Informing policy through evidence: A scoping review of factors that influence enrolment in community-based health insurance in East Africa

Abstract

Background: Community-based health insurance (CBHI) has emerged as a promising option to enhance the attainment of Universal Health Coverage in Low- and middle-income countries and Sub-Saharan Africa. However, CBHI schemes in Africa particularly in the eastern regions, grapple with chronic low enrolment, jeopardizing their sustainability and intended impact. Understanding the determinants of enrolment in these schemes is critical for designing effective strategies to boost participation. In this scoping review, we categorized and discussed these determinants across socio-ecological levels.
Methods: We conducted a scoping review of literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extended for Scoping Review checklist. Literature searches were conducted across academic databases to identify studies on determinants of enrolment to CBHI schemes in East Africa in June 2023 and updated in June 2025. Peer-reviewed, English-language studies using cross-sectional, case-control, qualitative, case studies, or mixed-methods designs were included which were conducted in East Africa and reported primary outcomes on determinants of CBHI enrolment (2000–2025). Excluded studies were reviews, non-peer reviewed articles, willingness to pay/willingness to enrol studies, and those on satisfaction, dropouts, or compulsory schemes (e.g., Rwanda post-2007, Seychelles as a high-income country). Data extraction and thematic analysis guided by a socio-ecological model framework were performed on the data.
Results: A total of thirty articles met the inclusion criteria. The findings unveiled a broad spectrum of determinants influencing CBHI enrolment. At the individual level, key factors included awareness, socio-demographics, and personal predisposition. At the household level, household characteristics, social capital, and cohesion played significant roles. Community-level determinants included cultural beliefs, religion, and geographical location, while system-level factors were stakeholder influence, governance, benefit package design, premium structure, human resource management, supply chain, access to care, and referral systems.
Conclusions: The findings emphasize the need for a holistic and multi-level approach to enhancing enrolment. Policymakers and stakeholders should integrate these determinants into interventions to strengthen CBHI schemes, expand healthcare access, and reinforce financial protection. Further studies are needed to explore the interplay between these factors.

Keywords

Community-based Health Insurance / Universal Health Coverage / Catastrophic Health Expenditure / Out-of-Pocket Payments / Socio-Ecological Model / East Africa

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