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Community-based health insurance and social capital: a review

• Hermann Pierre Pythagore Donfouet 1 &
• Pierre-Alexandre Mahieu 2  

Health Economics Review volume  2 , Article number:  5 ( 2012 ) Cite this article

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Community-Based Health Insurance (CBHI) is an emerging concept for providing financial protection against the cost of illness and improving access to quality health services for low-income rural households who are excluded from formal insurance. CBHI is currently being provided in some rural areas in developing countries and there is ongoing research about its impact on the well-being of the poor in these areas. However, the success of CBHI revolves around the existence of social capital in the community. This has led researchers to explore the impact of CBHI on the well-being of the poor in rural areas, especially as it relates to social capital. The overall objective of this paper is to review recent developments that address the link between CBHI and social capital. Policy implications are also discussed.

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Introduction.

Financing quality health care is a major challenge in developing countries. Health plays a key role in the economic development of a country. For this reason, policy-makers in developing countries have increased their efforts towards providing quality health care both in urban and rural areas [ 1 , 2 ]. Despite these efforts, many countries still have low geographical coverage quality health care. For Example, in Sub-Saharan African countries, inhabitants are facing precarious health conditions. About 26 per cent of children under five years old are underweight [ 3 ]. According to Morrisson et al. [ 4 ], the percentage of children suffering from acute malnutrition (and whose families are classified below the absolute poverty threshold) ranged from approximately 15 to 20 per cent in intermediate revenue countries (Cameroon, Ivory Coast, Zimbabwe), to more than 50 per cent in very poor countries such as Madagascar and Niger. About 42 million children below five years old suffered from acute malnutrition in Sub -Saharan Africa in 1996. The most recent estimates released by the United Nations Food and Agriculture Organization (UNFAO) [ 5 ] shows that the majority of the world's undernourished people live in developing countries. In the world, 925 million people are undernourished, of which 239 million live in Sub-Saharan Africa countries. This malnutrition will continue to cause poor health and affect the well-being of the households in this region of the World if adequate measures are not taken.

Over the last years, demographic growth coupled with unequal growth in these regions has increased the number of people who are living in extreme poverty. Nowadays, about 50 per cent of the people in Sub-Saharan Africa are living below the poverty threshold. Furthermore, more than 100 million people do not have a balanced diet [ 6 ]. Such a situation increasingly affects rural areas in developing countries which have very low standards of well-being [ 7 ] and quality health care [ 8 ]. Most households in these rural areas are characterised by a high prevalence rate of sanitation-related diseases, which undermines their health, in turn weakening their ability work and invest.

The disappearance of free health care (mostly primary health care) has resulted in the loss of a form of social protection for a large portion of the population especially rural households and those working in the informal sector. As a result, many policy-makers, international institutions, NGOs and the civil society have set out to seek effective alternatives in order to provide rural households a permanent solution to the problem of accessing health care. Development actors are increasingly considering community-based health insurance (CBHI) 1 as an instrument that can enable not only easy access to quality health care, but also reduce absolute poverty among low-income populations. CBHI is a form of micro health insurance which is mainly used in rural areas in developing countries [ 9 – 11 ]. Over the last decades, insurance was recognized as a financial instrument which could enable low-income households to manage their financial risks [ 11 ]. The role of CBHI therefore is to help low-income households manage risks and reduce their vulnerability in the face of financial shocks. CBHI is usually based on the following characteristics: voluntary membership, non-profit objective, linked to a health care provider (often a hospital in the area), risk pooling and relying on an ethic of mutual aid/solidarity [ 12 ], p.5. According to Churchill [ 13 ], p.12, CBHI: " refers to the protection of low-income people against specific perils in exchange for regular premium payments proportionate to the likelihood and cost of the risk involved". Several studies show that low-income households are willing to pay for CBHI [ 9 , 14 , 15 ]. In most cases, the payment of the premiums are in cash (monthly, quarterly, yearly) or in kind [ 16 ] such as agricultural commodities. However, the success of CBHI relies on the existence of social capital in the community. As declared by Woolcock and Narayan [ 17 ], p.3: "social capital refers to the norms and networks that enable individuals to act collectively". Fukuyama [ 18 ], p.4 asserted that "social capital can be defined simply as the existence of a certain set of informal values or norms shared among the members of a group that permit cooperation among them". Sobel [ 19 ] describes social capital as circumstances in which individuals can benefit from group membership. Thus, social capital refers to social life-networks, norms, and trust that enables households to act together more effectively to pursue shared objectives [ 20 , 21 ]. This social capital in the community can be an asset for the breakthrough of CBHI, thus contributing to the demand for CBHI at the community level. As outlined by the BIT [ 22 ], one of the key principles of a good functioning of CBHI is the solidarity and trust between members. This solidarity and trust stirs up members who are susceptible to risk to put together their resources for common use. Hence, the overall objective of the paper is to review the link between CBHI and social capital. The remainder of the paper is organized as follows; section 2 focuses on recent developments that address the link between CBHI and social capital, section 3 presents a theoretical framework that shows the link between CBHI and social capital, and section 4 concludes with some policy implications.

Recent works on CBHI and social capital

CBHI emanates from the limitations of the loan-based microcredit programs (microfinance) in protecting low-income households from health shocks. CBHI differs from other forms of microfinance in that it uses an insurance mechanism, i.e. a financial instrument which, in return for payment of a premium, provides members with a guarantee of financial compensation or service on the occurrence of specified events [ 23 ], p.13. Unlike microfinance where transfer in the first instance takes place from the credit provider to the poor, in case of CBHI a reverse transfer takes place, i.e., from the poor to the insurance provider [ 12 ], p.2. The success of CBHI depends on the existence of social capital in the community.

The concept of social capital has been a motivation for decision-makers to reflect on issues of health improvement. Many international organisations such as the OECD, the World Bank, the UNESCO, have emphasized on social capital, which they consider as a powerful tool for attaining the objectives of development actors both in developed and developing countries. In the 90s, one of the main goals of the World Bank was to use the potential of social capital to fight poverty and ensure availability and access to health, banking facilities and education. CBHI can only be effective and long-lasting with the aid of social capital in a community, as social capital has a positive effect on the community's demand for insurance. As outlined by the BIT [ 22 ], one of the key principles for the good functioning of a CBHI is the solidarity and trust between the members. Solidarity and trust stirs up members who are susceptible to risk to put together their resources for common use. In empirical analyses, ignoring the role of social capital in WTP may result in omitted variable bias, as the decision to pay for CBHI may be correlated with variables which are not included in the model. As a matter of fact, social capital in a community is vital for the sustainability and effective functioning of CBHI [ 24 , 25 ]. In some areas of Africa such as Duekoué (Ivory Coast), post electoral violence has led to the fragmentation and lack of trust. Therefore, it will be difficult to establish CBHI in that community.

Authors such as Coleman [ 21 ], Putnam et al. [ 26 ], Wilkinson [ 27 ], unanimously acknowledge that social capital in a community acts positively on the importance people attach to their health. Thus, a community with a high level of social capital will be more inclined to go through change. Therefore, more ready to support a new, unknown health policy such as CBHI. Consequently, adhesion to a group and trust are necessary to enable poor communities establish social capital and have access to CBHI. On the one hand, if connections are lacking, or if the level of social capital among the members of the group is weak, there is an increasing risk of seeing egoistic behaviour as the highest levels of moral risk and anti-selection. In addition, Baum [ 28 ], Kawachi et al. [ 29 ] demonstrate that a high level of trust in the community will facilitate cooperation, aids, access to health care. Thus acting together, low-income households will have opportunities to increase their income and social well-being [ 30 ]. As outlined by Woolcock and Narayan [ 17 ], social capital helps the poor to manage risk and vulnerability. Thus, CBHI which aims at managing risk and vulnerability may be well accepted by a community that possesses a high stock of social capital. A high level of social capital is associated with a high level of altruism among individuals; this makes it possible to take into consideration the well-being of other members of the group [ 31 ]. As outlined by Hsiao [ 32 ], p.5, social capital is a major determinant of the WTP for CBHI, the greater the social capital in the community, the more people are willing to prepay for CBHI. In his study, the author considers two communities. Community A has less social capital than community B. Thus, community B will have the greater potential of the establishment and success of CBHI than community A. He further concludes that community A will not be able to establish CBHI since there is a low level of social capital in that community. Furthermore, CBHI will be successful in community B even if the prepayment amount is greater than the expected economic/health gain because of the social capital in that community. Through his analysis, policymakers may understand why some CBHI have been successful while others have failed in developing countries.

Recently, Zhang et al. [ 24 ] explored the effect of social capital on the demand for CBHI subsidized by the Chinese government. The Government aimed at encouraging Chinese farmers in villages to join CBHI companies by subsidizing the annual allowance of each participant by 10-20 Yuan (1.25-2.50 US $). Trust and reciprocity were used as proxies of social capital to obtain the effect of social capital on the demand (WTP). Ten questions were asked to assess the effect of social capital on WTP (five questions on trust and five others on reciprocity). The answers to these questions ranged between "I agree" to "I disagree". Five questions were on horizontal trust (trust in community members) and not on vertical trust (trust in the government, municipal authorities, etc.). The questions were: "Do you think a majority of the villagers can be trusted? Do you think the villagers in your community can consider you to attain their goals if they had the opportunity? Do you think the villagers in your community can restore lost objects they have found to the rightful owners? Do you think a majority of your neighbours are trustworthy? Do you think the leaders of your village can be trusted?" The five questions on reciprocity were: "Do you think the villagers are concerned with problems that do not concern them, but that concern other villagers? Do you think villagers would help someone in need? Would you lend money to your neighbour if he needs to consult a doctor? If your village were a big family, would you be a member of this family? Would you support projects that do not benefit you, but benefit other inhabitants of your village?" Using logistic regression, the results of such a study demonstrate that social capital measured by trust and reciprocity has a positive and significant effect on the demand for CBHI.

In another recent study, Donfouet et al. [ 25 ] investigated the link between CBHI and social capital in rural Cameroon (Central Africa). The study is based on a face-to-face survey. Over 399 households across six villages in Bandjoun (Western Region of Cameroon) were selected by a two-stage cluster sampling technique. The six villages were: Tsela, Mbiem, Mbouo, Pète, Dja and Toba. Firstly, six villages were selected-based on population size and availability of health centres. Secondly, household heads in these villages were randomly selected. Guidelines for a rigorous contingent valuation 2 provided by Whittington [ 33 ], Arrow et al. [ 34 ], and Carson (2000) were followed as much as possible. Furthermore, to mitigate hypothetical bias, 3 an ex-ante approach (the budget reminder and the consequentialism script) was integrated in the questionnaire. The social capital was measured as the degree of involvement of households in associations. By using an interval regression model of Cameron [ 35 ], the results of the study confirmed that social capital has a positive, and significant impact on the demand for CBHI.

