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Extending voluntary health insurance to the informal sector: experiences and expectations of the informal sector in Kenya.

ABSTRACT: Background: Kenya has made a policy decision to use contributory health insurance as one of its key pre-payment health financing mechanisms. The National Hospital Insurance Fund (NHIF) is the main health insurer in Kenya. While the NHIF has hitherto focused its efforts on providing health insurance coverage to individuals in the formal sector, it has recently broadened its focus to include individuals in the informal sector. This paper provides an analysis of the perceptions, and experiences of informal sector individuals in Kenya with regard to enrolment with the NHIF. Methods: We collected data through key informant interviews (39) in two purposefully selected counties. Study participants were drawn from healthcare facilities contracted by the NHIF, and current, former, and prospective informal sector members. We analyzed data using a grounded approach. Results: Participants felt that the NHIF provided inadequate information about the registration and membership processes as well as benefit entitlements. There was variable and inconsistent communication by the NHIF. There was also variance between the official benefit package and the actual benefits received by members. The NHIF registration requirements and processes presented an administrative barrier to obtaining membership. The NHIF premium level and contribution mechanism presents a financial barrier to current and prospective members. Healthcare providers discriminated against NHIF members compared to cash-payers or private insurance holders. Conclusions: The NHIF could improve enrolment and retention of informal sector individuals by; 1) using communication strategies that are effective at reaching the informal sector, 2) improving the affordability of the premium rates, 3) simplifying the enrolment requirements and process, and 4) strengthening accountability mechanisms between itself and healthcare facilities to ensure that enrolled members receive the benefits that they are entitled to, and that client experience at healthcare facilities are satisfactory.

SUBMITTER: Barasa EW

PROVIDER: S-EPMC5698913 | biostudies-other | 2017

REPOSITORIES: biostudies-other

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Extending voluntary health insurance to the informal sector: experiences and expectations of the informal sector in Kenya.

Barasa Edwine W EW Mwaura Njeri N Rogo Khama K Andrawes Ledia L

Wellcome open research 20170928

<b>Background</b>: Kenya has made a policy decision to use contributory health insurance as one of its key pre-payment health financing mechanisms. The National Hospital Insurance Fund (NHIF) is the main health insurer in Kenya. While the NHIF has hitherto focused its efforts on providing health insurance coverage to individuals in the formal sector, it has recently broadened its focus to include individuals in the informal sector. This paper provides an analysis of the perceptions, and experien ...[more]

PMID: 29387800

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Project description:Universal health coverage (UHC) is important in terms of improving access to quality health care while protecting households from the risk of catastrophic health spending and impoverishment. However, progress to UHC has been hampered by the measures to increase mandatory prepaid funds especially in low- and middle-income countries where there are large populations in the informal sector. Important considerations in expanding coverage to the informal sector should include an exploration of the type of prepayment system that is acceptable to the informal sector and the features of such a design that would encourage prepayment for health care among this population group. The objective of the study was to document the views of informal sector workers regarding different prepayment mechanisms, and critically analyze key design features of a future health system and the policy implications of financing UHC in Kenya.This was part of larger study which involved a mixed-methods approach. The following tools were used to collect data from informal sector workers: focus group discussions [N = 16 (rural = 7; urban = 9)], individual in-depth interviews [N = 26 (rural = 14; urban = 12)] and a questionnaire survey [N = 455(rural = 129; urban = 326)]. Thematic approach was used to analyze qualitative data while Stata v.11 involving mainly descriptive analysis was used in quantitative data. The tools mentioned were used to collect data to meet various objectives of a larger study and what is presented here constitutes a small section of the data generated by these tools.The findings show that informal sector workers in rural and urban areas prefer different prepayment systems for financing UHC. Preference for a non-contributory system of financing UHC was particularly strong in the urban study site (58%). Over 70% in the rural area preferred a contributory mechanism in financing UHC. The main concern for informal sector workers regardless of the overall design of the financing approach to UHC included a poor governance culture especially one that does not punish corruption. Other reasons especially with regard to the contributory financing approach included high premium costs and inability to enforce contributions from informal sector.On average 47% of all study participants, the largest single majority, are in favor of a non-contributory financing mechanism. Strong evidence from existing literature indicates difficulties in implementing social contributions as the primary financing mechanism for UHC in contexts with large informal sector populations. Non-contributory financing should be strongly recommended to policymakers to be the primary financing mechanism and supplemented by social contributions.

