In this section, we present the results. The first section presents a brief description of the BEPHA staff interviewed. This is followed by the themes and sub-themes that emerged after analyzing the interviews.
Description of Respondents
As already indicated in table 1, we collected data from different levels of staff. The adherents were mainly elderly, retired men, and women, doing farming and small trading as a means of living. Most of them were women heading their families. Atim et al. [38] explained that households headed by women are more likely to be enrolled in MHI than households headed by men.
The staff members were mainly young adults who had no prior or professional experience with insurance schemes. Educational-wise, most of the staff had secondary education. Interestingly, all staff members were catholic. It should be noted that most of the operations at BEPHA are conducted manually, and the staff members lack basic computing skills. An overview of those interviewed is presented in table 3.
Table 3: Profile of staff interviewed (n=7)
Profile of staff interviewed
|
# of participants
|
Age group
|
|
20 - 25
|
3
|
26 - 30
|
2
|
36 - 40+
|
2
|
Gender
|
|
Male
|
3
|
Female
|
4
|
Number of years working in the present position
|
1 – 2 years
|
2
|
2 – 3 years
|
3
|
3 – 4 years
|
2
|
Marital status
|
|
Single
|
7
|
Married
|
0
|
Highest educational level
|
GCE O level
|
1
|
GCE A level
|
4
|
Professional certify.
|
1
|
Tertiary/ professional education
|
1
|
Religious background
|
Catholic
|
7
|
Protestant
|
0
|
Presentation of the themes
Here, we present the themes and sub-themes that emerged from the interviews. We found several factors; for easy presentation, they are grouped as individual, community, and system levels; and further divided as enablers and threats. We have added verbatim descriptions from respondents [36] to support our findings.
Theme 1: Individual levels
Factors that emerged as enablers were the reliability of the scheme, satisfaction with the services received, and trust in the insurer. In contrast, the amount paid for annual contributions and the package of services offered were threats. Most adherents explained that they joined BEPHA because they find the service more reliable, as an adherent explained:
“…When I was first told about my illness, I asked myself where am I going to get money to cover my medical expenses? I gave out my farms to get money to pay for my medical expenses. Then a friend told me about BEPHA, I registered, and whenever I fell ill and went for a consultation, the BEPHA agent asked that I pay only 25% on consultation. After my consultation, I presented my BEPHA member card at the reception, and the Cashier just told me I should go; all is fine. Now I see BEPHA keep to their promise….”
This quotation encapsulates the sentiment shared by a majority of members. The members explained that a co-payment of 25% is manageable as they could pay. Nsiah-Boateng et al. [39] reported that a high co-payment rate hinders individuals from joining MHI schemes and contributes to dropout. On the issue of reliability, another member explained his experiences by comparing the services of BEPHA with another scheme he was once a member as explained in the following statement:
“I registered with Nico paid my contributions. Once I was sick and went to the hospital and presented my membership at the reception, I almost pass-out when the Receptionist told me the scheme had closed. But since I joined BEPHA, I have not had any problem. They have not given me any reason to doubt their services. In addition, we know their offices, and we can reach them on the phone”.
Furthermore, the adherents were asked to explain the general satisfaction at the health facilities and when interacting with BEPHA staff. The adherents expressed satisfaction with the services received regarding access to health providers or specialists, as they do not have to wait in long queues. Another added that BEPHA staff are always available to listen to concerns from the members. They send us reminder messages when membership is about to expire. BEPHA staff visit us when we get sick and are hospitalized. Another added that they are more relaxed because they can manage their health issues without being scared of where to get money to cover the medical expenses.
The adherents explained that they were very satisfied with the services of BEPHA. Studies from Ghana [40] and Tanzania [41] have shown that the lack of money to pay for medical expenses discourages presentation for antenatal and midwifery care and consequently contributes to continued high maternal and neonatal mortality. Studies from other African countries show that they rely on out-of-pocket payments when people lack health insurance. Out-of-pocket payment in the form of user fees paid directly to health providers may plunge individuals or families into perpetual impoverishment [11]. In LMIC, studies have shown that preventable diseases and illnesses remain critical threats to the income earning capacity of the world’s rural poor. Therefore mitigating physical and financial barriers hindering access to quality health care, particularly among the marginalized and rural communities, will motivate enrollment in MHI schemes [5, 11].
Another factor that emerged is trust in the insurer. The respondents explained that BEPHA managers and staff are local community members. As one respondent explained,
“These are people we see every day. We meet with them at the place of worship, at the market, everywhere, we know them. They are no strangers to us….”.