Policy makers might want to increase social capital, but an open question is what type of social capital to increase. The two main types of social capital are often labelled "weak ties" (also called "bridging social capital") and "strong ties" (also called "bonding social capital"). According to Woolcock and Narayan [ 17 ], p. 8, "strong ties" refers to the close relationship between an individual and his family, friends, ethnic group, etc. This corresponds to intra-community social capital. "Weak ties" refers to the individual's contacts outside the ethnic group or the family (other entrepreneurs, other ethnic groups, banks, etc.). This corresponds to extra-community social capital. In other words, "strong ties" refers to the interactions that exist within a particular group (closed family, friends), whereas "weak ties" refers to the interactions across multiple groups (open groups or networks). Each type of social capital has pros and cons and it is unclear which one ought to be reinforced in priority. "Strong ties" implies a high level of solidarity between the members of the group, which is good for CBHI. However, similitude between members is a flaw for CBHI. For example if all members undertake risky behaviour, CBHI might not work properly. On the other hand, "weak ties" implies less solidarity, but members are different from each other. More risky behaviour might be compensated by less risky behaviour. Further studies could investigate which type of social capital has the strongest effect on CBHI. If "weak ties" works better, policy makers might, for instance, decide to start developing CBHI in bigger villages, since the level of extra-community social capital is high.

It should be noted that, though, social capital could significantly affect a households' decision for health insurance, up to date, there is no clear consensus on how social capital should be measured. As stated by Fukuyama [ 18 ], p.12: "one of the greatest weaknesses of the social capital concept is the absence of consensus on how to measure it" .

Theoretical framework

Popularized by Putnam [ 20 ], the concept of social capital has been the subject of several studies that have attempted to measure it. Some of these studies treat social capital as a dependent variable (a phenomenon which has to be explained), and this is the institutional view of social capital that argues that the vitality of community networks and civic society is largely the product of the political and institutional environment [ 17 , 36 ]. An alternative method, developed in recent years is to study the role or function, or better still, the contribution of social capital to health. Therefore, social capital is studied as an independent variable (this is a communitarian view of social capital). The issue is thus to bring out its contribution to access to basic health care for rural households. Its scope is basically social networks, trust or associations which can improve the health situation of households. Therefore, a positive relationship between CBHI and social capital is expected.

Let Y be the dependent variable, such as the willingness-to-pay (WTP) for CBHI, X 1 , X 2 ....X n the independent variables, and a random component. Y is a linear function of the explanatory variables:

In equation ( 1 ), one of the explanatory variables, say X 1 , refers to social capital and the others are related to socio-demographic characteristics such as age, gender, income, marital status, number of children in the households, profession etc.

Depending on how Y is measured, a specific estimation model can be used. For instance, if Y is a continuous variable, the ordinary least squared (OLS) model is used. If Y is a binary variable, the probit or logit model is used. If Y lies in interval, the interval regression is used [ 35 ].

The partial derivative of Y with respect to X 1 is:

If β 1 is positive and statistically significant at conventional levels, there is a positive relationship between the WTP for CBHI and social capital. Theoretically and empirically, β 1 must be positive since it is always expected that solidarity, norms, trust and participation at the community level to have a positive effect on the demand for CBHI.

Conclusions

Access to health services is a main concern in poor countries. Most policy debates are around how to keep the poor from falling into a poverty trap that is often caused by medical expenses. Delaying medical treatment or choosing self-treatment can generate serious health consequences. Hence tackling this issue is of utmost importance. Many policymakers in developing countries are trying to develop health care programs that would cater to the poor and be sustainable at the same time.

Lack of health insurance coverage of the poor in developing countries impedes access to adequate health care. Consequently, CBHI has been considered as an effective means to reach the poor with health care services. Since there has been an increased attention to such a health insurance scheme, the analysis of the demand for CBHI is extremely important for formulating policies and strategies for the health sector. Adequate knowledge of the determinants of healthcare demand is essential for devising strategies to increase allocative efficiency of resources. Nevertheless, for CBHI to have a long-term effect, there must be a social capital in the community. Thus, the overall objective of the study was to review recent developments that address the link between CBHI and social capital. A thorough review reveals that a higher level of social capital at the community level will positively and significantly impact households' decision for health insurance, which will in return increase the demand for CBHI. One important policy implication is to strengthen social ties at the community level. An open question for further studies is what type of social capital to develop in priority. Both inter and extra community social capital has pros and cons, and it is unclear which one ought to be reinforced.

a It is also called community health funds, mutual health organizations, rural health insurance, etc.

b Contingent valuation is a survey-based method used to assess the value participants attach to public goods which are not provided by the market. It is commonly used in the health, marketing, education and environment sectors.

c The hypothetical bias is the difference between the hypothetical WTP and the real WTP.

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Acknowledgements

This work was carried out with financial and scientific support from the International Labor Organization (40052113/0) under the Microinsurance Innovation Facility and the expertise of the European Development Research Network (EUDN). We will also like to thank the African Doctoral Dissertation Research Fellowship offered by the African Population and Health Research Center (APHRC) in partnership with the International Development Research Centre (IDRC) for financial assistance. The authors are grateful to Dr. Pongou Roland (University of Montreal), Dr. Marleen Dekker (University of Leiden) and two anonymous referees for useful comments. We are also grateful to Dr. Eric Tangumonkem for editing the English of the paper. The usual disclaimer applies.

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Donfouet, H.P., Mahieu, PA. Community-based health insurance and social capital: a review. Health Econ Rev 2 , 5 (2012). https://doi.org/10.1186/2191-1991-2-5

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Community-based health insurance

• Community-based health insurance (CBHI) schemes are usually voluntary and characterized by community members pooling funds to offset the cost of healthcare.
• Despite much hope in these systems, evidence suggests the impact of CBHI on financial protection and access to needed health care are moderate for those enrolled.
• Most CBHI schemes have low participation levels and the poorest people usually remain excluded.
• Theory and practice show that CBHIs play only a limited role in helping countries move towards universal health care (UHC).
• However, they can have other positive impacts such as community development and local accountability of health care providers.
• They can have other positive impacts however, such as community development and local accountability of health care providers.

CBHI is a form of micro health insurance, which is an overarching term for health insurance targeted to low-income people. The specific feature of CBHIs is the community involvement in driving its setup and in its management.

Small, voluntary CBHI schemes are generally characterized by the following institutional design features.

• Pooling of health risks and of funds occurs within a community or a group of people who share common characteristics, such as geographical location or occupation.
• Membership premiums are often a flat rate and independent of individual health risks.
• Entitlements to benefits are linked to contributions in most cases.
• Affiliation is voluntary.
• The scheme operates on a non-profit basis.

Both theory and evidence suggest that the traditional CBHI model – relying only on voluntary, small-scale schemes with little or no subsidization of poor and vulnerable groups – can play only a limited role in helping countries move towards universal health coverage(UHC). CBHIs cannot be expected to provide a major source of funding or coverage, and hence can at best provide only a complementary role as part of a national health financing strategy toward UHC. This is partly because people with few health needs tend not to join on a voluntary basis, and there is usually little or no subsidization for poor and other vulnerable groups.

Health service utilization rates of members, however, generally increase after enrollment.

Policy options

Although CBHIs in the traditional model are one way to organize community initiatives, they cannot be expected to provide a major source of funding or coverage. Financial protection arrangements based on mandatory or automatic coverage funded from general government revenue that subsidizes those unable to pay have shown more potential to reach UHC goals than voluntary, contribution-financed schemes. Some countries with CBHI schemes have taken action and transformed their CBHI model towards a national scheme.

For countries with established small-scale voluntary CBHI schemes, the government could capitalize on the positive results of improved local governance capacity and public acceptance of prepaid insurance contributions. Here, an option is to integrate or merge existing schemes into a single national pool with decentralized arms or closely interconnected pools beyond the community level. These can provide similar benefit packages and act – with national support – as strategic purchasers of health services, while maintaining local accountability. This could also promote quality gains and efficiency while guaranteeing higher levels of re-distributive capacity and financial protection.

In countries where there is no government engagement in CBHI development, governments may focus from the start on developing a national system geared towards universality and envisage to cover the whole population rather than diverting resources and efforts to establishing CBHIs as an interim solution with limited impact on progressing towards UHC.

WHO response

  WHO supports Member States to develop health financing strategies that aim at reducing fragmentation  and better pooling to  enhance the potential for re-distributive capacity with the aim to progress towards Universal Health Coverage.

The following institutional design features can be considered critical for a move away from small CBHI schemes towards a national health financing system for UHC:

• Mandatory coverage to the population;
• General government revenues to subsidize coverage of vulnerable and poor people;
• Larger/more diverse pool (for example, by increasing the number of enrolled people, pooling beyond local pools, or a single national pool); and
• A strong and explicit role (including incentives) of local government authorities in enrollment.

One key approach to reforming CBHIs is to increase the re-distributive capacity of the system. For such a reform to realize its potential, however, it must be set within an overall vision of health financing that aligns pooling with the other health financing functions. 

Related Links

Community based health insurance: how can it contribute to progress towards UHC?   Voluntary health insurance: potentials and limits to moving towards universal health coverage WHO global health expenditure database Tracking universal health coverage: First global monitoring report Health financing country diagnostic: a foundation for national strategy development

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Data will be made available on request.

• • Community-based health insurance scheme is a strategy that provides financial protection against health-related poverty.
• • Little has been known about the role of community-based health insurance on healthcare seeking behavior in Ethiopia.
• • According to the findings of this study, the proportion of people who sought appropriate healthcare was low (47.3%).

Community-based health insurance is a new and promising concept for delivering easily accessible, affordable, and efficient healthcare services. More importantly, a significant risk pooling arrangement between the wealthy and poor. So far, little has been done regarding community-based health insurance and healthcare seeking behavior in developing countries. Therefore, the aim of this study was to assess healthcare seeking behavior of households due to the introduction of the scheme and associated factors in Addis Ababa. Community-based cross-sectional study was conducted among 270 male and 207 female respondents. The data was collected using standardized and pretested questionnaire and it was analyzed using SPSS software. A bivariate and multivariable logistic regression analysis was applied to determine the relationship between healthcare seeking behavior and determinant variables. Finally, statistical association was declared with a p-value of less than 0.05 in the multivariable logistic regression analysis. The proportion of people who had appropriate healthcare-seeking behavior was 47.31% (95 %CI: 43.27–51.39%). Furthermore, having more than four children [AOR: 0.171, 95%, CI:(0.403–0.99)], being Muslim [AOR: 1.712, 95 %CI: (1.117 2.625)], owning a government house [AOR: 4.472, 95%, CI: (2.037–9.819)], and having under-five children [AOR: 0.548, 95%, CI: (0.375–0.801)] were factors significantly associated with healthcare-seeking behavior. Even though this study was conducted in an urban area, it showed that the magnitude of appropriate healthcare-seeking behavior was low. Therefore, the government of Ethiopia should work to improve housing conditions and family planning provision for the residents to improve the healthcare seeking behavior of community-based health insurance users.

1. Introduction

Health insurance has been advocated worldwide to increase access to healthcare services since the 1990s because it prevents patients from paying premiums directly and spreads the financial burden among all the insured ( Tesfay, 2014 ). The community-based health insurance (CBHI) scheme is an emerging strategy for providing financial protection against health related poverty ( Kebede & Geberetsadik, 2019 ). It is a healthcare funding option that may help to broaden coverage and improve health-care access in rural and underserved areas ( Bennett, 2004 ).

CBHI (Community Based Health Insurance) is a novel idea for offering financial protection against the costs of disease and improving access to high-quality health care for low-income households and the informal sector that are not protected by formal insurance ( Donfouet & Mahieu, 2012 ). As a strategy for achieving universal health coverage, some African countries have recently introduced health insurance to improve citizens' access to health care, mobilize resources for service improvement, and ultimately contribute to improved health quality ( Wiesmann & Consultant, 2014 ). Ghana, Senegal, and Rwanda are a few of the African countries that have tried out CBHI as a national health program. Rwanda is one of the few African countries that has gone to great lengths to introduce CBHI ( Shimeles, 2010 ).

