Quality of care and health insurance uptake in Namibia

Despite efforts to expand health insurance in low- and middle-income countries, uptake remains low. Poor quality of care, especially in public facilities, is often cited as a barrier to health insurance enrolment but limited empirical evidence exists.

We examine whether the quality of antenatal care (ANC) influences women's enrolment in health insurance programmes in Namibia.

In Namibia, insurance uptake is modest but growing, and health facility density and ANC quality vary regionally.

We link Namibia's 2009 Service Provision Assessment (SPA), a census of all health facilities, with the 2013 Demographic and Health Survey (DHS). Using geospatial data, we construct a cluster-level ANC quality index covering structural readiness, process adherence and client experience. Multivariate regressions estimate the association between ANC quality and insurance uptake, adjusting for socioeconomic and demographic factors.

We find no statistically significant association between ANC quality and insurance uptake nationally. However, the relationship varies by region: in areas with low health facility density (south), higher ANC quality is marginally associated with increased insurance uptake, while no significant association is found in regions with greater facility density (north). Indicators of wealth and education consistently predict higher enrolment, regardless of ANC quality.

Improving ANC quality is essential for health outcomes but, on its own, is unlikely to drive insurance uptake nationally. Quality appears more influential in underserved regions, while socioeconomic inequalities dominate enrolment patterns.

This study expands scarce low- and middle-income countries (LMICs) evidence on quality and insurance demand, applies a novel geospatially linked ANC quality index using a facility census and highlights the need to tailor insurance expansion strategies to subnational contexts of socioeconomic inequality and service access.