Background Characteristics of Participants
Among the total 224 participants, Eighty-three percent of the household heads were male. The median age of the household head was 54 years. Eighty-three percent of household heads were literate, two out of three had nuclear families, and the average number of family members was 5.6. Among the total households, 45% of households had elderly members in their family, and a quarter of households had children below five years in their family. Nearly half of the families major expenditure was on household general expenses, while 30.8% and 24.1% of the participants reported that their major expenditure was on education and health, respectively. On average, one-fifth (20.4%) of their income was spent on health. While assessing the family's socioeconomic status, more than half of the participants had lower socioeconomic status. The proportion of households having at least one member with chronic illness in their family was 56.3% and among those, nearly two-thirds (64.3%) had only one member with chronic illness in the family. Around three percent had a member with disability in their family.
The socio-demographic characteristics of the study participants are presented in Table 2.
Table 2: Socio-demographic characteristics of the study participants (N=224)
Variables
|
Frequency
|
Percentage
|
Mean age (±SD) of household head 54 .8 (±13.12) years
|
Gender of Household head
|
|
|
Male
|
192
|
85.7
|
Female
|
32
|
14.3
|
Ethnicity
|
|
|
Janajati
|
150
|
67.0
|
Brahmin/ Chhetri
|
65
|
29.0
|
Dalit
|
9
|
4.0
|
Literacy Status
|
|
|
Literate
|
188
|
83.9
|
Illiterate
|
36
|
16.1
|
Types of Family
|
|
|
Nuclear Family
|
152
|
67.9
|
Joint and Extended
|
72
|
32.1
|
Average member (±SD) in family 5.6 (±1.93)
|
|
Elderly member in the family
|
|
|
No
|
123
|
54.9
|
Yes
|
101
|
45.1
|
Number of elderly members in the family (n=101)
|
|
|
1
|
58
|
57.4
|
2
|
39
|
38.6
|
3
|
3
|
3.0
|
4
|
1
|
1.0
|
Children in Family
|
|
|
No
|
167
|
74.6
|
Yes
|
57
|
25.4
|
Number of children in the family (n=57)
|
|
|
1
|
47
|
82.5
|
2
|
9
|
15.8
|
3
|
1
|
1.8
|
Chronic illness in the family
|
|
|
No
|
98
|
43.7
|
Yes
|
126
|
56.3
|
Number of family members with Chronic Illness in the family (n=126)
|
|
|
1
|
81
|
64.3
|
2
|
38
|
30.2
|
3
|
7
|
5.6
|
Family members with a disability
|
|
|
No
|
218
|
97.3
|
Yes
|
6
|
2.7
|
Major expenditure
|
|
|
Household
|
101
|
45.1
|
Education
|
69
|
30.8
|
Health
|
54
|
24.1
|
Socioeconomic status of household
|
|
|
Lower
|
126
|
56.3
|
Middle
|
95
|
42.4
|
Upper
|
3
|
1.3
|
Average family annual income = NRS 553200
|
Average expenditure in health (in percentage) = 20.4 + 16.2
|
Knowledge about health insurance
Comprehensive knowledge about health insurance services was referred to as knowing contribution amount, benefit ceiling, time of renewal, and service availability. Less than one in five (18.8%) of the participants had comprehensive knowledge about health insurance services (Table 3).
Table 3: Distribution of insured residents having comprehensive knowledge about Health Insurance in Bhaktapur District
Comprehensive Knowledge on health insurance
|
Frequency
|
Percentage
|
Yes
|
42
|
18.75
|
No
|
182
|
81.25
|
Total
|
224
|
100
|
Membership status and utilization of health insurance
Among study participants, 11.2% had dropped out from the health insurance program. Around seven percent had enrolled in other modes (private health insurance, other insurance through an employer) of health insurance schemes. The majority (91.5%) of the study participants were willing to continue the membership in the health insurance program. The household proportion of utilization of health insurance services was 77.2%.
