Factors favoring household adherence to self-sponsored health insurance in the Democratic Republic of the Congo

Abstract

Introduction Located in Central Africa, the Democratic Republic of the Congo is the second largest country in Africa with an area of 2,345,000 km2 and a population of nearly 100 million. Although rich in raw materials, it is unfortunately one of the poorest countries in the world. Its modest budget does not allow for significant investments in the social sector. Thus, there is no effective national health insurance system. Nevertheless, a mechanism that will lead to universal health coverage in the long term is being implemented in this country, and it will have to rely on the few community-based health insurance programs that have been successful in this country, where more than 85% of the workers are in the informal sector. For this reason, the ultimate goal of this study is to identify the factors associated with household affiliation to self-sponsored health insurance mechanisms, to contribute to the current debate on the construction of an adapted system that will lead the Congolese to universal health coverage. Methodology To do this, this study used the database that resulted from the Sustainable Development Goals Indicator Cluster Survey, conducted throughout the Democratic Republic of the Congo in 2020 by the Congolese Sustainable Development Observatory and the National Institute of Statistics. This survey provides data for 9,216 households, and this study used data for only 8,859 after excluding households with missing data for relevant variables. The dependent variable was whether or not the household was affiliated with a self-sponsored health insurance program. Jamovi software was used for statistical analysis of the data using chi-square and t-test for descriptive analyses, and binomial logistic regression to test the degree of association between the selected independent variables and the dependent variable. Results were considered significant for a P-value less than 0.05 and/or a 95% confidence interval. Results First, the study found that 84% of the heads of households are active, of which 15.2% are in the formal sector. Only 4.2% of these are covered by employer-sponsored health insurance. The rate of coverage of self-sponsored health insurance is 2% in the population, and households with a working head in the formal sector are almost as affiliated as those with a working head in the informal sector. The use of self-sponsored health insurance by workers in the formal sector indicates the low level of employer-sponsored health insurance in both quantitative and qualitative terms. Second, concerning the general characteristics that differentiate households that are members of self-sponsored health insurance from non-members, certain parameters showed statistical sensitivity, including age (the older the head of household, the more he enrolls his household in self-sponsored health insurance), sex of the head of household (men bring their households to it more than women), area of residence (households living in urban areas are more members of self-sponsored health insurance than those living in rural areas), the level of education of the head of household (those with access to higher education enroll their households more than others), and finally, subjective well-being (those who feel rich enroll their households more than those who feel less rich or poor). However, only the latter parameter remains sensitive when households with employer-sponsored health insurance are removed from the analysis. Finally, the factors associated with household enrollment in self-sponsored health insurance are the sex of the head of the household (men enroll their households 1.5 times more than women), the household’s area of residence (urban households are twice as likely as rural households), the education level of the head of the household (households with a university graduate in charge are twice as likely to be enrolled as others), and finally, subjective well-being (those who see themselves as rich are 10 times more likely to enroll their households than those who define themselves as poor). However, when households with employer-sponsored health insurance are pruned, only the “subjective well-being” parameter remains associated with household enrollment in self-sponsored health insurance. Conclusion Self-sponsored health insurance mechanisms—including community-based health insurance—will be the obvious entry point for the majority of the population into the national health insurance system to come in the DRC. The government will then have to consolidate the factors that facilitate this entry and correct the factors that do not facilitate it. Keywords: universal health coverage, self-sponsored health insurance, community-based health insurance