Why do people drop out of community-based health insurance? Findings from an exploratory household survey in Senegal

Abstract

AcknowledgementsThe author would like to thank Bart Criel, Pascal Ndiaye, Alfed Ndiaye, Werner Soors and all national stakeholders in Senegal for their contributions to the research project, the team of fieldwork assistants and supervisors, staff of the three CBHI schemes who gave up their time to facilitate the research, all the interviewees who also gave their time, the Institute of Tropical Medicine, Antwerp and the Stewart Halley Trust for providing funding for the research, and the two anonymous reviewers who provided valuable comments and insights. AbstractAlthough a high level of drop-out from community-based health insurance (CBHI) is frequently reported, it has rarely been analysed in depth. This study explores whether never having actively participated in CBHI is a determinant of drop-out. A conceptual framework of passive and active community participation in CBHI is developed to inform quantitative data analysis. Fieldwork comprising a household survey was conducted in Senegal in 2009. Levels of active participation among 382 members and ex-members of CBHI across three case study schemes are compared using logistic regression. Results suggest that, controlling for a range of socioeconomic variables, the more active the mode of participation in the CBHI scheme, the stronger the statistically significant positive correlation with remaining enrolled. Training is the most highly correlated, followed by voting, participating in a general assembly, awareness raising / information dissemination and informal discussions / spontaneously helping. Possible intermediary outcomes of active participation such as perceived trustworthiness of the scheme management / president; accountability and being informed of mechanisms of controlling abuse/fraud are also significantly positively correlated with remaining in the scheme. Perception of poor quality of health services is identified as the most important determinant of drop-out. Financial factors do not seem to determine drop-out. The results suggest that schemes may be able to reduce drop-out and increase quality of care by creating more opportunities for more active participation. Caution is needed though, since if CBHI schemes uncritically fund and promote participation activities, individuals who are already more empowered or who already have higher levels of social capital may be more likely to access these resources, thereby indirectly further increasing social inequalities in health coverage.

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

“…Out of the 42 quantitative studies (36 quantitative [21,23,27–29,36–37,39–47,49–52,54–59,61,63,65–66,68–69,73–74] and 6 mixed methods with quantitative (and qualitative) data [25,38,60,62,70,72]) one dealt with a randomized control trial (RCT), 5 with case-control methods and cohort studies, and the remaining 31 were cross-sectional surveys based on random samples. Twenty-nine studies examined correlates of uptake and renewal using multivariate analyses (logit/probit/tobit).…”

“…Meta-analysis was conducted for 18 [21–23,28,35,40,44–45,49–50,52,61,63,65,68–69,73–74] quantitative studies. We studied in depth the following variables:…”

Clients’ Experience and Satisfaction of Utilizing Healthcare Services in a Community Based Health Insurance Program in Bangladesh

“…There are various factors such as age, education, households’ head, household size, awareness about CBHI, self-related health, economic status, health provider characteristics which are often affect the CBHI enrolment [6,31,32,33]. Furthermore, perceived quality of health care services is the most vital single factor directly linked with participating in CBHI in many settings [33,34].…”

Understanding the limitations of “quasi‐mandatory” approaches to enrolment in community‐based health insurance: Empirical evidence from Tanzania

“…To understand the reasons behind this low uptake, researchers have been assessing what determines enrolment on both the demand and the supply side. The common demand side features that influence enrolment decisions include social‐economic and demographic factors, especially those related to access to and quality of healthcare; knowledge on health insurance; and willingness and ability to pay . On the supply side, attention has been paid to schemes' design and management issues, where premium prices, benefit packages, methods of premium collection, and administration capabilities have been reported to affect CBHI uptake .…”

“…The common demand side features that influence enrolment decisions include social-economic and demographic factors, especially those related to access to and quality of healthcare; knowledge on health insurance; and willingness and ability to pay. [11][12][13][14][15] On the supply side, attention has been paid to schemes' design and management issues, where premium prices, benefit packages, methods of premium collection, and administration capabilities have been reported to affect CBHI uptake. [16][17][18] The voluntary nature of CBHI schemes has also been described as challenging their sustainability, since people who experience illness appear to be more interested, resulting in a low rate of participation of healthy population groups.…”