“It is like an umbrella covering you, yet it does not protect you from the rain”: A mixed methods study of affordability of premiums, insurance coverage, the extent of the protection it provides in western Kenya
Authors: Maritim Beryl , Koon Adam D , Kimaina Allan , Lagat Cornelius , Riungu Elvira , Laktabai Jeremiah , Ruhl Laura J , Kibiwot Michael , Scanlon Michael L , Goudge Jane 
Published: November 2022

Countries in Sub-Saharan Africa are increasingly adopting mandatory social health insurance programs. In Kenya, mandatory social health insurance is being implemented through the national health insurer, the National Hospital Insurance Fund (NHIF), but the level of coverage and affordability especially for rural informal households is unclear. This study provides as assessment of affordability of NHIF premiums, the need for financial risk protection, and the extent of financial protection provided by NHIF among rural informal workers in western Kenya. Methods: We conducted a mixed methods study with a cross-sectional household survey (n = 1773), in-depth household interviews (n = 36), and 6 FGDs with community stakeholders. We estimated unaffordability of the monthly NHIF premiums (defined as the premium representing > 5% of total household expenditure) and the incidence and intensity of catastrophic and impoverishing health expenditures. Logistic regression was used to assess sociodemographic characteristics associated with incurring catastrophic health expenditures. We qualitatively explored households’ views on affordability and coverage of health insurance, their experiences with healthcare costs and coping strategies using framework analysis. Results We found that a vast majority of rural households did not have health insurance (88.4%) exposing them to financial risk while seeking healthcare. Health insurance was not affordable for majority of households - both insured (60%) and uninsured (80%). Rural households spent an average of 12% of their household budget on OOP spending which was catastrophic to 11.7% of the households. While uninsured households experienced higher and more intense levels of CHE compared to the insured households, both insured and uninsured households reported high OOP spending and similar levels of impoverishments by OOP. Insured households were exposed to OOP because of under-coverage of services by NHIF and weaknesses in health service delivery. Participants expressed concerns about value of health insurance coverage given its cost, services, and financial protection relative to other social and economic needs that they face on daily basis. Households resulted to borrowing, fundraising, taking short term loans from family and friends and sale of family assets in order to meet healthcare costs Conclusion: Rural informal workers have increased vulnerability to financial risk related to healthcare costs and lack adequate financial risk protection through public health insurance. Not only is the NHIF premium unaffordable to majority of these households but the financial protection that is provides is inadequate to shield households against catastrophic healthcare payments because inadequate benefit package and the unavailability of health services in public facilities.