Ethiopia has begun establishing a comprehensive and sustainable risk protection system with healthcare financing mechanisms tailored to the country's needs as financial risk protection is a critical component of Universal Health Coverage (UHC) in 2011 ( Shigute et al., 2020 ). Following the implementation of CBHI, evidence generally indicated a positive effect and direct relationship on healthcare seeking and utilization rates ( Studies, 2014 ). For the success of CBHI, continuous research work can help the concept improve and flourish in the future ( Roy & Sarkar, 2018 ).

Enrollment of CBHI has reached 45.5% of the target households for the program in less than two years. CBHI's uptake was enhanced by connecting it to current social services and government systems ( Taddesse et al., 2020 ). CBHI-related factors and their effect on the healthcare system altered household access to healthcare services, improved healthcare seeking behavior, and improved the quality of service provision ( H, 2007 , Jembere, 2018 ).

Some evidence suggests that both SHI and CBHI have a positive impact on healthcare quality, social inclusion, and reduce health-care costs. It may also increase routine and preventive care in general via reducing financial burdens by allowing them to rely on insurance coverage rather than spending a large portion of their income on healthcare ( Al-Hanawi et al., 2020 , Chomi et al., 2014 ). According to a study conducted in west Ethiopia, households that were members of a risk-sharing institution used health services at a higher rate, which directly increased their healthcare seeking behavior ( Atnafu et al., 2018 , Spaan et al., 2012 ). According to Molla Yismaw et al., the scheme encouraged rural households to seek healthcare, particularly for excluded people, such as the poor and chronically ill. Thus, the poor can benefit from indigent entitlement, and the chronically ill can be cross-subsidized by the healthy ( Jembere, 2018 ).

As a result, the CBHI scheme has become a vehicle for achieving universal health coverage by avoiding out-of-pocket expenses and increasing healthcare seeking behavior ( Kamau & Njiru, 2014 ). Public funding to subsidize premiums for the poor; promoting increased revenue collection from the “healthy and wealthy” to enhance cross subsidization and risk pooling; improving CBHI management; and improving the quality of care and health seeking behavior of households ( mabrate et al.., 2015 , Osei Asibey and Agyemang, 2017 , Sohn and Jung, 2016 ). Besides, health care utilization is expected to be higher among CBHI user households. However, there is no a research work that indicates the CBHI users’ health-care seeking behavior in Ethiopian including Addis Ababa. As a result, this study can serve as a starting point for more in-depth study on the subject. Therefore, the aim of this study was to assess the healthcare seeking behavior of households in Addis Ababa, Ethiopia in 2022, following the introduction of the community-based health insurance scheme.

2.1. Study area and population

The study was conducted in Addis Ababa, Ethiopia. Addis Ababa is one of the most populous cities in Africa. It is situated at 38.763611 '' E longitude, 9° 0' 19.443 9.005401'' N latitude. The city is composed of 11 sub-cities with an estimated population of 5,006,000. Among these, 47.5% were males and the remaining 52.5% were females ( Ethiopian Public Health Institute (EPHI) & ICF, 2021 ). According to the Addis Ababa city CBHI scheme office report, there were an estimated 897,750 head households in the city and 226,559 households were covered by community-based health insurance schemes in 2021 ( Health & Improvement, 2021 ). The city had a lower rate of infant mortality than the national average, and over 98% of homes in the city had access to clean drinking water ( CSA, 2012 ). The actual data collection was carried out from July 5 th to August 30 th , 2022 using a community-based cross-sectional study design among household heads in the selected sub-cities of Addis Ababa, Ethiopia as a study population.

3. Eligibility criteria

The study included people over the age of 18 and heads of household enrolled in CBHI, and who had lived in Addis Ababa for at least 6 months prior to the survey. However, the study excluded household heads who used the fee waiver service and membership periods of less than 6 months, and people who were seriously ill and unable to communicate.

4. Sample size determination and sampling procedure

Sample size was calculated using a single population proportion formula. Since no research has been done to show a relationship between CBHI and healthcare seeking behavior in the Addis Ababa context, a 50% proportion was used to obtain a bigger sample size with a 95% confidence level and a 5% margin of error.

Finally, the minimum sample size was 634 household heads, adding a 10% non-response rate and a design effect of 1.5.

A three-stage random sampling technique was employed to select the study participants. A simple random sample technique was applied at each stage to eliminate selection bias. Three sub-cities were selected and considered as a primary sampling unit. Then, each district in the selected sub-city was assumed as a secondary sampling unit, and households were the third sampling unit. By the lottery method, three sub-cities and twelve districts were selected. Based on the CBHI registration book, heads of households were selected by simple random sampling. The CBHI registration book was used as a sampling frame. Then proportional allocation was done for each selected district.

4.1. Study variables and definition

4.1.1. dependent variable.

Healthcare seeking behavior of CBHI users

4.1.2. Independent variables

Predisposing (socio-demographic) factors: like age, sex, marital status, past illness, education, household size, occupation

Enabling factors: like income, access to health care, location, price of services.

Perceived ill health and morbidity-related factors: Formal treatment of public health facilities or private health facilities

Community-based health insurance: is a scheme in which community members prepay for healthcare services, entitled to own the scheme, and control its management. It focuses on solidarity and mutual collective pooling of resources to share the financial costs of healthcare services.

Healthcare-seeking behavior: is a series of decisions about seeking (using) healthcare that are influenced by a variety of factors. It can be appropriate if the service is obtained from any healthcare facility and inappropriate if the service is from self-treatment, a traditional healer, or someone who did not know where to go ( Fikre Bojola et al., 2018 ).

4.2. Data quality assurance

Data was collected using structured questionnaire, which was adopted from different literature with slight modification ( Fikre Bojola et al., 2018 , Jembere, 2018 , Shimeles, 2010 ). The questionnaire consisted of five sections: socio-demographics, knowledge, attitudes, healthcare seeking, and overall satisfaction. Data was collected through face-to-face interviews after providing information about the purpose and confidentiality. Data quality was ensured through training of data collectors, supervisors, and pre-testing of questionnaires. A pretest was conducted among 5% of the sample in Yeka sub city district nine that was not included in the actual data and modification was done based on the pretest finding before the beginning of the actual data collection. Close supervision of data collectors was done and data was checked for completeness by the principal investigator.

4.3. Data entry and analysis

Data was cleaned, coded and entered into Epi-Data version 3.1, then exported to SPSS for analysis. Frequencies, proportions, and summary statistics were used to describe the study populations. A bivariate logistic regression analysis with a 95% confidence interval was performed to identify potential candidate variables using the crude odds ratio. In bivariate analysis, a p-value of less than 0.25 was used as a cut-off point to select candidate variables for the final model multivariable logistic regression. The normality of data was tested using Hosmer Lemeshow goodness of fit test. Finally, statistical significance was declared with a p-value of less than 0.05 as the cut-off point.

4.4. Ethical consideration

The ethical principles outlined in the Declaration of Helsinki guide the entire research process, which states that “it is the duty of the physician to promote and safeguard the health, well-being, and rights of patients, including those who are involved in medical research” ( Holstila et al., 2016 ). The researchers secured ethical approval from Kotebe Metropolitan University, Menelik II Medical and Health Science College research and ethical review board with reference number KMU/18/10/3001. Official letters were obtained from the Addis Ababa health bureau. Data was collected after having informed written consent from each respondent.

5.1. Scio-demographic characteristics of respondents

Overall, 577 respondents participated in this study, yielding a response rate of 91%. Male heads of households accounted for 64.1% of the total, while female heads of households accounted for 35.9%. The majority of respondents (45.9%) were over the age of 46 years, followed by the age categories of 36–45 years and 26–35 years, which accounted for 20.3 percent and 19.2 percent, respectively. Age groups were formed based on the assumption of youth, young adults, adults, and old age groups. In terms of marital status, 365 (63.3%) of the respondents were married, while 13% were never married, and the remaining 68 (11.8%) and 69 (12%) respondents were widowed or divorced, respectively ( Table 1 ).

Socio-demographic characteristics of respondents.

5.2. Motivation and reasons for CBHI membership

Seven questions were asked of respondents to determine why they joined the CBHI scheme. Multiple choices were given to identify various reasons why they became members of the CBHI scheme, with the two most common reasons being: first, 59.1% joined the scheme because premium payments were lower than out of pocket payments; and second, 42.6% joined the scheme because illness and injuries occur frequently in the household. Respondents were asked if any members of the household had been sick in the previous six months, and a significant number of respondents (96%) reported illness or injuries within the household. In addition, when asked whether they sought therapy or not, 89.4% reported that they sought treatment. In this study, families that encountered illness or injuries for family members were asked what their first treatment responses were for the occurrences of disease or injuries, and the majority of households (49.5%) reported that they have visited contemporary health-care facilities ( Table 2 ).

Motivation of households due to the introduction of CBHI scheme.

5.3. The effect of CBHI scheme on healthcare seeking behavior

Healthcare seeking behavior is more prominent in the process of using a formal (modern) healthcare facility. The CBHI plan has the ability to promote immediate health-care use by modern health-care institutions. Respondents were asked whether the CBHI program allows people to obtain modern healthcare treatments on a regular basis to support the aforesaid rationale. The vast majority of them (62.9%) revealed that the CBHI scheme encourages people to seek healthcare from contemporary health facilities. Furthermore, respondents who believed CBHI motivated households to seek modern health services were asked why they were motivated to seek modern healthcare on a regular basis, and the majority (53%) of respondents believed that lack of payment was a major factor ( Table 3 ).

Health seeking behavior of CBHI users.

5.4. Effect of the CBHI scheme on treatment choices

Respondents were asked to identify what kind of treatment actions they undertake when feeling ill before and after becoming a member of the scheme to examine the choice of treatment households employed. A significant number of respondents (78.8%) reported that they used home healing before becoming a CBHI member. On the other hand, nearly half of the respondents (56%) reported that they used home healing after becoming a CBHI member. After families join the CBHI program, modern healthcare facilities take the lion's share of visits to healthcare institutions for disease and injury treatment. The reason behind such action is the free accessibility of modern healthcare at the time of services. Nearly all respondents considered visiting modern healthcare institutions as their first and best option for treating illness after they became members of CBHI ( Table 4 ).

Household treatment habits before and after CBHI membership.

5.5. Level of healthcare-seeking behavior

Out of the total respondents, 273, 47.31% (95% CI: 43.27–51.39%) had appropriate healthcare seeking behavior. On the other hand, 304 (52.69%) had inappropriate health seeking behavior ( Fig. 1 ).

Healthcare seeking behavior of CBHI users in Addis Ababa, Ethiopia.

5.6. CBHI knowledge, attitude, and satisfaction of study participants

Of the total respondents, 63.6% had good knowledge, implying that respondents knew benefit packages of four and above. On the other hand, 36.4% had poor knowledge ( Fig. 2 ). Furthermore, of the total respondents, 79.9% reported a favorable attitude towards CBHI, and 53.6% of the study participants reported being satisfied with the CBHI scheme. According to the findings of the study, members' satisfaction with health facilities has increased since the introduction of CBHI. Only 41.6 percent of members were satisfied with the services they received prior to the CBHI scheme. However, following the implementation of CBHI, this percentage increased to 63.8%, owing primarily to a lack of payment and good health care treatment. However, some households (22.3%) were dissatisfied due to a lack of drug supply and additional out-of-pocket expenses.

