title: What Factors Affect Voluntary Uptake of Community-Based Health Insurance Schemes in Low- and Middle-Income Countries? A Systematic Review and Meta-Analysis.
abstract: BACKGROUND
  This research article reports on factors influencing initial voluntary uptake of community-based health insurance (CBHI) schemes in low- and middle-income countries (LMIC), and renewal decisions.
  
  
  METHODS
  Following PRISMA protocol, we conducted a comprehensive search of academic and gray literature, including academic databases in social science, economics and medical sciences (e.g., Econlit, Global health, Medline, Proquest) and other electronic resources (e.g., Eldis and Google scholar). Search strategies were developed using the thesaurus or index terms (e.g., MeSH) specific to the databases, combined with free text terms related to CBHI or health insurance. Searches were conducted from May 2013 to November 2013 in English, French, German, and Spanish. From the initial search yield of 15,770 hits, 54 relevant studies were retained for analysis of factors influencing enrolment and renewal decisions. The quantitative synthesis (informed by meta-analysis) and the qualitative analysis (informed by thematic synthesis) were compared to gain insight for an overall synthesis of findings/statements.
  
  
  RESULTS
  Meta-analysis suggests that enrolments in CBHI were positively associated with household income, education and age of the household head (HHH), household size, female-headed household, married HHH and chronic illness episodes in the household. The thematic synthesis suggests the following factors as enablers for enrolment: (a) knowledge and understanding of insurance and CBHI, (b) quality of healthcare, (c) trust in scheme management. Factors found to be barriers to enrolment include: (a) inappropriate benefits package, (b) cultural beliefs, (c) affordability, (d) distance to healthcare facility, (e) lack of adequate legal and policy frameworks to support CBHI, and (f) stringent rules of some CBHI schemes. HHH education, household size and trust in the scheme management were positively associated with member renewal decisions. Other motivators were: (a) knowledge and understanding of insurance and CBHI, (b) healthcare quality, (c) trust in scheme management, and (d) receipt of an insurance payout the previous year. The barriers to renewal decisions were: (a) stringent rules of some CBHI schemes, (b) inadequate legal and policy frameworks to support CBHI and (c) inappropriate benefits package.
  
  
  CONCLUSIONS
  The demand-side factors positively affecting enrolment in CBHI include education, age, female household heads, and the socioeconomic status of households. Moreover, when individuals understand how their CBHI functions they are more likely to enroll and when people have a positive claims experience, they are more likely to renew. A higher prevalence of chronic conditions or the perception that healthcare is of good quality and nearby act as factors enhancing enrolment. The perception that services are distant or deficient leads to lower enrolments. The second insight is that trust in the scheme enables enrolment. Thirdly, clarity about the legal or policy framework acts as a factor influencing enrolments. This is significant, as it points to hitherto unpublished evidence that governments can effectively broaden their outreach to grassroots groups that are excluded from social protection by formulating supportive regulatory and policy provisions even if they cannot fund such schemes in full, by leveraging people's willingness to exercise voluntary and contributory enrolment in a community-based health insurance.
authors: Micro Insurance Academy, New Delhi, India.|Erasmus University Rotterdam, Rotterdam, Netherlands.
authors: David Mark
authors: http://orcid.org/0000-0002-8757-4239
authors: DM
authors: Dror
authors: International Centre for Diarrheal Disease Research, Dhaka, Bangladesh.
authors: S A Shahed
authors: SA
authors: Hossain
authors: Micro Insurance Academy, New Delhi, India.
authors: Atanu
authors: A
authors: Majumdar
authors: The Uniformed Services University of the Health Sciences, Bethesda, MD, United States of America.
authors: Tracey Lynn
authors: TL
authors: Pérez Koehlmoos
authors: Peoples Open Access Education Initiative (Peoples-Uni), Delhi, India.
authors: Denny
authors: D
authors: John
authors: International Institute of Health Management Research, Dwarka, Delhi, India.
authors: Pradeep Kumar
authors: PK
authors: Panda
mesh_terms: D003695:Delivery of Health Care / Q000191:economics*; D006801:Humans; D007348:Insurance, Health / Q000191:economics*; D018803:Models, Economic; D012959:Socioeconomic Factors