Purpose: Penetration of health insurance in the informal sector is very poor, this calls for upward scaling of successful interventions to remedy this situation given that health insurance increases access to healthcare services and improves financial risk protection. This study assessed the factors influencing uptake of national health insurance schemes among informal sector in Vihiga sub-county, Kenya. Methods: Descriptive cross-sectional study design was used. The target population was the informal sector workers. A sample of 384 participants was selected by cluster and simple random sampling techniques. Data was collected using a semi-structured questionnaire. Descriptive statistics was summarized using tables, chi-square and bivariate logistic regression were used to test for associations (p<0.05). Results: The study revealed that there was a significant influence of trust and knowledge of the health insurance scheme on the uptake of national health insurance (p < 0.05). The study further revealed that the attractiveness of the scheme had a big influence on the uptake of national health insurance Conclusion: Trust and knowledge of the health insurance scheme had significant influence on uptake of national health insurance. Health Insurance Schemes should be designed in such a way that they attract informal sector workers and information regarding these schemes is disseminated to these people.

1. Factors Influencing the Uptake of National Health Insurance Schemes among the Informal Sectors in Vihiga Sub County.
IJPHER
Factors Influencing the Uptake of National Health
Insurance Schemes among the Informal Sectors in
Vihiga Sub County.
1Muranda M. Agiza, 2Owenga J. Adhiambo, 3Otieno D. Odongo, 4Onguru D. Ogungu, 5Orende
M. Awino, 6Atito R. Omolo
1,2,4,5,6
School of Health Sciences, Jaramogi Oginga Odinga University of Science and Technology, Bondo, Kenya
3In-depth Research Services Institute of Health and Social Work Nairobi, Kenya.
Purpose: Penetration of health insurance in the informal sector is very poor, this calls for
upward scaling of successful interventions to remedy this situation given that health
insurance increases access to healthcare services and improves financial risk protection.
This study assessed the factors influencing uptake of national health insurance schemes
among informal sector in Vihiga sub-county, Kenya.
Methods: Descriptive cross-sectional study design was used. The target population was the
informal sector workers. A sample of 384 participants was selected by cluster and simple
random sampling techniques. Data was collected using a semi-structured questionnaire.
Descriptive statistics was summarized using tables, chi-square and bivariate logistic
regression were used to test for associations (p<0.05).
Results: The study revealed that there was a significant influence of trust and knowledge of
the health insurance scheme on the uptake of national health insurance (p < 0.05). The study
further revealed that the attractiveness of the scheme had a big influence on the uptake of
national health insurance
Conclusion: Trust and knowledge of the health insurance scheme had significant influence
on uptake of national health insurance. Health Insurance Schemes should be designed in
such a way that they attract informal sector workers and information regarding these schemes
is disseminated to these people.
Keywords: National Health Insurance Fund; Health Insurance; Informal sector workers; Scheme related factors
INTRODUCTION
Health insurance schemes tend to increase the availability
of affordable healthcare as one can meet the costs of
medical expenses but the informal sector employees do
not have equal access to health services due to low
uptake. Trust in the scheme management is found to be a
significant enabler of enrolment into health insurance
schemes (Adebayo et al., 2015; Dror et al., 2016; Fadlallah
et al., 2018). when the rules of Community Based Health
Insurance schemes were perceived as rigid, and when
people felt there was a lack of clarity about the legal or
policy framework, they were less inclined to enroll and
renew also when a scheme is accommodating and has
support from policymakers it results to trust thereby
translating into higher enrollments (Dror et al., 2016).
*Corresponding Author: Muranda M. Agiza, School of
Health Sciences, Jaramogi Oginga Odinga University of
Science and Technology, Bondo, Kenya. E-mail:
mayaagiza@live.com Co-Author 2
E-mail:
owengajane55@gmail.com Co-Author 3
E-mail:
dvdotieno@gmail.com Co-Author 4
E-mail:
donguru@jooust.co.ke Co-Author 5
E-mail:
awinomerceline49@gmail.com Co-Author 6
E-mail:
atitoraphael@gmail.com
Research Article
Vol. 6(3), pp. 181-186, November, 2020. © www.premierpublishers.org. ISSN: 1406-089X
International Journal of Public Health and Epidemiology Research

2. Factors Influencing the Uptake of National Health Insurance Schemes among the Informal Sectors in Vihiga Sub County.
Muranda et al. 182
According to Maina et al. (2016), knowledge of health
insurance by the informal sector was beneficial.
