Abstract
Community Based Health Insurance (CBHI) schemes have become central to health systems financing as avenues of achieving universal health coverage in developing countries. Yet, while emphasis in research and policy has mainly concentrated on enrolment, very little has been apportioned to high rates of dropping out after initial enrolment. The main aim of this study is to understand the factors behind CBHI dropping out through a cross-sectional quantitative research design to gain insights into curtailing the drop out of CBHI in Uganda. The survey for the quantitative research component took place between August 2015 and March 2016 covering 464 households with under-5 children in south-western Uganda. To understand the factors associated with dropping out of CBHI, we employ a multivariate logistic regression on a subsample of 251 households who were either currently enrolled or had enrolled at one time and later dropped out. Overall, we find that 25.1 percent of the households that had ever enrolled in insurance reported dropping out. Household socioeconomic status (wealth) was one of the key factors that associated with dropping out. Larger household sizes and distance from the hospital were significantly associated with dropping out. More socially connected households were less likely to drop out revealing the influence of community social capital in keeping households insured. The findings have implications for addressing equity and inclusion concerns in community-based health insurance programmes such as one in south-western Uganda. Even when community based informal system aim for inclusion of the poorest, they are not enough and often the poorest of the poor slip into the cracks and remain uninsured or drop out. Moreover, policy interventions toward curtailing high dropout rates should be considered to ensure financial sustainability of CBHI schemes.
Highlights
More socially connected households were less likely to drop out revealing the influence of community social capital in keeping households insured
Community-based health insurance (CBHI) schemes are a type of private health insurance, often growing from traditional systems of shock coping such as self-help groups and involving substantial community presence in issues such as management and premium setting [1,2]
Over the last couple of decades, CBHI schemes have become central to health systems financing in the post Alma Ata declaration era of achieving universal health coverage [1,3,4]
Summary
Community-based health insurance (CBHI) schemes are a type of private health insurance, often growing from traditional systems of shock coping such as self-help groups and involving substantial community presence in issues such as management and premium setting [1,2]. In India, Panda and colleagues [14] study schemes operating in Bihar and Uttar Pradesh and report re-enrolment rates of less than 20 percent, implying dropout rates of as much as 80 percent. Another scheme in Ahmedabad, India recorded 63 percent drop outs [15]. The major drivers of dropping out are high premiums [9,12,13], restricted benefits packages [9], perceived poor quality of services [9–11] and poor understanding of insurance concepts [12,13]
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