Factors associated with utilization of health insurance among households
In the adjusted analysis of the association between the dependent and background variables, the number of elder members in the family showed a statistically significant association with service utilization of health insurance benefits. Similarly, while assessing the association between mediating and dependent variables, three mediating variables, i.e., presence of chronic illness in the family, willingness to continue, and membership duration, were significantly associated with service utilization of health insurance benefits.
After including variables which showed significant association in the final regression model, increase in the number of elder members in the family had higher odds (AOR=2.70; 95% CI: 1.09-7.07) for service utilization. Likewise, family having a member with chronic illness were five times more likely (AOR=5.10; 95% CI: 1.48-17.56) to utilize services compared to the family having no members with chronic illness. Additionally, the utilization of the insurance services increased by 2.1 times among those willing to continue in the health insurance program (AOR 2.18; 95% CI: 1.47-3.25) than those who did not want to continue the membership. Similarly, with the increase in the number of months of membership duration in the program, the utilization of health insurance services was also significantly higher (AOR 1.14; 95% CI: 1.05-1.24) (Table 5).
Table 4: Multivariate Analysis of factors associated with utilization of health insurance services
Variables
|
Category
|
Utilization of health insurance
N (%)
|
OR (95% CI)
|
AOR (95% CI)
|
Literacy
|
Illiterate
|
30 (17.3%)
|
Ref
|
Ref
|
|
Literate
|
143(82.7%)
|
0.63 (0.24-1.64)
|
1.75 (0.48-6.3)
|
Types of family
|
Joint/Extended
|
58 (33.5%)
|
Ref
|
Ref
|
|
Nuclear
|
115(66.5%)
|
0.75 (0.44-1.25)
|
1.64 (0.74- 3.63)
|
Number of Elderly
|
|
|
2.86 (2.39- 3.43) *
|
2.7 (1.09 -7.07) *
|
Expenditure in Health
|
|
|
1.02 (0.98-1.06)
|
1.00 (0.96-1.05)
|
Presence of Chronic Illness
|
No
|
57 (32.9%)
|
Ref
|
Ref
|
|
Yes
|
116(67.1%)
|
8.3 (4.32- 16.09) *
|
5.10 (1.48-17.56) *
|
Knowledge about health insurance
|
No
|
136 (78.6%)
|
Ref
|
Ref
|
|
Yes
|
37 (21.4%)
|
2.44 (0.47 -12.7)
|
2.02 (0.51-8.02)
|
Last annual contribution amount Paid
|
|
|
1.00 (1.00-1.00)
|
1.00 (0.99-1.00)
|
Willingness to continue
|
No
|
12(6.9%)
|
Ref
|
Ref
|
|
Yes
|
161(93.1%)
|
2.13 (0.76-5.99)
|
2.18 (1.47-3.25) *
|
Membership duration
|
|
|
1.15 (1.05-1.24)
|
1.14(1.05-1.24) *
|
* Statistically significant at p<0.05
Reasons for non-utilization of health insurance services
Common reasons for not utilizing health insurance services were having no health problems (22.99%), seeking other treatment (22.99%), and hearing poor experiences of utilizing insurance services from service users (19.54%). In addition, the participants reported other reasons as long waiting lines in the health facility, bothersome procedures to get treatment, lack of time, and being unaware of where to go for treatment, as the reasons for non-utilization of health insurance (Table 4).
Table 5: Reasons behind non-utilization of Health Insurance among insured resident in Bhaktapur district, (N=51)*
Reasons for non-utilization
|
Response
|
Response rate
|
No Health problem (No need)
|
20
|
22.99
|
Seek other treatment
|
20
|
22.99
|
Long distance to health facility
|
2
|
2.30
|
Do not address the health need by services
|
6
|
6.89
|
Heard bad news about service delivery
|
17
|
19.54
|
Do not like the staff at the health facility
|
8
|
9.20
|
Other
|
14
|
16.09
|
Total
|
87
|
100.00
|
* Multiple response