Determinants of Enrolment and Renewing of Community-Based Health Insurance in Households With Under-5 Children in Rural South-Western Uganda

The desire for universal health coverage in developing countries has brought attention to community-based health insurance (CBHI) schemes in developing countries. The government of Uganda is currently debating policy for the national health insurance programme, targeting the integration of existing CBHI schemes into a larger national risk pool. However, while enrolment has been largely studied in other countries, it remains a generally under-covered issue from a Ugandan perspective. Using a large CBHI scheme, this study, therefore, aims at shedding more light on the determinants of households’ decisions to enrol and renew membership in these schemes.  

We collected household data from 464 households in 14 villages served by a large CBHI scheme in south-western Uganda. We then estimated logistic and zero-inflated negative binomial (ZINB) regressions to understand the determinants of enrolment and renewing membership in CBHI, respectively.  

Results revealed that household’s socioeconomic status, husband’s employment in rural casual work (odds ratio [OR]: 2.581, CI: 1.104-6.032) and knowledge of health insurance premiums (OR: 17.072, CI: 7.027-41.477) were significant predictors of enrolment. Social capital and connectivity, assessed by the number of voluntary groups a household belonged to, was also positively associated with CBHI participation (OR: 5.664, CI: 2.927-10.963). More positive perceptions on insurance (OR: 2.991, CI: 1.273-7.029), access to information were also associated with enrolment and renewing among others. Burial group size and number of burial groups in a village, were all significantly associated with increased the likelihood of renewing CBHI.  

While socioeconomic factors remain important predictors of participation in insurance, mechanisms to promote inclusion should be devised. Improving the participation of communities can enhance trust in insurance and eventual coverage. Moreover, for households already insured, access to correct information and strengthening their social network information pathways enhances their chances of renewing.