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

Document Type: Original Article

Authors

1 Institute for Food and Resource Economics (ILR), University of Bonn, Bonn, Germany

2 Department of Economics and Technological Change, Center for Development Research (ZEF), University of Bonn, Bonn, Germany

3 Department of Environmental and Public Health, Kabale University, Kabale, Uganda

Abstract

Background: The desire for universal health coverage in developing countries has brought attention to community-based 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 south-western 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.

Highlights

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  1. World Health Organization (WHO). Health systems financing: the path to universal coverage. Geneva: WHO; 2010.
  2. Xu K, Evans DB, Carrin G, Aguilar-Rivera AM, Musgrove P, Evans T. Protecting households from catastrophic health spending. Health Aff (Millwood). 2007;26(4):972-983. doi:10.1377/hlthaff.26.4.972
  3. Kruk ME, Goldmann E, Galea S. Borrowing and selling to pay for health care in low- and middle-income countries. Health Aff (Millwood). 2009;28(4):1056-1066. doi:10.1377/hlthaff.28.4.1056
  4. World Health Organization (WHO). Fifty-eighth World Health Assembly. Geneva: WHO; 2005:16-25.
  5. Ekman B. Community-based health insurance in low-income countries: a systematic review of the evidence. Health Policy Plan. 2004;19(5):249-270. doi:10.1093/heapol/czh031
  6. Bennett S. The role of community-based health insurance within the health care financing system: a framework for analysis. Health Policy Plan. 2004;19(3):147-158. doi:10.1093/heapol/czh018
  7. Dror DM, Hossain SA, Majumdar A, Perez Koehlmoos TL, John D, Panda PK. What factors affect voluntary uptake of community-based health insurance schemes in low-and middle-income countries? A systematic review and meta-analysis. PLoS One. 2016;11(8):e0160479. doi:10.1371/journal.pone.0160479
  8. Adebayo EF, Uthman OA, Wiysonge CS, Stern EA, Lamont KT, Ataguba JE. A systematic review of factors that affect uptake of community-based health insurance in low-income and middle-income countries. BMC Health Serv Res. 2015;15:543. doi:10.1186/s12913-015-1179-3
  9. Nosratnejad S, Rashidian A, Dror DM. Systematic review of willingness to pay for health insurance in low and middle income countries. PLoS One. 2016;11(6):e0157470. doi:10.1371/journal.pone.0157470
  10. Panda P, Chakraborty A, Raza W, Bedi AS. Renewing membership in three community-based health insurance schemes in rural India. Health Policy Plan. 2016;31(10):1433-1444. doi:10.1093/heapol/czw090
  11. Basaza R, Criel B, Van der Stuyft P. Low enrollment in Ugandan Community Health Insurance schemes: underlying causes and policy implications. BMC Health Serv Res. 2007;7:105. doi:10.1186/1472-6963-7-105
  12. Basaza R, Criel B, Van der Stuyft P. Community health insurance in Uganda: why does enrolment remain low? A view from beneath. Health Policy. 2008;87(2):172-184. doi:10.1016/j.healthpol.2007.12.008
  13. Basaza RK, Criel B, Van der Stuyft P. Community health insurance amidst abolition of user fees in Uganda: the view from policy makers and health service managers. BMC Health Serv Res. 2010;10:33. doi:10.1186/1472-6963-10-33
  14. Biggeri M, Nannini M, Putoto G. Assessing the feasibility of community health insurance in Uganda: A mixed-methods exploratory analysis. Soc Sci Med. 2018;200:145-155. doi:10.1016/j.socscimed.2018.01.027
  15. Cecchi F, Duchoslav J, Bulte E. Formal insurance and the dynamics of social capital: Experimental evidence from Uganda. J Afr Econ. 2016;25(3):418-438. doi:10.1093/jae/ejw002
  16. Twikirize JM. Community health insurance as a viable means of increasing access to health care for rural households in Uganda. University of Cape Town; 2009.
  17. Fadlallah R, El-Jardali F, Hemadi N, et al. Barriers and facilitators to implementation, uptake and sustainability of community-based health insurance schemes in low- and middle-income countries: a systematic review. Int J Equity Health. 2018;17(1):13. doi:10.1186/s12939-018-0721-4
