Elsevier

Health Policy

Volume 76, Issue 1, March 2006, Pages 58-71
Health Policy

Understanding consumers’ preferences and decision to enrol in community-based health insurance in rural West Africa

https://doi.org/10.1016/j.healthpol.2005.04.010Get rights and content

Abstract

This paper presents a qualitative investigation of consumers’ preferences regarding the single elements of a community-based health insurance (CBI) scheme recently implemented in a rural region in west Africa. The aim is to provide adequate policy-guidance to decision makers in low and middle income countries by producing an in-depth understanding of how consumers’ preferences may affect decision to participate in such schemes. Although it has long been suggested that feeble levels of participation may very well be an expression of consumers’ dissatisfaction with scheme design, little systematic efforts have so far been channelled towards supporting such argument with empirical evidence. Consumers’ preferences were explored through means of 32 individual interviews with household heads. Analysis used the method of constant comparison and was conducted by two independent researchers. Data from 10 focus group discussions provided an additional valuable source of triangulation. Findings suggest that decision to enrol is closely linked to whether the single elements of the scheme match consumers’ needs and expectations. In particular, consumers justified decision to join or not to join the insurance scheme in relation to their preference for the unit of enrolment, the premium level and the payment modalities, the benefit package, the health service provider network and the CBI managerial structure. The discussion of the findings focuses on how understanding consumers’ preferences and incorporating them in the design of a CBI scheme may result in increased participation rates, ensuring that poor populations gain better access to health services and enjoy greater protection against the cost of illness.

Introduction

In 1998, a review by the World Health Organisation (WHO) stated that across the world, little attention had been paid to understanding consumers’ preferences in relation to the implementation of community-based health insurance (CBI) [1]. The authors concluded that the low demand for CBI was to be at least partly attributed to consumer dissatisfaction with scheme design, and recommended that, in order to enhance participation, research efforts be channelled towards understanding what communities expect from CBI and how they wish to see their expectations met [1]. The World Health Report 2000 further reinforced their argument by proposing that responsiveness to people's expectations be considered a central goal of any health system [2].

Six years later, demand for health insurance in low income countries remains low [1], [3], [4], [5], [6], [7], indicating that CBI schemes continue to fail to reach satisfactory levels of participation among target populations [3], [6], [8], [9]. A clear understanding of why enrolment rates remain low is missing. Economic analysis has provided a partial answer to the question as it has successfully investigated the extent to which individual and household characteristics affect demand for health insurance in low income settings [10], [11], [12], [13]. Little has been done, however, to follow the WHO recommendation and explore consumers’ preferences for different elements of a scheme and their impact on decision to enrol.

Three studies relied on contingent valuation methods to estimate willingness-to-pay for health insurance in low income countries [14], [15], [16] and two other studies engaged in a formal exploration of community preferences for a benefit package [4], [17]. There is, however, a clear paucity of studies which systematically explore community preferences taking into account the totality of elements which make up any insurance scheme, including, for example, items such as payment modalities, healthcare provider network and management structures.

Understanding consumers’ preferences, monitoring them over time and meeting them to the extent which is possible, can determine the success of any health intervention as it enables policy-making to be aligned more closely with public expectations [18], [19], [20]. The underlying assumption of such argument is that demand for a given product, including a health care intervention, largely depends on whether the attributes of the product satisfy consumers’ preferences as to make it preferable to others and worthwhile purchasing. Designing a successful health intervention, one that is deemed worthwhile demanding by the population, therefore requires that policy-makers have adequate knowledge of community preferences and set the parameters of an intervention in such a way as to maximise them [21].

This paper presents a qualitative investigation of consumers’ preferences for the single elements of a CBI scheme recently implemented in the District of Nouna, Burkina Faso. The aim is to generate a comprehensive understanding of consumers’ preferences and their impact on decision to enrol, useful to policy-makers in guiding the implementation of similar schemes across low and middle income countries.

Section snippets

Research context

The Nouna Health District is located in the northwest of Burkina Faso, about 300 km from the capital Ouagadougou. The government is the only provider of Western health care services in the area and since the early 1990s, access to services is subject to the payment of user fees [22]. Given the financial barrier imposed by payment at point of delivery, health services in the District are characterized by low utilization with an average of only 0.31 contacts per capita per year [23]. Less than one

Methods

Preferences regarding the specific components of the CBI scheme were explored within the framework of a wider study investigating determinants of enrolment in CBI in the District of Nouna. We conducted 32 in-depth interviews with household heads. Individual interviews were judged to be a better means of assessing consumers’ preference, when compared to focus group discussions, because they offer the individual an opportunity to express his/her view freely without fear of being judged by other

Findings

All 32 interviews were conducted between May and June 2004. Twenty-four interviews were carried out in Djula, the local lingua franca, six in Bwamu and two directly in French. Interviews lasted between 30 min and 1 h 30 min. Table 1 reports basic information about the interviewees. Preferences regarding the specific elements of the scheme are presented in five sections which are organized around the themes explored during the interview: unit of enrolment, premium level and payment modalities,

Methodological considerations

Qualitative methods have been recognised in the literature as an appropriate means of investigating consumers’ preferences for health care interventions as they allow an open and in-depth exploration of community views [18], [20], [21], [39]. Still, they have been used almost exclusively to assess attitudes and behaviours in relation to specific treatment options [20], rather than to investigate consumers’ preferences concerning broader issues of health policy, with one of few exceptions being

Conclusion

Our findings suggest that understanding consumers’ preferences is essential to guide the design of a health intervention, in this case CBI, and that qualitative methods of analysis can successfully be employed to this regard. Understanding, and thereafter meeting, consumers’ preferences can in fact ensure that policy makers set compound health interventions, such as CBI, in line with people's needs and expectations, thus maximising community participation. This is of particular importance when

Acknowledgements

This study was supported by the collaborative research grant SFB 544 of the German Research Society (DFG). The authors would like to thank Dr. Hengjin Dong, Dr. Maurice Yé and Mr. Yemalé Ghislain Tiawara for their support during the planning phases of this study as well as the teams of the Nouna Health Research Centre, in particular Dr. Bocar Kouyaté, and of the Association Tontines Nouna, in particular Ms. Aline Bagayoyo, for their valuable help during the data collection process. The authors

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