Abstract:
Introduction: Many low- and middle-income countries are attempting to
finance healthcare through voluntary membership of insurance schemes. This
study examined willingness to prepay for health care, social solidarity as well as
the acceptability of subsidies for the poor as factors that determine enrolment
in western Kenya.
Methods: This study employed a sequential mixed method design. We
conducted a cross-sectional household survey (n = 1,746), in-depth
household interviews (n = 36), 6 FGDs with community stakeholders and
key informant interviews (n = 11) with policy makers and implementers in a
single county in western Kenya. Social solidarity was defined by willingness to
make contributions that would benefit people who were sicker (“risk cross-
subsidization”) and poorer (“income cross-subsidization”). We also explored
participants’ preferences related to contribution cost structure – e.g., flat,
proportional, progressive, and exemptions for the poor.
Results: Our study found high willingness to prepay for healthcare
among those without insurance (87.1%) with competing priorities, low
incomes, poor access, and quality of health services, lack of awareness
of flexible payment options cited as barriers to enrolment. More than half
of respondents expressed willingness to tolerate risk and income cross-
subsidization suggesting strong social solidarity, which increased with socio-
economic status (SES). Higher SES was also associated with preference for
a proportional payment while lower SES with a progressive payment. Few
participants, even the poor themselves, felt the poor should be exempt from
any payment, due to stigma (being accused of laziness) and fear of losing
power in the process of receiving care (having the right to demand care).Conclusion: Although there was a high willingness to prepay for healthcare,
numerous barriers hindered voluntary health insurance enrolment in Kenya.
Our findings highlight the importance of fostering and leveraging existing
social solidarity to move away from flat rate contributions to allow for fairer risk
and income cross-subsidization. Finally, governments should invest in robust
strategies to effectively identify subsidy beneficiaries