  18. Lu C, Chin B, Lewandowski JL, et al. Towards universal health coverage: an evaluation of Rwanda Mutuelles in its first eight years. PLoS One. 2012;7(6):e39282. doi:10.1371/journal.pone.0039282
  19. Chemouni B. The political path to universal health coverage: Power, ideas and community-based health insurance in Rwanda. World Dev. 2018;106:87-98. doi:10.1016/j.worlddev.2018.01.023
  20. Jin Y, Hou Z, Zhang D. Determinants of Health Insurance Coverage among People Aged 45 and over in China: Who Buys Public, Private and Multiple Insurance. PLoS One. 2016;11(8):e0161774. doi:10.1371/journal.pone.0161774
  21. Herberholz C, Fakihammed WA. Determinants of Voluntary National Health Insurance Drop-Out in Eastern Sudan. Appl Health Econ Health Policy. 2017;15(2):215-226. doi:10.1007/s40258-016-0281-y
  22. Jehu-Appiah C, Aryeetey G, Agyepong I, Spaan E, Baltussen R. Household perceptions and their implications for enrollment in the National Health Insurance Scheme in Ghana. Health Policy Plan. 2012;27(3):222-233. doi:10.1093/heapol/czr032
  23. Aregbeshola BS, Khan SM. Predictors of enrolment in the National Health Insurance Scheme among women of reproductive age in Nigeria. Int J Health Policy Manag. 2018;7(11):1015-1023. doi:10.15171/ijhpm.2018.68
  24. Williams GA, Parmar D, Dkhimi F, Asante F, Arhinful D, Mladovsky P. Equitable access to health insurance for socially excluded children? The case of the National Health Insurance Scheme (NHIS) in Ghana. Soc Sci Med. 2017;186:10-19. doi:10.1016/j.socscimed.2017.05.023
  25. Dong H, De Allegri M, Gnawali D, Souares A, Sauerborn R. Drop-out analysis of community-based health insurance membership at Nouna, Burkina Faso. Health Policy. 2009;92(2-3):174-179. doi:10.1016/j.healthpol.2009.03.013
  26. Mebratie AD, Sparrow R, Yilma Z, Alemu G, Bedi AS. Dropping out of Ethiopia's community-based health insurance scheme. Health Policy Plan. 2015;30(10):1296-1306. doi:10.1093/heapol/czu142
  27. Atinga RA, Abiiro GA, Kuganab-Lem RB. Factors influencing the decision to drop out of health insurance enrolment among urban slum dwellers in Ghana. Trop Med Int Health. 2015;20(3):312-321. doi:10.1111/tmi.12433
  28. Duku SK, Asenso-Boadi F, Nketiah-Amponsah E, Arhinful DK. Utilization of healthcare services and renewal of health insurance membership: evidence of adverse selection in Ghana. Health Econ Rev. 2016;6(1):43. doi:10.1186/s13561-016-0122-6
  29. Iqbal M, Chowdhury AH, Mahmood SS, Mia MN, Hanifi SMA, Bhuiya A. Socioeconomic and programmatic determinants of renewal of membership in a voluntary micro health insurance scheme: evidence from Chakaria, Bangladesh. Glob Health Action. 2017;10(1):1287398. doi:10.1080/16549716.2017.1287398
  30. Basaza RK, O'Connell TS, Chapcakova I. Players and processes behind the national health insurance scheme: a case study of Uganda. BMC Health Serv Res. 2013;13:357. doi:10.1186/1472-6963-13-357
  31. Nabyonga Orem J, Mugisha F, Kirunga C, Macq J, Criel B. Abolition of user fees: the Uganda paradox. Health Policy Plan. 2011;26 Suppl 2:ii41-51. doi:10.1093/heapol/czr065
  32. Amone J, Asio S, Cattaneo A, et al. User fees in private non-for-profit hospitals in Uganda: a survey and intervention for equity. Int J Equity Health. 2005;4(1):6. doi:10.1186/1475-9276-4-6
  33. Okwero P, Tandon A, Sparkes S, McLaughlin J, Hoogeveen JG. Fiscal Space for Health in Uganda. Washington, DC: The World Bank; 2010.
  34. Carpenter R, Beichl L, Steinmann R. Microinsurance in Uganda: Country diagnostic report on market and regulations. Uganda: Making Finance Work for Africa (MFW4A); 2013.
  35. Musau SN. Community-based health insurance: experiences and lessons learned from East Africa. Bethesda, Maryland: Abt Associates, Partnerships for Health Reform (PHR); 1999. Vol 34.
  36. Uganda Community Based Health Financing Association. Community Health Insurance National Experience Sharing Forum. Kampala: UCBHF; 2014.
  37. Katabarwa M. Modern health services versus traditional engozi system in Uganda. Lancet. 1999;354(9175):343. doi:10.1016/s0140-6736(05)75256-9
