Table 2 Positive and negative factors influencing uptake of CBHI and other forms of social health insurance in SSA, and implications for policymakers
Factor | Examples of countries where factors noteda | Issues identified and policy implications | References |
|---|---|---|---|
Factors positively linked to uptake | |||
Provision of uniform benefit packages offering wide illness coverage | Ghana | Benefits should be predefined and comprehensive, with a good coverage of likely disease burden | |
Provision of services at accredited facilities helps to ensure uniformity of benefits offered | |||
Adequate public financing/realistic pricing | Ghana, Rwanda, Burkina Faso | Use of funds from taxation is necessary to allow funding to become progressive and to encourage/enable the less well-off to join through subsidies and fee exemptions | NHIS [Ghana] [40]; Odeyemi & Nixon [6]; Logie [18]; Schmidt [29]; De Allegri [35]; Parmar [37]; Souares [38] |
Targeted subsidies positively influenced enrolment in Nouna, BF, although there is also a danger of adverse selection | |||
Elimination or minimisation of copayments | Rwanda | Increases in subsidies to the point where copayments are eliminated could lead to as much as 100% coverage | |
User fees in Rwanda were found to be linked to substantial inequality in utilisation, with medical visits being more common among the more well-off uninsured | |||
Strong desire/willingness to join | Cameroon, Nigeria | Greatest willingness noted among poorest households in Nigeria | |
Policy makers should undertake research to determine WTP; social marketing can encourage participation | |||
Avoidance of focus on maximisation of health revenue | Rwanda | CBHI participation and a focus on the generation of healthcare revenues are mutually exclusive | Schmidt [29] |
Improvements in education and socioeconomic status | Burkina Faso | Enrolment in schemes may increase in line with social and economic progress and development over the long term | De Allegri [35] |
Provision of maternal healthcare benefits | Senegal, Mali, Ghana, Rwanda, Nigeria | Inclusion of maternal healthcare benefits promotes interest in CBHI as a demand-side driver, and CBHI is a primary contributor to strong maternal health services | |
Scheme organisers should ensure that packages are comprehensive, as excessive limitation discourages uptake | |||
Awareness of the limitations of traditional medicine | Burkina Faso | Noted in the Nouna, BF survey. Further research is needed, but this observation emphases the value of improved education and communication | De Allegri [35] |
Negative factors that discourage or limit uptake | |||
Excessive requirement for OOP expenditure, inability to pay | Uganda, Burkina Faso, Guinea, Senegal, Nigeria | Major determinant of enrolment; even where implementation has been predominantly successful, the very poorest populations may still find participation financially difficult | Basaza [13, 32, 33]; Dong [36]; Criel [39]; Onwujekwe [25]; Metiboba [7]; Jütting [27] |
OOP remains significant in healthcare systems in many countries (despite actions such as abolition of user fees in government institutions in Uganda) | |||
Regressive flat-rate payments are a problem in Nigeria, and inability to pay premiums is the single biggest obstacle in Uganda. There are no mechanisms in place to help those who cannot afford to join | |||
Ambiguous and contradictory healthcare funding policy is a significant problem that must be addressed | |||
Social exclusion due to religion or ethnicity | Senegal | Noted in Senegal, where the Roman Catholic Church supports the Mutuelles, and where Christians were reported in 2003 to be more likely than Moslems to enrol. In interviews, Moslems were under the mistaken impression that CBHI was open to Christians only | Jütting [27] |
Lack of legal framework or umbrella organisation | Guinea, Benin | Failure to provide any proper governance or official framework for CBHI schemes is linked to low enrolment | Soors [20] |
Lack of government (or donor) support | Uganda, Burkina Faso, Nigeria | Small budgets, low enrolment and lack of government support cause schemes to fail. Schemes need substantial support to build their sustainability; technical and policy decisions should account for this | |
Excessively rigid enrolment requirements or institutional rigidity | Uganda, Burkina Faso | Failure to recruit the required number of people in a village has been a key feature affecting schemes in Uganda (mandatory 60% of a group or 100 families per village) | Basaza [32, 33]; De Allegri [35]; Onwujekwe [25]; Onwujekwe [23] |
Rules for group membership should reflect what is achievable | |||
Mismatch of values expressed by promoters and subscribers; failure to align the ‘real’ market with the theoretical one, and to match benefits with WTP | Senegal, Burkina Faso, Nigeria | Need to align expectations/needs of promoters (focus on financial sustainability) and subscribers (who look for sustainability and solidarity) | Ouimet [12]; Dong [15–17]; Onwujekwe [23]; Onwujekwe [24]; Metiboba [7] |
Increase participation of members in decision making; failure to engage beneficiary participation in Nigeria has been pinpointed as a major problem | |||
Ensure that prospective members are willing to pay for the benefits on offer, and that the market in any locality matches the theoretical one on which projections are based | |||
Lack of information | Uganda, Burkina Faso, Nigeria | Governments and promoters must ensure that schemes are properly and accurately publicised, and the public properly informed; lack of knowledge can lead to scepticism | Basaza [13]; De Allegri [35]; Dienye [22]; Onwujekwe [23]; Metiboba [7] |
Lack of information is a significant problem in Nigeria | |||
Authorities must ensure that government and health officials are fully informed about the packages on offer | |||
Poor quality of healthcare | Uganda, Guinea | Concerns relate to cleanliness, long queues before being seen, and lack of some prescribed medicines | |
Noted as the main reason for lack of interest in the Maliando Mutual Health Organisation in Conakry, Guinea | |||
Lack of trust; perception that schemes are unfair or even unnecessary; dislike of health care personnel and cultural resistance | Uganda | Belief that non-members are treated better in hospital than scheme members | |
Integrity of fund managers and transparency of operation: “Nothing is done to ensure that fund managers account to scheme members” (Ugandan interview respondent) | |||
Some members pay premiums continuously but never fall sick | |||
“I wasn’t bothered since I am young and not likely to fall sick”; “If I do not fall sick, I should not pay for someone else” (Ugandan survey respondents) | |||
Schemes must be fair, well run and affordable, and the public sufficiently well-informed to appreciate the need for coverage and mutuality | |||
High drop-out rates | Burkina Faso | Related to other factors noted in this table: affordability, health needs and demand, quality of care and household characteristics | Dong [36] |
Improve perception of schemes by heads of households, ensure that large households are able to maintain contributions (e.g. flexibility in payment options); ensure that service offered meets expectations (e.g. in line with education, etc.) | |||