Harnessing rural community savings groups for contribution collection in the Zambia national health insurance scheme: an analysis of community perspectives using the motivation and ability framework

Abstract

BACKGROUND: Many countries seek universal health coverage through national health insurance schemes based on payroll contributions from formal sector employees. Zambia, having recently adopted such a scheme, faces challenges in collecting contributions from its large informal sector. Expanding insurance to this sector requires trust and private information, qualities often found in community-based organizations such as savings groups (SGs). This study explores stakeholder perspectives on the feasibility of leveraging SGs for contribution collection from the informal sector in Zambia's national health insurance scheme. METHODOLOGY: We conducted an exploratory qualitative research study in two districts of Zambia, comprising nine focus group discussions with community members and eight key informant interviews with stakeholders. We applied thematic analysis using the motivation and ability framework, which stipulates several dimensions of assessing feasibility including the triggers, abilities, motivation, and action. RESULTS: Participants indicated that there were existing "insurance" features in the SGs that could be leveraged to make members appreciate the concept of health insurance. They emphasized the importance of enhanced knowledge about the national health insurance scheme at community level as a key trigger to facilitate engagement of the SG members. The ability of these groups to be used for contribution collection was strengthened by the presence of a collective constitution governing all members. Furthermore, the results revealed a promising opportunity to utilize mobile technology to collect contributions from rural communities. Notably, the motivation within the community was underscored by the recognition of social advantages emanating from the SG and the members' eagerness to contribute towards emergencies such as healthcare. However, participants identified potential threats to using the SGs for contribution collection, including inconsistent income, mishandling of contributions, and instability within the SGs. CONCLUSION: Our study suggests the feasibility of utilizing SGs for contribution collection, yet their effective use may necessitate government oversight, policy development, and capacity building. Interventions such as proper financial management and technology integration can optimize the potential of leveraging SGs for inclusive healthcare coverage.