Abstract
Background Community-based health insurance (CBHI) schemes are an emerging mechanism for providing financial protection against health-related poverty. In Rwanda, CBHI is being implemented across the country, and it is based on four socioeconomic categories of the “Ubudehe system”: the premiums of the first category are fully subsidized by government, the second and third category members pay 3000 frw, and the fourth category members pay 7000 frw as premium. However, low adherence of community to the scheme since 2011 has not been sufficiently studied. Objective This study aimed at determining the factors contributing to low adherence to the CBHI in rural Nyanza district, southern Rwanda. Methodology A cross-sectional study was conducted in nine health centers in rural Nyanza district from May 2017 to June 2017. A sample size of 495 outpatients enrolled in CBHI or not enrolled in the CBHI scheme was calculated based on 5% margin of error and a 95% confidence interval. Logistic regression was used to identify the determinants of low adherence to CBHI. Results The study revealed that there was a significant association between long waiting time to be seen by a medical care provider and between health care service provision and low adherence to the CBHI scheme (P value < 0.019) (CI: 0.09107 to 0.80323). The estimates showed that premium not affordable (P value < 0.050) (CI: 0.94119 to 9.8788) and inconvenient model of premium payment (P value < 0.001) (CI: 0.16814 to 0.59828) are significantly associated with low adherence to the CBHI scheme. There was evidence that the socioeconomic status as measured by the category of Ubudehe (P value < 0.005) (CI: 1.4685 to 8.93406) increases low adherence to the CBHI scheme. Conclusion This study concludes that belonging to the second category of the Ubudehe system, long waiting time to be seen by a medical care provider and between services, premium not affordable, and inconvenient model of premium payment were significant predictors of low adherence to CBHI scheme.
Highlights
Community-based health insurance (CBHI) schemes are an emerging mechanism for providing financial protection against health-related poverty
Low enrolment rates endanger the sustainability of community-based health insurance (CBHI) schemes because they reduce the size of the insurance pool and because they bear a negative impact on further enrolment and dropout [2]
E questionnaire was the method used to collect information on socioeconomic status of the individual determined by the category of the Ubudehe system to which its household belongs, satisfaction with quality of health care services provided, affordability of premium and copayment fees and knowledge of the CBHI scheme management. e satisfaction with quality of health care services module includes questions regarding overall quality of health care services, availability of medical equipment and prescribed drugs, waiting time to be seen by a health care provider, waiting time between services, and health care providers’
Summary
As universal health coverage (UHC) is becoming a priority, there is a need to increase the financial accessibility of health care services, protecting the population from catastrophic expenditure, and decreasing the risk of extreme poverty [1]. Low enrolment rates have been found to be related to affordability of premiums, noncooperative attitudes of health providers, poor quality of care as well as lack of basic information, and participation on the design and operations of schemes [7]. A study conducted in Ghana has identified barriers to the enrolment rate including lack of trust in the scheme, perceived poor quality of care, long waiting time for services among insured clients, and delay in card production [12]. All of these factors are contributing to low enrolment in the developing world [13]
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