Uptake of the Akwa-Ibom State Health Insurance Scheme among Low-Income Households in Uyo Local Government Area, Akwa-Ibom State: Levels and Determinants

Abstract

Achieving Universal Health Coverage in Nigeria depends on the ability of state-level health insurance schemes to reach low-income and informal-sector households, who remain the most exposed to catastrophic out-of-pocket health expenditure. The Akwa-Ibom State Health Insurance Scheme (AKSHIS) was established to extend affordable coverage to state residents, yet enrolment among low-income households in Uyo Local Government Area (LGA) continues to fall short of target. This study examined the current level of uptake of AKSHIS and the socio-economic, cultural, and informational factors that determine enrolment among low-income households in Uyo LGA. A cross-sectional survey was conducted among 406 low-income households in Uyo LGA, selected through a multi-stage sampling technique. A structured, interviewer-administered questionnaire captured enrolment status, reasons for non-enrolment, and socio-economic, cultural, and informational factors influencing uptake. Data were analyzed using descriptive statistics, chi-square tests, Pearson correlation, binary logistic regression, and structural equation modeling (SEM) to identify significant predictors of enrolment. Overall, 67% of respondents were currently enrolled in AKSHIS. Among the 33% not enrolled, the leading reasons cited were insufficient information (50.24%) and the cost of premiums (32.50%). Logistic regression identified awareness (β = 1.65, p<0.001), income level (β = 1.35, p<0.001), education level (β = 0.75, p=0.001), importance placed on quality care (β = 0.60, p<0.001), and accessibility of health facilities (β = 0.50, p<0.001) as significant positive predictors of enrolment. Income and education were significantly correlated with enrolment (r = 0.65 and r = 0.58, respectively, p<0.01), confirming that socio-economic status significantly influences uptake (χ²(1, N=406) = 25.34, p<0.001). Negative cultural beliefs about the reliability of health insurance (OR = 0.426, p=0.005) and negative perceptions of it as a financial burden (OR = 0.522, p=0.020) were significantly associated with reduced odds of enrolment, while higher income (OR = 1.27, p=0.015) and education (OR = 1.46, p=0.010) increased the odds of enrolment. Uptake of AKSHIS among low-income households in Uyo LGA is moderately high but constrained by informational gaps, affordability, and unfavorable cultural perceptions. A multifaceted strategy combining subsidized premiums, targeted community outreach, and trust-building initiatives is required to close the enrolment gap.