Background

Health insurance has been documented as one of the primary methods of financing healthcare for Sustainable Development Goals (SDGs) by 2030. Yet, there is a dearth of evidence on the determinants of health insurance coverage among women in Mauritania. We examine the factors associated with health insurance coverage among women in Mauritania using a nationally representative survey dataset.

Prevalence of health insurance coverage

Among the women Overall, the coverage of health insurance among the women was 8.7%. Of this proportion of women, the majority subscribed to social security health insurance (7.6%) followed by employer-based health insurance (0.8%)

Distribution of health insurance coverage across the explanatory variables

The results showed that health insurance coverage is prevalent among women aged 35 and above (11.6%), those who had attained higher education (35.6%), those who were working (12.3%), those with multiparity (9.8%), and those exposed to mass media: television (14.1%), radio (10.9%), newspaper or magazine (17.5%), and internet (16.9%). Additionally, the percentage of health insurance coverage was high among women with male household heads (9.3%), those in the richest wealth index (25.7%), those in the urban areas (15.3), and those from Tiris zemour et Inchiri region (31.5%).

Discussions

Factors identified to be associated with health insurance coverage were age, level of education, current working status, parity, exposure to watching television, internet usage, wealth index, and region.

The finding showed that the coverage of health insurance among women in Mauritania is low (8.7%). This finding contradicts that of Ghana but is similar to that of Tanzania which recorded health insurance coverage of 62.4% and 9.1%, respectively. The disparities in health insurance coverage between the countries could be due to the health policy priority, sociocultural, and demographic variation in these countries.

Our result is consistent with health insurance coverage from studies conducted in Mauritania, Ethiopia, and Nigeria where the coverage was less than 10% among women in those countries. The low health insurance coverage found in this study could have negative implications for the attainment of the SDG target 3.8 if not addressed holistically. The low health insurance coverage among women as found in this current study is ascribed to the household inequality between men and women in the control and access to the household financial resources and also decision-making about health choices. Women in many households across the global south of which Mauritanian is no exception have limited access to household financial resources as well as a reduced role in health decision-making.

Therefore, these women might be less likely to decide on their own volition to subscribe to health insurance without the consent of their husbands who can eventually refuse a such suggestion. This observation points to the need for the government and national health authorities in Mauritania to programmes that will empower women to own their health and be able to make health decisions without impediment from spouses.

The low health insurance coverage could stem from issues such as ineffective procedures for collecting premiums, poor understanding of rules, misinformation by recruiters and mistrust among the populace and the health insurance organizations, and low awareness and attitudinal problems of the populace towards health insurance.

Women aged 35 years and above were more likely to subscribe to health insurance than their younger counterparts. The results concur with literature reviews conducted in West Africa and Nigeria  which suggest that people who are 30 years or older have a higher likelihood of subscribing to health insurance. This could be attributed to the fact that people of advanced age relatively have a higher probability of falling sick as their health deteriorates with aging, hence their decision to subscribe to health insurance as they are likely to have frequent health utilization.

These findings could also be because people who are 35 years or older could be economically active and hence have purchasing power to pay for their health insurance subscriptions and premiums. On the other hand, older women may be mothers and/or caregivers who are more likely to have more children who may often fall sick hence their decision to subscribe to health insurance to prevent out-of-pocket payment.

Women in this category as well may have gone through childbearing and are well abreast with the expensive medical bills one will have to pay during pregnancy, childbirth, and postnatal care. This could also explain the higher odds of health insurance coverage among women who had given birth before, especially those with multiparity and grand parity.

Educated women were more likely to subscribe to health insurance in this study than those without any form of education. Our results are similar to findings reported in Ghana, Peru, Zambia, and SSA  where educated women were more likely to be covered by health insurance. Educated women are more likely to be employed and financially capable of paying subscription and premium fees. They are also well-informed and able to access health information about health which may drive them to hold positive health-seeking behaviors. In addition, educated women are likely to have their health insurance covered by their employers since many educated individuals tend to be employed. As with Ghana, workers have health insurance deducted from their Social Security and National Insurance Trust (SSNIT) contributions and only pay a small upfront fee to be covered.

In furtherance, women who were employed or currently working had higher odds of being covered by insurance. The results show that when women are empowered financially, they can take care of their health needs by subscribing to insurance policies that will prevent catastrophic out-of-pocket payments.

We found exposure to mass media: watching television and internet usage to be associated with health insurance coverage. Our finding on internet usage is similar to the association of health insurance coverage in Ethiopian women. Access to mass, and watch adverts and health educational programs that emphasize the need to be covered by health insurance to prevent out-of-pocket payments. These pieces of information are also important for women to make critical decisions about their health. To meet the universal health coverage goal of 2030, various national health departments and ministries have had to implement health insurance as a pro-poor initiative to reduce household expenditure on health. As such, deliberate media campaigns can be pivotal in awareness creation and sensitization for subscription to health insurance.

Health insurance coverage was associated with women’s household wealth index. Health insurance is meant to cushion households from the severe catastrophic burden of health financing. Yet, those in much poorer homes are less likely to subscribe. Increasing wealth index showed higher odds of women being covered by health insurance in this study, which confirm the findings of several studies conducted across the world. These findings reflect the need for women’s empowerment, health utilization, and promotion of maternal and child health. Empowered women can break the power dynamics and have provident decisions and control over their health and that of their children.

The geographical region of residence was found to be associated with health insurance coverage. Specifically, women from Tagant, Tiris zemour et Inchiri, and Adrar regions were more likely to be covered by health insurance. Prior studies have also revealed different levels of health insurance coverage in regions of countries such as Malawi, Nigeria, Ghana, Kenya, and Ethiopia. Factors such as high literacy and availability of community-based insurance schemes could have contributed to the higher likelihood of health insurance coverage among women residing in the aforementioned regions in Mauritania. In our current study, the identified regions could be highly associated with increased literacy rates giving the populace in these areas access to information about health insurance hence their high subscription.

Public health policy implication

The low health insurance coverage could lead to poor health service utilization among women in Mauritania. Targeted education and awareness creation across the country to whip up interest in health insurance subscriptions is highly recommended. Women’s empowerment strategies in the form of employment, education, and access to information among others could serve as enabling environments for increased subscription.

As a result, efforts should be taken to guarantee that health insurance procedures and rates are fair and reasonable for those in households with lower wealth indices. To facilitate enrollment and lower financial barriers in communities, this can entail targeted subsidies or financial assistance programs.

Strength and limitation

The current study used the most recent nationwide dataset Additionally, our study is the first of its kind to the best of our study knowledge to be conducted among women in Mauritania. Some limitations need to be acknowledged. Since the data analyzed was secondary sourced, there may be other factors or variables that could have influenced health insurance coverage which were not included in the study because they were not available in the DHS dataset. Also, the cross-sectional nature of the DHS limits the study’s ability to make causal inferences. Additionally, data was collected using self-reports. Hence, the data may be prone to recall and social desirability biases.