Sociodemographic patterns of health insurance coverage in Namibia

Universal Health Coverage (UHC) is defined by the World Health Organization (WHO) to be where “…all people obtain the health services they need without suffering financial hardship when paying for them” [1]. However, the number of people globally facing catastrophic payments on health is rising [2]. Around 800 million people spend more than 10% of household expenditure on health and around 100 million people are being pushed into extreme poverty every year due to out-of-pocket (OOP) expenditures on health [2].

Namibia is committed to achieving UHC. As an upper-middle income country, with a small population of around 2.5 million people, Namibia’s total health expenditure (THE) as a percentage of gross domestic product (GDP) and per capita health expenditure are comparatively high relative to other sub-Saharan African countries [3‐5]. Healthcare in Namibia is funded through Government funding, prepaid private expenditure, OOP expenditure and donor funding [4]. In 2014/15, 64% of THE was provided by the Namibian Government, which equated to around 13% of government expenditure for the fiscal year [4]. Additionally, household expenditures on health fall well below the level indicative of catastrophic health expenditures [6]. However, despite its strong financial position, Namibia may still face challenges to achieving UHC. Namibia experiences substantial wealth inequality across the population [7], which may affect the ability of individuals and households to afford healthcare [8]. Additionally, THE is unevenly distributed, with 36% of THE providing health insurance that covers less than one fifth of the population [4]. Given these inequities in health financing in Namibia, additional financial resources may be needed to realise UHC [4].

Health insurance and other pre-financing mechanisms have been identified as important components of UHC strategies [9‐12]. Health insurance has been associated with health-seeking behaviour across sub-Saharan Africa (SSA) and has been found to reduce OOP expenditures, catastrophic spending on health, financial barriers to healthcare, and to protect against poverty in a number of developing countries [13‐22]. In Namibia, health insurance has been associated with cancer screening [23‐25], timely antenatal care visits and skilled attendance at birth [26, 27], as well as reductions in the economic consequences of HIV-associated health costs [28]. However, the impact of health insurance on health-seeking behaviour more broadly is less well understood in the country. In addition to understanding the coverage of health insurance in a population, it is also important to assess equity in health insurance coverage. Inequalities in Namibia, such as the country’s high income inequality, notable unemployment rate and variable access to and completion of education [7, 29‐31], may directly or indirectly impact upon the ability of households to afford healthcare or health insurance. Wealth and education have been widely associated with having insurance in other settings [32‐38]; by comparison, the sociodemographic factors associated with health insurance in Namibia have not been well described.

As health insurance is one strategy that could help to achieve UHC, it will be important to assess equity in health insurance coverage across different sociodemographic groups. A better understanding of the sociodemographic factors that are associated with health insurance coverage may help to inform the design and implementation of strategies to improve financial protection from healthcare-associated costs. As such, we first aimed to investigate the relation between health insurance and health service utilisation, and secondly to explore the coverage of health insurance and the demographic factors associated with health insurance in Namibia, using data from the 2013 Namibia Demographic and Health Survey (DHS).

Weighted and unweighted analyses were conducted; here we present unweighted results, with weighted results presented in Additional file 1: Table S1 and Table S2. No material difference was observed between weighted and unweighted results.

Our findings suggest that health insurance plays a role in healthcare access and health service utilisation in Namibia; however, just 17.5% of this DHS population were insured, leaving a large proportion of the population potentially disadvantaged when accessing healthcare. We found that sex, education and wealth were independently associated with health insurance. Education also modified the association between health insurance and sex and wealth, whereby education was more strongly associated with health insurance in the less wealthy and women. Furthermore, the likelihood of women being insured increased with education level.

There are many factors that may contribute to health insurance coverage; our findings that wealth and education are associated with having health insurance are consistent with those from other settings [32‐38]. Wealthier households often have more disposable income to afford insurance. In Namibia, a country with a high income inequality, poorer households can only allocate minor shares of expenditure to healthcare [8]. Furthermore, the structure of many health insurance schemes favours wealthier populations; for example, high annual premiums instead of installment payment options and reimbursement mechanisms, which mean healthcare must first be paid for OOP [42]. The association between sex and health insurance is more complex; by contrast to our findings, studies in Ghana and South Africa identified men to be less likely to have health insurance than women [32, 34]. It has also been suggested that women, as care-givers, are more conscious of the importance of healthcare and insurance and may be more likely to seek healthcare [34, 43]. Similarly, in our analysis, women were more likely to have sought healthcare than men but this health-seeking attitude was not reflected in the patterns of health insurance coverage.

