Determinants of Enrollment and Retention in a National Social Health Insurance Scheme: A Study of Organized Informal Sector Groups in Nairobi County, Kenya

Abstract

Purpose: Achieving Universal Health Coverage (UHC) requires innovative strategies to extend social health insurance to the informal sector, which constitutes a majority of the workforce in many low- and middle-income countries. This study investigated the determinants of enrollment and retention among organized informal sector groups in Kenya's National Hospital Insurance Fund (NHIF). Methodology: A descriptive cross-sectional design was employed, using semi-structured interviews with 84 members of self-help groups in Kibera, Nairobi County. Data were analyzed using descriptive statistics and content analysis. Findings: Socio-demographic factors — including age, income, and education level — significantly influence enrollment. While 87.5% of respondents viewed NHIF membership as important and the benefit package as adequate, a critical gap was identified in members' knowledge of their entitlements, with respondents aware of only 59% of available benefits. Furthermore, over half (54.2%) of members reported that promised benefits were frequently unavailable at accredited healthcare facilities, and communication channels were found to be inadequate, with 40% of members learning about benefits through informal networks like friends rather than official NHIF sources. Value: The study concludes that beyond affordability, knowledge of benefits and the actual availability of services at the point of care are pivotal determinants of enrollment and retention. Recommendations include revising communication strategies, strengthening provider compliance, and exploring tiered premium structures to enhance the scheme's attractiveness and sustainability for the informal sector. Keywords: Social Health Insurance, Informal Sector, National Hospital Insurance Fund (NHIF), Enrollment, Retention, Universal Health Coverage (UHC), Kenya, Health Financing