Trust matters: Villagers' trust in providers and insurers in the context of a community-based health insurance scheme in Cambodia

Objective. To measure villagers' trust levels and examine the association between enrollment in Community-Based Health Insurance (CBHI) and villagers' trust in a health insurer and healthcare providers in Cambodia. This represents the first study measuring and modeling villagers' trust in public and private providers and a CBHI insurer in a low-income, post-conflict country.;Background. CBHI schemes have been launched in recent years to reduce poverty associated with healthcare and improve access to health services in low- and middle-income countries. These schemes have gained international recognition as part of a solution to healthcare financing problems. Nevertheless, increasing local CBHI enrollment remains a challenge. This study hypothesized that trust influences CBHI enrollment where villagers have little experience with and poor confidence in public providers, financial institutions and the practice of prepaying for healthcare.;Methods. This study was conducted in Thmar Pouk, Cambodia, where a CBHI scheme operates with the highest enrollment rate (19%) in the country. A mixed methods approach was applied to measure villagers' trust in public providers, the CBHI insurer and private providers who are not covered by the scheme, and assess whether this affects their decisions to enroll in CBHI schemes. Focus group discussions and household surveys were carried out to identify villagers' relationships with healthcare providers and the insurer, measure trust levels, and explore the association between provider trust, insurer trust and enrollment in CBHI schemes.;Results. After controlling for demographic factors, healthcare utilization and household socio-economic status, the study found that greater trust in the CBHI insurer and public healthcare providers is associated with higher CBHI enrollment. Villagers' trust in private providers did not affect CBHI enrollment. Trust in public and private providers were listed as the fifth and second most important consideration for choosing the healthcare provider, respectively.;Conclusions. This study found statistically significant relationships between villagers' trust in public providers/insurers and their decision to enroll in CBHI schemes. The results underscore the importance of increasing and maintaining villagers' trust in the operation of CBHI schemes, and highlight the need for public providers and health insurers to place greater emphasis on building trusting relationships with villagers.