Inclusive Commercial Health Insurance (ICHI) is a new type of public-private partnership-based voluntary health insurance scheme vigorously promoted by the Chinese government in recent years. It is also the application of “Inclusive Finance” in the field of health insurance. Inclusive finance is a core concept of finance that refers to equitable access for all levels of society, at affordable costs, to a wide range of financial services, provided by a variety of sound and sustainable institutions (1–3). The idea of inclusive finance came from the International Year of Microcredit (2005), launched by the United Nations and the World Bank to recognize the critical role inclusive finance plays in expanding access to financial services for low- and middle-income households as well as helping them in resisting risks (1).

ICHI scheme is city-customized, and its inclusiveness is mainly reflected in three aspects: (1) Low premium and community rating. ICHI scheme adopts community rating, and the average premium nationwide is <0.28% of disposable income per capita (2021). This makes ICHI affordable for almost all households, even those in poverty. (2) Low threshold for enrolment. There is no restriction on age or occupation and no strict restriction on pre-existing medical conditions, which makes ICHI accessible to all groups in society, especially to older adult groups and those with pre-existing health problems. (3) High benefit ceiling. As a complementary insurance to basic social health insurance, ICHI focuses on covering high out-of-pocket expenses (especially for serious and catastrophic diseases) after reimbursement by basic social health insurance, with a benefit ceiling of RMB 1 million. This will help most households to withstand the financial shock of catastrophic health expenditure due to serious diseases.

Public-private partnerships are the foundation on which ICHI scheme operates. Specifically, the underwriter of ICHI scheme is usually a co-insurer formed by several large insurance companies under the guidance of the local government, so, in essence, ICHI scheme is a private health insurance. The government makes overall planning or assists in formulating insurance guarantee plans, participates in product design and promotion, and provide supports such as sharing health insurance data. With the joint efforts of the government and insurance companies, as of 31 December 2021, ICHI scheme has been launched in 244 prefecture-level cities, with a cumulative total of about 140 million enrolments (including second-year renewals) and a total premium size of about RMB 14 billion (4).

From the perspective of insurance economics, the operation of such a low-premium insurance requires a large risk pool. However, the overall resident enrolment rate of ICHI scheme is only around 5% nationwide, and the enrolment rate in most cities has remained relatively low, which is not sufficient to form a sustainable premium pool to share the risk (4–6). In other words, higher resident enrolment will be key to the financially sustainable development of ICHI scheme. From the perspective of developing the broader health system, a higher enrolment rate will make ICHI scheme a core component of China Multi-level Health Insurance System, a system that seeks a mix of public and private sources to provides more supplementary insurance schemes on top of basic social health insurance, as ICHI scheme is expected to fill the gap between the “basic” protection of social health insurance and the “high-premium” protection of private health insurance. Furthermore, from the perspective of international impact, the sustainability of the ICHI scheme will provide a practical model for other social health insurance-led countries to link social insurance and private insurance, with the aim of alleviating the growing financial pressure of social health insurance as a single payer. Based on the above, it is of particular importance to further increase resident enrolment at this stage.

Since ICHI is a new type of insurance scheme originated in China, there is an absence of research specific to ICHI scheme in international context yet. Chinese scholars' literature on how to increase resident enrolment of ICHI scheme mainly focuses on theoretical research and macro data analysis. Most scholars focused on its special “dual supplier” and studied from the perspective of the government and insurance companies, mainly by analyzing the government's macro development data for products in representative cities (7, 8) and the operational effectiveness of inclusive public-private partnership model (9–11), as well as discussing the design logic of existing products and the operating model of insurance companies (5, 6, 12). Despite the optimization of public-private partnership model and insurers' operating models, as well as greater government advocacy to encourage residents into the ICHI system, many residents still choose to drop or refuse to enroll in ICHI scheme. This environment surrounding the ICHI system suggests the need to explore a new question. In the case of voluntary health insurance, the focus is not only on the sound operation of the supply side, but we need to be aware that residents' subjective behavioral intention to purchase is the direct internal motivation for their choice to enroll. Therefore, understanding the motivational factors and barriers that can explain residents' behavioral intentions toward ICHI from a demand-side perspective is essential to finding ways to increase the enrolment. In this context, this study aims to contribute to knowledge on this topic by identifying the multidimensional factors that influence residents' behavioral intentions toward ICHI scheme, exploring the multivariate psychographic process in the formation of their enrolment intention, and developing a conceptual model to describe the interrelationships between the key psychographic factors. Finally, feasible suggestions for health policymakers and promoters to increase ICHI enrolment among residents would be put forward according to the research results.

