings and Credit Associations (ASCAs) or Rotating Savings and Credit Associations (ROSCAs) can play a significant role in mitigating food insecurity, socioeconomic inequality, promoting health, and/or increasing agency in women in urban sub-Saharan Africa (SSA). These organizations exist in most low- and middle-income countries (LMICs) worldwide under various names. A comprehensive search of scholarly outputs across six electronic databases (Pub-Med, Google Scholar, EBSCOhost, Scopus, Sabinet, and Cochrane) from 2000 to 2021 was completed. Twenty-eight (28) records met our inclusion criteria, and their quality was appraised using the Critical Appraisal Skills Programme (CASP) qualitative checklist. We identified through thematic analysis that ROSCAs/ASCAs play a crucial role in advancing social, economic, and health transformations, especially among women in urban SSA. However, while ROSCAs/ACSAs played important roles in food security, it was often not the primary motivation for participation. None of the selected studies identified the importance of dietary quality or access to healthy food in relation to food security. This review suggests a window of opportunity to promote partnerships and collaborations of ROSCAs/ASCAs with relevant stakeholders to leverage the functionalities of ROSCAs/ASCAs as vehicles for re-alignment of priorities, increased knowledge, and opportunities to encourage affordable healthy diets in urban SSA.

Equity in health insurance schemes enrollment in low and middle-income countries: A systematic review and meta-analysis

Background

Ensuring access to essential quality health services and reducing financial hardship for all individuals regardless of their ability to pay are the main goals of universal health coverage. Various health insurance schemes have been recently implemented in low- and middle-income countries (LMICs) to achieve both of these objectives. We systematically reviewed all available literature to assess the extent to which current health insurance schemes truly reach the poor and underserved populations in LMICs.

Methods

In the systematic review, we searched on PubMed, Web of Science, EconLit and Google Scholar to identify eligible studies which captured health insurance enrollment information in LMICs from 2010 up to September 2019. Two authors independently selected studies, extracted data, and appraised included studies. The primary outcome of interest was health insurance enrollment of the most vulnerable populations relative to enrollment of the best-off subgroups. We classified households both with respect to their highest educational attainment and their relative wealth and used random-effects meta-analysis to estimate average enrollment gaps.

Results

48 studies from 17 countries met the inclusion criteria. The average enrollment rate into health insurance schemes for vulnerable populations was 36% with an inter-quartile range of 26%. On average, across countries, households from the wealthiest subgroup had 61% higher odds (95% CI: 1.49 to 1.73) of insurance enrollment than households in the poorest group in the same country. Similarly, the most educated groups had 64% (95% CI: 1.32 to 1.95) higher odds of enrollment than the least educated groups.

Conclusion

The results of this study show that despite major efforts by governments, health insurance schemes in low-and middle-income countries are generally not reaching the targeted underserved populations and predominantly supporting better-off population groups. Current health insurance designs should be carefully scrutinized, and the extent to which health insurance can be used to support the most vulnerable populations carefully re-assessed by countries, which are aiming to use health insurance schemes as means to reach their UHC goals. Furthermore, studies exploring best practices to include vulnerable groups in health insurance schemes are needed.

Registration

Not available

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-021-01608-x.

A Comparative Cross-Sectional Study of the Prevalence and Determinants of Health Insurance Coverage in Nigeria and South Africa: A Multi-Country Analysis of Demographic Health Surveys

Background: The core Universal Health Coverage (UHC) objectives are to ensure universal access to healthcare services by reducing all forms of inequalities. However, financial constraints are major barriers to accessing healthcare, especially in countries such as Nigeria and South Africa. The findings of this study may aid in informing and communicating health policy to increase financial access to healthcare and its utilization in South Africa and Nigeria. Nigeria-South Africa bilateral relations in terms of politics, economics and trade are demonstrated in the justification of the study setting selection. The objectives were to estimate the prevalence of health insurance coverage, and to explore the socio-demographic factors associated with health insurance in South Africa and Nigeria. Methods: This was a cross-sectional study using the 2018 Nigeria Demographic Health Survey and the 2016 South Africa Demographic Health Survey. The 2018 Nigeria Demographic Health Survey data on 55,132 individuals and the 2016 South Africa Demographic Health Survey on 12,142 individuals were used to investigate the prevalence of health insurance associated with socio-demographic factors. Percentages, frequencies, Chi-square and multivariate logistic regression were e mployed, with a significance level of p < 0.05. Results: About 2.8% of the Nigerian population and 13.3% of the South African population were insured (Nigeria: males-3.4%, females-2.7% vs. South Africa: males-13.9%, females-12.8%). The multivariate logistic regression analyses showed that higher education was significantly more likely to be associated with health insurance, independent of other socio-demographic factors in Nigeria (Model I: OR: 1.43; 95% CI: 0.34-1.54, p < 0.05; Model II: OR: 1.34; 95% CI: 0.28-1.42, p < 0.05) and in South Africa (Model I: OR: 1.33; 95% CI: 0.16-1.66, p < 0.05; Model II: OR: 1.76; 95% CI: 0.34-1.82, p < 0.05). Respondents with a higher wealth index and who were employed were independently associated with health insurance uptake in Nigeria and South Africa (p < 0.001). Females were more likely to be insured (p < 0.001) than males in both countries, and education had a significant impact on the likelihood of health insurance uptake in high wealth index households among both male and females in Nigeria and South Africa. Conclusion: Health insurance coverage was low in both countries and independently associated with socio-demographic factors such as education, wealth and employment. There is a need for continuous sensitization, educational health interventions and employment opportunities for citizens of both countries to participate in the uptake of wide health insurance coverage.

