Susanne Rabisch. Fieldwork Research Report Kenya

Transcription

1 Susanne Rabisch Fieldwork Research Report Kenya Impact Assessment of Health Microinsurance for the Social Protection of Informal Workers: A Qualitative Study for the Case of Kenya Aim of the field research The aim of my field research was to assess the impact of health on the working poor in Nairobi, Kenya. My analysis is mainly based on qualitative expert interviews with clients in order to gain an in- depth understanding of the benefits and shortcomings that the utilization of health micro- insurance has had for the lives of informal workers in Kenya. The focus of my analysis is on the potential improvement of social protection of informal workers through health. My thesis will provide an empirical study of the potential and shortcomings of health micro- insurance as a complementary instrument to public sector policy for promoting social protection for informal workers. The theoretical frameworks I will employ in my analysis of the field data will be the theoretical accounts of Social Capital and the theory of insurance and risk management. My previous work experience at a health micro- insurance company in Nairobi has highly motivated me to explore the actual impact and client value that this risk management tool offers to informal workers in Kenya. During my literature research and in the course of my work at the International Labour Organization, I noticed that in most cases, the benefits of health are assessed through quantitative means or through interviews with insurance providers themselves and that the voices of clients are often not heard. Therefore, the fieldwork in Nairobi and the analysis of the individual case data represent the heart of my Master s thesis. I based my approach on the opinion that without listening to insurance clients experiences and needs, it will be implausible to give well- reasoned recommendations to improve the potential of Social Finance instruments such as health micro- insurance to achieve better social protection for low- income, informal workers in Kenya. Positive experiences during the fieldwork Upon my arrival in Kenya, I started my fieldwork research by getting into contact with the insurance company Pioneer Assurance for which I had worked as an intern for 3 months in When I presented my research idea and my requests to be connected to the health clients of the company I was skeptical if the management will allow me to directly contact the clients and give me free choice of interview partners, since I was going to collect direct and open opinions about the impact and possible challenges that these low- income clients encountered with the insurance product. To my surprise, the 1

2 management was very supportive and even welcomed my return to conduct research about the health product. Within a day I was connected to the distribution channel representatives and even though only one of the two proposed Microfinance institutions agreed for me to conduct interviews with their members, I was positively surprised about Pioneer s openness and trust to give me full freedom to contact any client I wished to contact. In the process of identifying the specific clients there have been some challenges as outlined below, however, the fieldwork could have been delayed if the insurance company had taken longer to organize my meetings with the distribution channel managers. In general, I had the impression that the stakeholders were very interested to assist my research process and they provided me with support wherever possible. If it was to explain the insurance product in detail or to help convince clients, who were sometimes reluctant to talk to a foreigner, that I am trustworthy and that there is no reason to feel shy. This way, I was able to build rapport with the interviewees much more quickly and the interviews turned out very fruitful. Especially noteworthy was that some of the interviewees opened up to me about the very sensitive issue of health care and health care spending in their families and the fears and hopes that come with the insurance product they purchased. This openness and the sharing of details on the impact of health on a psychological and sociological (ie. Social Capital) level, supported me in my approach that a qualitative study is a much- needed tool to assess the full impact of health in especially in a society like Kenya, where many traditional health risk management tools are still in place today. Through the interviews I was able to learn many details about the emergency social network support groups called Harambees and could explore in more detail how insurance can have an impact on this long established form of Social Capital for health risk management. I was very grateful that interviewees were ready to sacrifice some of their working time (especially because most of them were self- employed) to express their opinions to me and encouraged me to keep researching the topic to help establish better health care financing tools for informal workers. I was also impressed by the helpfulness of the network I had established during my work for the International Labour Organization. When I arrived on 5. May a very controversial national health care corruption scandal had just unfolded a couple of days before and after I learned that the Central Organization of Trade Unions (COTU) is a central player in the fight against the alleged corrupt representatives at the National Hospital Insurance Fund (NHIF), I contacted the General Secretary of an affiliated union who I had met during my time at the ILO. He immediately arranged interviews for me with both, high- level officials at COTU and NHIF. This way, I could include this corruption obstacle in Kenya s transition to Universal Health Care into my analysis. Through interviews with 2