Given that ICHI has stronger private health insurance attributes from a demand-side perspective, the theoretical part of this study was based on broader research on private health insurance to explore the factors influencing residents' enrolment intention. Particularly, the following variables are examined and explained in the following paragraphs: enrolment intention, perceived value variables (i.e., perceived benefit and perceived sacrifice), involvement and government participation.

Enrolment intention is the dependent variable in this study which refers to the subjective tendency of residents to invest in ICHI scheme, and it also directly reflects the possibility of making the enrolment decision (13, 14). Previous literature has suggested that people would have a greater intention to enroll in health insurance if they perceive the potential benefits outweigh the costs (15). This trade-off of benefit and sacrifice often relies on Perceived Value Theory in marketing. According to Zeithaml (16), perceived value is defined as the overall evaluation of the product by consumers after comprehensively considering the perceived benefits and the sacrifices, and it can influence consumers' purchase behaviors. In the field of studies of health insurance, perceived value as a pre-influencing factor of behavioral intention has been used in several studies and a causal relationship was found between them (15, 17, 18).

In practical empirical studies, the perceived value variable can be divided into perceived benefit and perceived sacrifice in order to better measure it (16, 19). Many studies based on the above classification of perceived value has suggested that perceived benefit has a positive influence on behavioral intention to invest, while perceived sacrifice has a negative influence (20–22). Thus, this study proposed the following hypotheses:

However, the use of perceived value as an independent variable to measure behavioral intention assumed perfect and equal knowledge amongst individuals who can make comprehensive consideration and trade-off between benefits and costs. In fact, most consumers are often in a state of information asymmetry and do not have a strong subjective intention to collect and process more information regarding products that are not of interest to them or that they feel less relevant to. Therefore, it is difficult for them to make such a comprehensive consideration. To solve this problem, an antecedent factor of perceived value is needed to describe consumers' perceived relevance to the product and to explain the process of information collection and processing. Based on literature reviews, Involvement was considered a suitable antecedent factor which is defined as a motivational variable reflecting the degree of a person's perceived relevance of the object to the individual based on his inherent needs, values, and interests (23). It has been proposed by precious literature that, when making decisions, individuals with deeper involvement tend to search for more information and more proactively (24), process relevant information more systematically (25), and will have a more comprehensive consideration on the strengths and weaknesses of possible alternatives (26). Therefore, the degree of a consumer's involvement will have an impact on information processing and consideration of benefits and sacrifices (26–28). Moreover, several studies have demonstrated that involvement has a positive impact on consumers' perception of benefits, while their perception of sacrifice decreases with increasing involvement and duration (29, 30). Therefore, the following hypotheses were proposed:

In addition to the impact of involvement on perceived value, involvement was often seen as an important psychographic construct due to its potential influence on consumer's behavior with respect to decision making and purchase intention (31, 32). It has been suggested in many empirical studies that involvement has a positive influence on consumers' behavioral intention to purchase (33–35). Therefore, we proposed the following hypothesis:

