Abstract
Background: Globally, developing countries have inadequate capacity to raise tax to finance well-functioning health systems. In sub Saharan Africa, over 40% of the total health expenditure comes from households and mostly out of pocket payments. Over 20% of the population spend more than 10% of their total household consumption expenditure on health care. Prepayment schemes are crucial for promoting resource pooling and risk sharing to prevent catastrophic health expenditure, yet in Uganda only 1% of women and less than 2% of men are covered by health insurance schemes. Private insurance companies cover approximately 12% of Ugandans who are formally employed. We analyzed factors associated with enrollment and retention in ICOCARE health insurance scheme and examined ways to increase enrollment and reduce dropouts. Methods: This was a cross sectional study which employed both quantitative and qualitative methods of data collection. We interviewed 194 respondents who included both active and non-scheme members of the ICOCARE community health insurance scheme. We conducted three focus group discussions and two key informant interviews with key stakeholders. Quantitative data was analyzed using Statistical Package for Social Scientists software version 20 and STATA 13 while qualitative data was analyzed using the six steps of thematic analysis developed by Braun and Clarke. Results: We found that enrollment and retention into ICOCARE health insurance scheme was influenced by quality of care, extra charges to members, service exclusions, and knowledge of Community Health Insurance principles, previous illness experiences, distance from home to service provider and means of transport used to reach the health facilities. Members living in less than 5km to the service provider were 8 times more likely to enroll and retain membership into ICOCARE health insurance scheme [p-value <0.05 and CI (3.288-22.302)]. Conclusions: Knowledge on Community Health Insurance principles, benefits and coverage of non communicable diseases which is excluded in most CHI benefit packages influenced enrollment and retention. Transport costs to service providers deterred potential members from renewal of membership. CHI schemes need to intensify community education on CHI principles and identify service providers in areas where members can easily access care to minimize extra costs.
A rapid evaluation of the Rajiv Aarogyasri community health insurance scheme in Andhra Pradesh, India