Knowledge of CBHI users about benefit packages in Addis Ababa, Ethiopia.

5.7. Factors associated with healthcare seeking behavior among CBHI users

Factors associated with healthcare seeking behavior were identified using binary logistic regression analysis at a p-value < 0.25. As a result, sex of respondents, religion, marital status, participation in CBHI related meetings, family size, ownership housing, knowledge, attitude, satisfaction, a desire of CBHI users to cut off CBHI membership, the presence of chronic illness in the family, and the availability of under five children in the family were significantly associated and selected for multivariable logistic regression.

Finally, five independent variables have a significant relationship with appropriate healthcare seeking behavior, namely: religious affiliation, family size, housing condition, and the presence of under-five children, were significantly associated with healthcare seeking behavior of CBHI users at a p-value of < 0.05 ( Table 5 ).

Factors associated with healthcare seeking behavior of respondents.

Note: HCSB: is the dependent variable , COR: Crude odds ratio, AOR: Adjusted odds ratio, *: Significant result, 1: Reference category, **: p-value <=0.01, *: p-value<=0.05.

6. Discussion

This study aimed to identify the relationship between healthcare seeking behavior and associated factors among households who were enrolled in community-based health insurance. Prior to joining CBHI, 8.7% of people used contemporary healthcare. However, after joining CBHI, this percentage jumped to 69%, which was consistent with research done in northern Ethiopia ( Bhageerathy et al., 2017 , Jembere, 2018 ). The possible reason could be that after paying the premium, members might be tempted to test the services that were promised.

This study's finding revealed that 47.31% of the study participants had appropriate healthcare-seeking behavior. This was comparable to that of research finding from northern Ethiopia ( Tesfay, 2014 ). However, it was lower than a result found from the Tehuldere district of northern Ethiopia at 71.5% ( Jembere, 2018 ), the Sidama zones of south west Ethiopia at 72.8% ( Begashaw et al., 2016 ) and the Dale district southern Ethiopia at 80.7% ( Fikre Bojola et al. 2018 ). The difference in healthcare seeking behavior might be due to the impact of COVID-19, which created fear in the community of seeking treatment from modern health facilities. Besides, the difference in study period and the sociodemographic characteristics might be responsible for the discrepancy. For instance, in the study's Tehuldere district, most of the study participants were males, and in Ethiopian culture, men have more decision-making power for treatment and public actions (processes during membership).

Based on the result of this study household heads with a family size greater than four members had a 63% higher risk of inappropriate healthcare seeking behavior than those with a family size of less than four members. It was in line with a finding from a population-based survey conducted in North West Ethiopia ( Atnafu et al., 2018 ). This might be due to the fact that those who have larger family members might give less attention to members of the household in terms of their nutritional needs, and this makes them prone to illness and an increased probability of using inappropriate medical care. This finding is in support of research done in Ghana and Kenya ( Muriithi, 2013 , Osei Asibey and Agyemang, 2017 ).

In addition, housing condition showed a significant association with appropriate healthcare seeking behavior where households having a government house had more than four times the odds of having appropriate healthcare seeking behavior when compared with households living in a rental house, which is consistent with a study finding from Singapore and Mumbai ( Bardhan et al., 2018 , Chan et al., 2018 ). The possible reason for this could be that households with their own house might spend more money on their health needs than households that spend money on house rent might invest the least in their health needs.

On the other hand, households that had under-five children showed a significant association with healthcare seeking behavior. Hence, households that had under five children were more likely to have appropriate healthcare seeking behavior compared with their counterparts. It was in line with the study findings done in the Amhara region's Ensaro district ( Dagnew et al., 2018 , Sisay et al., 2015 ). The reason behind it could be due to the fact that households who have under-five children might give more emphasis to their children's health.

Moreover, being a Muslim household head had nearly two times the odds of appropriate healthcare seeking behavior compared with orthodox Christian followers. This finding was supported by a study finding done in India's urban health centers ( Patil et al., 2016 , Vu et al., 2016 ). It is possible that orthodox religious followers might use additional alternatives, such as holy water.

Limitation: This study relied on the six-month experience of health care needs of the respondent prior to the study, making it vulnerable to recall bias. For the sickness report, the study used an individual's viewpoint and an oral report. The study design was not robust enough to distinguish between the cause and impact relationship.

7. Conclusion

The result of this study showed that the proportion of respondents who had appropriate healthcare seeking behavior among CBHI users was low. Moreover, family size, the presence of under-five children, religious affiliation, and housing ownership was significantly associated with healthcare seeking behavior. Therefore, the government of Ethiopia should work hard to improve housing conditions and contraceptive provisions for residents to improve the healthcare seeking behavior of CBHI users.

8. Consent for publication

Not applicable.

9. Data availability

The study has no funding source.

CRediT authorship contribution statement

Genanew Kassie Getahun: Conceptualization, Data curation, Visualization, Investigation, Writing – original draft, Writing – review & editing. Kumlachew Kinfe: Conceptualization, Supervision, Data curation, Writing - original draft, Writing - review & editing. Zewdu Minwuyelet: Methodology, Supervision, Writing – review & editing.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgment

We would like to acknowledge the study participants and data collectors of this study.

Data availability

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Open Access

Peer-reviewed

Research Article

The interaction of healthcare service quality and community-based health insurance in Ethiopia

Roles Conceptualization, Data curation, Formal analysis, Methodology, Software, Supervision, Writing – original draft

* E-mail: [email protected]

Affiliation USAID Transform: Primary Health Care Activity, Pathfinder International, Addis Ababa, Ethiopia

Roles Project administration, Resources, Writing – review & editing

Roles Data curation, Formal analysis, Writing – original draft

Affiliation Pathfinder International, Boston, Massachusetts, United States of America

Roles Conceptualization

Roles Data curation

Roles Data curation, Supervision

Affiliation USAID Transform: Primary Health Care Activity, Abt associate, Addis Ababa, Ethiopia

Roles Validation, Writing – review & editing

Affiliation Abt associate, Cambridge, Massachusetts, United States of America

Roles Project administration, Writing – review & editing

Affiliation USAID Transform: Primary Health Care Activity, JSI Research & Training Institute, Inc., Addis Ababa, Ethiopia

Roles Conceptualization, Validation, Writing – review & editing

Roles Conceptualization, Writing – review & editing

Affiliation USAID Ethiopia, Addis Ababa, Ethiopia

Roles Writing – review & editing

Roles Conceptualization, Methodology, Writing – review & editing

Affiliation USAID Contractor, Global Health Bureau, Office of Population and Reproductive Health, USAID, Washington, DC, United States of America

Affiliation Global Health Bureau, USAID, Washington, DC, United States of America

• Bekele Belayihun Tefera, 
• Mengistu Asnake Kibret, 
• Yordanos B. Molla, 
• Girma Kassie, 
• Aynalem Hailemichael, 
• Tarekegn Abate, 
• Hailu Zelelew, 
• Binyam Fekadu Desta, 
• Elizabeth Futrell, 

• Published: August 19, 2021
• https://doi.org/10.1371/journal.pone.0256132
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Community-based health insurance (CBHI) as a demand-side intervention is presumed to drive improvements in health services quality, and the quality of health services is an important supple-side factor in motivating CBHI enrollment and retention. There is, however, limited evidence on this interaction. This study examined the interaction between quality of health services and CBHI enrollment and renewal. A mixed-method comparative study was conducted in four agrarian regions of Ethiopia. The study followed the Donabedian model to compare quality of health services in health centers located in woredas/districts that implemented CBHI with those that did not. Data was collected through facility assessments, client-exit interviews, and key informant interviews. In addition to manual thematic analysis of qualitative data, quantitative descriptive and inferential analyses were done using SPSS vs 25. The process related (composite index including provider-client interpersonal communication) and outcome related (client satisfaction) measures of service quality in CBHI woreda/districts differed significantly from non-CBHI woredas/districts, but there were no significant differences in overall measures of structural quality between the two. The study found better diagnostic test capacity, availability of tracer drugs, provider interpersonal communication, and service quality standards in CBHI woredas. A higher proportion of clients at CBHI health centers gave high ratings of overall satisfaction with services. Individual and household factors including family size, age, household health care-related expenditures, and educational status, played a more significant role in CBHI enrollment and renewal decisions than health service quality. Key-informants reported in interviews that participation in the scheme increased accountability of health facilities in CBHI woredas/districts, because they promised to provide quality services using the CBHI premium collected at the beginning of the year from all enrolled households. This study indicates a need for follow-up research to understand the nuanced linkages between quality of care and CBHI enrollment.

Citation: Tefera BB, Kibret MA, Molla YB, Kassie G, Hailemichael A, Abate T, et al. (2021) The interaction of healthcare service quality and community-based health insurance in Ethiopia. PLoS ONE 16(8): e0256132. https://doi.org/10.1371/journal.pone.0256132

Editor: Hafiz T.A. Khan, University of West London, UNITED KINGDOM

Received: April 9, 2021; Accepted: July 29, 2021; Published: August 19, 2021

This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.

Data Availability: All relevant data are within the manuscript and its Supporting information files.

Funding: This study is conducted under the TRANSFORM project. The project was funded by United States Agency for International Development (USAID) and provided support in the form of salaries for BBT, BFD, MAK, GK, AH, TA (cooperative agreement number AID-663-A-17-00002).

Competing interests: The authors have read the journal’s policy and have the following competing interests: TA and HZ are paid employees of ABT Associates Inc. BFD is a paid employee of JSI Research and Training Institute Inc. This does not alter our adherence to PLOS ONE policies on sharing data and materials. There are no patents, products in development or marketed products associated with this research to declare.

Introduction

Timely access to health care can minimize the impact of ill health. Health insurance can reduce the cost of accessing health services and lessen the impact of ill health on the household’s ability to earn income [ 1 , 2 ]. Many low-income countries have introduced revenue-supported health insurance for urban informal workers and rural residents. With a mix of government co-funding, premiums, and registration fees, households can ameliorate the impact of illness by sharing risk and spreading out the costs of health care over time. Community-based health insurance (CBHI), often administered by communities or local governments, elicits voluntary enrollment for a fee for a period of one year [ 3 , 4 ]. In return, enrollees receive a specified set of services with no out-of-pocket co-payment at the point of care. CBHI has been promoted widely in low- and middle-income countries [ 5 ]. However, enrollment into CBHI or other types of insurance has historically been low in sub-Saharan Africa [ 6 ].

With the aim of ensuring access to quality health care services by all citizens without financial burden, the Ethiopian government established the Health Insurance Agency [ 7 ]. In 2011, the agency began piloting a CBHI scheme in 13 woredas in four of its largest agrarian regions (Amhara; Oromia; the Southern Nations, Nationalities, and Peoples’ Region [SNNPR]; and Tigray) [ 8 ]. Prompted by the pilot’s success and viability, the government of Ethiopia scaled CBHI up to 512 woredas in six regions, expanding to Benishangul-Gumuz, Harari, and two city administrations (Addis Ababa and Dire Dawa) [ 8 , 9 ]. As of 2019/20, CBHI schemes are functional as part of a phased national rollout plan, in 700 woredas and cities—covering some 32.2 million people or almost a third of Ethiopia’s population [ 10 ]. The voluntary CBHI scheme is available to households in rural, semi-urban, and urban areas who are not employed within the formal sectors of the economy. The scheme charges member households a nominal one-time registration fee along with a yearly enrollment/renewal premium. The annual premium is between USD 7 and 8 per rural household and USD 10 and 14 per urban household. A general subsidy from the federal government matches 10% of the CBHI enrollment proceeds. Also, local governments at the woreda and regional level allocate a certain amount of budget as targeted subsidy each year to cover the free enrollment of select poor and indigent households unable to pay for CBHI membership [ 11 ]. CBHI covers basic costs for inpatient and outpatient services at public health facilities within a member’s catchment area.

