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Low enrolment in micro-health insurance (MHI) schemes is a recurring issue affecting the viability of such schemes. Beyond the efforts addressing low subscription and retention in these schemes, little is known on how social representations are related to micro-health insurance schemes enrolment and retention. This scoping review aimed at exploring the role of social representations in shaping enrollment and retention in MHI in sub-Saharan Africa. We reviewed qualitative, quantitative and mixed methods studies conducted between 2004 and 2019 in sub-Saharan Africa. We limited our search to peer-reviewed and grey literature in English and French reporting on social representations of MHI. We defined social representations as conventions, cultural and religious beliefs, local rules and norms, local solidarity practices, political landscape and social cohesion. We applied the framework developed by Arksey and O'Malley and modified by Levac et al. to identify and extract data from relevant studies. We extracted information from a total of 78 studies written in English (60%) and in French (40%) of which 56% were conducted in West Africa. More than half of all studies explored either cultural and religious beliefs (56%) or social conventions (55%) whereas only 37% focused on social cohesion (37%). Only six papers (8%) touched upon all six categories of social representation considered in this study whereas 25% of the papers studied more than three categories. We found that all the studied social representations influence enrollment and retention in MHI schemes. Our findings highlight the paucity of evidence on social representations in relation to MHI schemes. This initial attempt to compile evidence on social representations invites more research on the role those social representations play on the viability of MHI schemes. Our findings call for program design and implementation strategies to consider and adjust to local social representations in order to enhance scheme attractiveness., (© The Author(s) 2022. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Community-based health insurance (CBHI) has been implemented in many low- and middle-income countries to increase financial risk protection in populations without access to formal health insurance. While the design of such social programmes is fundamental to ensuring equitable access to care, little is known about the operational and structural factors influencing enrolment in CBHI schemes. In this study, we took advantage of newly established data monitoring requirements in Senegal to explore the association between the operational capacity and structure of CBHI schemes-also termed 'mutual health organizations' (MHO) in francophone countries-and their enrolment levels. The dataset comprised 12 waves of quarterly data over 2017-2019 and covered all 676 MHOs registered in the country. Primary analyses were conducted using dynamic panel data regression analysis. We found that higher operational capacity significantly predicted higher performance: enrolment was positively associated with the presence of a salaried manager at the MHO level (12% more total enrolees, 23% more poor members) and with stronger cooperation between MHOs and local health posts (for each additional contract signed, total enrolees and poor members increased by 7% and 5%, respectively). However, higher operational capacity was only modestly associated with higher sustainability proxied by the proportion of enrolees up to date with premium payment. We also found that structural factors were influential, with MHOs located within a health facility enrolling fewer poor members (-16%). Sensitivity analyses showed that these associations were robust. Our findings suggest that policies aimed at professionalizing and reinforcing the operational capacity of MHOs could accelerate the expansion of CBHI coverage, including in the most impoverished populations. However, they also suggest that increasing operational capacity alone may be insufficient to make CBHI schemes sustainable over time., (© The Author(s) 2022. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

In the past two decades, community-based Health Insurance (CBHI) is expanding in most of sub-Saharan African countries with the aim of improving equitable access to health services for the informal sector population. However, population enrolment into CBHI and membership renewals thereafter remains stubbornly low. The purpose of this systematic review is to generate an evidence to better understand barriers to uptake of CBHI in sub-Saharan African countries. We systematically searched for relevant studies from databases: PubMed, Scopus, Cumulative Index of Nursing and Allied Health Literature (CINAHL), PsychInfo, ProQest, Excerpta Medica dataBASE (EMBASE) and Africa-Wide Information. The search strategy combined detailed terms related to (i) CBHI, (ii) enrolment/renewal and (iii) sub-Saharan African countries. A narrative synthesis of findings was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The protocol for this systematic review was registered with International Prospective Register of Systematic Reviews (PROSPERO) (ref: CRD42020183959). The database search identified 4055 potential references from which 15 articles reporting on 17 studies met the eligibility criteria. The findings revealed that barriers to uptake of CBHI in sub-Saharan Africa were multidimensional in nature. Lack of awareness about the importance of health insurance, socio-economic factors, health beliefs, lack of trust towards scheme management, poor quality of health services, perceived health status and limited health benefit entitlements were reported as barriers that affect enrolments into CBHI and membership renewals. The methodological quality of studies included in this review has been found to be mostly suboptimal. The overall findings of this systematic review identified major barriers of CBHI uptake in sub-Saharan African countries which may help policymakers to make evidence-informed decisions. Findings of this review also highlighted that further research with a robust methodological quality, depth and breadth is needed to help better understand the factors that limit CBHI uptake at individual, societal and structural levels in sub-Saharan Africa., (© The Author(s) 2021. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

