Thesis:

Determinants of national health insurance fund enrolment among primi mothers: a case study of Meru county, Kenya

Access to healthcare remains a critical challenge for first-time mothers (primi mothers) in Meru County, Kenya, exacerbated by low enrollment rates (18%) in the National Health Insurance Fund (NHIF) compared to the national average (26%) for women of reproductive age. This disparity contributes to elevated maternal mortality (398 deaths per 100,000 live births) and financial hardship, with 63% of informal-sector primi mothers citing unaffordable premiums despite subsidized maternity packages. The study aimed to identify determinants of NHIF enrollment among this vulnerable group, with specific objectives to examine associations between sociodemographic characteristics (age, income, education, marital status), awareness levels, premium affordability, outlet accessibility/service efficiency, and enrollment patterns. A cross-sectional survey design was employed, collecting data from 224 primi mothers across six Meru sub-counties (Imenti South, Imenti North, Buuri, Imenti Central, Tigania East, Tigania West), achieving a 92% response rate. The target population comprised 1,248 primi mothers from NHIF-accredited facilities, with 243 participants selected via systematic sampling. Data were gathered using structured questionnaires and semi-structured interviews, piloted with 24 participants (10% of the sample) to refine instruments. Validity was ensured through expert review and Cronbach’s alpha (α ≥ 0.65), while reliability was confirmed via test-retest methods. Ethical compliance included informed consent, anonymized data storage, and protocols for handling sensitive financial/health information. Analysis employed descriptive statistics, Pearson Chi-Square tests, and regression modeling. Key findings revealed: 1) Predominance of young mothers (63.8% aged 15–24); 2) Significant enrollment predictors: awareness (β = 0.285, p < 0.001), poverty (B = 0.056, p = 0.026), and religious affiliation (B = 0.105, p < 0.001); 3) Radio (27.2%), healthcare providers (32.6%), and family/peer networks (17.0%) as primary awareness sources; 4) Affordability barriers, with 55.5% citing premium costs as prohibitive and 15.2% unable to pay; 5) Service efficiency gaps, where only 31% were satisfied with NHIF outlet waiting times. Regression confirmed waiting time satisfaction (B = 0.28) and overall satisfaction (B = 0.65) as key drivers of outlet satisfaction (R² = 0.56). The study concludes that NHIF enrollment among primi mothers is hindered by intersecting economic, informational, and structural barriers, disproportionately affecting low-income, informally employed, and geographically isolated women. Recommendations include implementing income-tiered premiums (Ksh 100–500 monthly), integrating NHIF registration with antenatal care, deploying mobile enrollment units to remote wards, training community health workers as insurance ambassadors, and collaborating with religious leaders to address cultural barriers. Future research should evaluate these interventions through longitudinal studies and explore digital payment solutions to enhance accessibility.