  38. Ministry of Finance, Planning and Economic Development. Background to The Budget Fiscal Year 2018-2019. Kampala: Ministry of Finance, Planning and Economic Development; 2018.
  39. Uganda Bureau of Statistics (UBOS). Uganda National Household Survey 2016/2017. Kampala: UBOS; 2017.
  40. Kusi A, Enemark U, Hansen KS, Asante FA. Refusal to enrol in Ghana's National Health Insurance Scheme: is affordability the problem? Int J Equity Health. 2015;14:2. doi:10.1186/s12939-014-0130-2
  41. Gustafsson-Wright E, Poplawska G, Tanovic Z, van der Gaag J. The impact of subsidized private health insurance and health facility upgrades on healthcare utilization and spending in rural Nigeria. Int J Health Econ Manag. 2018;18(3):221-276. doi:10.1007/s10754-017-9231-y
  42. Uganda Bureau of Statistics (UBOS). National Population and Housing Census 2014: Provisional Results. Kampala: UBOS; 2014.
  43. Caeyers B, Chalmers N, De Weerdt J. Improving consumption measurement and other survey data through CAPI: Evidence from a randomized experiment. J Dev Econ. 2012;98(1):19-33. doi:10.1016/j.jdeveco.2011.12.001
  44. StataCorp. Stata Statistical Software: Release 14. College Station, TX: StataCorp LP; 2015.
  45. Iacobucci D, Schneider MJ, Popovich DL, Bakamitsos GA. Mean centering helps alleviate "micro" but not "macro" multicollinearity. Behav Res Methods. 2016;48(4):1308-1317. doi:10.3758/s13428-015-0624-x
  46. Hu MC, Pavlicova M, Nunes EV. Zero-inflated and hurdle models of count data with extra zeros: examples from an HIV-risk reduction intervention trial. Am J Drug Alcohol Abuse. 2011;37(5):367-375. doi:10.3109/00952990.2011.597280
  47. Hilbe JM. Modeling Count Data. New York: Cambridge University Press; 2014.
  48. Vyas S, Kumaranayake L. Constructing socio-economic status indices: how to use principal components analysis. Health Policy Plan. 2006;21(6):459-468. doi:10.1093/heapol/czl029
  49. Dercon S, De Weerdt J, Bold T, Pankhurst A. Group-based funeral insurance in Ethiopia and Tanzania. World Dev. 2006;34(4):685-703.
  50. De Weerdt J, Dercon S, Bold T, Pankhurst A. Membership based indigenous insurance associations in Ethiopia and Tanzania. In: Chen MA, Jhabvala R, Kanbur R, Richards C, eds. Membership Based Organizations of the Poor. Routledge; 2007:157-176.
  51. Panda P, Chakraborty A, Dror DM, Bedi AS. Enrolment in community-based health insurance schemes in rural Bihar and Uttar Pradesh, India. Health Policy Plan. 2014;29(8):960-974. doi:10.1093/heapol/czt077
  52. Mladovsky P. Why do people drop out of community-based health insurance? Findings from an exploratory household survey in Senegal. Soc Sci Med. 2014;107:78-88. doi:10.1016/j.socscimed.2014.02.008
  53. Abuosi AA, Domfeh KA, Abor JY, Nketiah-Amponsah E. Health insurance and quality of care: Comparing perceptions of quality between insured and uninsured patients in Ghana's hospitals. Int J Equity Health. 2016;15:76. doi:10.1186/s12939-016-0365-1
  54. Amo-Adjei J, Anku PJ, Amo HF, Effah MO. Perception of quality of health delivery and health insurance subscription in Ghana. BMC Health Serv Res. 2016;16:317. doi:10.1186/s12913-016-1602-4
  55. Dalinjong PA, Laar AS. The national health insurance scheme: perceptions and experiences of health care providers and clients in two districts of Ghana. Health Econ Rev. 2012;2(1):13. doi:10.1186/2191-1991-2-13
  56. Buttorff C, Trujillo AJ, Ruiz F, Amaya JL. Low rural health insurance take-up in a universal coverage system: perceptions of health insurance among the uninsured in La Guajira, Colombia. Int J Health Plann Manage. 2015;30(2):98-110. doi:10.1002/hpm.2209
  57. Kijima Y, Matsumoto T, Yamano T. Nonfarm employment, agricultural shocks, and poverty dynamics: evidence from rural Uganda. Agric Econ. 2006;35(s3):459-467. doi:10.1111/j.1574-0862.2006.00191.x
  58. Morgan R, Tetui M, Muhumuza Kananura R, Ekirapa-Kiracho E, George AS. Gender dynamics affecting maternal health and health care access and use in Uganda. Health Policy Plan. 2017;32(suppl_5):v13-v21. doi:10.1093/heapol/czx011
