Open Peer Review Any reports and responses or comments on the article can be found at the end of the article. RESEARCH ARTICLE Extending voluntary health insurance to the informal sector: experiences and expectations of the informal sector in Kenya [version 1; peer review: 3 approved] Edwine W. Barasa , Njeri Mwaura , Khama Rogo , Ledia Andrawes 3 Health Economics Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya Health in Africa Initiative, The World Bank Group, Nairobi, Kenya Institute of Global Prosperity, University College London, London, UK Abstract : Kenya has made a policy decision to use contributory health Background insurance as one of its key pre-payment health financing mechanisms. The National Hospital Insurance Fund (NHIF) is the main health insurer in Kenya. While the NHIF has hitherto focused its efforts on providing health insurance coverage to individuals in the formal sector, it has recently broadened its focus to include individuals in the informal sector. This paper provides an analysis of the perceptions, and experiences of informal sector individuals in Kenya with regard to enrolment with the NHIF. : We collected data through key informant interviews (39) in two Methods purposefully selected counties. Study participants were drawn from healthcare facilities contracted by the NHIF, and current, former, and prospective informal sector members. We analyzed data using a grounded approach. : Participants felt that the NHIF provided inadequate information Results about the registration and membership processes as well as benefit entitlements. There was variable and inconsistent communication by the NHIF. There was also variance between the official benefit package and the actual benefits received by members. The NHIF registration requirements and processes presented an administrative barrier to obtaining membership. The NHIF premium level and contribution mechanism presents a financial barrier to current and prospective members. Healthcare providers discriminated against NHIF members compared to cash-payers or private insurance holders. : The NHIF could improve enrolment and retention of informal Conclusions sector individuals by; 1) using communication strategies that are effective at reaching the informal sector, 2) improving the affordability of the premium rates, 3) simplifying the enrolment requirements and process, and 4) strengthening accountability mechanisms between itself and healthcare facilities to ensure that enrolled members receive the benefits that they are entitled to, and that client experience at healthcare facilities are satisfactory. Keywords Universal Health Coverage, social health insurance, informal sector 1 2 2 3 1 2 3 Reviewer Status Invited Reviewers version 1 published 28 Sep 2017 1 2 3 report report report , Population Council, Nairobi, Timothy Abuya Kenya 1 , London School of Hygiene & Michelle Remme Tropical Medicine, London, UK 2 , University for Gilbert Abotisem Abiiro Development Studies, Wa, Ghana 3 28 Sep 2017, :94 ( First published: 2 ) https://doi.org/10.12688/wellcomeopenres.12656.1 28 Sep 2017, :94 ( Latest published: 2 ) https://doi.org/10.12688/wellcomeopenres.12656.1 v1 Page 1 of 13 Wellcome Open Research 2017, 2:94 Last updated: 10 JUL 2019