The adherents were further asked if they supported BEPHA because of their religious link. It was observed that BEPHA is a product of the Bamenda Ecclesiastical province, a branch of the Roman Catholic mission, and 50% of adherents were Roman Catholic members. The adherents banged the table and screamed No! No! No! this is not the case”, then one adherent did not hesitate to explain:
“Yes, I am a Roman Catholic member, but religion does not matter when it comes to one’s health. My family and I have trust in BEPHA because their services are reliable. When you pay your annual contribution, you enjoy the services as agreed, no ups and downs.”
Another adherent explained although, in the beginning, BEPHA was targeting predominantly roman catholic members, over the years, that has changed, and membership is open to anybody interested can abide by the terms and conditions of the scheme, and is willing to pay. The manager corroborated this explanation during the interview by reiterating that the scheme accepts everybody regardless of religious background. Basaza et al. [42] found that people's lack of knowledge and trust were significant barriers to scheme management.
Threats that emerged at this level were the amount paid for annual contribution and the service package offered. The Adherents explained that the amount paid for the annual contribution fee was high. At the time of data collection, the adherents had been informed that the annual contribution fee would be increased from francs CFA 5000 to CFA 5500 (i.e., equivalent to USD 9 to USD 10). The adherents were elderly, retired, and self-employed and were concerned that they would not afford the amount. For instance, during one of the FGDs, one of the respondents had this to say
“We have witnessed what BEPHA has done to our families, and we all want to register and continue to be members. But poverty is making killing us, and we are afraid that if the premium of annual contributions is increased, we might not be able to continue because we cannot pay the amount….”
Since MHI generally targets marginalized communities, the premiums charged are relatively low [11]. Previous studies have shown that the amount of money paid either as the annual contribution or premiums influences enrollment to MHI. MHI schemes with high premiums negatively influenced uptake and inequity among the poor and most vulnerable populations [21]. However, it was found that having a single method of payment for all members lowered enrollment, but when the amount is adjusted and paid as installments, it encourages enrollment [43]. In a review conducted by Okoroh et al. [44], schemes that collect premiums at intervals throughout the year encourage enrollment. In contrast, collecting the entire premium once per year makes enrollment less affordable for poorer households.
Another factor in this level was the package of service offered. The adherents reported that although they were satisfied with the services offered, they suggested that HIV/AIDS care should be included on the list of services. In this context, HIV/AIDS-related illnesses are expected within the community as many families have been directly or indirectly infected and affected by the disease. They suggested that adding HIV/AIDS-related services to the service package would attract uptake. According to the BEPHA manager, HIV/ADIS-related services are not included because the state has not provided a clear treatment guideline. Since HIV/AIDS treatments are offered haphazardly, assessing and reimbursing service providers would be challenging. However, studies have shown that when the services offered by MHI are tailored to members’ needs, non-discriminatory [45], and cover outpatient services increases the scheme enrollment [46].
Theme 2: Community Level
At this level, factors identified as enablers were membership criteria and community involvement in decision-making. On the other hand, the threat was adverse selection.
Most MHIs have stringent membership criteria in Cameroon as they allow only families enrollment, except BEPHA, which accepts registration from individuals, families, groups, and school pupils. Studies from Rwanda and Ghana show that schemes that accept group membership was perceived by members as a severe barrier to scheme sustainability [38]. On involving the community in decision-making processes in the scheme, the women reported they were satisfied with their level of involvement in the scheme whereas, the men disagreed. This is because more women than men are employed at BEPHA. According to Kyomugisha et al. [45], enrollment increases when community members are decision-making. Conversely, low community participation decreases the value placed on the scheme; consequently, scheme membership.
Threats in this level were the lack of solidarity and adverse selection. The staff reported that people believe those who enroll in an MHI scheme have or are suffering from an illness; lack of solidarity. A study conducted in rural Benin example shows that saving money for a disease is seen as “wishing oneself disease” [47] p. 29. In such a community, the demand for health insurance risks being very low. Noubiap et al. [17] explained that when community members feel a sense of solidarity, they are more likely to join the scheme. On adverse selection, the staff interviewed explained that the main reason why most applicants’ subscriptions are disqualified at registration is that they wait until they have been diagnosed with an illness before rushing to register or join the scheme. When prospective members use their health conditions as the fundamental motive for joining the MHI scheme, it is detrimental because they tend to withdraw immediately after their conditions are treated [48].