If the knowledge score about insurance increased by 1 unit
and the chance of CBHI enrollment increased by 1.8
points. Moreover, an informed household head has a
higher probability of enrollment than non‐informed ones
(Atafu & Kwon, 2018). Several articles established the
relationship between insurance benefits and uptake of
health insurance (Boateng & Awunyor-Vitor, 2013;
Fadlallah et al., 2018; Masengeli et al., 2017; Odeyemi,
2014) the studies suggested a significant positive
relationship between insurance scheme benefits and
enrolment/ uptake of health insurance. In the study by Dror
et al. (2016) benefits package was only mentioned but not
analyzed further to determine whether it influenced health
insurance uptake. The benefits one is likely to get from
subscribing to the scheme increases the likelihood of
enrolling in the insurance scheme (Boateng & Awunyor-
Vitor, 2013). (Masengeli et al., 2017) conducted a study at
Bungoma County Referral Hospital, the Results showed
that ownership of health insurance cover was significantly
associated with awareness of the benefits of health
insurance. Specifically insured persons were more positive
in their perceptions of benefits of health insurance as
compared to non-insured persons.
According to Fadlallah et al. (2018) benefit packages that
are tailored to the needs of a community are non-
discriminatory and cover outpatient services increased
enrollment in a CBHI scheme. On the other hand,
packages with limited disease coverage contributed to low
uptake. Scheme benefits need to be comprehensive and
easily understood, and administrators and providers
trusted by beneficiaries (Odeyemi & Nixon, 2013).
(Boateng & Awunyor-Vitor, 2013) established the
relationship between the scheme attractiveness and
enrollment into health insurance scheme. A clients’
confidence in the scheme influence people’s perception of
personal benefits. This was evident in this study as
respondents cited unattractiveness of the scheme as a
reason for never enrolling in the scheme. Unattractiveness
was not reported in any other study that the researcher
came across, although low participation of people in the
informal sector was attributed to NHIF scheme design
features including inflexible payment schedules and
limited information about the features of the scheme
(Mukhwana et al., 2015).
Summary of Materials and methods Used
(Masengeli et al., 2017) conducted a cross-sectional
descriptive study in Bungoma County Referral Hospital,
the study adopted systematic and purposive sampling
techniques. Structured questionnaires and Key Informant
Interview were used as data collection tools. Crude Odds
Ratio (OR) was used to determine relationship between
variables; t-test was used to compare relationship between
the study variables. (Mukhwana et al., 2015) employed
stratified, purposive and quota sampling methods.
Questionnaires, In-depth interviews and Focus Group
Discussions were used as data collection tools. Chi-
square test and logistic regression (univariate, bivariate
and multivariate) analysis was used to assess for
statistically significant associations. (Mulupi et al., 2013)
adopted a Cross-sectional household survey and focus
group discussions, Cluster sampling was used. The
adopted methodologies however had the following
disadvantages, (Masengeli et al., 2017; Mukhwana et al.,
2015) used purposive sampling techniques which resulted
to bias with the participants because of the possibility of
unrepresentative samples and also the possibility of
generalizations of the study findings. They also used
interviews which are deemed to be expensive, they require
trained expert, are time consuming and tend to result to
bias since one may ask a leading question. Structured
questionnaires were adopted by (Masengeli et al., 2017)
therefore the study participants were not able to have their
freedom of response since they were limited to the choices
that they had been given and the researcher was also not
able to obtain in-depth information from the study
participants. (Mukhwana et al., 2015; Mulupi et al., 2013)
used Focus group discussions which are time consuming
and are not easy to organize.
This study deviated from the previous studies by adopting
cross- sectional study design. cluster sampling and simple
random sampling techniques were used so as to avoid
biasness and generalization of the study findings. To
collect data Semi structured questionnaire were used as it
enhances the freedom of response and allows for the
collection of in-depth information, they are also simpler to
formulate. Chi-square test, and logistic regression analysis
were used to detect associations.
