Assessing awareness and attitudes towards National Health Insurance Scheme (NHIS) uptake among informal sector workers in Kampala, Uganda

Abstract

Background: Uganda’s proposed National Health Insurance Scheme (NHIS) aims to reduce the high burden of out-of-pocket payments (41% of total health expenditure) and advance Universal Health Coverage. Success hinges on the enrolment of informal sector workers, who constitute 78–80% of the national labour force and over 80% of Kampala’s economy. However, urban-specific evidence on their awareness, attitudes, and barriers to uptake has been lacking. Objective: This study assessed awareness, attitudes, perceived barriers, preferred communication channels, and factors influencing potential uptake of the proposed NHIS among informal sector workers in Kampala. Methods: An explanatory sequential mixed-methods design was employed, whereby a structured cross-sectional quantitative survey was administered to 384 informal sector workers across Kampala's five divisions in the first phase, followed by in-depth qualitative interviews with a purposively selected subsample of 15 participants to contextualise and explain the quantitative findings. Quantitative data were analysed using descriptive statistics, chi-square tests, and multivariate logistic regression in STATA 17.0, while qualitative data were analysed thematically using NVivo 12. Results: Awareness of the proposed NHIS was low (14.1%), and among those aware, only 11.1% knew the proposed annual premium of UGX 100,000. Attitudes were generally positive (M = 3.58, SD = 0.65), but trust in government management was modest (M = 3.44, SD = 0.91). Key barriers included lack of information (M = 3.45, SD =0.84), poor health worker attitudes (mean = 3.38), and irregular income (M = 3.26, SD = 1.22). Social media (74.0%) and television (58.3%) were the most preferred channels, while religious leaders were the most trusted (M = 4.08, SD = 0.87). Multivariate logistic regression showed that enrolment intent was driven by perceived net benefit (OR = 2.85, p < .001), perceived cost reduction (OR = 2.29, p = .007), and institutional trust (OR = 1.57, p = .024), rather than demographic factors. Significant geographic and occupational variations in intent were observed. Conclusion: Informal sector workers in Kampala are willing to join the NHIS, but this willingness is conditional on closing the information gap, introducing flexible payment options, building institutional trust, and ensuring service quality. The findings underscore the need for equity-responsive design that addresses uniform premium challenges and geographic disparities to enhance uptake and advance Universal Health Coverage.