Project description:PurposeThe objective of this project is to study the willingness to pay (WTP) for health insurance (HI) of individuals working in the informal sector in Sierra Leone, using a purposely-designed survey of a representative sample of this sector.MethodsWe elicit the WTP using the Double-Bounded Dichotomous Choice with Follow Up method. We also examine the factors that are positively and negatively associated with the likelihood of the respondents to answer affirmatively to joining a HI scheme and to paying three different possible premiums, to join the HI scheme. We additionally analyze the individual and household characteristics associated with the maximum amount the household is willing to pay to join the HI scheme.ResultsThe results indicate that the average WTP for the HI is 20,237.16 SLL (3.6 USD) per adult but it ranges from about 14,000 SLL (2.5 USD) to about 35,000 SLL (6.2 USD) depending on region, occupation, household and respondent characteristics. The analysis of the maximum WTP indicates that living outside the Western region and working in farming instead of petty trade are associated with a decrease in the maximum premium respondents are WTP for the HI scheme. Instead, the maximum WTP is positively associated to being a driver or a biker; having secondary or tertiary education (as opposed to not having any); the number of pregnant women in the household; having a TV; and, having paid for the last medical requirement.ConclusionsIn summary, the various analyses show that a premium for the HI package could be set at approximately 20,000 SLL (3.54 USD) but also that establishing a single premium for all individuals in the informal sector could be risky. The efficient functioning of a HI scheme relies on covering as much of the population as possible, in order to spread risks and make the scheme viable. The impact of the various population characteristics raises the issue of how to rate premiums. In other words, setting a premium that may be too high for a big proportion of the population could mean losing many potential enrollees and might have viability consequences for the operation of the scheme.

Project description:BackgroundZimbabwe's tax-based healthcare financing model has been characterised by perennial financing deficits and widespread application of user fees and has thus been socially exclusive. The country's urban informal sector population is not spared from these challenges. The study explored the potential demand for National Health Insurance (NHI) among respondents from selected urban informal sector clusters of Harare. The following clusters were targeted: Glenview furniture complex, Harare home industries, Mupedzanhamo flea market, Mbare new wholesale market and Mbare retail market.MethodsA cross-sectional survey was administered to 388 respondents from the selected clusters, and data on the determinants of Willingness to Join (WTJ) and Willingness to Pay (WTP) was gathered. Respondents were recruited via a multi-stage sampling procedure. In the first stage, the five informal sector clusters were purposely selected. The second stage involved a proportional allocation of respondents by cluster size. Finally, based on the stalls allocated by municipal authorities in each area, respondents were selected using systematic sampling. The sampling interval (k) was determined by dividing the total number of allocated stalls in a cluster (N) by the sample size proportionate to that cluster (n). For each cluster, the first stall (respondent) was randomly chosen, and thereafter, a respondent from every 10th stall was selected and interviewed at their workplace. Contingent valuation was adopted to elicit WTP. Logit models and interval regression were applied for the econometric analyses.ResultsA total of 388 respondents participated in the survey. The dominant informal sector activity among the surveyed clusters was the sale of clothing and shoes (39.2%), followed by the sale of agricultural products (27.1%). Concerning employment status, the majority were own-account workers (73.1%). Most of the respondents (84.8%) completed secondary school. On monthly income from informal sector activities, the highest frequency (37.1%) was observed in the Zw$(1000 to <3000) or US$(28.57 to <85.71) category. The mean age of respondents was 36 years. Out of the 388 respondents, 325 (83.8%) were willing to join the proposed NHI scheme. WTJ was influenced by the following factors: health insurance awareness, health insurance perception, membership to a resource-pooling scheme, solidarity with the sick, and household recently experiencing difficulties paying for healthcare. On average, respondents were willing to pay Zw$72.13 (approximately US$2.06) per person per month. The key determinants of WTP were household size, respondent's education level, income, and health insurance perception.ConclusionsSince the majority of respondents from the sampled clusters were willing to join and pay for the contributory NHI scheme, it follows that there is potential to implement the scheme for the urban informal sector workers from the clusters studied. However, some issues require careful consideration. The informal sector workers need to be educated on the concept of risk pooling and the benefits of being members of an NHI scheme. Household size and income are factors that require special attention when deciding on the premiums for the scheme. Moreover, given that price instability hurts financial products such as health insurance, there is a need for ensuring macroeconomic stability.

Project description:BackgroundIncorporating private healthcare providers into social health insurance schemes is an important means towards achieving universal health coverage in low and middle income countries. However, little research has been conducted about why private providers choose to participate in social health insurance systems in such contexts, or their experiences with these systems. We explored private providers' perceptions of and experiences with participation in two different social health insurance schemes in Sub-Saharan Africa-the National Health Insurance Scheme (NHIS) in Ghana and the National Hospital Insurance Fund (NHIF) in Kenya.MethodsIn-depth interviews were held with providers working at 79 facilities of varying sizes in three regions of Kenya (N = 52) and three regions of Ghana (N = 27). Most providers were members of a social franchise network. Interviews covered providers' reasons for (non) enrollment in the health insurance system, their experiences with the accreditation process, and benefits and challenges with the system. Interviews were coded in Atlas.ti using an open coding approach and analyzed thematically.ResultsMost providers in Ghana were NHIS-accredited and perceived accreditation to be essential to their businesses, despite challenges they encountered due to long delays in claims reimbursement. In Kenya, fewer than half of providers were NHIF-accredited and several said that their clientele were not NHIF enrolled. Understanding of how the NHIF functioned was generally low. The lengthy and cumbersome accreditation process also emerged as a major barrier to providers' participation in the NHIF in Kenya, but the NHIS accreditation process was not a major concern for providers in Ghana.ConclusionsIn expanding social health insurance, coordinated efforts are needed to increase coverage rates among underserved populations while also accrediting the private providers who serve those populations. Market pressure was a key force driving providers to gain and maintain accreditation in both countries. Developing mechanisms to engage private providers as stakeholders in social health insurance schemes is important to incentivizing their participation and addressing their concerns.

