Factors influencing low enrolment in a community health insurance scheme, Karachi, Pakistan

Date of Award


Document Type


Degree Name

Master of Science in Health Policy & Management (MSc Health Policy & Mgmt)


Community Health Sciences


In recent years, researches have generated evidence on the potential of Community Health Insurance (CHI) in developing countries to increase access to health care and offer financial protection against the cost of illness for people excluded from formal insurance systems. In 2011, New Jubilee Insurance (NJI) Pakistan launched a community based health insurance scheme called Family Health Insurance scheme aimed at household level. Purpose: CHI has proved to be beneficial for financial and social protection of community members worldwide. Despite its proven feasibility in low-income countries, enrollment in the Njl's FHI scheme has remained low. Moreover, there has been a significant drop-out from the initial enrollment of the scheme's insured members. Aim: This study aims to explore the inhibiting as well as enabling factors influencing enrollment of community members in this scheme. Methodology: A case study design was applied whereby data was collected between 15th July, 2014 and 26th August, 2014 from FHI scheme management as well as community members. As case study looks at in-depth understanding of a case, data collection methods involved review of the scheme's marketing, Key Informant Interviews with insured, uninsured households as well as those who dropped out from FHI scheme. Key Informant Interviews with community stakeholders and liaison person between insurance company and community was also carried out. Purposive as well as quota sampling was done to ensure representativeness from one of the three jurisdictions where community resides. A total of 9 X KIs with stakeholders and 18 Ms with community members were done. Sample size was determined upon theoretical saturation of data. Direct observation of marketing techniques was also done. Interviews were transcribed, translated and content analysis was done. For quantitative arm, purposive sampling was done with eligibility criteria for insured and uninsured households. A total of 200 households: 100 insured and 100 uninsured households were selected for structured survey. Results: Quantitative results were analyzed using SPSS version 19.0 whereas manual analysis was done for qualitative arm. The study derived a series of explanations for the reported underachievement at both the supply and demand side of PHI scheme. Lack of awareness regarding insurance, lack of trust in management, inability to afford premiums, limited nature of package, ambiguity regarding pre-existing conditions, negative marketing by drop-outs, and exclusion of vulnerable groups are some of the common reasons among uninsured group. On the other hand, insured members of the scheme also had little knowledge about the scheme. The major reason for enrollment in this scheme was the influence of community leader's guidance. Stakeholders also believed in modification of marketing strategies and innovations in increasing community awareness. Conclusion: The main policy challenge at present is the need to retain community's interest in scaling up CHI by learning from the lessons learnt from this case study of one Muslim community in Karachi. The results of this study shall be used by the insurance sector to develop community based policies and plan strategies to overcome the problem of low enrollment so that it has positive impact on the health of people.

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