Mixed effects analysis of factors associated with health insurance coverage among women in sub-Saharan Africa

Abstract

Introduction In the pursuit of achieving the Sustainable Development Goal targets of universal health coverage and reducing maternal mortality, many countries in sub-Saharan Africa have implemented health insurance policies over the last two decades. Given that there is a paucity of empirical literature at the sub-regional level, we examined the prevalence and factors associated with health insurance coverage among women in in sub-Saharan Africa. Materials and methods We analysed cross-sectional data of 307,611 reproductive-aged women from the most recent demographic and health surveys of 24 sub-Saharan African countries. Bivariable and multivariable analyses were performed using chi-square test of independence and multi-level logistic regression respectively. Results are presented as adjusted Odds Ratios (aOR) for the multilevel logistic regression analysis. Statistical significance was set at p<0.05. Results The overall coverage of health insurance was 8.5%, with cross-country variations. The lowest coverage was recorded in Chad (0.9%) and the highest in Ghana (62.4%). Individual-level factors significantly associated with health insurance coverage included age, place of residence, level of formal education, frequency of reading newspaper/magazine and watching television. Wealth status and place of residence were the contextual factors significantly associated with health insurance coverage. Women with no formal education were 78% less likely to be covered by health insurance (aOR = 0.22, 95% CI = 0.21–0.24), compared with those who had higher education. Urban women, however, had higher odds of being covered by health insurance, compared with those in the rural areas [aOR = 1.20, 95%CI = 1.15–1.25]. Conclusion We found an overall relatively low prevalence of health insurance coverage among women of reproductive age in sub-Saharan Africa. As sub-Saharan African countries work toward achieving the Sustainable Development Goal targets of universal health coverage and lowering maternal mortality to less than 70 deaths per 100,000 live births, it is important that countries with low coverage of health insurance among women of reproductive age integrate measures such as free maternal healthcare into their respective development plans. Interventions aimed at expanding health insurance coverage should be directed at younger women of reproductive age, rural women, and women who do not read newspapers/magazines or watch television.

Health Insurance Coverage and Its Associated Factors Among Reproductive-Age Women in East Africa: A Multilevel Mixed-Effects Generalized Linear Model

“…This finding was consistent with studies conducted elsewhere. [16][17][18] This is because single women may not afford the premiums, deductibles, and have low perceived illness. According to the current study, participants who engaged in some types of job were positively associated with better coverage of health insurance.…”

“…Other studies have also reported a direct relationship between maternal age and health insurance coverage. 16,18,19,21 This similarity might be due to the fact that as age increases the risk of getting illness increases; thus, the chance of health insurance coverage will increase. 27 Consistent with previous studies, 16,19,20,22,23 there is a positive relationship between educational status and health insurance coverage among RAG women.…”

“…16,18,19,21 This similarity might be due to the fact that as age increases the risk of getting illness increases; thus, the chance of health insurance coverage will increase. 27 Consistent with previous studies, 16,19,20,22,23 there is a positive relationship between educational status and health insurance coverage among RAG women. This positive association might have occurred because education enhances access to information and high-income, occupations tend to offer insurance and income provides the means to pay insurance premiums.…”

“…By considering the binary nature of the outcome variable, it was coded as 1 if RAG women were covered by social security or other employer-based insurance or any of the health insurance schemes or mutual health organization or community-based insurance or privately purchased commercial insurance, otherwise it was coded as 0. After reviewing different works of literature [16][17][18][19][20][21][22][23] age, marital status, educational level, currently working, place of residence, country, wealth index, sex of head of household, age of household head, media exposure, visited by a fieldworker in the last 12 months, visited a health facility in the last 12 months, and cigarette smoking were considered as independent variables.…”

“…15 Despite improvement in access to modern healthcare services in East African countries, health-service delivery and health status of the the RAG remained low mainly due to the low level of health-sector financing and lack of access to health insurance by women. 13,16 Moving away from out-of-pocket (OOP) payments for health care at the time of use to pre-payment (health insurance) is an important step towards averting the financial hardship associated with paying for health-care services. 11 However, large scale evidences supporting this fact is lacking.…”