In sub-Saharan African countries, out-of-pocket payments can be a major barrier to accessing appropriate healthcare services. Community-based health insurance (CBHI) has emerged as a context-appropriate risk-pooling mechanism to provide some financial protection to populations without access to formal health insurance. The aim of this rapid review was to examine the peer-reviewed literature on the impact of CBHI on the use of healthcare services as well as its capacity to improve equity in the use of healthcare between different socio-economic groups. A systematic search of three electronic databases (Pubmed, Cochrane Library and Littérature en Santé) was performed. Data were extracted on scheme and study characteristics, as well as the impact of the schemes on relevant outcomes. Sixteen publications met the inclusion criteria, studying schemes from seven different countries. They provide strong evidence that community-based health insurance can contribute to improving access to outpatient care and weak evidence that they improve access to inpatient care. There was low evidence on their capacity to improve equity in access to healthcare among insured members. In the absence of sufficient public spending for healthcare, such schemes may be able to provide some valuable benefits for communities with limited access to primary-level care in sub-Saharan Africa. The overall high risk of bias of the studies and the wide existing variety of insurance arrangements suggest caution in generalizing these results. These findings need to be validated and further developed by rigorous studies., (© The Author(s) 2021. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Community-based health insurance (CBHI) has gained popularity in many low- and middle-income countries, partly as a policy response to calls for low-cost, pro-poor health financing solutions. In Africa, Rwanda has successfully implemented two types of CBHI systems since 2005, one of which with a flat rate premium (2005-10) and the other with a stratified premium (2011-present). Existing CBHI evaluations have, however, tended to ignore the potential distributional aspects of the household contributions made towards CBHI. In this paper, we investigate the pattern of socioeconomic inequality in CBHI household premium contributions in Rwanda within the implementation periods. We also assess gender differences in CBHI contributions. Using the 2010/11 and 2013/14 rounds of national survey data, we quantify the magnitude of inequality in CBHI payments, decompose the concentration index of inequality, calculate Kakwani indices and implement unconditional quantile regression decomposition to assess gender differences in CBHI expenditure. We find that the CBHI with stratified premiums is less regressive than CBHI with a flat rate premium system. Decomposition analysis indicates that income and CBHI stratification explain a large share of the inequality in CBHI payments. With respect to gender, female-headed households make lower contributions towards CBHI expenditure, compared with male-headed households. In terms of policy implications, the results suggest that there may be a need for increasing the premium bracket for the wealthier households, as well as for the provision of more subsidies to vulnerable households., (© The Author(s) 2020. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

