A discrete choice experiment to predict factors associated with enrollment to a National Health Insurance Scheme among people in formal employment in Kampala District, Uganda

Abstract

Introduction: Despite significant healthcare needs, Uganda is the only East African country without an operational National Health Insurance Schemes (NHIS). Since March 2020, discussions have been ongoing about the proposed NHIS, particularly expected enrollment. Studies have associated socioeconomic and scheme-level factors to NHIS enrollment. We assessed the importance of different design attributes and scheme tradeoffs in Kampala, to enrollment. Findings will inform policy decisions and help create a more equitable and accessible health care system in Uganda, reducing the inequity in health care coverage. Methodology: Between January and March 2021, we conducted a Discrete Choice Experiment (DCE) among 433 participants. Prior to the DCE, a situational assessment using focus group discussions was conducted to guide on attributes and the respective levels. Scheme specific attributes included premium cost per person per month, payment modalities, unit of enrollment, and health benefit packages. We included participants under formal employment. A conditional logistic regression model was used to analyze the relative importance of treatment attributes, and the trade-offs people were willing to make. Results: Over 69.1% (299) respondents were willing to take up NHIS with males more likely (52.5%, p = 0.02) than females. Of the scheme level factors, respondents were more likely to take up a NHIS with comprehensive health package OR = 4.5 compared to those who prefer a basic health package (95% CI: 3.52 – 5. 82, p = 0.00). The odds of enrollment to NHIS among respondents who prefer annual contribution are 1.79 times those who prefer monthly premium contribution (95% CI: 1.51 – 2.13, p = 0.00). In addition, the relative importance of providing a NHIS with comprehensive health service benefits was 0.5. (difference between the highest and the lowest marginal effect). Conclusion: Scheme level factors have an effect on enrollment to NHIS hence the need to incorporate the consumer preferences when designing and implementing NHIS.