Perceptions and uptake of health insurance for maternal care in rural Kenya: a cross sectional study

Introduction In Kenya, maternal and child health accounts for a large proportion of the expenditures made towards healthcare. It is estimated that one in every five Kenyans has some form of health insurance. Availability of health insurance may protect families from catastrophic spending on health. The study intended to determine the factors affecting the uptake of health insurance among pregnant women in a rural Kenyan district. Methods This was cross-sectional study that sampled 139 pregnant women attending the antenatal clinic at a level 5 hospital in a Kenyan district. The information was collected through a pretested interview schedule. Results The median age of the study participants was 28 years. Out of the 139 respondents, 86(62%) planned to pay for their deliveries through insurance. There was a significant relationship between insurance uptake and marital status Adjusted odds ratio (AOR) 6.4(1.4-28.8). Those with tertiary education were more likely to take up insurance AOR 5.1 (1.3-19.2). Knowing the benefits of insurance and the limits the insurance would settle in claims was associated with an increase in the uptake of insurance AOR 7.6(2.3-25.1), AOR 6.4(1.5-28.3) respectively. Monthly income and number of children did not affect insurance uptake. Results Being married, tertiary education and having some knowledge on how insurance premiums are paid are associated with uptake of medical insurance. Information generated from this study if utilized will bring a better understanding as to why insurance coverage may be low and may provide a basis for policy changes among the insurance companies to increase the uptake.


Introduction
According to the 2014 demographic and health survey, the maternal mortality ratio stands at 362 per 100,000 live births [1]. Although this dropped from the previous ratio of 520 per 100000 live births, many agree the ratio is still unacceptably high. Home deliveries and delivery by unskilled personnel have been thought to contribute to these high ratios. To this end, there has been a push to encourage pregnant women to visit health facilities for antenatal care and to deliver in health facilities. The national survey indicates that about 61% of women delivered in a health facility between 2010 and 2014 [1]. Appropriate health financing measures could hold the key to improving maternal health in Kenya and other countries by increasing access to and utilization of health services [2]. However, paying for health care remains a major challenge in Kenya and most African countries [3,4]. In Kenya, the government contributes 41% of the total health expenditure with households "out of pocket" contributing to about 30% of the expenditure [5]. Paying for healthcare out of pocket, may push households into poverty with 6-10% of households reporting catastrophic spending on health [6].
This leads families to seek alternate sources of financing including health insurance and community financing schemes. The use of supply side financing initiatives may limit patient choice of health facility while also not encouraging the delivery of quality services.
Contributory mechanisms such as health insurance provide a means for patients to exercise some choice over facility and send appropriate signals to encourage quality of care at health facilities by giving consumers the power to choose. Insurance coverage has been on the increase in the last decade with about 20% of Kenyans having some form of health insurance coverage up from around 10% in 2006 [7]. In terms of insurance coverage, the National  [9]. There have been several attempts to explore the factors that increase uptake of insurance with an attempt to leverage on those to increase the coverage of health insurance. Insurance uptake has been found to increase as one advance in age. This may be due to an increase in purchasing power [10]. Subsequently women of child bearing age (18-45 years) are excluded from insurance and this affects more so those in the rural areas [6].
Those in formal employment are more likely to have some form of medical insurance unlike those in the informal sector and those who are unemployed [11,12]. Other factors like, marital status, educational status, profession and household income all have significant impact on uptake of insurance [13]. There have been several qualitative assessments of insurance uptake to understand the attitudes and perceptions towards health insurance, Some still think insurance is for those in the formal sector and others do not understand how they would pay for a service that they may not use [14]. In areas where little information about the insurance companies is available, some people may be opposed to giving money to insurance companies in the fear that the money will be misappropriated and they may not get the services paid for [15]. In Written informed consent was obtained from all the study participants before participating in the study. The consent was available in English and in Swahili for those who did not understand English.

Results
A total of 139 participants were interviewed. The median age was 28 years, (Interquartile range (IQR) 18-43). Majority (75%) were married and 37% of the study participants were in their first pregnancy. 86(62 %) of the women recruited in the study indicated that they would be paying for their deliveries or hospitalizations using medical insurance. NHIF was the preferred choice in all the cases. 23(17%) of the women would pay out of pocket and another 17% would request for assistance from relatives. The remainder (5%) had no idea of how they will pay for the delivery.

Socio-demographic factors
Marital status, Odds Ratio (OR) 2.4 (1.4 -5.8), Tertiary education level OR 7.6(2.7-21.1) and a monthly income of $55 OR 4.6(1.8-11.5) were associated with uptake of insurance. Table 1 summarizes the various socio demographic factors in relation to insurance uptake.

Knowledge on insurance
Participants' knowledge was probed using 8 questions. About 86(62%) of respondents indicated they would pay for their delivery through insurance, with NHIF being the most preferred insurance.
Knowing health insurance to be beneficial OR 10.2 (4.5-23.3), knowing how insurance premiums and claims relate OR 9.1(3.7-22.6) and knowing the limits in claims one is entitled to OR 7.3(2.4-21.1) were associated with increased insurance uptake.

Attitude towards insurance
Participants' attitude was probed using four questions. In the case of hospitalization, 69(80%) of those with insurance felt they still had Page number not for citation purposes 4 enough money to pay out of pocket. Those who felt that amounts paid to insurance was not large enough to affect the meeting of basic needs OR 3.4(1.5-7.5) and the feeling that is was an wise investment to have medical insurance OR 1.5(0.7-3.3) were associated with an increase insurance uptake.

