title: Determinants of Voluntary National Health Insurance Drop-Out in Eastern Sudan.
abstract: BACKGROUND
  Low enrolment and high drop-out rates are common problems in voluntary health insurance schemes. Yet, most studies in this research area focus on community-based health insurance and enrolment, rather than drop-out.
  
  
  OBJECTIVE
  This study examines what causes informal sector families not to renew their voluntary National Health Insurance Fund (NHIF) health insurance membership in Eastern Sudan.
  
  
  METHODS
  Primary data from about 600 informal sector households that dropped out or remained insured, collected through a household survey conducted in March 2014, were used. Logistic regressions were employed to examine what determines drop-out of the voluntary NHIF scheme.
  
  
  RESULTS
  The logistic regression results are consistent with the existing literature and confirm the importance of household head, household and community characteristics. Notably, worse family health status and higher health care utilization decrease the probability of drop-out, which requires further analysis as it may indicate the problem of adverse selection and insufficient risk management. Most importantly, the results consistently show that household heads who are satisfied with health services and those who understand the main features of the voluntary NHIF scheme are less likely to drop out. Also, 30 % of drop-out households hold a social support card and reported that the social support scheme is the main reason for not renewing their voluntary NHIF health insurance membership as they qualify for sponsored NHIF health insurance membership.
  
  
  CONCLUSIONS
  This study shows that satisfaction with health services and knowledge of the health insurance scheme are important factors explaining drop-out of a national health insurance programme. The results suggest that education and information campaigns should be developed further to raise understanding of the NHIF voluntary scheme. In addition, information systems and coordination between the main agencies should be strengthened to reduce administrative costs and ensure policy coherence.
authors.affiliation: Faculty of Economics, Centre for Health Economics, Chulalongkorn University, Bangkok, 10330, Thailand. chantal.h@chula.ac.th.
authors.forename: Chantal
authors.identifier: http://orcid.org/0000-0002-7065-5614
authors.initials: C
authors.lastname: Herberholz
authors.affiliation: National Health Insurance Fund (NHIF), Kassala, Sudan.
authors.forename: Wael Ahmed
authors.initials: WA
authors.lastname: Fakihammed
mesh_terms: D000328:Adult; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D017057:Medically Uninsured / Q000706:statistics & numerical data; D008875:Middle Aged; D009313:National Health Programs / Q000191:economics / Q000706:statistics & numerical data*; D010352:Patient Dropouts / Q000706:statistics & numerical data*; D013397:Sudan; D011795:Surveys and Questionnaires