Project description:BACKGROUND:Insurance organizations are essential stakeholders in health care ecosystems. For addressing future health care needs, insurance companies require access to health data to deliver preventative and proactive digital health services to customers. However, extant research is limited in examining the conditions that incentivize health data sharing. OBJECTIVE:This study aimed to (1) identify the expectations of insurance customers when sharing health data, (2) determine the perceived intrinsic value of health data, and (3) explore the conditions that aid in incentivizing health data sharing in the relationship between an insurance organization and its customer. METHODS:A Web-based survey was distributed to randomly selected customers from a Finnish insurance organization through email. A single open-text answer was used for a qualitative data analysis through inductive coding, followed by a thematic analysis. Furthermore, the 4 constructs of commitment, power, reciprocity, and trust from the social exchange theory (SET) were applied as a framework. RESULTS:From the 5000 customers invited to participate, we received 452 surveys (response rate: 9.0%). Customer characteristics were found to reflect customer demographics. Of the 452 surveys, 48 (10.6%) open-text responses were skipped by the customer, 57 (12.6%) customers had no expectations from sharing health data, and 44 (9.7%) customers preferred to abstain from a data sharing relationship. Using the SET framework, we found that customers expected different conditions to be fulfilled by their insurance provider based on the commitment, power, reciprocity, and trust constructs. Of the 452 customers who completed the surveys, 64 (14.2%) customers required that the insurance organization meets their data treatment expectations (commitment). Overall, 4.9% (22/452) of customers were concerned about their health data being used against them to profile their health, to increase insurance prices, or to deny health insurance claims (power). A total of 28.5% (129/452) of customers expected some form of benefit, such as personalized digital health services, and 29.9% (135/452) of customers expected finance-related compensation (reciprocity). Furthermore, 7.5% (34/452) of customers expected some form of empathy from the insurance organization through enhanced transparency or an emotional connection (trust). CONCLUSIONS:To aid in the design and development of digital health services, insurance organizations need to address the customers' expectations when sharing their health data. We established the expectations of customers in the social exchange of health data and explored the perceived values of data as intangible goods. Actions by the insurance organization should aim to increase trust through a culture of transparency, commitment to treat health data in a prescribed manner, provide reciprocal benefits through digital health services that customers deem valuable, and assuage fears of health data being used to prevent providing insurance coverage or increase costs.

Project description:BackgroundIn settings where abortion is legally restricted, or permitted but not widely accessible, women face significant barriers to abortion access, sometimes leading them to seek services outside legal facilities. The advent of medication abortion has further increased the prevalence of informal sector abortion. This study investigates the reasons for attempting self-induction, methods used, complications, and sources of information about informal sector abortion, and tests a specific recruitment method which could lead to improved estimates of informal sector abortion prevalence among an at-risk population.MethodsWe recruited women who have sought informal sector abortion services in Cape Town, South Africa using respondent driven sampling (RDS). An initial seed recruiter was responsible for initiating recruitment using a structured coupon system. Participants completed face-to-face questionnaires, which included information about demographics, informal sector abortion seeking, and safe abortion access needs.ResultsWe enrolled 42 women, nearly one-third of whom reported they were sex workers. Thirty-four women (81%) reported having had one informal sector abortion within the past 5 years, 14% reported having had two, and 5% reported having had three. These women consumed home remedies, herbal mixtures from traditional healers, or tablets from an unregistered provider. Twelve sought additional care for potential warning signs of complications. Privacy and fear of mistreatment at public sector facilities were among the main reported reasons for attempting informal sector abortion. Most women (67%) cited other community members as their source of information about informal sector abortion; posted signs and fliers in public spaces also served as an important source of information.ConclusionsWomen are attempting informal sector abortion because they seek privacy and fear mistreatment and stigma in health facilities. Some were unaware how or where to seek formal sector services, or believed the cost was too high. Many informal methods are ineffective and unsafe, leading to potential warning signs of complications and continued pregnancy. Sex workers may be at particular risk of unsafe abortion. Based on these results, it is essential that future studies sample women outside of the formal health sector. The use of innovative sampling methods would greatly improve our knowledge about informal sector abortion in South Africa.

Dataset Information

Extending voluntary health insurance to the informal sector: experiences and expectations of the informal sector in Kenya.

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Extending voluntary health insurance to the informal sector: experiences and expectations of the informal sector in Kenya.

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