Furthermore, according to Liang and Lai (36), it was believed that consumers will pass “Problem recognition—Information collection—Evaluation of alternatives—Purchase process evaluation—Post-purchase services evaluation” five stages, and finally form behavioral intentions and make a purchase decision. In this study, involvement refers to residents' perception of the relevance to ICHI based on their inherent needs, values, and interests, including the process of problem recognition and information collection. In contrast, perceived value refers to a comprehensive evaluation of ICHI scheme after weighing the benefits and sacrifices. This evaluation includes alternatives before purchase, the purchase process, and post-purchase services, the last of which is especially vital for insurance products. Therefore, we deduced there was an influence pathway of “involvement—perceived value—enrolment intention” between the three variables, and similarly, many studies have shown that perceived value mediates the effect of involvement on behavioral intention (37–39). Therefore, the following hypotheses were proposed:

In addition, according to previous research conducted for this study, it has been clarified that ICHI scheme is subject to a certain degree of government intervention. Many studies have shown the role of government as promoter and regulator of ICHI scheme in enhancing residents' perception of benefits, reducing their perceived risk, and thus increasing their enrolment intention (4, 9, 11). Thus, this study proposed the following hypotheses:

Figure 1 shows the theoretical model proposed in this study.

The findings from this study provide a more holistic picture of the multidimensional factors that influence residents' enrolment intention as well as their influencing mechanisms, from a demand-side perspective. In exploring the influence of control variables, we found that there are demographic variables (e.g. age, education level, health status, and existing level of insurance coverage) that influenced residents' enrolment intention, and the impact of existing level of insurance coverage was the most significant. Among the demographic variables studied in this study, it is noteworthy that income level has no effect on enrolment intention. This could be explained by the low premiums of ICHI scheme, which account for a relatively small percentage of residents' total income. To conclude, in the future promotion to more cities, designers of ICHI scheme should pay increased attention to the influence of the differing individual characteristics of residents in different cities on their intentions to enroll. Moreover, our findings also provided additional evidence and pilot directions for many domestic scholars who advocate the city-differentiated customized insurance schemes (6, 12).

Then, based on the revised conceptual model of the psychographic factors influencing enrolment intention, we found the following: First, we discovered a statistically significant positive impact of involvement on both perceived benefit and enrolment intention. Reflecting on the difference in the influence capability of three dimensions of involvement, it is noted that the impact of product involvement is the strongest. This indicated that more attention should be paid to the product design to make it more related to residents' lives in future development, because this factor is not only an instrumental pre-factor for the formation of residents' value perception, but also a significant driving factor for increased enrolment intention. These findings strengthened the conclusions of existing studies (30, 33, 34) and further complemented the differing influence capabilities of the different dimensions of involvement as well.

Second, our research revealed that involvement does not affect residents' perceived sacrifice, and the mediating effect of perceived sacrifice between involvement and enrolment intention is therefore not significant. This might seem to be in conflict with Venkatraman's research (29). On the other hand, residents' perceived benefit was found to mediate the effect of involvement on enrolment intention. These findings suggested that the reason why residents' enrolment intention increases with the deepening of involvement is that they are more aware of benefits brought by ICHI scheme, rather than their decreased concern over potential sacrifices. One possible explanation is that the overall involvement among residents is currently low. According to the study of Maheswaran and Meyers-Levy (26), individuals in the low involvement condition often draw and apply the inference that they agree more with issues associated with positive rather than negative information, while under high involvement individuals would presumably assign more weight to the negatively framed rather than the positively framed information and be more persuaded by it. This explanation was also consistent with the descriptive statistical analysis of each model construct variable that the average score of involvement was the lowest (see Table 1). Thus, at the current stage, policymakers and product providers should seek to improve the overall involvement of residents, and to achieve this, increasing product involvement by optimizing product design to make it more relevant to residents' lives is considered the most beneficial approach based on the influence capability analysis above.

Third, our results indicated that perceived benefit positively affects residents' enrolment intention while perceived sacrifice negatively affects their enrolment intention, which was in line with the basic connotation of the perceived value theory. In addition, empirical analysis based on further subdivisions of different research dimensions showed that functional value and price value have a more significant impact on enrolment intention. In contrast, the impact of service value and product value is relatively weak. For one thing, product designers can further improve residents' perceived benefit by optimizing existing functional value and price value, as well as expanding additional functional value such as value-added services. For another, product promoters can employ better publicity strategies to reduce residents' enrolment concerns.