Practices among the study participants
Practices were assessed using 5 questions. 30% of the participants reported a previous hospitalization. 9% of those who had been hospitalized had paid for their care using medical insurance. From the respondents, having been hospitalized in the previous year OR 0.9(0.4-1.8), one was more likely to take up insurance. 58(67%) of those who has insurance felt there were more likely to seek medical care. The summary of the factors associated with an increase in the insurance uptake are summarized in Table 2 below.

Multivariable analysis
The factors that were significantly related to insurance uptake were; marital status, education level, monthly income, knowledge that health insurance to be beneficial, Knowing the relationship between premiums and claims, Knowing amounts paid for claims by insurance, participants feeling they have enough money in savings to pay for medical bills and feeling that the amounts paid to insurance are not substantial to affect them meeting their basic needs. These were considered for multivariable analysis. There was a significant relationship between insurance uptake and marital status AOR 6.4(1.4-28.8). Those with tertiary education were more likely to take up insurance AOR 5.1(1.3-19.2). Knowing the benefits of insurance and the limits the insurance would settle in claims was associated with an increase in the uptake of insurance AOR 7.6(2.3-25.1), AOR 6.4(1.5-28.3) respectively. Monthly income did not seem to affect insurance uptake. Employment status was excluded from the multivariate analysis due to co linearity. Table 3 summarizes the multivariable analysis.

Discussion
This study aimed to determine the factors that affect the uptake of the health insurance among pregnant women attending an antenatal clinic (ANC) in a level five facility in rural Kenya. In the study, uptake of insurance was at 62%. This is much higher than the current national uptake of around 20% [6]. Being married, having tertiary education and knowledge of the insurance benefits was associated with an increase in uptake. Other studies have also shown than more educated women were more likely to take up medical insurance [10]. Education is a factor that also improves the health seeking behaviour and hence insurance uptake [21]. The increased uptake among married women has been confirmed in other studies [22,23]. Some of the hypothesized reasons are that having financial support from a spouse increases the opportunities for access of health insurance coverage as a result of increase income, another reason may be the fact that some employers provide cover for spouses and children and hence one can be insured through the spouses insurance cover [10]. In this study, the numbers of those employed and unemployed were almost similar, however employment was found to be collinear and hence was excluded in the analysis for its relation to insurance uptake. This differs from previous studies that have shown employment to be a major contributor to insurance uptake [11,12,24] in an effort to increase insurance coverage, there is a push to have insurance schemes for those in the informal sector through microfinance schemes [25]. Although household size and household income were not significant factors that affect uptake, household size in previous studies has been attributed as a major factor that affects uptake of insurance [26]. Once a household has many children, the resources are strained and thus find it hard to put money aside to pay for medical insurance. Several studies in Africa has shown that households with higher income were more likely to take up insurance [27,28].

Knowledge on Insurance
From the discussion on knowledge on insurance majority agreed that health insurance is beneficial. These findings are in keeping with previous studies among Kenyan communities who also agreed that it is important to have a form of health insurance to cater for medical expenses especially in cases of emergencies to reduced catastrophic spending on health [24]. The knowledge level is much higher compared to neighboring countries in the region [26]. This may be explained by the fact that most of the study respondents had attained at least secondary education and hence had some

Attitudes and practices towards insurance
In this study most women felt they had enough money to cater for the medical bills. Previous studies have shown income to be a major contributor to health seeking behaviour and insurance uptake [30].
The effect of catastrophic financial effects was not anticipated in this group as they felt that the paying of insurance would have a minimal effect on the ability to cater for the basic needs. This may be due to the fact that most women sampled seemed to have a source of income. As in many areas of the world, having insurance may have one seeking health care more frequently [6]. Although we did not asses this directly, those with insurance indicated they were likely to visit health facilities; the concept of moral hazard in health insurance may lead to a strain in the health services in areas with high insurance as many people will seek care even though they are not sick [31]. Limitations The main limitations of this study is that it relied on the participants responses and hence not in a position to verify their marital status, education level or income level. Some of the questions were prone to recall bias. To counter this bias, we attempted to seek clarification with each participant during the interview process whenever the investigators noted the information was not consistent. The other limitation is that these findings may not be generalizable to the whole population as we did not sample any men hence a similar study in men would shed more light into the real situation in the region.

Conclusion
This study highlights some of the attitudes and perceptions towards health insurance in a rural region where coverage is still relatively low. We conclude that in this area, being married, having tertiary education and having some knowledge on how insurance premiums are paid are associated with uptake of health insurance. As we strive towards provision on universal care, we note that insurance coverage is still low, there is need to offer alternative forms of health insurance, to offer people opportunities to interact with the insurance providers to ask questions and clarify various aspects of the insurance. We also recommend that future studies on insurance uptake should include qualitative methods of data collection to adequately capture the attitudes and feelings of those who are participating and also carry out similar work in men to provide and cleared picture of the situation.
What is known about this topic  Medical insurance coverage is low in the region.
 The more educated one is the more likely they are to take up insurance.

What this study adds
 Education to at least tertiary level is what affects insurance uptake.
 Nation health insurance (NHIF) is the preferred insurance provider to most.
 Income and household size may not affect insurance uptake.
6 Tables   Table 1: Baseline characteristics affecting insurance uptake   Table 2: Knowledge, attitudes and practices affecting insurance uptake