Community health insurance (CHI) is receiving increased attention as a means of health financing in low- and middle-income countries. In countries with limited ability to develop and sustain national health insurance programmes, CHI has emerged as a valuable alternative to user fees since, by pooling risks and resources at the community level, it promises to ensure better access to health services and greater financial protection against the costs of illness for traditionally excluded and disadvantaged populations. (1-3)
In practice, however, CHI often falls short of achieving its potential, primarily because it fails to secure satisfactory levels of participation.(4-7) Although the inability to secure satisfactory enrolment rates among target populations remains a major concern across all low- and middle-income countries, (4,8-10) the problem assumes acute proportions in sub-Saharan Africa, where schemes rarely attain 10% coverage among target populations. (7) For this reason, they often cease to exist within a few years of their inception. (4,7,11)
Although the problem of low enrolment has long dominated the policy debate, rigorous scientific evaluations of the factors affecting the decision to enrol in CHI in sub-Saharan Africa are still very scarce. (6,12) While several studies have documented voluntary health insurance experiences in Asia, (8,10,13-16) only a limited number of evaluations have explored the factors influencing the decision to enrol or not to enrol in CHI in sub-Saharan countries. (17-19) The literature on CHI in sub-Saharan Africa has long been dominated by consultancy reports, which have focused on assessing the managerial and financial capacity of existing schemes rather than systematically exploring the factors motivating or discouraging enrolment. (20-23) Understanding the reasons behind low enrolment rates is therefore a relevant research question.
Our study aimed to identify factors shaping the decision to enrol in CHI in a population-based study applying a case-control methodology. We hypothesized that the decision to enrol in CHI was shaped by a combination of household head, household and community characteristics. The study was conducted in the Nouna Health District, Burkina Faso, in 2004.
The Nouna Health District is located in the northwest of the country, about 300 km from the capital, Ouagadougou. A CHI scheme was initiated there at the beginning of 2004. The aim is to set up a district-wide scheme by progressively offering CHI to all the villages of the district and to all sectors of the district capital, the town of Nouna. Our study is limited to those parts of the district--12 villages and 3 town sectors--in which the first enrolment campaign took place between February and May 2004. The insurance product on offer was identical across the 15 communities. The unit of enrolment was the household. The yearly premium amounted to 1500 CFA francs (US$ 3) for each adult and 500 CFA francs (US$ 1) for each child (less than 15 years of age). The benefit package included a wide range of first-line and second-line services that were available at the health facilities within the district. It excluded reimbursement for all traditional healing practices. Decisions regarding the services that should be included and those that should be excluded from the benefit package were guided by the results of a study which explored community preferences for such a package prior to the implementation of the scheme. This study and details of the benefit package are described in detail elsewhere. (24,25) Depending on their geographic location, villages and town sectors were designated to receive primary care either at one of five rural first-line facilities or at the urban first-line facility located on the premises of the district hospital. If referred, all patients were entitled to receive secondary care at the district hospital. …