Lastly, we found that government participation positively moderates the effect of perceived benefit on enrolment intention. It is conceivable that under the national conditions of China, residents have a trust relationship with the government. This means that involving the government can strengthen residents' perception of the benefits of ICHI scheme, thereby increasing their intention to enroll. However, contrary to our expectation, government participation negatively moderates the effect of perceived sacrifice on enrolment intention. Considering that there have been few quantitative studies on government participation in ICHI scheme, additional research is required to determine the causes of this negative moderating effect. Our future study will refine the measurement dimensions of the government participation variable and take into account factors such as different intervention channels and publicity methods to examine the moderating effect of government participation in greater depth. Last but not least, since government participation does have a significant moderating effect, it is recommended for policymakers to clarify the functional positioning of each participating government department.

On the one hand, this paper further complemented the differing capabilities of the different dimensions of involvement and perceived benefit to influence enrolment intentions, expanding the research boundaries of involvement theory and perceived value theory. On the other hand, research targeting the enhanced sustainability of health insurance programs will provide a practical model for other social health insurance-led countries to link social insurance and private insurance, with the aim of alleviating the growing financial pressure of social health insurance as a single payer. However, the current study is not without limitations. First, this study was limited in scope by several factors, including the epidemic situation, and we only selected one of the most representative cities, Nanjing, to serve as the survey sample area in this case. Consequently, the research conclusions may have certain regional characteristics instead of being universal. Second, in the absence of well-established scales for measuring government participation variables, the questionnaire development in this section lacks a solid theoretical and practical basis. This may lead to empirical data that may not accurately reflect government participation actions. Lastly, the involvement theory and the perceived value theory are primarily used in the construction of the conceptual model. This may result in that not all influencing factors and intermediate variables are included, such as residents' attitudes toward the product. Future studies could incorporate the attitude variables from the Theory of Planned Behavior, and comprehensively consider the formation mechanism of residents' enrolment intention.

Although ICHI scheme has been rapidly promoted in China under the joint efforts of the government and insurance companies, the overall enrolment rate of residents remains low currently. While existing studies have mostly focused on the supply-side perspective, this study proposed that it is equally important to understand the multidimensional factors that influence residents' behavioral intention from a demand-side perspective. By examining these factors and their interrelationships, this study developed a multivariate conceptual model of the psychographic process by which residents' enrolment intentions are formed. Based on this model, we suggested ways for health policymakers and promoters to increase the enrolment among residents. Through analysis, this study has identified that involvement and the two constructs of perceived value (i.e. perceived benefit and perceived sacrifice) are all crucial psychographic process factors that influence the formation of residents' enrolment intentions, and that government participation is a moderator of this psychographic process. When analyzing the interrelationships between the five constructs in the model, two findings deserve special attention: First, perceived benefit mediates the effect of involvement on enrolment intention, while perceived sacrifice does not. This result indicated that one of the main dilemmas in the current development of ICHI scheme is the low level of involvement among residents. Second, government participation positively moderates the influence path of “perceived benefit—enrolment intention” but negatively moderates the path of “perceived sacrifice—enrolment intention”. Further research is required to understand the opposite moderating direction of government participation as a moderator. At the current stage, policymakers and product providers should seek to improve the overall involvement of residents, and to achieve this, increasing product involvement by optimizing product design to make it more relevant to residents' lives is considered the most beneficial approach.

The original contributions presented in the study are included in the article/Supplementary material, further inquiries can be directed to the corresponding authors.

Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

TS, YW, JX, RS, and RJ contributed to the study design. TS, YW, and XH made contributions to the acquisition, analysis, and interpretation of data. TS prepared the first draft of the manuscript. YW, RS, and RJ made substantial revisions to the manuscript prior to its submission. All authors have approved the submitted version.