Do free healthcare policies play a role in expanding national health insurance enrollment among informal sector workers? The case of the Afya Care pilot program in Kenya

Several Sub-Saharan African countries have transitioned from fiscally unsustainable free healthcare policies to national health insurance schemes. These national schemes often expect informal sector workers to contribute directly to the scheme. Although enrollment in the national scheme is critical to achieving universal health coverage, informal sector workers’ inclusion remains challenging. In this paper, using the case of the Afya-Care free healthcare policy pilot in Kenya, we examine an issue that has thus far received limited attention in the literature: the extent to which earlier exposure to free healthcare policies shapes later informal sector workers’ decisions to enrol and contribute to a public health insurance scheme. We used nationally representative repeated cross-sectional household data collected among informal sector workers in Kenya in 2018 and 2020 before and after the Afya Care-free healthcare pilot, respectively. Using a sample of 6900 informal sector workers, we constructed a pre-and-post quasi-experimental design applying difference-in-differences estimation modelling to assess the effect of exposure to the Afya-Care free healthcare policy pilot on individuals' decisions to enrol later in the national health insurance scheme. No Difference was observed between the two groups before intervention. However, after the intervention, our findings show a 10.5% difference in national health insurance scheme enrollment between the control and intervention groups (p < 0.001). Individuals in the intervention counties had a 65% greater probability of enrolling in the national health insurance scheme than did those in the control counties (odds ratio -1.65; p = 0.07; 95% CI—0.96- 2.83). Heterogeneity analysis revealed a significant increase in enrollment in the intervention group by 30% and 18% among the least educated and among the poorest individuals, respectively. Our findings suggest that exposure to the Afya Care-free healthcare policy favoured the decision to enrol in the national health insurance scheme and enhanced equity. However, registration in the scheme remains low. Increased enrollment is likely to follow only from an enhanced government commitment to improve information campaigns to boost awareness, to expand subsidies to increase premium affordability, especially among low-income informal sector workers, and to subsidise those who cannot afford to pay.