Enrollment in CBHI reflects a financial investment in the health system by individual citizens. At the same time, increased demand for quality services has the potential to lower average quality if limited resources are strained. Since 1998, the Ethiopia Ministry of Health has invested and given health facilities autonomy to use the revenue they collect from user fees and other sources to improve access to and quality of healthcare service. Studies in different countries, including Ethiopia, focus on factors that affect CBHI enrollment and renewal and the role of CBHI on service quality [ 1 , 12 – 18 ]. Findings showed that long waiting times, poor patient-provider interactions, unavailability of diagnostics and essential drugs, unfavorable client perception of health care quality, and low client-service satisfaction were associated with high CBHI scheme dropout rates. This indicates that quality of healthcare affects decisions about whether to reenroll in CBHI [ 19 – 22 ]. However, service quality was not shown to be the reason for CBHI drop-out rates in pilot areas [ 12 ]. Enrollment rates were also affected by timing, the payment modality involved in enrolling into the insurance, trust in scheme management, and distance to health facilities. Acceptance of modern medicine or attitude toward planning for future illnesses might also affect enrollment [ 19 , 20 , 23 , 24 ]. Quality of health services is critical for member satisfaction and sustainability of the CBHI scheme. As CBHI is scaled up and more time passes, the role of quality of health services in CBHI enrollment in Ethiopia might become more evident.

The Ethiopian Hospital and Primary Health Care Alliance for Quality guidelines steer efforts to enhance the health care delivery structure and process and improve the client experience of care. By aiming to increase the availability of supplies, use new tools, apply innovations, strengthen providers skills, and improve work environments, implementation of CBHI in a woreda has the potential to ensure a threshold level of quality of healthcare service. CBHI provides financial protection to its members and increases health care seeking behavior and health service utilization [ 25 , 26 ]. This, in turn, creates pressure on health facilities and providers, and may affect the quality of healthcare service at the health centers, but there is limited evidence on the interaction between CBHI and quality of health services. This study examined the interaction between quality of healthcare service and CBHI uptake. The following research questions were explored: (i) Has the introduction and implementation of CBHI improved quality of healthcare services? and (ii) Does quality of healthcare affect enrollment in and renewal of CBHI?. The study presents quality of healthcare services through the Donabedian model, which posits that the presence of structural quality facilitates process quality, which leads to outcome quality based on client experience and satisfaction [ 27 ]. This model was adopted because it explores all the three elements of quality and postulates that the CBHI implementation mechanism itself and the related enhanced revenue generation would improve quality of health care service; enhanced quality of health care service or perceived quality itself would generate greater enrollment into CBHI.

Study area and period

Since 2017, USAID Transform: Primary Health Care project, in collaboration with the Ministry of Health, has supported continuous improvement of quality of healthcare services in Ethiopia. Benefiting nearly 53 million people, Transform strengthens the management and performance of Ethiopia’s national health system by improving quality of service delivery across the continuum of primary health care, improving household and community health practices and health care-seeking behaviors, and strengthening program learning to impact policy and activities related to the prevention of child and maternal deaths. The study was conducted in selected health centers located within, USAID Transform: Primary Health Care implementation regions and focused on interaction between CBHI enrollment and healthcare service quality. Data was collected from August to September 2019.

Study design

An embedded mixed-method comparative study was conducted in four agrarian regions of Ethiopia (Amhara, Oromia, SNNPR, and Tigray) to provide information on quality of healthcare services in woredas that implemented CBHI and those that did not. The study was guided by the Donabedian model.

Sampling and sample size determination

As there is no pre-determined estimate of level of differences to base our assumptions for estimating sample size, standard sample size formula could not be used to calculate sample. Woredas were selected from the four regions where USAID Transform: Primary Health Care is implemented. The sampling frame included woredas that have implemented CBHI for at least 24 months and non-CBHI woredas that are in USAID Transform: Primary Health Care areas. Within the CBHI and non-CBHI groups, woredas with health centers that initiated a quality improvement (QI) intervention with the project’s support and woredas with health centers that have not yet initiated a QI intervention were included. Two woredas from each category were randomly selected from Amhara, Oromia, and SNNP, and a single woreda was randomly selected from Tigray for each of the four categories. A total of 28 woredas were selected from the four regions.

Two health centers were randomly selected from each of the 28 woredas for a total of 56 health centers. Exit interviews were conducted among participants who used in the selected health center for any health services. Participant selection was completed through consecutive sampling method until an adequate sample from each health center was obtained. The plan for exit interviews was to include one participant from a health center in non-CBHI woreda for every three-participants interviewed from a health center located in CBHI woreda. For each health center in a woreda that was not implementing CBHI (non-CBHI woreda), five participants were interviewed while 15 were interviewed from health centers located in CBHI woredas. This provided a total of 140 interviews from participants in non-CBHI woredas and 420 interviews with participants in CBHI woredas (which included 224 currently CBHI enrolled, 112 who dropped out of CBHI and 84 who never enrolled participants) for a total of 560 study participates.

The qualitative key informant interviews were conducted with people who had experience with the interaction between CBHI and quality of health services. With the same sampling techniques used in quantitative data collection, 28 key informant interviews were conducted: four with regional officials, four with zonal officials, four with woreda CBHI officials or CBHI management team members (in CBHI woredas), eight with woreda office heads (four from CBHI woredas and four from non-CBHI woredas), and eight with health center heads in each of the study’s regions.

Data-collection process and instruments

The assessment used three data collection methods ( Fig 1 ). Structural-quality measures were investigated through a facility survey with a standard tool. Process-quality measures were investigated based on exit interviews with participants about their perception of provider adherence to quality standards and procedures, as well as key informant interviews at health facilities, woreda, zonal, and regional health bureaus. Outcome-quality measures were explored based on client satisfaction as they exited the health facility.

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https://doi.org/10.1371/journal.pone.0256132.g001

Participants exit interview.

Exit interviews were conducted using a structured questionnaire translated into local languages with 560 participants who visited health centers selected for the study on the day of data collection. Along with participant demographic information, the exit interviews elicited participants’ views on health care services received during the visit preceding the interview, previous experience in the same health center, and attitudes toward CBHI in general. In addition to individual characteristics (such as age, sex, marital status, education) and out-of-pocket expenditure during the facility visit on the day of the interview, eight indicators were used to measure client service satisfaction, comparing clients from CBHI woredas with their counterparts. These indicators were: overall quality of service, availability of medicines and supplies, availability of diagnostic services, cleanliness of facility, wait time between arrival and service, wait time between services, friendliness of staff, and availability of private counseling services. In addition to client service satisfaction, the exit interview included tracer indicators that were used to develop composite measures of interpersonal relations (4 indicators) and client perception about provider adherence to proper procedure (10 Likert scale indicators). The exit interview instrument was adapted from the evaluation tool used for the CBHI pilot in Ethiopia [ 28 ].

Facility survey.

Structure quality was assessed in 56 health facilities using a standard facility assessment tool focused on an inventory of availability and readiness of basic health facility infrastructure: basic amenities (6 tracer items), basic equipment (6 tracer items), diagnostic capacity (7 tracer items), essential medicines (25 tracer items), and standard precautions for infection prevention (9 tracer items). In addition to facility surveys, interviews were conducted with facility heads and supplemented with observation of facility adherence to service quality standards. Observation of service quality standards included 18 tracer indicators on the facility’s QI structure, capacity to implement QI, providers’ ability to provide patient-centered care, patient-safety practices, availability of quality monitoring and sharing processes, and practices for QI learning. The facility survey instrument and analysis methodology were adopted from WHO’s SARA tool [ 29 ]. The facility service quality standard assessment tool was adopted from the national standards used for facility quality inventory [ 30 ].

Key informant interviews.

A qualitative assessment to understand the design, operation, and implementation of CBHI at different levels of the health system was conducted with 28 key informants who were heads of regional health bureaus, zonal offices, woreda health offices, health centers, as well as woreda level CBHI focal persons. The questionnaires were prepared in English, translated into the local languages (Tigrigna, Amharic, and Oromifa), and translated back into English to check consistency. Twenty data collectors who were fluent in the local language (five for each region) were selected for data collection and four supervisors with experience in CBHI, and service quality integration were selected for supervision. Training, consisting of mock interviews and practical exercises for both data collectors and supervisors, was conducted over five days in July 2019. The questionnaires were pretested and refined to ensure they were clear and could be understood by both the data collectors and respondents.

Data management and analysis

The research team assessed the quality, accuracy, and completeness of the collected data using range plausibility and cross-validation checks. The data was collected using local languages and back translated in English before analysis. The quantitative data was entered into EPI-Data vs 3.02 for Windows and exported into SPSS vs 25 for further analysis. Data analysis consisted of descriptive statistics and comparisons across woredas as defined by CBHI status. Composite indicators (summary measures) were analyzed and compared. A two-level hierarchical linear model was performed to study the relative strength of structure, process, and individual characteristics in predicting client satisfaction with quality of services. Similarly, logistic regression was used to determine the predictors of CBHI enrollment. A 95% level of significance was considered for variables found to have significant association (p-value ≤0.05) with the outcome variable.

Qualitative data analysis.

The key informant responses were audio-recorded, transcribed verbatim in local languages (Amharic, Oromifa and Tigrigna) and translated into English. Thematic analysis was used to analyze the data in three phases: preparation, team organization and reporting the summary result in each team. The first phase of the analysis started with careful reading of the data multiple times to become immersed in and familiar with the data. In the organization phase, each transcript was read carefully by the first author who highlighted the theme text (words or phrases) that appeared to describe the phenomenon under the study (use of CBHI, quality service, interaction). The highlighted theme text was openly and manually coded with descriptors. The third author read the data to confirm the descriptive codes. These codes were revised, and the codes that emerged from the revision were jointly reviewed before they were integrated into the analysis. The other authors collaborated with the first and third author to review, discuss and agree on the final code categories. The final analysis was summarized manually based on agreed emerging themes.

Ethical considerations

Ethical approval was obtained from Amhara, Oromia, SNNPR and Tigray Regional public health research institute institutional review board (IRB) committees, and permission letters were secured from the sampled health facility head. Each respondent gave informed verbal/oral consent after being told the purpose, risks, benefit, confidentiality, voluntary nature of participation, whom and how to contact principal investigators and procedures of the study in the presence of head of the facility. All respondent identifiers were kept confidential, and data were anonymized.

Table 1 describes basic data by woreda insurance and personal insurance status within the woredas where CBHI was introduced. Woredas with insurance show higher age; it is likely that an older population is less educated and may also have a larger family. The differences in health expenditure across the woredas indicate that insurance has reduced health expenditure in the past year at point of care.

https://doi.org/10.1371/journal.pone.0256132.t001

Has the introduction and implementation of CBHI improved quality of health services?