  59. Kalisa IR, Musange SF, Collins D, Saya U, Kunda T. The Development of Community-Based Health Insurance in Rwanda: Experiences and Lessons. Kigali: University of Rwanda College of Medicine and Health Sciences, School of Public Health; 2016.
  60. Shigute Z, Mebratie AD, Sparrow R, Yilma Z, Alemu G, Bedi AS. Uptake of health insurance and the productive safety net program in rural Ethiopia. Soc Sci Med. 2017;176:133-141. doi:10.1016/j.socscimed.2017.01.035
  61. Kalk A, Groos N, Karasi JC, Girrbach E. Health systems strengthening through insurance subsidies: the GFATM experience in Rwanda. Trop Med Int Health. 2010;15(1):94-97. doi:10.1111/j.1365-3156.2009.02424.x
  62. Fenny AP, Yates R, Thompson R. Social health insurance schemes in Africa leave out the poor. Int Health. 2018;10(1):1-3. doi:10.1093/inthealth/ihx046
  63. Liu H, Sun Q, Zhao Z. Social learning and health insurance enrollment: Evidence from China's New Cooperative Medical Scheme. J Econ Behav Organ. 2014;97:84-102. doi:10.1016/j.jebo.2013.10.012
  64. Shakya HB, Christakis NA, Fowler JH. Social network predictors of latrine ownership. Soc Sci Med. 2015;125:129-138.
  65. Shakya HB, Christakis NA, Fowler JH. Association between social network communities and health behavior: an observational sociocentric network study of latrine ownership in rural India. Am J Public Health. 2014;104(5):930-937. doi:10.2105/ajph.2013.301811
  66. Jones B. Beyond the State in Rural Uganda. Edinburgh: Edinburgh University Press; 2009.
  67. Katabarwa NM, Richards FO, Jr., Ndyomugyenyi R. In rural Ugandan communities the traditional kinship/clan system is vital to the success and sustainment of the African Programme for Onchocerciasis Control. Ann Trop Med Parasitol. 2000;94(5):485-495. doi:10.1080/00034983.2000.11813567
  68. Katabarwa MN, Habomugisha P, Agunyo S, et al. Traditional kinship system enhanced classic community-directed treatment with ivermectin (CDTI) for onchocerciasis control in Uganda. Trans R Soc Trop Med Hyg. 2010;104(4):265-272. doi:10.1016/j.trstmh.2009.10.012
  69. Stahl DO, Haruvy E. Other-regarding preferences: Egalitarian warm glow, empathy, and group size. J Econ Behav Organ. 2006;61(1):20-41. doi:10.1016/j.jebo.2004.10.008
  70. Genicot G, Ray D. Group formation in risk-sharing arrangements. Rev Econ Stud. 2003;70(1):87-113.
  71. Kansanga MM, Asumah Braimah J, Antabe R, Sano Y, Kyeremeh E, Luginaah I. Examining the association between exposure to mass media and health insurance enrolment in Ghana. Int J Health Plann Manage. 2018;33(2):e531-e540. doi:10.1002/hpm.2505
  72. Cofie P, De Allegri M, Kouyate B, Sauerborn R. Effects of information, education, and communication campaign on a community-based health insurance scheme in Burkina Faso. Glob Health Action. 2013;6:20791. doi:10.3402/gha.v6i0.20791
  73. Bocoum F, Grimm M, Hartwig R, Zongo N. Can information increase the understanding and uptake of insurance? Lessons from a randomized experiment in rural Burkina Faso. Soc Sci Med. 2019;220:102-111. doi:10.1016/j.socscimed.2018.10.029
  74. Rivera-Hernandez M. The role of religious leaders in health promotion for older Mexicans with diabetes. J Relig Health. 2015;54(1):303-315. doi:10.1007/s10943-014-9829-z
  75. Ruijs WL, Hautvast JL, Kerrar S, van der Velden K, Hulscher ME. The role of religious leaders in promoting acceptance of vaccination within a minority group: a qualitative study. BMC Public Health. 2013;13:511. doi:10.1186/1471-2458-13-511
  76. Govule P, Waelkens MP. Feasibility of Community Health Insurance in Ediofe and ST Assumpta, Arua District. Int J Public Health Res. 2015;3(3):108-117.
  77. Reinikka R, Svensson J. Working for god? Evidence from a change in financing of nonprofit health care providers in Uganda. J Eur Econ Assoc. 2010;8(6):1159-1178. doi:10.1111/j.1542-4774.2010.tb00551.x
  78. Duchoslav J, Cecchi F. Do incentives matter when working for god? The impact of performance-based financing on faith-based healthcare in Uganda. World Dev. 2019;113:309-319. doi:10.1016/j.worlddev.2018.09.011