Elsevier

Social Science & Medicine

Volume 62, Issue 6, March 2006, Pages 1520-1527
Social Science & Medicine

“To enrol or not to enrol?”: A qualitative investigation of demand for health insurance in rural West Africa

https://doi.org/10.1016/j.socscimed.2005.07.036Get rights and content

Abstract

In spite of the fact that feeble levels of participation have long been identified as a major constraint to the successful long-term implementation of community-based health insurance (CBI) in low-income countries, evidence on determinants of enrolment in CBI is still lacking. The application of econometric modelling has provided a partial answer to the question, but on its own it has proved to be insufficient to guide policy making. This paper aims to fill this gap in knowledge using qualitative research methods. In-depth interviews with 32 household heads were conducted in the Nouna Health District, Burkina Faso, West Africa to assess determinants of enrolment in a newly established CBI scheme. The findings highlight that factors previously neglected in the literature, such as institutional rigidities and socio-cultural practices, play an important role in shaping the decision to enrol. The discussion of the findings focuses on the policy implications, offering concrete recommendations to maximise enrolment, within and beyond Burkina Faso.

Introduction

Community-based health insurance (CBI) has recently been praised as a valuable alternative to user fees, since, through the pooling of risks and resources, it promises better access to health services and greater financial protection to poor populations (Dror & Jacquier, 1999; Preker et al., 2004).

A review of the literature, however, reveals that CBI often fails to reach satisfactory coverage rates, leading to feeble levels of resource mobilisation and poor survival of schemes (Bennett, Creese, & Monasch, 1998; Ekman, 2004; Waelkens & Criel, 2004). Although the question is of primary importance, few authors have focused on understanding what factors influence decision to enrol in CBI. Those who have examined this question have done so through the application of econometric modelling, used to investigate the extent to which specific individual and household characteristics influence the decision to enrol (Jütting, 2004; Ranson, 2004; Schneider & Diop, 2004). In spite of its substantial contribution to the field, econometric modelling alone is insufficient to explain enrolment in CBI because inevitably it can only focus on a restricted number of variables.

A complementary approach to understanding the demand for health insurance in low-income settings comes from qualitative analysis, which, within the field of health economics, is increasingly recognised as a valuable tool when in need to make sense of complex decision-making processes (Coast, 1999; Ryan et al., 2001). Still, we are only aware of one study looking at determinants of enrolment using qualitative methods. On the basis of the responses elicited through focus group discussions, Criel and Waelkens (2003) conclude that declining enrolment rates in the Maliando scheme in Guinea-Conakry cannot be attributed to the community lack of understanding or acceptance of the new initiative, as expected, but rather to the poor quality of health care available and to operational difficulties which arose during the implementation of the scheme.

This paper presents a qualitative investigation of determinants of enrolment in a newly implemented CBI scheme in the district of Nouna, Burkina Faso. The aim is to generate a more comprehensive understanding of demand for health insurance in low-income countries. Qualitative methods were used to inform and complement the quantitative analysis conducted afterwards.

Section snippets

Research context

The Nouna Health District is located in the northwest of Burkina Faso. The government is the only health service provider in the region. Given the financial barrier imposed by user fees, health services are characterised by low utilisation with an annual per capita average of 0.16 contacts (Ministère de la Santé, 2002).

Plans to initiate a CBI scheme in the district followed the request of the local Ministry of Health (Ministère de la Santé, 2000) and were preceded by extensive research

Methods

Determinants of enrolment were explored using 32 in-depth individual interviews with household heads. Individual interviews were preferred to focus group discussions, because, although influenced by community factors, ultimate decision to enrol rests within the single household. We interviewed exclusively household heads because in the local context, they decide on the allocation of household resources.

We selected individuals using a stratified purposive sampling design based on insurance

Findings

All interviews were conducted between May and June 2004. 24 interviews were conducted in Dioula, 6 in Bwamu, and 2 in French. Interviews lasted between 30 min and 1 h 30 min. Table 1 reports basic information about the interviewees.

The presentation of findings is organised in six sections, each focusing on a different set of relevant issues, and is illustrated using verbatim quotations, translated into English by the first author. We observed no remarkable difference in the comments generated by

Discussion

Although drawing specifically from the experience of the Nouna district, we discuss findings in relation to their broader policy implications, trusting that the circumstances presented in this article are pertinent to other contexts and their discussion informative for decision-makers across low-income settings.

Econometric analysis of enrolment in CBI looks at affordability purely in terms of the impact of household income on the decision to enrol (Jütting, 2004; Ranson, 2004; Schneider & Diop,

Acknowledgements

This study was supported by the research grant SFB 544 of the German Research Society (DFG). Our gratitude goes to Dr. Kouyaté, Dr. Yé, Mr. Tiawara, the Nouna Health Research Centre, and the Association Tontines Nouna, in particular Aline Bagayoyo, for their support during data collection. We would like to thank the three anonymous reviewers, Dr. Hengjin Dong, and Dr. Evelyn Wladarsch for their valuable comments and Sarah Reidell for the language editing.

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