Abstract
Background
Low enrolment and high drop-out rates are common problems in voluntary health insurance schemes. Yet, most studies in this research area focus on community-based health insurance and enrolment, rather than drop-out.
Objective
This study examines what causes informal sector families not to renew their voluntary National Health Insurance Fund (NHIF) health insurance membership in Eastern Sudan.
Methods
Primary data from about 600 informal sector households that dropped out or remained insured, collected through a household survey conducted in March 2014, were used. Logistic regressions were employed to examine what determines drop-out of the voluntary NHIF scheme.
Results
The logistic regression results are consistent with the existing literature and confirm the importance of household head, household and community characteristics. Notably, worse family health status and higher health care utilization decrease the probability of drop-out, which requires further analysis as it may indicate the problem of adverse selection and insufficient risk management. Most importantly, the results consistently show that household heads who are satisfied with health services and those who understand the main features of the voluntary NHIF scheme are less likely to drop out. Also, 30 % of drop-out households hold a social support card and reported that the social support scheme is the main reason for not renewing their voluntary NHIF health insurance membership as they qualify for sponsored NHIF health insurance membership.
Conclusions
This study shows that satisfaction with health services and knowledge of the health insurance scheme are important factors explaining drop-out of a national health insurance programme. The results suggest that education and information campaigns should be developed further to raise understanding of the NHIF voluntary scheme. In addition, information systems and coordination between the main agencies should be strengthened to reduce administrative costs and ensure policy coherence.
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Notes
The World Health Organization (WHO), however, reported that the total expenditure on health as a percentage of GDP stood at 8.4 in 2011 [29].
A combined dataset, comprising the dataset used in this study and additional data collected from never-insured individuals using convenience sampling, was used in Fakihammed [36].
The Sudan Technical and Ethical Review Committee, whose approval was obtained, set a range of 30–40 for the total number of blocks/villages.
The authors are grateful to an anonymous referee for suggesting this.
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Acknowledgments
The authors would like to thank the staff of the NHIF Kassala State and key people from the communities for assisting with the data collection. The authors are also grateful to the anonymous referees for providing valuable comments.
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Chantal Herberholz and Wael Ahmed Fakihammed confirm that no funding has been received for the conduct of this study and/or preparation of this research article. Chantal Herberholz declares that she has no conflicts of interest. Wael Ahmed Fakihammed was working with the NHIF, Kassala state, Sudan, when the data were collected, and he is still working there today, serving as SSHS/CBHI State Coordinator, BMB Mott MacDonald. Permission to collect the data was obtained by Wael Ahmed Fakihammed from the Sudan Technical and Ethical Review Committee. Informed consent was obtained from all individual participants included in the study.
Author contributions
Chantal Herberholz is the principal investigator and bears the ultimate responsibility for this research article. She was responsible for study conception and research design, conducting the research (excluding data collection), and writing, as well as revising, the first and final versions of this research article. The data were collected and entered into a database by Wael Ahmed Fakihammed, who was also responsible for questionnaire and sampling design. Wael Ahmed Fakihammed further contributed to conducting the research by providing vital information about the local contexts and helping to analyze the data, as well as sending comments on the drafts.
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Herberholz, C., Fakihammed, W.A. Determinants of Voluntary National Health Insurance Drop-Out in Eastern Sudan. Appl Health Econ Health Policy 15, 215–226 (2017). https://doi.org/10.1007/s40258-016-0281-y
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DOI: https://doi.org/10.1007/s40258-016-0281-y