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What Factors Affect Uptake of Voluntary and Community-based Health Insurance Schemes in Low-and Middle- income countries? A Systematic Review

What do we want to know?

Most healthcare expenditures in developing countries are borne through out-of-pocket (OOP) spending payable by healthcare-seekers at the time and place of treatment. This healthcare financing situation is inequitable and inefficient, and leads most poor people into a poverty trap. The solution to this problem (proposed by WHO and other international bodies) is to achieve universal health coverage (UHC) for entire countries. In most low and middle income countries, mandating participation in health insurance or its provision free of charge are impossible; an alternative way to enhance coverage has emerged, through community-based health insurance (CBHI) schemes, where the community plays an important role in mobilizing, pooling, allocating, managing and/or supervising health-care resources. CBHI schemes have been shown to be effective in reducing out-of-pocket payments of their members, and in improving access to health services. However, many schemes also reported low enrolment rates. If CBHI should move from niche to scale as a social protection mechanism, such schemes need to attract more members and retain them. Hence, we want to know what factors affect enrolment on a voluntary basis, and enhance membership renewals.

Review objectives 

  • To develop a framework to distinguish different factors influencing uptake;
  • To provide a summary of the existing literature relating to each of these factors;
  • To identify issues that require additional essential primary research (stand-alone research or evaluation of current and future initiatives).

The central research question addressed by this systematic review is to understand the demand- and supply-side correlates of enrolment and renewal decisions of CBHI members in low-and middle-income countries.

Who wants to know and why?

This review is pertinent to policy-makers, government officials, politicians, community representatives, researchers and implementers, all of whom wish to pursue effective methods to enhance health insurance coverage. The option of introducing CBHI programs and expanding existing ones for the poor and those in the informal sector in low-and middle-income countries may require reshaping existing programs and assessing the opportunity / business case of CBHI.

What did we find?

Based on 54 studies that were retained for detailed analysis of factors influencing uptake and renewal/drop-out in CBHI schemes in low-and middle-income countries, one can say that: education of the head of households, age of the head of the household, household size, female-headed household and married head of the household and presence of chronic illness episodes in the household were positive effects on enrollment in CBHI.  Affordability (financial constraints, lack of money etc.) and how the premiums were collected (timing and modalities of collection) represented the major constraint for enrolment decisions. Trust in scheme management was a facilitator of enrolment decisions. Proximity to health facilities was a factor enhancing, just as distance was a barrier to enrollment. Presence of acute illness episodes and presence of elderly persons in the household had also a negative association with enrolments in CBHI. And in certain socio-cultural contexts, savings and prepayment for illness were perceived by the community as inviting diseases.

As regards renewal decisions, surprisingly, household income and female-headed household were negatively associated with renewal. Education of the head of household, household size and trust in the scheme management were positively associated with renewal decisions. An insurance claim was found to be a motivating factor to renew membership. Trust in scheme management was found to be an enabler for renewal of membership

What are the conclusions?

Based on the findings, a number of key recommendations can be made to maximise enrolment and renewal. The role of government support is crucial even when it does not include funding, as people prefer to be insured by schemes that are accepted by authorities and function within appropriate regulatory and legislative policies. Donors have a special role in creating an enabling environment for the development and expansion of CBHI and by making CBHI more inclusive through financial support to include the poorest of the poor. The improvement in the quality of healthcare, community’s knowledge and understanding of insurance principle and CBHI and providing inputs towards benefit packages can also enhance uptake. Additional research is needed to assess which interventions are most effective in improving, trust, affordability and understanding of CBHI.

How did we get these results?

The initial list of 15,770 studies was subjected to four rounds of filtering, removing duplicates, applying inclusion and exclusion criteria to titles and abstracts and removing irrelevant entries; 251 studies were retrieved for screening based on full reports, which were examined by applying the double screening and data extraction process of EPPI-Reviewer. Of the 251 full text studies, fifty-four studies (36 quantitative, 12 qualitative and 6 mixed-method studies) have been retained for this systematic review. Since the mixed-method studies include both quantitative and qualitative data, we have included 42 quantitative (36 quantitative and 6 mixed-method with quantitative data) and 18 qualitative (12 qualitative and 6 mixed-method with qualitative data) studies for analysis. While all the 18 qualitative studies have been considered for a thematic synthesis, only 18 out of 42 quantitative studies could be included for the meta-analytic synthesis. A discussion of the vote count findings for the variables in the full range of 42 quantitative studies has been included in an attempt to explain any differences in results derived from the meta-analysis. Finally, we give results from 54 studies that report the affecting factors of enrolment and renewal in CBHI scheme using quantitative and qualitative methods. We emphasised the results from the economics and health based literature which focused the issue of enablers and facilitator of CBHI schemes.

This review should be cited as: Panda P, Dror IH, Koehlmoos TP, Shahed Hossain SA, John D, Khan JAM, Dror DM (2015) What Factors Affect Uptake of Voluntary and Community-based Health Insurance Schemes in Low-and Middle- income countries? A Systematic Review. 3ie Systematic Reviews

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