The staff reported that adverse selection[1] forces prospective members to abuse the scheme, such as falsifying the scheme’s membership card. The staff reported that individuals who are not registered falsify the scheme’s membership cards because they want to enjoy the services without paying for them. This was observed because the scheme processes are done manually. For example, BEPHA’s membership card is paper-based. The staff explained their concerns because their processes are not yet computerized. They added that these are common threats in the sector, particularly in Cameroon, and are the main reasons why many MHIs go bankrupt. The lack of computerized devices and digital skills in MHI schemes, particularly in LMICs, is acute [48]. Yawson et al. [49] explained that adverse selection could have severe consequences for smooth functioning, affecting the long-term sustainability of the MHI scheme. This is why Atinga et al. [50] recommend that mechanisms are needed to curtail the false documentation phenomenon. The staff explained some measures BEPHA has put into preventing fraudulent activities. These measures include;
- Implementation of ceiling period.
- Education and dissemination of information to members during the registration
- Created partnerships with healthcare facilities
- Developed guidelines and policies with their partners
- Recruited BEPHA agents at every partner health facility to assist members during consultation.
Theme 3: System-level
The factors that emerged as enablers were the modality of reimbursement and access to the insurer, whereas lack of skilled technical staff and resources and lack of legal framework were threats.
At BEPHA, the co-payment rate is 25% upfront before the consultation. The members expressed satisfaction with the method, unlike schemes where members are asked to pay the total amount and are reimbursed later. The Adherents explained that with BEPHA, immediately after making the co-payment amount, the BEPHA agent takes care of the rest of the administrative activities; filling forms, collecting receipts, and submitting them to BEPHA offices while they (adherents) go and have their treatment. However, the adherents explained that while the agent's presence at the health facility is significantly helpful, the assessor added that assessing and evaluating receipts are still done manually, which could delay the process and, consequently, payments. According to the literature, MHI schemes use different payment methods to pay service providers; however, capitation payment is a potentially appealing method and contributes to the scheme's success [48]; however, delays in processing the claims negatively influenced service delivery [50].
Access to the insurer was found to increase enrollment, as explained in the following statements:
“…we do not have any problem accessing BEPHA, their offices, and the staff. We meet the everywhere, at the market, and worship at the same church, so they are always there with us.”
And another Adherent added, “the staff even visited the hospital when my daughter had an operation.”
The threats that emerged were the lack of skilled personnel and resources and a national policy for MHI. The lack of skilled personnel was evident from BEPHA’s staff composition. It was observed that most staff had neither professional nor academic experiences in managing MHI or management positions. It was also observed that staff working in the scheme had worked or known within the Roman Catholic network. According to findings from the scheme’s management, only staff who had worked within the Roman Catholic network were either appointed or recruited to work in the scheme because it was easier to track their work experience and ethics. The manager added that they must ascertain the staff has a good work ethic and prove some trustworthiness before staff is appointed. These qualities are easier to ascertain if the staff is known within the Roman Catholic network than when recruited directly from the general public. Studies have shown that the administrative team is very crucial in the sustainability of an MIH scheme. The qualifications of the scheme managers and the establishment of a robust administrative team are critical to preventing “unintended external interferences” and facilitating smooth management and implementation of processes [26] in the scheme.
Another threat in this group was the lack of resources. It was observed that all BEPHA’s processes are done manually, from registering members, creating membership cards, and submitting receipts for reimbursement. There are no computers and staff have no access to the internet. It is well known that manual activities are susceptible to errors and mistakes and are time-consuming. At the time of data collection, the scheme had started computerizing some activities; however, a concern raised by staff was a lack of basic digital skills. In this information age, basic digital skills are indispensable as they facilitate the smooth processing of activities and promote the scheme's sustainability [25].
The lack of a legal framework or policy for the MHI scheme is a significant setback to the sustainability of MHI in general and BEPHA in particular. It was observed that nine years since the creation of BEPHA, the premium collected from members could neither cover the medical expenses nor pay staff salaries. Furthermore, it was observed that the scheme could not increase the premium annually because the members would not afford it. As a result, the scheme is operating on a small budget. This threatens the scheme’s financial viability and long-term sustainability [11]. One of the staff did not hide his sentiment:
“I see the happiness and difference this scheme has brought to the life of people, but I go to work every day with a heavy heart because we might wake up one day with the announcement that we are closing up as others have done because we are unable to pay our bills… if the government does not come on board.”
This, the staff lamented, is due to the lack of MHI policy in Cameroon. A national policy with modalities to subsidize MHI schemes positively influences the uptake. In contrast, its absence negatively influences MHI sustainability [42].
[1] Is when people most likely to purchase health insurance are those most likely to use it.