Barriers and facilitators to health insurance enrolment among people working in the informal sector in Morogoro, Tanzania

Background : Health insurance is a crucial pathway towards the achievement of universal health coverage. In Tanzania, health-financing reforms are underway to speed up universal health coverage in the informal sector. Despite improved Community Health Fund (iCHF) rollout, iCHF enrolment remains a challenge in the informal sector. This study aimed to explore the perspectives of local women food vendors (LWFV) and Bodaboda (motorcycle taxi) drivers on factors that challenge and facilitate their enrolment in iCHF. Methods: A qualitative study was conducted in Morogoro Municipality through in-depth interviews with LWFV (n=24) and Bodaboda drivers (n=26), and two focus group discussions with LWFV (n=8) and Bodaboda drivers (n=8). Theory of planned behaviour (TPB) constructs (attitude, subjective norms, and perceived control) provided a framework for the study and informed a thematic analysis focusing on the barriers and facilitators of iCHF enrolment. Results: The views of LWFV and Bodaboda drivers on factors that influence iCHF enrolment converged. Three main barriers emerged: lack of knowledge about the iCHF (attitude); negative views from friends and families (subjective norms); and inability to overcome challenges, such as the quality and range of health services available to iCHF members and iCHF not being accepted at non-government facilities (perceived control). A number of facilitators were identified, including opinions that enrolling to iCHF made good financial sense (attitude), encouragement from already-enrolled friends and relatives (subjective norms) and the belief that enrolment payment is affordable (perceived control). Conclusions: Results suggest that positive attitudes supported by perceived control and encouragement from significant others could potentially motivate LWFV and Bodaboda drivers to enroll in iCHF. However, more targeted information about the scheme is needed for individuals in the informal sector. There is also a need to ensure that quality health services are available, including coverage for non-communicable diseases (NCDs), and that non-government facilities accept iCHF.