In Tanzania, the health financing system is extremely fragmented with strategies in place to supplement funds provided from the central level. One of these strategies is the Community Health Fund (CHF), a voluntary health insurance scheme for the informal rural sector. As its implementation has been challenging, we investigated different CHF implementation practices and how these practices and the wider health financing context affect CHF implementation and potentially enrolment. Two councils were purposively selected for this study. Routine data relevant for understanding CHF implementation in the wider health financing context were collected at council and public health facility level. Additionally, an economic costing approach was used to estimate CHF administration cost and analyse its financing sources. Our results showed the importance of considering different CHF implementation practices and the wider health financing context when looking at CHF performance. Exemption policies and healthcare-seeking behaviour influenced negatively the maximum potential enrolment rate of the voluntary CHF scheme. Higher revenues from user fees, user fee policies and fund pooling mechanisms might have furthermore set incentives for care providers to prioritize user fees over CHF revenues. Costing results clearly pointed out the lack of financial sustainability of the CHF. The financial analysis however also showed that thanks to significant contributions from other health financing mechanisms to CHF administration, the CHF could be left with more than 70% of its revenues for financing services. To make the CHF work, major improvements in CHF implementation practices would be needed, but given the wider health financing context and healthcare-seeking behaviours, it is questionable whether such improvements are feasible, scalable and value for money. Thus, our results call for a reconsideration of approaches taken to address the challenges in health financing and demonstrate that the CHF cannot be looked at as a stand-alone system., (© The Author(s) 2019. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

A variety of health financing schemes shaped on pre-payment scheme have been implemented across Sub-Saharan Africa (SSA) to address the Millennium Development Goals (MDGs). In Mauritania, the Obstetric Risk Insurance package (ORI) focusing on maternal and perinatal health has been progressively implemented at the health district level since 2002. Here, our main objective was to assess the effectiveness of the ORI in increasing facility-based delivery rates, as well as increases in family planning, antenatal and postnatal care, caesarean delivery and neonatal health, from demographic and health survey data between 2002 and 2011. We also examined whether the effects of the ORI varied between strata of the population. The study was based on a quasi-experimental before-and-after design to assess the causal link between availability of ORI and increase in use of maternal health services and neonatal mortality. In combination with geographical information system, difference-in-differences and odd ratio approaches were used to address our objectives. Indicators of access to care for pregnant women and neonatal health and improved in both non-intervention and intervention groups during the study period. There was no global effect of the availability of ORI on facility-based delivery rates, nor on the use of antenatal and postnatal care services, except for qualified antenatal services. However, delivery rates in local health centres with ORI increased more rapidly than in those with no ORI, the contrary was shown for hospitals. Caesarean delivery and family planning decreased with ORI. Although late neonatal mortality rates remained low in the country, a significant decrease was seen in districts without ORI. Except for some strata of the population, ORI has not really met its objective of attracting more pregnant women towards facility-based health care., (© The Author 2016. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

Low renewal rate is a key challenge facing the sustainability of community-based health insurance (CBHI) schemes. While there is a large literature on initial enrolment into such schemes, there is limited evidence on the factors that impede renewal. This article uses longitudinal data to analyse what determines renewal, both 1 year and 2 years after the introduction of three CBHI schemes, which have been operating in rural Bihar and Uttar Pradesh since 2011. We find that initial scheme uptake is ∼23-24% and that 2 years after scheme operation, only ∼20% of the initial enrolees maintain their membership. A household's socio-economic status does not seem to play a large role in impeding renewal. In some instances, a greater understanding of the scheme boosts renewal. The link between health status and use of health care in maintaining renewal is mixed. The clearest effect is that individuals living in households that have received benefits from the scheme are substantially more likely to renew their contracts. We conclude that the low retention rates may be attributed to limited benefit packages, slow claims processing times and the gap between the amounts claimed and amounts paid out by insurance., (© The Author 2016. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Low contract renewal rates have been identified as one of the challenges facing the development of community-based health insurance (CBHI) schemes. This article uses longitudinal household survey data gathered in 2012 and 2013 to examine dropout in the case of Ethiopia's pilot CBHI scheme. We treat dropout as a function of scheme affordability, health status, scheme understanding and quality of care. The scheme saw enrolment increase from 41% 1 year after inception to 48% a year later. An impressive 82% of those who enrolled in the first year renewed their subscriptions, while 25% who had not enrolled joined the scheme. The analysis shows that socioeconomic status, a greater understanding of health insurance and experience with and knowledge of the CBHI scheme are associated with lower dropout rates. While there are concerns about the quality of care and the treatment meted out to the insured by providers, the overall picture is that returns from the scheme are overwhelmingly positive. For the bulk of households, premiums do not seem to be onerous, basic understanding of health insurance is high and almost all those who are currently enrolled signalled their desire to renew contracts., (Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine © The Author 2015; all rights reserved.)

