Factors that affect social health insurance enrollment and retention of the informal sector in the Philippines: a qualitative study

24 Background. The primary goal of providing social protection to informal sector workers is to 25 guarantee a minimum level of income and dignity that allows for better protection against 26 income shocks and other vulnerabilities. With the passage of the Universal Health Care Act in 27 the Philippines, the determination of factors affecting enrollment and retention into social 28 health insurance among informal sector workers in the Philippines is crucial to design 29 appropriate policies and programs fit to their needs. 30 Methods. This study aimed to identify factors that affect social health insurance enrollment 31 and retention of the informal sector in the Philippines through qualitative research methods of 32 face-to-face, semi-structured focus group discussion and key informant interviews. 33 Results. The analysis identified five broad themes that affect informal sector enrollment and 34 retention in social health insurance: 1) overlaps in categorization, 2) insufficient or 35 inappropriate social health insurance initiatives for the informal sector, 3) awareness and 36 understanding of social health insurance, 4) supply side factors, and 5) convenience and 37 amount of premium payment. 38 Conclusion. individuals protective to national health insurance scheme. the of the Philippines, the diversity of informal work and dynamic nature of the sector works against an 41 ideal one-size-fits-all solution to increasing informal sector enrollment and retention to social 42 health insurance. 43


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Background 49 Since its establishment in 1995 through the National Health Insurance Act, the Philippine 50 Health Insurance Corporation has developed various strategies in ensuring universal health 51 care (UHC). This is complemented by national health policies which guarantee Filipinos 52 equitable access to quality and affordable health goods and services. The recently signed 53 UHC Law "guarantees all Filipinos equitable access to quality and affordable health goods 54 and services and protected against financial risk protection". With its implementation, Filipino 55 citizens will either be indirect contributors (sponsored, subsidized by the government) or direct 56 contributors. Efforts of developing countries like the Philippines to expand health coverage are 57 characterized by a common enrollment and financing pattern: commencing with formal sector 58 workers followed with government-subsidized enrollment of the poor (2). The informal sector 59 group is typically left behind which then makes them vulnerable to health catastrophes. 60 The International Labor Organization describes the work undertaken by informal laborers as 61 any economic activity undertaken by workers and profitable units that are not legally or 62 sufficiently recognized by formal arrangement (3). The Philippine Department of Labor and 63 Employment estimates that in 2017, 22.71 million individuals or 56% of the total employed 64 population were in the informal sector (4). The sector is identified as the "missing middle" 65 whose membership and retention to a national health insurance program is crucial to attain 66 UHC. They are some of the most mobile and volatile members of the Philippine social health 67 insurance (SHI), influenced by a multitude of factors that affect voluntary payment options. To 68 date, just over 27% (6.3 million) of informal sector members in the Philippines are registered 69 to SHI and only 1% (2.4 million) are actively paying members. This translates into a $959 70 million annual premium loss for the country (5). 71 The primary goal of providing social protection to informal sector workers is to guarantee a 72 minimum level of income and dignity that allows for better protection against income shocks 4 affecting enrollment and retention into SHI of the informal sector in the Philippines is crucial to 75 design appropriate policies and programs fit to their needs. 76

Methods 77
This study aimed to identify factors that affect SHI enrollment and retention of the informal 78 sector in the Philippines through face-to-face, semi-structured focus group discussion and key 79 informant interviews. 80

Sampling and participants 81
This study used convenience, purposive, and snowball sampling to select study participants. 82 For key informant interviews, participants from government and non-government agencies 83 were targeted through an online search of department heads and key leaders. Critical 84 employees within the agencies were chosen based on their roles and its relevance to the 85 informal sector. Recommendations by other targeted participants as well as authors of 86 published literature on informal sector in the Philippines were also invited to participate in the 87 study. Informal sector participants for the focus group discussion were recruited through 88

unions. 89
The targeted participants were contacted via letter of invitation, e-mail, text messages, and 90 phone calls. Out of the 35 potential participants, 16 participated in key informant interviews 91 and six informal sector workers joined the focus group discussion. No response was received 92 from three potential key informants while one was not able to participate due to scheduling 93 conflicts. Due to the precarious nature of their work, four informal sector representatives were 94 unable to join the focus group discussion. 95

