Elsevier

Health Policy

Volume 92, Issues 2–3, October 2009, Pages 174-179
Health Policy

Drop-out analysis of community-based health insurance membership at Nouna, Burkina Faso

https://doi.org/10.1016/j.healthpol.2009.03.013Get rights and content

Abstract

Objectives

This study aims to identify the reasons why enrolled people decide not to renew their membership in following years.

Methods

Household survey is used to collect information on the factors influencing dropping out from community-based health insurance (CBI). Information from CBI agency databank is used to describe the general situation of enrolment and drop-out.

Results

Since the launch of CBI the enrolment rate has been low ranging from 5.2% to 6.3%. The drop-out rate, however, has been high ranging from 30.9% to 45.7%. It is found, by the multivariate analysis, that female household head, higher age or lower education of a household head, lower number of illness episodes in the past three months, fewer children or elderly in a household, poor perceived health care quality, less seeking care in the past month positively effected on drop-out, increasing the rate. However, the household six-month expenditure and the distance to the contracted health facility did not have the hypothesised sign. In contrast, a higher household expenditure and a shorter distance to the contracted health facility increased the drop-out.

Conclusions

High drop-out rates endanger the sustainability of CBI not only because they reduce the size of the insurance pool, but also because they bear a negative impact on further enrolment and drop-out. The drop-out rate in the scheme of the Nouna Health District, Burkina Faso, is very high. The reasons for drop-out may be related to affordability, health-needs and health demand, quality of care, household head and household characteristics. This study represents a valuable attempt towards further increasing the sustainability of CBI schemes, by understanding not what motivates people to first enrol in CBI, but what motivates them to renew membership year after year.

Introduction

In the past decades, community-based health insurance (CBI) has been seen as a promising new tool of health system improvement for rural populations in low-income countries, particularly in sub-Saharan Africa (SSA) [1], [2]. In CBI, community members pool their resources to share the financial risks of health care. They own the scheme and control its management, including the collection of premiums, the payment of health care providers, and the negotiation of the benefits package. Unlike private insurance, premiums are community rated and not based on individual risk assessments. CBI has the advantage of dissociating the time of payment from the time of service use. This system is clearly better adapted than user fees to the seasonal fluctuations in revenue and expenditure flows of rural households [3]. There is strong evidence that CBI provides financial protection by reducing out-of-pocket health care spending and moderate evidence that it improves cost-recovery [4]. There is no evidence that CBI improves the quality of care [4].

Particularly in SSA, however, the successful development of CBI schemes is severely hampered by low enrolment rates [5], [6], [7], [8], [9], [10]. Low enrolment rates have been found to be related to affordability of premiums, adverse selection, non-cooperative attitudes of health providers and poor quality of care [8], [9], [11], [12], [13], [14], lack of understanding of the risk pooling concept, [11], [15], [16], poor marketing of schemes [7], [8], and lack of basic information on the design and operations of schemes as well as lack of trust in their management [8], [9], [10].

In addition, even schemes with relatively high enrolment rates often suffer from substantial fluctuations in membership [7], [17]. While authors have focus in understanding what motivates people to first enrol in CBI, the problem of membership retention has been repeatedly reported, but not thoroughly analysed in the literature. Criel and Waelkens provide a qualitative analysis of declining subscription rates in the Maliando scheme in Guinea Conakry, but complementary quantitative analyses of such patterns are absent from the literature [7].

Since 2004, a CBI scheme has been operative in the catchment area of the demographic surveillance system (DSS) of the Nouna Health District, rural Burkina Faso. The scheme has been designed according to the scientific evidence emerging from a number of studies which preceded its implementation. These included a study on community preferences for a benefit package, a study on willingness-to-pay for the selected package, a study on health service cost and premium estimation [18], [19], [20].

In order to scientifically assess the sustainability of CBI and its effects on health service utilization, the area where the scheme is operative has been divided into 33 clusters and CBI has progressively been offered to 11 additional clusters every year. Since 2006, the residents of all 33 clusters have enjoyed the opportunity to enrol in CBI. Field experience, however, shows that the enrolment rate is low. In addition, drop-out rates, meaning people who discontinue membership after enrolling one year, are very high.

The study presented in this paper aims to identify the reasons why previously enrolled people decide not to renew their membership in following years. This analysis is justified by a need to understand the specific reasons motivating people to drop-out of schemes. The aim is to empower decision makers with the information necessary to design measures that can enhance retention in CBI, thus increasing the sustainability of schemes in Burkina Faso as elsewhere in SSA. Given that similar analyses of drop-out behaviour are absent from the literature, this article contributes to the wealth of knowledge on CBI.

Section snippets

Method

The study site is the Nouna Health District which has roughly 230,000 inhabitants. The district is located in the Northwest of Burkina Faso, about 300 Km from the capital Ouagadougou. The area is a dry orchard Savannah, populated almost exclusively by subsistence farmers of different ethnic groups [18], [19].

A household survey was used to collect information on the factors influencing the decision to drop-out of CBI. Specifically, we looked at which socio-demographic, economic, and health care

General information on drop-out and non-drop-out households

The household heads in the drop-out group had a significantly lower education than in the non-drop-out group (Table 1). The households in the drop-out group also had a significantly higher household size, were more likely to live in the town of Nouna, and more likely not to be Muslim (Table 1). No significant difference between the two groups was detected in terms of the age and sex of the household head, the judgement on the quality of care, the household illness reporting pattern, the

Discussion

To our knowledge, this is one of very few studies looking at the reasons motivating drop-out of CBI [7]. High drop-out rates endanger the sustainability of CBI schemes not only because they reduce the size of the insurance pool, but also because they bear a negative impact on further enrolment and drop-out. Proof of this statement is the everyday experience of schemes which cease to exist a few years after their inception exactly because they do not even manage to retain the members which they

Conclusion

High drop-out rates endanger the sustainability of CBI not only because they reduce the size of the insurance pool, but also because they bear a negative impact on further enrolment and drop-out. The drop-out rate in the scheme of the Nouna Health District, Burkina Faso, is very high. The reasons for drop-out may be related to affordability, health-needs and health demand, quality of care, household head and household characteristics. This study represents a valuable attempt towards further

Acknowledgements

This work was supported by the collaborative research grant ‘SFB 544’ of the German Research Society (DFG). The views expressed in this paper are those of the authors. The authors would like to thank all staff from the Nouna Health Research Centre for their valuable help during the data collection process.

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