Continued low rates of enrolment in community-based health insurance (CBHI) suggest that strategies proposed for scaling up are unsuccessfully implemented or inadequately address underlying limitations of CBHI. One reason may be a lack of incorporation of social and political context into CBHI policy. In this study, the hypothesis is proposed that values and power relations inherent in social networks of CBHI stakeholders can explain levels of CBHI coverage. To test this, three case studies constituting Senegalese CBHI schemes were studied. Transcripts of interviews with 64 CBHI stakeholders were analysed using inductive coding. The five most important themes pertaining to social values and power relations were: voluntarism, trust, solidarity, political engagement and social movements. Analysis of these themes raises a number of policy and implementation challenges for expanding CBHI coverage. First is the need to subsidize salaries for CBHI scheme staff. Second is the need to develop more sustainable internal and external governance structures through CBHI federations. Third is ensuring that CBHI resonates with local values concerning four dimensions of solidarity (health risk, vertical equity, scale and source). Government subsidies is one of the several potential strategies to achieve this. Fourth is the need for increased transparency in national policy. Fifth is the need for CBHI scheme leaders to increase their negotiating power vis-à-vis health service providers who control the resources needed for expanding CBHI coverage, through federations and a social movement dynamic. Systematically addressing all these challenges would represent a fundamental reform of the current CBHI model promoted in Senegal and in Africa more widely; this raises issues of feasibility in practice. From a theoretical perspective, the results suggest that studying values and power relations among stakeholders in multiple case studies is a useful complement to traditional health systems analysis., (Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine © The Author 2014; all rights reserved.)

Community-based health insurance expansion has been proposed as a financing solution for the sizable informal sector in low-income settings. However, there is limited evidence of the administrative costs of such schemes. We assessed annual facility and district-level costs of running the Community Health Fund (CHF), a voluntary health insurance scheme for the informal sector in a rural and an urban district from the same region in Tanzania. Information on resource use, CHF membership and revenue was obtained from district managers and health workers from two facilities in each district. The administrative cost per CHF member household and the cost to revenue ratio were estimated. Revenue collection was the most costly activity at facility level (78% of total costs), followed by stewardship and management (13%) and pooling of funds (10%). Stewardship and management was the main activity at district level. The administration cost per CHF member household ranged from USD 3.33 to USD 12.12 per year. The cost to revenue ratio ranged from 50% to 364%. The cost of administering the CHF was high relative to revenue generated. Similar studies from other settings should be encouraged., (Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine © The Author 2013.)

This article assesses insurance uptake in three community-based health insurance (CBHI) schemes located in rural parts of two of India's poorest states and offered through women's self-help groups (SHGs). We examine what drives uptake, the degree of inclusive practices of the schemes and the influence of health status on enrolment. The most important finding is that a household's socio-economic status does not appear to substantially inhibit uptake. In some cases scheduled caste/scheduled tribe households are more likely to enrol. Second, households with greater financial liabilities find insurance more attractive. Third, access to the national hospital insurance scheme Rashtriya Swasthya Bima Yojana does not dampen CBHI uptake, suggesting that the potential for greater development of insurance markets and products beyond existing ones would respond to a need. Fourth, recent episodes of illness and self-assessed health status do not influence uptake. Fifth, insurance coverage is prioritized within households, with the household head, the spouse of the household head and both male and female children of the household head, more likely to be insured as compared with other relatives. Sixth, offering insurance through women's SHGs appears to mitigate concerns about the inclusiveness and sustainability of CBHI schemes. Given the pan-Indian spread of SHGs, offering insurance through such groups offers the potential to scale-up CBHI., (Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine © The Author 2013; all rights reserved.)