Structural quality for health centers located in CBHI woredas showed general service-readiness index mean score (a composite summary measure combining information from observation of five general service-readiness domains: basic amenities, standard precautions, basic equipment, diagnostics, and essential medicines) of 0.62. This implies facilities’ readiness to provide 62% of general health services ( Table 2 ). There was no statistically significant difference between overall structural quality in CBHI and non-CBHI health centers based on the general service-readiness index (mean difference = -0.002, p<0.9). However, the average diagnostic test capacity and availability of tracer drugs was better in CBHI woredas and availability of basic equipment was better in non-CBHI woredas.`

https://doi.org/10.1371/journal.pone.0256132.t002

The general process score is a composite index of observed availability of service-quality standards, clients’ perception of providers adherence to proper procedures, and clients’ perception of interpersonal relations. This score showed differences between CBHI and non-CBHI woredas. Availability of service quality standards was better in CBHI woredas with a statistically significant difference between health centers located in CBHI and non-CBHI woredas (mean difference = 0.06, p<0.01). Client perception about interpersonal relationships between clients and service providers was also slightly better in CBHI woredas, but the difference was not statistically significant (mean difference = 0.11, P<0.08). The mean value of the general service process index for health centers located in CBHI woredas was perceived to follow proper service processes 92% of the time, while health centers in non-CBHI woredas were perceived to follow proper service processes 87% of the time. However, this difference was not a statistically significant (mean difference = 0.05, p<0.06).

Clients were asked to rate their level of satisfaction from very satisfied, to neutral and to very dissatisfied, based on their experience of service received ( Table 3 ). More than 92% of respondents from health centers located in CBHI woredas were either satisfied or very satisfied with overall service quality. A higher proportion of clients of health centers in CBHI woredas gave high ratings of overall satisfaction (very satisfied/satisfied) than those in non-CBHI woredas (mean difference = 0.36, P <0.001).

https://doi.org/10.1371/journal.pone.0256132.t003

Following the comparative analysis, a two-level hierarchical linear model was used to analyze predictors of overall satisfaction of respondents living in CBHI and non-CBHI woredas. There was a significant heterogeneity among health centers regarding satisfaction with perceived service quality ( Table 4 ). The intraclass correlation coefficient (ICC) in the null model for overall client satisfaction was 37.9%. This means that 38% of the variation in overall client satisfaction between the health centers is due to the difference between the health centers (cluster variation). The fixed estimate, that is estimated overall average satisfaction score across all health centers and client (individual), is 4.1 and is statistically significant. The fixed-effect model indicates that among the individual-level characteristics, client perception of interpersonal relations, perception of provider adherence to proper procedures, and client’s spending on non-medical costs were significantly associated with overall average client satisfaction (p<0.05). No facility-level variables significantly contributed to overall average client satisfaction with service quality. Therefore, predictors of client satisfaction were related to their perception of service received.

https://doi.org/10.1371/journal.pone.0256132.t004

Does quality of care affect enrollment in and renewal of CBHI?

Of the total respondents in the CBHI woredas, 81% were ever enrolled as a CBHI member. Of these, 69% were currently enrolled, and 31% did not renew. More than 79% of respondents in both groups said they enrolled to protect themselves from financial shortfalls when seeking care, and 46% of respondents said they enrolled because the premium was lower than the out-of-pocket payments for user-fees and other associated costs they and their household members incurred every time they sought health care ( Table 5 ). Of the participants currently enrolled in CBHI scheme, 36% named frequent illness as their reason for enrollment. The decision to join a CBHI scheme is made on voluntary basis by each household, nearly 6% of respondents reported pressure to enroll by kebele administration (CBHI officials) during the enrollment process.

https://doi.org/10.1371/journal.pone.0256132.t005

Financial protection and low premiums were the main reasons for CBHI enrollment and renewal. Among those never enrolled (n = 77), lack of understanding of the enrollment process (43%) and affordability (22%) played a prominent role, and some stated they wanted to confirm the benefits of the scheme with others (17%). Similarly, among members who did not renew (n = 99), 23% stated they did not have adequate knowledge about membership renewal, and 21% said that the enrollment fee was not affordable at the time of the renewal period and 11% declined to renew due to low service quality of available health care.

The logistic regression results showed that participant age, household family size, and high health care spending played an important role in CBHI enrollment and renewal. The findings determined a 5% increase in the odds of CBHI enrollment for a one unit increase in respondent age (AOR = 1.05, 95% CI: 1.03–1.07) indicating an increase in CBHI enrollment as the age of the client increases. Household family size was positively associated with enrollment: households with more than one member were 1.3 times as likely to enroll as single-member households (AOR = 1.27, 95% CI: 1.09–1.46). Educational status was significantly associated with renewal: respondents with a secondary level of education and above were less likely to drop out of the CBHI scheme (AOR = 0.89, 95% CI: 0.81–0.98). From a statistical point of view, our regression analysis failed to establish a significant association of service quality indicators (structural, process, and outcome quality) with CBHI enrollment and renewal ( Table 6 ).

https://doi.org/10.1371/journal.pone.0256132.t006

Qualitative findings

Factors influencing CBHI enrollment and delivering quality service are categorized by three themes (service availability and quality, right to access service). All key informant interview respondents said health service quality generally has improved in both CBHI and non-CBHI woredas recently. Clients in CBHI woredas are more likely to demand quality service than those in non-CBHI woredas who are paying out-of-pocket for health care services. This is because CBHI woredas promise to provide quality services using the CBHI premium that is collected at the beginning of the year from all enrolled households regardless of pre-existing health conditions. Their demands include the right to be served on time, the right to access basic drugs and laboratory services within a single facility, and the right to be treated respectfully by providers.

When we ask patients to buy drugs from a private pharmacy , CBHI members started to ask a question like , “ who is going to pay us ?”, and “ who will reimburse our expenses ?”. They say it is their right to get full service from here [health facility] as they were promised . They demand all services to be available at the facility . –CBHI health center head

Key informants reported that these client expectations drove CBHI health facilities to work towards fulfilling the minimum quality requirement promised during CBHI enrollment.

One zonal CBHI focal person shared:

We had a challenge of renewing memberships and enrolling potential new members . This was because of the weakness in the service provision . Lack of adequate drug supply and poor service delivery had contributed .

According to the key informant interviews (with z onal and woreda CBHI focal persons ), drug- and diagnostic-supply shortages in CBHI health facilities have forced providers to refer patients to private facilities for certain services. While alternatives are limited in Ethiopia, drug purchases, for example, can be made in the private sector. The clients were offered reimbursement for the costs they incurred in the private facilities, but because clients did not expect these referrals, these incidents have led to misunderstandings and client dissatisfaction. The study findings showed a shortage of drugs and supplies received from Ethiopian pharmaceuticals supply agency (EPSA) in both CBHI and non-CBHI facilities. However, facilities in CBHI woredas have the advantage of accessing financing from the CBHI scheme to procure drugs and supplies. As another interview participant (woreda CBHI focal person) mentioned, “ In addition to the drugs supplied through EPSA , the facilities’ boards have recommended to buy additional drugs from private suppliers and make it available for patients . We are trying our best to do that .”

In summary, comparing quality of health services across health centers in CBHI and non-CBHI woredas, our findings revealed no significant differences at the structural level—for example, in facility-level preparedness to treat illness. But upon examination of specific indicator domains—for example, availability of diagnostics test and tracer drugs, we found minor differences. This and the fact that our exit interviews indicated that clients visiting health centers in both CBHI and non-CBHI woredas reported no structural issues related to quality of health service implies that the health centers are comparable in their overall preparedness to treat illness, but availability of replenishable items such as drugs and diagnostic tests was slightly better in CBHI woredas.

There were differences in process- and outcome-quality indicators across health centers in CBHI and non-CBHI woredas. Provider-client interactions and perceived adherence to service quality standards appeared to influence client satisfaction more than any other factor. Respondents who were already engaged with the health centers might view facility care more positively than the general population. This type of finding has been noted elsewhere [ 23 ]. Subjective measures like the Likert scale might yield more optimistic values than those respondents report if probed. A study conducted in Burkina Faso found that, when probed, households gave less favorable answers to questions regarding satisfaction with health insurance than they did initially [ 31 ]. It is also possible that those who chose not to renew their CBHI enrollment or who never enrolled participated in the exit interviews to a lesser extent, as they might live further away from health centers. We should expect lower values than those reported for the current study, but we have no reason to think that values in one set of regions were more or less inflated than any other set of regions. Although nearly all respondents reported high satisfaction, clients of health centers in CBHI woredas ranked their satisfaction with services higher than clients of health centers in non-CBHI woredas. Clients in non-CBHI woredas reported lower availability of essential drugs, and when drug supply at the health center was low, more people reported purchasing drugs from private facilities. This phenomenon was not observed in the CBHI areas, indicating that it might be easier for clients in health centers in CBHI woredas to acquire drugs through non-payment.

Individual and household factors played a role in CBHI enrollment and renewal decisions than did quality of health service. Educational status, family size, and age were associated with insurance uptake. These individual factors raise a concern for equity in access to quality health services. Lower levels of education among those who did not renew might indicate the difficulty of reaching these clients with tailored information and education campaigns. The non-CBHI members in CBHI woredas demonstrated lesser understanding of insurance, signaling the need for more effective insurance education activities in the CBHI woredas. Household family size was positively associated with enrollment indicating those with more than one family member are motivated to enroll. The analysis indicated that older people are likely to be ill more frequently and therefore more inclined to enroll in insurance. The insured reported more illness, although this question did not elicit consistent answers from the uninsured. An ever-present problem with voluntary enrollment into insurance is adverse selection: those with higher risk of illness and more in need of health care are the first to enroll. The requirement to launch CBHI in woredas where half of the households in the woreda are willing to enroll can facilitate risk spread among the woreda population at large, strengthening the viability of health insurance and preventing strain on the quality of health service.

Among the primary purposes of health insurance is financing health care at the population level to alleviate the burden of expensive care incurred in a short period of time by individual households. A few insured patients had borrowed large sums of money in previous year before joining the scheme to finance health care costs. This suggests some degree of adverse selection, indicating incomplete risk sharing, as those who enrolled might have higher risk. Adverse selection can be hard to avoid when insurance enrollment is voluntary. Insured participants in this study borrowed less in general and paid much lower prices for drugs to buy from private pharmacies, a common health-care expense. Although there is some payment for care among the insured, it is relatively small. This finding is consistent with Mebratie and colleagues’ research findings, which showed a relationship between non-medical-related costs and enrollment status [ 12 ]. Respondents who spent more on these costs were less likely to enroll in or renew CBHI, because the insurance covers only medical treatment and not non-medical expenses such as transport, lodging, or food. Choosing to enroll in insurance is a complicated decision, and quality of health service is only one factor that influences this choice [ 12 , 23 ]. The descriptive and qualitative analysis revealed that quality of health care which includes availability of essential drugs is critical for enrollment and renewal of in the CBHI scheme. However, statistical analysis of the quantitative data showed that structural and process quality indices, and outcome proxy indicators showed no significant influence on CBHI enrollment or renewal decisions. Therefore, quality has not been the deciding factor in uptake of insurance. These results are consistent with other study findings [ 23 ]. However, more clients in CBHI facilities expressed satisfaction with the quality of services they received compared to their counterparts. The government has a universal responsibility to deliver an acceptable level of quality health care services in all facilities, whether CBHI or non-CBHI.

