The impact of digital health insurance for low-income women in Kenya

Objective This study evaluates how a subsidized, mobile phone-based health insurance program affected insurance uptake, healthcare utilization and health expenditures for low-income women and their family members in Western Kenya. The program, targeting pregnant women and mothers of children below age four, addressed both demand- and supply-side constraints, providing subsidies through mobile money and support in digital registration while upgrading selected facilities and digitally training community health workers. Methods The research was based on a cluster-RCT conducted between 2019 and 2021 in 24 villages in Kakamega County. After a baseline survey, 240 households (more than 1,300 individuals) were interviewed every week during 18 months to collect detailed financial and health data while the program was rolled out in the treatment communities, moving to phone-based interviewing after the onset of COVID-19. Results The intervention had a significant impact on individual insurance uptake of 65.8 percentage points (from a baseline control mean 18.9 percent). We find weak positive impacts on formal healthcare utilization, and substantial increases in financial coverage of medical costs and associated reductions in out-of-pocket expenditures, particularly for medicines. Results are strongest for women, young children and individuals living closest to the clinics. Dynamic analyses show that impacts become increasingly pronounced over time, suggesting that women may need some time to get used to the digital insurance scheme. Conclusion The program not only reduced the costs of enrolment, but also eliminated other (administrative, logistical, trust) barriers. The introduction of the scheme by trusted local agents, the hands-on assistance with the digital registration procedures at women’s homes, and support in retrieving the necessary documentation such as children’s birth certificates, have likely all contributed to the high enrolment rates, thereby improving access to good-quality care. Digital insurance has the potential to substantially enhance universal health coverage and financial protection for poor households. ### Competing Interest Statement The authors have declared no competing interest. ### Clinical Trial NCT04068571 ### Funding Statement This study was funded by the Dutch National Postcode Lottery, the Joep Lange Institute, and the Dutch Ministry of Foreign Affairs through the Health Insurance Fund. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethical approval was granted by the Amref Health Africa Ethics and Scientific Review Committee (P679-2019, 8th August 2019), with an amendment (21st April 2020) for the COVID-19-induced switch to telephone interviews and extension of the field work. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study will be deposited in an online repository in the near future and will be available upon reasonable request to the authors.