3 informal workers clients and trade union and national health officials I am now able to better understand both sides of the national health care process. This was particularly important, because the health insurance product, whose impact I was assessing is in the process of being restructured as a Public- Private Partnership between the commercial insurer and the National Hospital Insurance Fund and is therefore also affecting the informal workers I was targeting in my interviews. Challenges in the research process When I decided to analyze the impact of health on clients, I was working as an intern in the medical insurance company Pioneer Assurance in Nairobi in I knew their commercial health product Afya in depth and was interested how it really affected the lives of informal workers and how health could have an impact on their social protection. At the time, Pioneer had a relatively large client base with their main distribution channel Faulu Kenya (a Microfinance Bank). I was planning to use Pioneer s detailed client records to gain access to informal workers specifically. However, when I returned to start my fieldwork, I came to find that Pioneer and Faulu had terminated their partnership and have entirely restructured the health product to a Public- Private Partnership with the National Hospital Insurance Fund (NHIF) and only acted as an agent to sell the new public health product and add a life insurance component to it. This new product was now also sold through new distribution channels, which I was not familiar with yet. Therefore, I lost quite a bit of time to understand the new product through interviews with the manager of the department of Pioneer Assurance as well as with the respective distribution channel manager. As an additional challenge, because the product was only introduced very recently, hardly any written marketing and information materials have been available. After understanding the changes in the health insurance product, one of the main challenges during the research process was getting access to the right clients of the health insurance product. On the one hand, I had the advantage that I already had a network developed with practitioners during my internship with Pioneer Assurance in Through Pioneer I was connected to one of the distribution channels for the health, which is Ukristo na Ufanisi SACCO, a local Savings and Credit Cooperative, which offers the insurance as part of their financial products to the lower income segment of Nairobi. Their branches are located according to their target clients in slum regions of the city. On the other hand, it was a major challenge to find clients that are informal workers, because the client records I had access to did not contain any information about the employment status of the insurance members. The manager of the SACCO recommended to me to attend one of the education/marketing meetings, which are usually attended by large numbers of 3

4 SACCO members who might also be part of the health insurance scheme. However, upon joining the workshop, in which I expected to find sufficient members to organize a focus group discussion, was only attended by two health insurance members. Therefore, my only chance to find sufficient members in one place to get a focus group discussion organized was unfortunately lost, because no other educational meetings were to take place during the time of my fieldwork. This, however, would have been very important, because the members were already in a common location and had taken time off their self- employment business. As a result, due to the employment and locality challenges I was unable to organize a focus group discussion with members of the health insurance and had to focus on one- on- one expert interviews with clients. Even organizing individual interviews posed a challenge, because the relatively new partnership with Pioneer Assurance resulted in a small membership base of around 150 clients in the only distribution channel ( SACCO) that was willing to let me interview their members. After trying to contact members on the phone and trying to convince them to take time off for an interview unsuccessfully, I decided the best strategy would be to spend most of my day at the SACCO office and approach health clients while they are at the SACCO to do their financial transactions. This strategy turned out to be successful, yet time consuming, because on some days there were no health insurance clients at the office. Also, some of the members were reluctant to talk to me either because I was an outsider or because their English skills were not sufficient to conduct an interview. This was especially a problem in the very low income segment of the SACCO membership. However, during my four weeks of fieldwork I was able to conduct a sufficient number of expert interviews with both clients who have renewed their health contract and those who decided against it. Schedule of Activities Week 1 May 7- May 13 Meetings with Pioneer Assurance manager to discuss field work details Manager to get approval for member interviews Week 2 May 14- May 20 Interview with Ukristo na Ufinisi SACCO manager Week 3 May 21- May 27 Daily presence at SACCO offices to find willing interviewees Week 4 May 28- June 3 Daily presence at SACCO offices to find willing interviewees trade union representative affiliated with COTU Interview with Five health client interviews Transcription of Three client interviews 4

5 Final design of interview questions and development of a strategy to get in touch with the target group Researching local media about NHIF corruption scandal and building it into my research Pioneer Assurance to gain an in depth understanding of the new public- private partnership between NHIF and Pioneer in provision Pioneer Assurance manager of the Microinsurance department Interview with PA of the Secretary General of COTU Interview with NHIF representative Attendance of Financial Education Workshop in order to identify interviewees Health client interview earlier interviews Pioneer representative to thank for cooperation and give a short anonymous overview of client experiences as feedback of fieldwork Transcription of earlier interviews Success of field research Even though I have encountered some challenges during the field research, overall my research aim was fulfilled and I was able to collect much needed data for the completion of my Master s thesis. The time period of one month was sufficient to conduct fourteen expert interviews that reflect both opinions of informal workers, who are members of health and representatives of commercial and national health insurance representatives as well as the management of health distribution channels. This qualitative data is the central aspect of my analysis of the impact of health on the social protection of informal workers in Kenya. Therefore, I would have not been able to complete my thesis without these invaluable interview data. With this qualitative study I am aiming to start addressing the research gap that exists between the technical and theoretical literature on the 5

6 impact of health, which is mainly based on quantitative studies, and the client s actual experiences and changes of their lives. I am very grateful for the ICDD Master s thesis research grant, because it gave me the opportunity to analyze the impact of from the informal worker s perspective. 6