This study highlighted important findings to support the interaction between CBHI and quality of healthcare service. However, the data was not conclusive on factors that affect insurance uptake, exposing limitations of the study that also recognize the complexity of linking insurance with quality of health care. First, to show the linkages between facility- and individual-level quality scores and CBHI status, the facility-level was disaggregated into individual-level (client) data. There may be an atomistic fallacy. Second, poor quality of care might discourage people from using health centers altogether. This study explored health center users’ perceptions through exit interviews. The users had already made the choice to visit health centers, which indicates an inclination to value health center care already. Non-CBHI facility users may see a one-time payment as more affordable than the yearly CBHI fee. It is possible that quality of care is a small factor in the enrollment decisions of those already attending health centers and paying for services.

General structural quality of service was not statistically different between health centers in CBHI and non-CBHI woredas. However, availability of diagnostic test capacity and tracer drugs was slightly better in CBHI woredas than their non-CBHI counterparts. Process- and outcome-related measures of service quality based on clients experience in CBHI woredas scored better than and showed a statistically significant difference from non-CBHI woredas. The quantitative results were supported by key informant interview analysis: CBHI served to improve accountability of health facilities as well as critical aspects of service delivery (like drug availability), hence clients in CBHI facilities were satisfied. Regarding effects of service quality on CBHI enrollment or renewal, only within the woredas where insurance is being implemented and community members would have the choice of enrolling into insurance; showed individual and household (education, family size, age, and health care expenditure,) factors played a significant role in CBHI enrollment and renewal decisions.

The findings revealed that perceived quality of health care is essential for enrollment and renewal. However, health service quality was not shown to have a significant impact on CBHI enrollment or renewal in the statistical analysis of the quantitative data. An important point to note in this respect is ‘clients’ perception of quality, which is based on their experience of care and can differ from observed facility readiness and service availability or process of care provided according to standards and guidelines. Follow-up research is needed for a more nuanced look at the link between service quality and enrollment. Ease of enrollment is an important factor in increasing and retaining CBHI membership. Our findings indicate that households that did not renew CBHI lived further away from health centers, and some might have lacked information about the renewal process. Therefore, CBHI enrollment messages should address existing inequities and reach inaccessible households with tailored messages. Future education campaigns should consider emphasizing that future health risks are likely to be uniform across households and might not be related to the past incidences of ill health. Because age also seems to be a positive factor in enrollment, the program might want to consider offering young families a lower rate or making universal enrollment mandatory.

Supporting information

S1 data. study data..

https://doi.org/10.1371/journal.pone.0256132.s001

S1 File. Analysis.

https://doi.org/10.1371/journal.pone.0256132.s002

S2 File. Interview guide.

https://doi.org/10.1371/journal.pone.0256132.s003

S3 File. Survey tools.

https://doi.org/10.1371/journal.pone.0256132.s004

Acknowledgments

The Authors would like to acknowledge the contribution of Catherine Kirk, Miranda Beckman, Cecelia Angelone, Talia Flores for reviewing and providing feedback, and Zewdu Tesfaye, regional monitoring and evaluation, Health Care financing, quality improvement and assurance officers, and project regional managers and cluster staff for supporting data collection and supervision.

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The impact of community-based health insurance on health service utilization and financial risk protection in Ethiopia

Affiliations.

• 1 MERQ Consultancy PLC, Addis Ababa, Ethiopia. [email protected].
• 2 World Health Organization - Ethiopia, Addis Ababa, Ethiopia.
• 3 MERQ Consultancy PLC, Addis Ababa, Ethiopia.
• 4 Department of Health Policy and Management, Institute of Health, Jimma University, Jimma, Ethiopia.
• 5 School of Public Health and Tropical Medicine, Tulane University, New Orleans, USA.
• 6 Ministry of Health, Addis Ababa, Ethiopia.
• PMID: 36683041
• PMCID: PMC9869550
• DOI: 10.1186/s12913-022-09019-6

Background: Evidence on the effectiveness of community-based health insurance (CBHI) in low-income countries is inconclusive. This study assessed the impact of CBHI on health service utilization and financial risk protection in Ethiopia.

Methods: We conducted a comparative cross-sectional study nested within a larger national household survey in 2020. Data was collected from three groups of households-CBHI member households (n = 1586), non-member households from CBHI implementing woredas (n = 1863), and non-member households from non-CBHI implementing woredas (n = 789). Indicators of health service utilization, out-of-pocket health spending, catastrophic health expenditure, and impoverishment due to health spending among CBHI members were compared with non-members from CBHI implementing woredas and households from non-CBHI implementing woredas. Propensity score matching (PSM) was used to account for possible selection bias.

Results: The annual number of OPD visits per capita among CBHI member households was 2.09, compared to 1.53 among non-member households from CBHI woredas and 1.75 among households from non-CBHI woredas. PSM estimates indicated that CBHI members had 0.36 (95% CI: 0.25, 0.44) and 0.17 (95% CI: -0.04, 0.19) more outpatient department (OPD) visits per capita per year than their matched non-member households from CBHI-implementing and non-CBHI implementing woredas, respectively. CBHI membership resulted in a 28-43% reduction in annual OOP payments as compared to non-member households. CBHI member households were significantly less likely to incur catastrophic health expenditures (measured as annual OOP payments of more than 10% of the household's total expenditure) compared to non-members (p < 0.01).

Conclusion: CBHI membership increases health service utilization and financial protection. CBHI proves to be an important strategy for promoting universal health coverage. Implementing CBHI in all woredas and increasing membership among households in woredas that are already implementing CBHI will further expand its benefits.

Keywords: Community-based health insurance; Ethiopia; Financial risk protection; Health care utilization; Health financing.

© 2023. The Author(s).

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Conflict of interest statement

MERQ is an independent research institution with no conflicts of interest in relation to this study. All authors declared that they have no conflicts of interest.

Financial and non-financial reasons for…

Financial and non-financial reasons for not seeking care during illness

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Scaling up community-based health insurance in Ethiopia: a qualitative study of the benefits and challenges

• Addis Kassahun Mulat 1 , 2   na1 ,
• Wenhui Mao 2   na1 ,
• Ipchita Bharali 2 ,
• Rahel Belete Balkew 1 &
• Gavin Yamey 2  

BMC Health Services Research volume  22 , Article number:  473 ( 2022 ) Cite this article

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Ethiopia has achieved impressive improvements in health outcomes and economic growth in the last decade but its total health spending is among the lowest in Africa. Ethiopia launched a Community-Based Health Insurance (CBHI) scheme in 2011 with a vision of reaching 80% of districts and 80% of its population by 2020. This study aimed to identify early achievements in scaling up CBHI and the challenges of such scale-up.

We interviewed 18 stakeholders working on health financing and health insurance in Ethiopia, using a semi-structured interview guide. All interviews were conducted in English and transcribed for analysis. We performed direct content analysis of the interview transcripts to identify key informants’ views on the achievements of, and challenges in, the scale-up of CBHI.

Implementation of CBHI in Ethiopia took advantage of two key “policy windows”—global efforts towards universal health coverage and domestic resource mobilization to prepare countries for their transition away from donor assistance for health. CBHI received strong political support and early pilots helped to inform the process of scaling up the scheme. CBHI has helped to mobilize community engagement and resources, improve access to and use of health services, provide financial protection, and empower women.

Gradually increasing risk pooling would improve the financial sustainability of CBHI. Improving health service quality and the availability of medicines should be the priority to increase and sustain population coverage. Engaging different stakeholders, including healthcare providers, lower level policy makers, and the private sector, would mobilize more resources for the development of CBHI. Training for operational staff and a strong health information system would improve the implementation of CBHI and provide evidence to inform better decision-making.

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Introduction

Universal health coverage (UHC) aims to ensure people have access to the high quality health care that they need when they need it, without suffering financial hardship. In recent years, the UHC movement has gained global momentum [ 1 ]. However, most Sub-Saharan African countries have found it challenging to raise revenues for financing the delivery of an essential package of health services. In the face of this challenge, there has been growing interest in Social Health Insurance (SHI) and Community-Based Health Insurance (CBHI), as seen by the launch of SHI and CBHI schemes in Ethiopia, Ghana, Kenya, Lesotho, Nigeria, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe [ 2 ].

Ethiopia is one of the countries that spends the least on healthcare services in Africa. In 2016, health expenditure was only 1.4% of gross domestic product (GDP) [ 3 ]. National health financing indicators showed that only 11.1% of the total government budget was allocated to health in 2014 [ 4 ], below the 15% threshold target of the Abuja Declaration [ 5 ]. The public sector dominates the provision of health care services, with nearly 75% of hospitals run by the ministry of health or other government agencies [ 6 , 7 ]. Public health care facilities provide healthcare services at nominal prices or free of charge depending on a patient’s ability to pay [ 6 ]. However, access to healthcare remains a barrier to reaching UHC in Ethiopia, especially in rural areas [ 8 ].

Ethiopia has shown improvements in health outcomes over the last decade. For example, the under-five mortality rate fell from 86.7 to 50.7 per 1000 live births between 2009 and 2019 [ 9 ]. The country has also experienced sharp economic growth in the last decade [ 10 ]. However, despite impressive gains in recent years, use of health services in Ethiopia remains low. The rate of outpatient visits per capita stands at less than 0.48 annually [ 10 ], far below the World Health Organization’s suggested rate of 1.0. In 2013, only 62% of individuals in Ethiopia reported seeking health services when they fell ill [ 11 ]. Out of pocket payment (OOP) accounted for about 34% of total health expenditure in 2017, indicating the heavy financial burden on households of paying for health care [ 11 ]. OOP also has a detrimental impact on use of services. In one study, over 40% of individuals not seeking healthcare when they were ill cited financial limitations as the primary reason [ 12 ].

To accelerate progress towards UHC, the government of Ethiopia piloted CBHI in 13 woredas (districts) between 2011 and 2013. CBHI is a voluntarily insurance scheme. The financial contribution during the pilot stage was 180 Ethiopian Birr (ETB) per household annually (10.4 US$ in 2011 US dollars). However, the members’ contributions varied among the pilot districts, ranging from 34.4 ETB to 132 ETB annually [ 13 ]. The CBHI benefits package includes all family health services and curative care (inpatient services, outpatient services and acute illnesses), which are part of Ethiopia’s essential health package [ 14 ]. Based on the encouraging results of CBHI pilots, the government scaled up the scheme to over 350 woredas in 2017. As a result, more than 14.5 million people had health insurance coverage through CBHI in 2017. The government then planned to expand CBHI to 80% of woredas and 80% of the population by 2020 [ 4 ].

In 2009, De Allegri and colleagues reported that enrolment rates for CBHI were less than 10% in sub-Saharan Africa countries [ 15 ]. In comparison, the Ethiopian scheme enrollment rate was over 50% on average, but coverage varied across the pilot regions. While the Amhara region recorded a 68% coverage rate, the highest rate among the four regions, coverage in the Tigray region was the lowest at 49%. Some of the factors that led to such variations in coverage of across the pilot regions included commitment from the local administration, waiting times at the facilities, and delays in renewing CBHI [ 16 ]. A USAID report found that the quality of service was poor at some CBHI health facilities and there were gaps in human resources, shortages of drugs and medical equipment, power outages and poor water supply [ 17 ]. Thirty nine percent of non-members raised concerns about the affordability of premiums and the registration fee. Combined with the 16% of non-members taking the “wait and see” approach, this suggested that the fees or premiums were too high to be affordable. Fiscal space for health from public sources needed to be expanded to ensure full coverage by CBHI of indigents (poor and very poor people) and to ensure the financial viability of the scheme [ 18 ].