Education, as well as being an independent determinant of health insurance in this Namibian population, also modified sex and wealth disparities in insurance coverage. We found that greater educational attainment increased the likelihood of women being insured. Additionally, when women were educated to higher level there was no difference in insurance compared with men, irrespective of wealth and other sociodemographic factors. This indicates that progression through the education system is especially important for women being insured and is consistent with previous findings that secondary or higher educational attainment is linked to increased coverage of health insurance in other sub-Saharan African populations [35, 36]. We also found that education level was more strongly associated with health insurance in less wealthy populations. Our findings therefore highlight the value and impact of education on health insurance. Education may influence health insurance coverage in a number of ways. Education could improve knowledge and attitudes towards health seeking and the value of health insurance. In Namibia, education has been associated with willingness to join and pay for low-cost health insurance [44] and has also been associated with increased awareness about insurance schemes elsewhere [45, 46]. Therefore, education may empower women and relatively poorer individuals to make choices, including decisions around health [47].

Due to the cross-sectional nature of the data, it was not possible to assess the temporality of the associations observed between sociodemographic factors and health insurance nor between health insurance and health service utilisation. Wealth was also measured at the household level, restricting our understanding of the effects of individual wealth on health insurance. Other factors beyond the scope of this analysis may also influence health service utilisation or health insurance coverage, such as the likelihood that the consumer will become ill, preexisting medical conditions, or individual knowledge, attitudes and practice towards health and insurance [42, 48‐50]. It was also not possible to explore the willingness to pay for health insurance. A further limitation is that the data used for these analyses were collected in 2013, and thus may not fully reflect the situation in Namibia at present.

Education and public engagement have been identified as key strategies for the uptake and acceptability of health insurance in other settings [49, 51]. Improving access to, and the quality of, education is an important component of multiple government strategies in Namibia [29, 52, 53] and our findings further highlight the importance of the country’s commitments to improving education. Although access to education in Namibia is high overall, including for women, attendance and the quality of education is variable and often inadequate in lower-income communities, marginalised populations and in remote or rural areas [29]. Whilst a high percentage of the Namibian population complete primary education, transition to and completion of secondary and higher education could be improved [29]. Our findings suggest that improvements in access to education may help individuals to better manage their health but further research is needed to better understand this relationship. These findings have implications for the design and implementation of strategies to scale-up health insurance coverage or improve financial protection for more vulnerable populations. Health insurance could be scaled-up through community engagement strategies that utilise the media and other advocacy tools [54, 55]. Furthermore, mechanisms to make health insurance more affordable through subsidisation, for example, may help to increase uptake [12, 44]. Employer-provided schemes, which accounted for more than half of insurance in this population, could be expanded to the informal sector. For example, one study in Namibia found that employers on commercial farms were receptive to providing a co-pay insurance plan for their employees [56]. An alternative solution in countries like Namibia, where around a fifth of healthcare is financed via private health insurance, is that Governments could target public financing to populations less able or likely to participate in voluntary insurance schemes [57].

In conclusion, health insurance is an important component of health service utilisation in Namibia, but inequities in the coverage of these insurance schemes means that many individuals could be at a disadvantage when accessing healthcare. Specifically, women and those with lower levels of education and wealth were less likely to be covered by health insurance. Our findings suggest that, in Namibia, education may be important for bridging gaps in health insurance coverage for women and the less wealthy, but further research is needed to fully understand this relationship. These findings could inform the design and implementation of interventions to scale-up health insurance or provide greater financial protection from healthcare-associated costs for uninsured populations. Additional research is also needed to evaluate the effectiveness of insurance schemes and the quality of care received as a result of being insured in Namibia and elsewhere if UHC is to be realised.