METHODOLOGY
The researcher adopted a descriptive cross- sectional
study design. The target population for this study was the
informal sector workers from Vihiga Sub County, however
data on informal sector workers in Vihiga Sub County is
not known, the researcher therefore used data of the
employment population in Vihiga Sub-County. According
to (KNBS & SID, 2013) the population in working ages is
in the age group of 15-64 years. Participants included in
the study were working in the informal sector and residents
of Vihiga Sub County, the study excluded individuals that
did not work in the informal sector and were not residents
of Vihiga Sub-County. The required sample size of 384
was calculated using the Fischer et al (1998) formula and
Sampling done using cluster sampling and simple random
sampling techniques. Cluster sampling was done by ward
and a sample size from each ward determined. The
calculated sample size of each ward was then multiplied

3. Factors Influencing the Uptake of National Health Insurance Schemes among the Informal Sectors in Vihiga Sub County.
Int. J. Public Health Epidemiol. Res. 183
by a co- efficient of variation to obtain the number of males
that were sampled from each of the four wards and the
remaining ones after subtraction was considered as
female. The participants were then selected randomly from
the male and female categories using simple random
sampling technique. In the collection of data Semi-
structured questionnaires were used. Chi-square test and
bivariate regression analysis were used to detect
associations. Data analysis was done by the use of
descriptive statistics and presented in tables. Scientific
and ethical approval to conduct the study was obtained
from the Ethical Review Committee at Jaramogi Oginga
Odinga Teaching and Referral Hospital respectively before
the start of the study. Permission to conduct the study was
sought from the relevant County, sub County and local
authorities.
RESULTS
This section represents factors influencing the uptake of
National Health Insurance schemes among the informal
sector workers. Trust in the scheme management,
knowledge of health insurance schemes and
attractiveness to health insurance scheme were some of
the scheme related factors that were analyzed using
descriptive statistics, chi-square test and bivariate logistic
regression.
Trust
Respondents were asked their opinions regarding trust in
the scheme management which was two questions of five-
point Likert scale of Strongly agree, Agree, Neither agree
nor disagree, Disagree, Strongly Disagree. The first was
the provision of in-depth information on the packages the
schemes offer and the second was allowing the individual
to make an informed decision. The variables were factored
into one variable called Trust and grouped into three
categories Yes/No/Not sure by factor analysis. Bivariate
logistic regression was done to determine the influence of
Trust in the scheme management on the uptake of national
health insurance. The results in Table 1 show that there
was a significant influence of trust on the uptake of national
health insurance. Those that trusted in the management of
the scheme and felt that there was clarity about the legal
or policy framework and transparency to allow individuals
make an informed decision were 2.82 times more likely to
enroll for national health insurance as compared to those
who did not trust the management (OR=2.82,
95%CI=1.20-6.64, p-value< 0.05)
Table1: Influence of Trust in the scheme management
on the uptake of national health insurance
Uptake of national health
insurance
Yes n (%) No n (%) OR 95%CI p-
valu
e
Trust
No 7(5.30) 31(12.30) Ref
Yes 109(82.58) 171(67.86) 2.8228
9
1.20 -
6.64
0.01
7
Not
sure
16(12.12) 50(19.84) 1.4171
43
0.52 -
3.83
0.49
2
Knowledge of Health insurance scheme
To determine the impact of knowledge on the uptake of
health insurance schemes, cross tabulation and chi-
square test of association was done. Table 2 below reveals
that knowledge of health insurance scheme had a
statistically significant association with the uptake of
national health insurance schemes (p-value<0.001). The
result shows that 248(64.58%) were aware that health
insurance partially or fully covers medical bill however,
majority 129(52.02%) of them did not enroll for health
insurance, 123(90.44%) out of 136(35.42%) respondents
who were not aware that health insurance partially or fully
covers medical bills did not register for national health
insurance. Of 210(54.69%) who were aware that nuclear
family use card to seek medical attention, 112(53.33%)
enrolled for national health insurance. The results further
reveal that majority 139(88.54%) of 157respondents who
were not aware that health insurance minimizes the risk of
impoverishment did not enroll for national health
insurance. Respondents who enrolled for national health
insurance, 95(50.00) were aware that contributions are not
refundable when one withdraws from insurance scheme.
In terms of how the medical bills are paid by the insurance
company, majority of the respondents who enrolled for
national health insurance 193(50.26%)were aware that
patients fill claim forms which are used by the hospitals to
demand payment and majority 101(52.33%)of them
enrolled for national health insurance. In addition,
159(41.41%) were aware that patients are made aware of
how much they spend at any given visit. However, majority
of them did not enroll for national health insurance
85(53.46%).