Social protection response to the COVID-19 crisis: options for developing countries

The public health response to COVID-19 in many countries has involved strict restrictions on movement and economic activity which threaten the livelihoods of economically vulnerable households. In response, governments are adopting emergency economic measures to provide households with some safety net. We provide an overview of the policies that could form a comprehensive social protection strategy in low-income and middle-income countries, with examples of specific policies that have been adopted. Our core argument is that these countries can cast an emergency safety net with extensive coverage if they use a broader patchwork of solutions than higher-income countries. These strategies could include expanding their social insurance system, building on existing social assistance programmes, and involving local governments and non-state institutions to identify and assist vulnerable groups who are otherwise harder to reach.

Risk reduction of diarrhea and respiratory infections following a community health education program - a facility-based case-control study in rural parts of Kenya

Background

Diarrheal and acute respiratory infections remain a major cause of death in developing countries especially among children below 5 years of age. About 80% of all hospital attendances in Kenya can be attributed to preventable diseases and at least 50% of these preventable diseases are linked to poor sanitation. The purpose of this study was to assess the impact of a community-based health education program, called Familia Nawiri, in reducing the risk of diarrhea and respiratory infections among people living in three rural Kenyan communities.

Methods

Cases were defined as patients attending the health facility due to diarrhea or a respiratory infection while controls were patients attending the same health facility for a non-communicable disease defined as an event other than diarrhea, respiratory infection. Adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using a logistic regression model to assess the risk of diarrheal or respiratory infection in association with exposure to the health education program.

Results

There were 324 cases and 308 controls recruited for the study with 57% of the cases and 59% of the controls being male. Overall, 13% of cases vs. 20% of control patients were exposed to the education program. Participants exposed to the program had 38% lower odds of diarrhea and respiratory infections compared to those not exposed to the program (adjusted OR 0.62, 95% CI 0.41–0.96). A similar risk reduction was observed for participants in the study who resided in areas with water improvement initiatives (adjusted OR 0.65, 95% CI 0.47–0.90). Variables in the adjusted model included water improvement projects in the area and toilet facilities.

Conclusion

Findings from this study suggest participants exposed to the education program and those residing in areas with water improvement initiatives have a reduced risk of having diarrhea or respiratory infection.

Policy levers and priority-setting in universal health coverage: a qualitative analysis of healthcare financing agenda setting in Kenya

BACKGROUND

Competing priorities in health systems necessitate difficult choices on which health actions and investments to fund: decisions that are complex, value-based, and highly political. In light of the centrality of universal health coverage (UHC) in driving current health policy, we sought to examine the value interests that influence agenda setting in the country's health financing space. Given the plurality of Kenya's health policy levers, we aimed to examine how the perspectives of stakeholders involved in policy decision-making and implementation shape discussions on health financing within the UHC framework.

METHODS

A series of in-depth key informant interviews were conducted at national and county level (n = 13) between April and May 2018. Final thematic analysis using the Framework Method was conducted to identify similarities and differences amongst stakeholders on the challenges hindering Kenya's achievement of UHC in terms of its the optimisation of health service coverage; expansion of the population that benefits from essential healthcare services; and the minimisation of out-of-pocket costs associated with health-seeking behaviour.

RESULTS

Our findings indicate that the perceived lack of strategic leadership from Kenya's national government has led to a lack of agreement on stakeholders' interpretation of what is to be understood by UHC, its contextual values and priorities. We observe material differences between and within policy networks on the country's priorities for population coverage, healthcare service provision, and cost-sharing under the UHC dispensation. In spite of this, we note that progressive universalism is considered as the preferred approach towards UHC in Kenya, with most interviewees prioritising an equity-based approach that prioritises better access to healthcare services and financial risk protection. However, the conflicting priorities of key stakeholders risk derailing progress towards the expansion of access to health services and financial risk protection.

CONCLUSIONS

This study adds to existing knowledge of UHC in Kenya by contextualising the competing and evolving priorities that should be taken into consideration as the country strategises over its UHC process. We suggest that clear policy action is required from national government and county governments in order to develop a logical and consistent approach towards UHC in Kenya.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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