Setting and data collection 96
A topic guide was developed by the researchers in preparation for the interviews and focus 97 group discussion. The topic guide was based on important points to cover during the interview 5 or discussion based on literature review. The topic guide was not pilot tested but was refined 99 after each interview and discussion. 100 A total of 16 key informant interviews and one focus group discussion were conducted in 101 meeting rooms or offices. Before beginning each interview and focus group discussion, the 102 researchers introduced themselves and the participants were oriented on the research 103 purpose, objectives, its funder, the purpose of the interview or discussion, participation risks, 104 right to refuse or end participation, right to retract statement, and confidentiality of their identity 105 and responses. The participants were then asked to sign a written informed consent form. 106 The interviews and focus group discussion were held between August to September 2019 in 107 Manila, Philippines. Interviews lasted between one to three hours while the focus group 108 discussion ran for four hours. No more than three researchers were present per interview and 109 discussion. All researchers present during the interview or discussion hold post-graduate 110 degrees and have previous experience and training in conducting qualitative research 111 methods. Besides the researchers and participants, no other individuals were present. 112 Interviews and discussions were held in the local language and/or English, depending on the 113 preference of the participants. The interviews and discussion were audio recorded with the 114 consent of the participants. Notes were also taken during the interview by one of the 115 researchers to aid in data collection and analysis. Renumeration was only provided to informal 116 sector workers to replace income lost by attending the discussion. No repeat interviews were 117 carried out. 118

Analysis 119
Iterative, inductive thematic and content analysis was used to synthesize findings. These types 120 of analysis were chosen due to the wide variety of research questions and topics that can be 121 addressed through these methods (6). 122 The transcription of audio recordings was ongoing during the study and were completed 123 between one to four weeks after each interview or discussion. Transcription was done by a 6 researcher who was present during the interview or discussion. This was done to achieve 125 familiarity and entirety of the data and allow understanding of phrasing or the meaning of a 126 term within the context of the interview or discussion. 127 The transcribed text was disassembled for thematic analysis using Google Sheets by one 128 researcher. The topic guide was used for initial a priori coding. A second researcher then 129 repeatedly analyzed the transcripts and a priori coded data for grounded coding. Emerging 130 themes and codes were sharpened and refined throughout this period and was done 131 repeatedly until new data did not alter the definition of the themes and codes. Data saturation 132 was declared once no new patterns and themes emerged from the data. 133 The data were grouped and regrouped continuously to show patterns that may indicate an 134 explanation for factors that affect national health insurance enrolment and retention of the 135 informal sector. Interpretation and conclusion were conducted by one researcher. 136 Interpretation and conclusion were based both in and outside the context of the data. 137 Relationships between the themes was also considered in interpreting the data and drawing 138 conclusions. 139

Results 140
The analysis identified five broad themes that affect informal sector enrollment and retention 141 in SHI (Table 1). The findings are discussed in more detail below with examples selected from 142 the dataset indicated between quotation marks. 143 There have been recommendations to remove local government sponsorship due to its 154 politicization and free riding (those with capacity to pay apply to be sponsored). Stringent 155 screening is necessary to identify qualified members, but this is difficult due to lack of social 156 workers in health facilities and shared data between agencies to determine trueness of The lack of coverage for outpatient and primary care services, which are the most common 236 services used by informants, discourages them from premium payment. While some 237 medicines are covered by SHI, these are often out-of-stock in public health facilities, thus 238 rendering the membership useless. In addition, when informants apply for SHI reimbursement, 239 the tediously slow process is a deterrent to claim the benefit. An informal worker shared: 240