4. Factors Influencing the Uptake of National Health Insurance Schemes among the Informal Sectors in Vihiga Sub County.
Muranda et al. 184
Table 2: Level of Association between knowledge of health insurance schemes and uptake of national health
insurance scheme
Uptake of national health
insurance
Chi-square
Variables N(%) No n(%) Yes n(%) p-value
Health insurance partially or fully covers medical bills <0.001***
Aware 248(64.58) 129(52.02) 119(47.98)
Not aware 136(35.42) 123(90.44) 13(9.95)
Nuclear family members use card to seek medical
attention
<0.001***
Aware 210(54.69) 98(46.67) 112(53.33)
Not aware 170(45.31) 150(88.51) 20(11.46)
Health insurance minimizes the risk of impoverishment <0.001***
Aware 227(59.11) 113(49.78) 114(50.22)
Not aware 157(40.89) 139(88.54) 18(11.46)
Contributions are non-refundable <0.001***
Aware 190(49.48) 95(50.00) 95(50.00)
Not aware 194(50.52) 157 (80.93) 37(19.07)
Patients fill claim forms <0.001***
Aware 193(50.26) 92(47.67) 101(52.33)
Not aware 191(49.74) 160 (83.77) 31(16.23)
Patients are informed of how much they spend at any
visit
<0.001***
Aware 159(41.41) 85(53.46) 74 (46.54)
Not aware 225(58.59) 167 (74.22) 58(25.78)
Note: Level of Significance: *P≤0.05; ** P≤0.01; *** P≤0.001
Attractiveness of the scheme
Table 3 below shows the descriptive statistics (Frequency
and percentage) of the level of attractiveness of the
scheme and the uptake of national health insurance.
Majority of the respondents 208(54.17%) reported that
accessibility of national health insurance had a large
influence on the uptake of national health insurance while
36(9.38%) said that accessibility of national health
insurance had no influence on uptake of national health
insurance.
The availability of national health insurance is also a factor
that attracts people to the health insurance scheme. The
results reveal that 199(51.82%) respondents said that
availability of national health insurance had a large
influence on the uptake of national health insurance,
77(20.05%) said that the availability of national health
insurance had a small influence on the uptake of national
health insurance and only 29(7.55%) reported that there is
no influence on availability of national health insurance on
the uptake of national health insurance.
Majority of the respondents 145(37.76%) out of 384
reported that the conditions for enrolling in the preferred
scheme had a big influence on the uptake of national
health insurance while 44(11.46%) reported that
conditions for enrolling in the preferred scheme had no
influence on the uptake of national health insurance
scheme.
Premiums charged both for public and private scheme was
also a factor that was considered to attract people to
scheme. The results show that 149(38.80%) respondents
reported that premium charged had large influence on
uptake of national health insurance, 87(22.66%) reported
that premium charged had small influence on uptake of
national health insurance, 34(8.85%) said that premium
charged had no influence on uptake of national health
insurance and 86(22.40%) were not sure. Further, the
results reveals that majority of the respondents
114(29.69%) agreed to the hypothesis that penalties for
late/non-payment of premiums had large influence on
national health insurance uptake while 35(9.11%) reported
that penalties for late/non-payment of premiums had no
influence on the uptake of national health insurance.
It is clear in the result in Table 3that enrollment for national
health insurance depends of healthcare services covered.
Majority 182(47.40%) responded that health care services
covered had large influence on the uptake of national
health services and only 36(9.38) reported the contrary
that healthcare services covered had no influence on the
uptake of national health insurance

