Antecedents and consequences of participation in health insurance among co-operative members in Arumeru and Moshi districts, Tanzania

Abstract

Social protection inclusiveness and coverage is a global challenge. Health insurance, as one of the categories of social protection, is exposed to similar challenges. This has led to an increased participation gap, unequal access, and utilisation of health insurance among individuals. Several initiatives are devised to initiate stronger linkages and better harmonisation between machinery to increase the number of people accessing and utilising health insurance. Co-operatives are among the institutions that have demonstrated the opportunity to close health insurance participation gaps. Recognising this, the government of Tanzania, through the National Health Insurance Fund (NHIF), has created a special voluntary health insurance scheme for co-operative members, namely Ushirika Afya in Kiswahili. The purpose of Ushirika Afya was to increase health insurance coverage among cooperators. However, statistics show that the number of individuals who have subscribed to health insurance schemes is still low. Thus, this study aimed to analyse the antecedents and consequences of participation in health insurance, taking cooperative members as a case. Specifically, the study first determined the influence of co-operative members’ traits on health insurance participation. Secondly, the study analysed the determinants of willingness to pay (WTP) for health insurance among co-operative members. Thirdly, the study evaluated the association between cooperative members’ health insurance literacy (HIL) and health insurance participation. Lastly, the study examined the role of participation in health insurance on the changes in wellbeing status among co-operative members. In attaining these objectives, the theory of planned behaviour, social capital theory, institutional theory of organisations, and the theory of dispositional optimism were adopted as the theoretical lenses in analysing the relationship of variables in this study. By adopting a cross-sectional survey, 550 co-operative members were selected from the Arumeru and Moshi Districts in the Arusha and Kilimanjaro Regions of Tanzania. The Partial Least Squares Structural Equation Modeling (PLS-SEM) was used to analyse and test the relationship between and among variables of this study. PLS-SEM was adopted because this study involved formative measured indicators, and the structural models were complex, containing many constructs and indicators that involved the analysis of the mediators and moderators. In analysing the influence of co-operative members’ traits on health insurance participation behaviour, findings indicated that members’ characteristics, attitudes, and behavioural control positively xv and significantly influence health insurance participation behaviour among cooperative members. Also, this study’s findings partially supporting the social capital theory revealed that, except for price, trust issues fully and partially mediate quality attributes and access criteria, respectively, regarding willingness to pay for health insurance. Study findings further indicated that HIL is positively and significantly associated with participation in health insurance, particularly Ushirika Afya. Besides, the link between HIL and participation in Ushirika Afya health insurance is found to be strong when the co-operative institutions' capabilities level is high and weakens when the institutions' capabilities level is low. Moreover, the study findings also revealed that participation in the Ushirika Afya health insurance scheme significantly positively impacts changing dimensions of wellbeing statuses among cooperative members. Supporting the theory of dispositional optimism, optimistic cooperative members entrusting higher levels of expectations when participating in health insurance were likely to report positive changes and improvements in their wellbeing status compared with their counterparts. Based on these findings, this study recommends that insurers evaluate and consider variations in members’ dynamics that reinforce and raise their likelihood of participating in health insurance. Further, the study recommends maintaining firm trust among cooperators, management, health insurers, and health facilities for enhanced willingness to pay for health insurance. Also, for sustainable participation in health insurance among co-operative members, it is important to formulate awareness programmes and continuous training that target to increase HIL and build strong co-operative institutional capabilities in aspects of health insurance. Altogether, these will increase participation in health insurance and eventually contribute positively to improving the wellbeing of individuals and the economy