"To enrol or not to enrol?": A qualitative investigation of demand for health insurance in rural West Africa.

In spite of the fact that feeble levels of participation have long been identified as a major constraint to the successful long-term implementation of community-based health insurance (CBI) in low-income countries, evidence on determinants of enrolment in CBI is still lacking. The application of econometric modelling has provided a partial answer to the question, but on its own it has proved to be insufficient to guide policy making. This paper aims to fill this gap in knowledge using qualitative research methods. In-depth interviews with 32 household heads were conducted in the Nouna Health District, Burkina Faso, West Africa to assess determinants of enrolment in a newly established CBI scheme. The findings highlight that factors previously neglected in the literature, such as institutional rigidities and socio-cultural practices, play an important role in shaping the decision to enrol. The discussion of the findings focuses on the policy implications, offering concrete recommendations to maximise enrolment, within and beyond Burkina Faso.