5. Factors Influencing the Uptake of National Health Insurance Schemes among the Informal Sectors in Vihiga Sub County.
Int. J. Public Health Epidemiol. Res. 185
Table 3: Level of influence of attractiveness of the schemes on the uptake of health insurance scheme
No influence Small influence Large influence Not sure missing
n(%) n(%) n(%) n(%) n(%)
Accessibility of national health
insurance
36(9.38) 61(15.89) 208(54.17) 54(14.06) 25(6.51)
Availability of national health
insurance
29(7.55) 77(20.05) 199(51.82) 53(13.80) 26(6.77)
Conditions for enrollment 44(11.46) 90(23.44) 145(37.76) 73(19.01) 32(8.33)
Premiums charged 34(8.85) 87(22.66) 149(38.80) 86(22.40) 28(7.29)
Penalties for late/non-payment of
premiums
35(9.11) 115(29.95) 114(29.69) 88 (22.92) 32(8.33)
Healthcare services covered 36(9.38) 79(20.57) 182(47.40) 57(14.84) 30(7.81)
DISCUSSION
The results showed that there was a significant influence
of trust on the uptake of national health insurance
schemes. Those that trusted in the management of the
schemes and felt that there was clarity about the legal or
policy framework and transparency to allow individuals
make an informed decision were 2.82 times more likely to
enroll for national health insurance as compared to those
who did not trust the management (OR=2.82 , 95%
CI=1.20 - 6.64, p<0.05). This corroborates with previous
studies whereby trust in the scheme management was a
significant enabler of enrolment, when the rules of
schemes were perceived as rigid, and when people felt
there was lack of clarity about the legal or policy
framework, they were less inclined to enroll and renew
(Dror et al., 2016). When quality healthcare is provided,
trust of the clients in the health system and the health
insurance scheme increases (Boateng & Awunyor-Vitor,
2013). High levels of trust are associated with numerous
benefits among them, access to healthcare services. In
order to overcome the health disparities that exist across
the lower-income populations and the uninsured, there is
therefore need for these insurance schemes to build trust
within the informal sector.
Knowledge of the health insurance scheme had a
statistically significant association with the uptake of
national health insurance (p<0.05). This concurs with the
studies by (Atafu & Kwon, 2018; Maina et al., 2016) where
inadequate knowledge and understanding of the scheme
influences uptake in that most individuals end up not
enrolling in any health insurance scheme. It’s therefore
important for the government and other organizations that
offer health insurance to develop clear policies and other
mechanisms they can adopt with regards to educating the
communities thus increasing knowledge and penetration
of these schemes.
Attractiveness of the scheme was assessed by asking the
respondents the extent to which certain factors influenced
health insurance uptake. All the factors listed had a large
influence on health insurance uptake with exception of
penalties for late nonpayment 115(32.7%) that had
outcome of small influence. According to Boateng and
Awunyor-Vitor (2013) respondents cited unattractiveness
of the scheme as a reason for never enrolling in the
scheme. Also low participation of people in the informal
sector was attributed to NHIF scheme design features
including inflexible payment schedules and limited
information about the features of the scheme (Mukhwana
et al., 2015).
CONCLUSION
Trust and knowledge of the health insurance scheme had
significant influence on uptake of national health
insurance. Attractiveness of the scheme was also found to
influence uptake.
RECOMMENDATIONS
Insurance schemes should build trust within the informal
sector by giving out detailed information regarding the
schemes as this will enable them make informed
decisions. The government through the Ministry of Health
should ensure there is continuous education to individuals
and the community about health insurance. Health
Insurance Schemes should be designed in such a way that
they attract informal sector workers.
ETHICAL DECLARATIONS
Conflict of interests: The authors declare no conflicts of
interest
Funding: The Authors did not receive any grant for the
study. The expenses for the study were funded by the
corresponding author Mrs. Marion Agiza Muranda
Ethical Approval: Ethical approval was obtained from
Jaramogi Oginga Odinga Teaching and Referral Hospital

6. Factors Influencing the Uptake of National Health Insurance Schemes among the Informal Sectors in Vihiga Sub County.
Muranda et al. 186
ERC and a study permit from National Commission for
Science, Technology and innovation (NACOSTI).
Informed Consent: Written consent was obtained from
the community members before starting the study.
ACKNOWLEDGEMENT
The the University of Jaramogi Oginga Odinga University
of Science & Technology for. We recognize the support
from the lectures and our peers for the support and
direction in any respect towards the completion of this
manuscript. The study participants and publication
committee.
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Accepted 22 October 2020
Citation: Muranda MA, Owenga JA, Otieno DO, Onguru
DO, Orende MA, Atito RO (2020). Factors Influencing the
Uptake of National Health Insurance Schemes among the
Informal Sectors in Vihiga Sub County. International
Journal of Public Health and Epidemiology Research, 6(3):
181-186.
Copyright: © 2020 Muranda et al. This is an open-access
article distributed under the terms of the Creative
Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium,
provided the original author and source are cited.