Abstract
BackgroundThe sustainability of a voluntary community-based health insurance scheme depends to a greater extent on its ability to retain members. In low- and middle-income countries, high rate of member dropout has been a great concern for such schemes. Although several studies have investigated the factors influencing dropout decisions, none of these looked into how long and why members adhere to the scheme. The purpose of this study was to determine the factors affecting time to drop out while accounting for the influence of cluster-level variables.MethodsA community-based cross-sectional study was conducted among 1232 rural households who have ever been enrolled in two community-based health insurance schemes. Data were collected using an interviewer-administered questionnaire via a mobile data collection platform. The Kaplan–Meier estimates were used to compare the time to drop out among subgroups. To identify predictors of time to drop out, a multivariable analysis was done using the accelerated failure time shared frailty models. The degree of association was assessed using the acceleration factor (δ) and statistical significance was determined at 95% confidence interval.ResultsResults of the multivariable analysis revealed that marital status of the respondents (δ = 1.610; 95% CI: 1.216, 2.130), household size (δ = 1.168; 95% CI: 1.013, 1.346), presence of chronic illness (δ = 1.424; 95% CI: 1.165, 1.740), hospitalization history (δ = 1.306; 95% CI: 1.118, 1.527), higher perceived quality of care (δ = 1.322; 95% CI: 1.100, 1.587), perceived risk protection (δ = 1.218; 95% CI: 1.027, 1.444), and higher trust in the scheme (δ = 1.731; 95% CI: 1.428, 2.098) were significant predictors of time to drop out. Contrary to the literature, wealth status did not show a significant correlation with the time to drop out.ConclusionsThe fact that larger households and those with chronic illness remained longer in the scheme is suggestive of adverse selection. It is needed to reconsider the premium level in line with household size to attract small size households. Resolving problems related to the quality of health care can be a cross-cutting area of intervention to retain members by building trust in the scheme and enhancing the risk protection ability of the schemes.
Highlights
Universal health coverage requires that everyone in a country has adequate access to essential health care without financial difficulty, regardless of living standards [1]
This indicates the need to reconsider the premium level in line with household size
Despite community-based health insurance (CBHI) is enhancing health care access to its members for highrisk individuals living with chronic conditions, it lacks the ability to protect them from financial hardships at the time of receiving health care
Summary
Universal health coverage requires that everyone in a country has adequate access to essential health care without financial difficulty, regardless of living standards [1]. A growing number of low and middle-income countries, including Ethiopia, are implementing voluntary community-based health insurance (CBHI) schemes as a riskpooling mechanism for rural communities and informal sector workers [3, 4]. The key indicators for measuring membership that determine the sustainability of voluntary insurance schemes are growth rate, coverage ratio, and renewal rate [6,7,8,9]. The renewal rate measures the proportion of insured that stay enrolled in the scheme after their coverage term expires. It is an indicator of scheme performance in retaining its members [7, 9]. The sustainability of a voluntary community-based health insurance scheme depends to a greater extent on its ability to retain members. The purpose of this study was to determine the factors affecting time to drop out while accounting for the influence of cluster-level variables
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