Convenience and amount of payment 243
Informants find the payment of premium to be an inconvenience, citing that payment sites are 244 inaccessible and requires that they take a day off from work. The combined cost of income 245 lost, transportation, and the premium discourages informal workers to pay their contributions Attainment of UHC has been a key priority both in the Philippines and the global agenda of 282 social protection. Governments usually rely on three strategies to increase health coverage: 283 1) a centrally managed and tax-financed national health care system, 2) development of social 284 health insurance schemes, and 3) promotion of private health insurance (7). These strategies 285 mostly target the sector of the population in the civil service or formal economy (8). In low-and 286 middle-income countries (LMIC), attaining UHC is complicated by the large and continuously 287 rising share of the population employed in the informal sector (2). 288 There is a gap in identifying or validating whether or not sponsored members are part of the 289 informal economy or not. In theory, they are members who don't have the capacity to pay their 290 premiums. However, there is still a question on whether or not they do not have the capacity 291 to pay as the process of identifying such members may be affected by politics. This can result 292 in underestimation of the informal economy workers. The informal sector is highly diverse and 293 ranges from professionals to below-minimum wage workers (5). Knowing the size and scope 294 of the informal sector is then crucial for policymakers to design appropriate policies and 295 programs for their assistance and social protection (2). 296 Our results also show that a lack of awareness about SHI is a barrier to both enrollment and 297 retention. In a 2013 South Africa study, 24% of participants identified lack of awareness as 298 the most important barrier to enrollment (9). In a 2017 Nigeria study, education was a 299 consideration for varied awareness levels of a SHI (10). A systematic review published in 2012 300 that included 19 LMIC studies found that education increases a person's likelihood of 301 enrollment (11). It is then likely that a person with higher educational attainment may better 302 understand and comprehend the benefits of participating in a SHI (10). The better an individual 303 understands the benefits of health insurance, the more likely they are to participate in the 304 scheme (12). 305 This study found that unaffordability of the premium is a deterrent to enrollment and retention. 306 Two studies in Kenya found that the premium amount was thought of by the informal sector 307 as unaffordable and posits that, while some entities are able to afford the premium, substantial 308 sections of the informal sector were unable to cope with this and would continue to require 309 government subsidies to be included in the health insurance scheme (13,14). In financing 310 UHC, policy-makers should take into account whether the informal sector has the financial 311 capability to participate in a prepayment scheme for health care (14). Wealthier individuals are 312 more likely to participate in a SHI, so it is unsurprising that amount of premium payment is a 313 determinant of enrollment and retention (12). The policy direction of expanding contribution 314 collection to the informal economy is led by the assumption that the sector is the "missing 315 middle" or that they have substantial financial resources that can be tapped to finance UHC 316 (14). In an environment characterized by seasonal employment and high variations in income, Interviews and focus group discussions reveal that informal workers find premium payments 319 inconvenient, inaccessible, and result in income loss due to the indirect costs of payment. 320 Frequent lapsed contributions also occur due to the seasonal and unprotected nature of 321 informal work. Collecting premium contributions from the informal sector continues to be a 322 challenge for many LMICs (16). More flexible terms of premium collection that adapts to local 323 realities are considered the most appropriate approach compared to the one-size-fits-all model 324 currently used by the Philippines (12, 17). The various preferences in payment schedule, 325 mode, and location emphasizes the diverse priorities and needs within the sector. Purchasers 326 in the Philippines must then determine the extent to which they can accept and accommodate 327 irregularity of premium payment from the sector (12). 328 Another crucial set of factors identified in this study are on supply-side issues which includes 329 the (perceived) quality of health care services and the benefit package offered by a SHI. In 330 supply-side issues, many other factors may come into play: the state and proximity of a 331 healthcare facility, availability of medical staff, waiting times, and availability of medicines, 332 among others. A similar phenomenon was observed in Tanzania, where dropout was primarily 333 related to the lack of quality care services and failure of SHI to meet the needs of the 334 beneficiaries. In this case, respondents resorted to more convenient alternatives such as 335 traditional medicines, private health facilities, and pharmacies (12). In Kenya, participants 336 found benefit packages attractive and comprehensive on paper, but benefits received in 337 practice was limited. This, coupled with poor bedside manners of health staff, ultimately led to 338 attrition (13). 339

Conclusion 340
Informal workers are individuals who are not covered by protective labor laws and tend to not 341 belong or contribute to a national health insurance scheme. In the case of the Philippines, the 342 diversity of informal work and dynamic nature of the sector works against an ideal one-size-Due to the significant size and unorganized nature of the sector, it remains a significant 345 challenge to capture each individual segment that comprises its entirety. It may be more 346 significant to target individuals within the informal sector who have the ability to contribute and 347 pay premiums. Specifically targeting these individuals will enable the Philippines SHI to 348 allocate resources towards strategies that can create sustainability of the financial pool. 349

Study limitations 350
This study is limited by the underrepresentation of informal sector members from semi-rural 351 and rural areas. Only informal sector members connected to labor groups in Manila were 352 reached to take part in the study. The viewpoints of semi-rural and rural workers were then 353 not captured in the study. 354 The study also did not include informal sector workers in the high-income quintile. They may 355 have provided insights that differed from those found in this study. 356 The study was unable to gather insights from representatives of other Philippine social 357 insurance agencies who may have been able to share their knowledge on informal sector 358 enrollment retention for non-health social insurance schemes. 359

List of abbreviations 360
UHCuniversal health care 361 LMIClow-and middle-income country 362 SHIsocial health insurance 363

Ethical considerations 364
This study received ethics approval from Corazon Locsin Montelibano Memorial Regional 365