Swiss Tropical and Public Health Institute, Basel, Switzerland.
University of Basel, Basel, Switzerland.
Int J Equity Health. 2018 Nov 20;17(1):170. doi: 10.1186/s12939-018-0889-7.
Rotating savings and credit associations (ROSCAs) are highly active in many sub-Saharan African countries, serving as an important gateway for coping with financial risk. In light of the Kenya's National Hospital Insurance Fund's (NHIF's) strategy of targeting ROSCAs for membership enrolment, this study sought to estimate how ROSCA membership influences the determinants of voluntary health insurance enrolment.
A cross-sectional survey of 444 households was carried out in Kisumu City between July and August 2016. A structured questionnaire was administered on health insurance membership, household attributes, headship characteristics and health-seeking behaviour. We assessed the influence of ROSCA membership on the associations between NHIF enrolment and the explanatory variables using univariate logistic regression.
The study found that education was associated with NHIF demand regardless of ROSCA membership. Both ROSCA and non-ROSCA households with high socioeconomic status showed stronger health insurance demand compared with poorer households; there was, however, no evidence that the strength of this association was influenced by ROSCA status (p-value = 0.47). Participants who were self-employed were significantly less likely to enrol into the NHIF if they did not belong to a ROSCA (interaction test p-value = 0.03). NHIF enrolment was found to be lower among female-headed households. There was a borderline effect of ROSCA membership on this association, with a lower odds ratio amongst non-ROSCA members (p-value = 0.09): the low treatment numbers amongst the insured infers that ROSCA membership may play a role on the association between gender and NHIF demand.
Our findings suggest that ROSCA membership may play a role in increasing health insurance demand amongst some traditionally under-represented groups such as women and the self-employed. However, the strategy of targeting ROSCAs to increase national health insurance enrolment may yield exiguous results, given that ROSCA membership is itself influenced by several non-observable factors - such as time-availability and self-selection. It is therefore important to anchor outreach to ROSCAs within a broader, multi-pronged approach that targets households within their social, economic and political realities.
在许多撒哈拉以南非洲国家，轮转储蓄信贷协会（ROSCAs）非常活跃，是应对金融风险的重要途径。鉴于肯尼亚国家医院保险基金（NHIF）的战略是针对 ROSCA 进行会员招募，本研究旨在估计 ROSCA 会员资格如何影响自愿健康保险参保的决定因素。
2016 年 7 月至 8 月在基苏木市对 444 户家庭进行了横断面调查。通过问卷调查了解了健康保险参保情况、家庭属性、户主特征和就医行为。我们使用单变量逻辑回归评估了 ROSCA 会员资格对 NHIF 参保与解释变量之间关联的影响。
研究发现，无论 ROSCA 会员资格如何，教育都与 NHIF 的需求有关。高社会经济地位的 ROSCA 和非 ROSCA 家庭与较贫困家庭相比，对健康保险的需求更强；然而，没有证据表明这种关联的强度受到 ROSCA 状况的影响（p 值=0.47）。如果不属于 ROSCA，自营职业者加入 NHIF 的可能性显著降低（交互检验 p 值=0.03）。女性户主家庭的 NHIF 参保率较低。ROSCA 会员资格对这种关联有边缘效应，非 ROSCA 成员的优势比较低（p 值=0.09）：参保人数较少表明 ROSCA 会员资格可能在性别和 NHIF 需求之间的关联中发挥作用。
我们的研究结果表明，ROSCA 会员资格可能在增加一些传统上代表性不足的群体（如女性和自营职业者）对健康保险的需求方面发挥作用。然而，鉴于 ROSCA 会员资格本身受到几个不可观察因素的影响，例如时间可用性和自我选择，针对 ROSCA 来增加国家健康保险参保率的策略可能收效甚微。因此，重要的是将针对 ROSCA 的外展工作纳入一个更广泛的、多管齐下的方法中，该方法针对家庭的社会、经济和政治现实。
