Abstract:
Background: Universal health coverage (UHC) is important in terms of improving access
to quality health care while protecting households from the risk of catastrophic health
spending and impoverishment. However, progress to UHC has been hampered by the
measures to increase mandatory prepaid funds especially in low- and middle-income
countries where there are large populations in the informal sector. Important
considerations in expanding coverage to the informal sector should include an
exploration of the type of prepayment system that is acceptable to the informal sector and
the features of such a design that would encourage prepayment for health care among this
population group. The objective of the study was to document the views of informal
sector workers regarding different prepayment mechanisms, and critically analyze key
design features of a future health system and the policy implications of financing UHC in
Kenya.
Methods: This was part of larger study which involved a mixed-methods approach. The
following tools were used to collect data from informal sector workers: focus group
discussions [N = 16 (rural = 7; urban = 9)], individual in-depth interviews [N = 26 (rural
= 14; urban = 12)] and a questionnaire survey [N = 455(rural = 129; urban = 326)].
Thematic approach was used to analyze qualitative data while Stata v.11 involving
mainly descriptive analysis was used in quantitative data. The tools mentioned were used
to collect data to meet various objectives of a larger study and what is presented here
constitutes a small section of the data generated by these tools.
Results: The findings show that informal sector workers in rural and urban areas prefer
different prepayment systems for financing UHC. Preference for a non-contributory
system of financing UHC was particularly strong in the urban study site (58%). Over
70% in the rural area preferred a contributory mechanism in financing UHC. The main
concern for informal sector workers regardless of the overall design of the financing
approach to UHC included a poor governance culture especially one that does not punish
corruption. Other reasons especially with regard to the contributory financing approach
included high premium costs and inability to enforce contributions from informal sector.
Conclusion: On average 47% of all study participants, the largest single majority, are in
favor of a non-contributory financing mechanism. Strong evidence from existing
literature indicates difficulties in implementing social contributions as the primary
financing mechanism for UHC in contexts with large informal sector populations. Noncontributory financing should be strongly recommended to policymakers to be the
primary financing mechanism and supplemented by social contributions.