After CBHI pilots were launched in 2011, several studies explored the willingness of people to join CBHI and the satisfaction of those who joined [ 13 , 19 , 20 , 21 ]. Service provision, wait times, and procedures to get reimbursement from CBHI were associated with both willingness to enroll in CBHI and the satisfaction with CBHI [ 22 , 23 ].

After 2016, a number of studies assessed the implementation of CBHI and its impact on service use, financial burden, quality and equity [ 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 ]. Abazinab et al. found that the public sector, the main provider for CBHI beneficiaries, was short of qualified personnel and laboratory services [ 24 ]. Mekonen et al. observed that CBHI provided significant financial protection from catastrophic health expenditure in northeast Ethiopia [ 29 ]. Lavers conducted a study on the political drivers of the adoption and evolution of state health insurance in Ethiopia [ 33 ]. Lavers’ study showed that while political commitment to self-reliance and long-term development helped to expand UHC and CBHI in Ethiopia, fragmentation and cross-subsidization to improve financial and administrative sustainability needed further attention.

While these studies identified gaps in and achievements of CBHI, little is known about the factors that contributed to the success of CBHI in Ethiopia and the potential barriers that may impede further achievements. This study therefore aimed to identify success in and challenges for scaling up CBHI.

We used a qualitative design, which can be used to assess the opinions of policy makers, groups and organizations involved in the policy process and also affected by the policies [ 34 , 35 ]. We used this design to explore how policy makers in Ethiopia understand the achievements and challenges of CBHI.

Sampling technique

We used a purposive sampling technique to recruit key informants who had sufficient knowledge and expertise about the scale-up of CBHI. We conducted a desk-based review to identify key policy makers and stakeholders who directly and indirectly participated in the health financing and health insurance policy process in Ethiopia. Additional interviewees were identified through snowballing. We requested the participation of interviewees via telephone. Follow-up contact was attempted for participants who did not initially respond. We conducted interviews until theoretical saturation was reached.

Data collection

We conducted semi-structured interviews with 18 key informants (KIs). The interview guide was developed based on the initial literature review and discussion among the authors. We pilot tested the interview guide with two interviewees and, based on the pilot testing, we then made minor modifications to the interview guide (the piloted interviews have been included in the analysis). The interview guide and the type of organization that the KIs are affiliated with (e.g. multilateral donor, bilateral donor, Ethiopian ministry of health, Ethiopian ministry of finance, insurance agency) are shown in Appendices 1 and 2 (any identifying features have been removed, to protect confidentiality). The participants were selected from national level government organizations (six KIs), multilateral and bilateral development partners (five KIs), non-government organizations (NGOs) (six KIs), and the private sector (one KI). One author (AKM), an experienced health policy researcher, conducted all of the interviews in English via telephone. Interviews lasted an average of 45 min. All interviewees consented to be tape recorded. The recordings were transcribed by external consultants based in India, and coded for analysis using NVivo 11 software.

Data analysis

We performed directed content analysis (also called deductive content analysis) of the interview transcripts to characterize key informants’ views on the challenges and good practices related to CBHI [ 36 ]. Two authors developed the code book based initially on the interview transcripts. They then coded six full interviews to test the code book (Appendix 3 ). Emerging themes derived from coding the transcripts were added into the code book. Three authors then coded all the interviews using the revised code book.

We organized the emerging themes into two categories: good practices for the implementation of CBHI (six themes) and major challenges for the scale-up of CBHI (six themes).

Ethical considerations

The study protocol was reviewed by Duke University’s Institutional Review Board (IRB) and was determined as not being human subjects research, and thus it received a waiver from full IRB review. Written informed consent form was obtained from each interview participant ahead of the interview session and oral consent was obtained from all participants prior to the interview. If the participant consented to being audio-recorded, interviews were audio-recorded and de-identified. To protect key informants’ confidentiality, no identifying information about them has been included in this paper. Participants were not compensated for their participation in the study.

Good practices for the implementation of CBHI

Six themes emerged related to good practices in implementing CBHI.

Political commitment to UHC and preparedness for future donor transitions

Two thirds of interviewees said that the global call for action around UHC had become the top health priority for the Ethiopian government, and had helped to catalyze the adoption of CBHI in Ethiopia. To achieve UHC for both the informal and formal sectors, said the KIs, there was increasing demand for new approaches to health financing and resource mobilization. After reviewing practices from other countries (especially African countries), the informants argued that these factors accelerated the push for health insurance to become the first policy tool choice to achieve UHC in Ethiopia.

“As part of SDGs [the Sustainable Development Goals], the government wants to meet universal health coverage by 2030 and one of the means is through health insurance. So, this is among the reasons behind designing the health financing and health insurance strategy.” KI 07

Half of the KIs said that another key factor driving the adoption of health insurance was the country’s impending transition away from development assistance for health and the growing realization among country stakeholders that alternate health financing sources would need to be identified. Half of the interviewees expressed concerns that donor financing would start decreasing over time, especially given Ethiopia’s rapid economic growth in recent years. Financing through health insurance, they argued, has provided additional resources to support the pathway towards self-sufficiency in Ethiopia and has become a key policy agenda item in the health sector.

“government health financing in the health sector remains usually donor dependent; if you look at the most recent national health accounts it is still about 35% of the health sector [that] is financed by external donors. Of course, this is down from about 50%, three to four years’ back … so then the government sees health insurance as one of the mechanisms of a way out from donor dependency of the health sector”-KI 08

Strong leadership and accountability, and wide engagement of stakeholders

Most interviewees (15 out of 18) agreed that CBHI was driven and implemented by strong political will and support, and said that commitment and leadership at the federal level helped to mobilize resources and improve accountability of different government agencies. At the top level, explained the KIs, it also provides clear directions to enhance the engagement of the private sector and of NGOs.

“I think, first of all, that the Ethiopian government is very strong in terms of political leadership which is in my humble opinion, one of the most important things if not the most important thing to have a successful health financing reform … generally, they can be quite directive in how they want to have NGOs and donors work within the country.”- KI 05

KIs described how the strong political commitment at the top levels of the Ministry of Finance, Ministry of Health and Ethiopian Health Insurance Agency (EHIA) also contributed to the development of CBHI. Additionally, other related stakeholders, including regional governments, development partners, the private sector, international and local NGOs, civil society organizations (CSOs), medical associations and academic institutions widely participated in the development of CBHI at different stages and in different ways. For example, development partners and NGOs provided technical assistance, while regional governments played an important role in adapting the framework issued by the federal government and mobilizing the community.

“The federal ministry of health provided leadership support for the health insurance initiative. Donors and then the developing partners were also involved in the design and implementation process in the form of providing technical assistance and financial support for the implementation of the program. Of course, we have other local actors like the regional governments, zonal administrations, woreda administrations, health service providers. They have their own roles and responsibilities, particularly if you see the regional governments in the area of the community health insurance [that] involved the community. The role of the regional governments & woreda administrations were very high [important] like in community mobilization and developing and adapting the legal frameworks that is provided from the federal government. Yes, there are a number of non-governmental organizations that are supporting the government in implementing health insurance, mainly the international NGOs, for example WHO is providing support, UNICEF is providing support, the World Bank is providing capacity building support, Clinton Health Access Initiative is also providing technical & financial support, the Korean International Health by the Korean government they are also involved. The degree of involvement could vary but [they are] providing support for the government in addition to our project.” —KI 14

Promoting resource mobilization and community participation

About half of respondents believed that by putting health care financing and health insurance at the top of its policy agenda, this in turn helped the government to mobilize resources for the health sector. On the demand side, government subsidies can be provided through insurance. Additionally, premiums collected by CBHI from individuals also join the overall funding pool, and CBHI re-allocates the funds to those who need health care. Compared with paying out-of-pocket payments at the point of care, KIs argued that the pooling and financial risk protection provided by CBHI should improve access to and affordability of health care.

“The objective of the health insurance is to generate additional finance for the health sector because we have already identified insufficiency of financing as one of the major problems of the quality compromised in Ethiopia. So it was assumed that the health insurance will bring additional resource to the health care system which is one of the objectives.”-KI 09

Beyond financial contributions, said the KIs, communities were involved in decision-making and governance of the health system, which was a unique opportunity to promote community engagement. The fact that communities started to make health service providers accountable was an important driver for quality improvement in service provision. So far, explained the KIs, exempted health services of CBHI are provided for free, which motivated the community to use the public facilities more often instead of paying out of pocket for services in private facilities. The increased service use by CBHI beneficiaries provided additional incentive to the providers to be responsive to the community’s increasing health demands and to improve quality of health services.

“Before CBHI programs, health facilities were not functional during weekends especially on Saturday... After the launching of CBHI, some facilities made Saturday a regular working day so that people from the rural community would access health care services to insured CBHI program members. This shows that the health facilities have become responsive for the need of the community.”- KI 15

Improved access and service use and positive impact on women’s empowerment

KIs argued that increased enrolment in CBHI has contributed to changes in health seeking behaviors. Most KIs stressed that CBHI increased access to and use of both inpatient and outpatient services.

“In those places [woredas/districts] where the health insurance scheme is properly implemented with broad community awareness and participation, service utilization has increased. In general, as health-seeking behavior improved the health service utilization has improved in CBHI woredas.” -KI 02

In addition to changes in health service use, most KIs said that the scheme promoted women’s empowerment by reducing their financial burden in accessing health care. The scheme provided additional support for women to seek health care when it is was needed, and also helped to raise women’s voices and concerns in demanding better services through community mobilization in decision-making.

“Women [are] also empowered and able to use the services since they were not forced to pay during the service provision. In Ethiopia women are mostly depending on their husbands. They are raising some issues if there is a gap. It also enables them to ask the facilities for their rights, collectively and individually.”- KI 08

Financial protection helping to address equity and poverty reduction

More than half of the KIs agreed that CBHI provided financial protection through risk sharing, prepayment, and subsidies to address equity and poverty reduction in the resource-poor settings. In particular, there has been a “fee waiver” for those who could not afford health services; the government has paid on behalf of the poor population. Health service expenditures exceeding 3000 birr to 4000 birr have been covered through CBHI, which meant that out-of-pocket payments and catastrophic health expenditures of CBHI beneficiaries were reduced. One-third of respondents held the opinion that CBHI had helped the government’s efforts on poverty reduction in the community.

“While the scheme helped the government as an alternative domestic resource mobilization platform, it helps the members of the insurance scheme to access and utilize health care services without too much worrying about financial expenses … So far, the scheme managed to reduce the out of pocket spending of the members though it is marginal.”- KI 12

“[On] equity, in areas where the woredas are committed to pay for the poor, it [CBHI] really had protected the poor. In woredas where there is almost universal health coverage, it [CBHI] is really bringing equity [in] utilization of services.” -KI 03

Learning process from the pilot and from other countries

Many stakeholders (7 out of 18) believed that CBHI benefitted from the adoption of lessons learnt from the pilot program and from other country experiences. Before the introduction of CBHI, the Ethiopian government learned from CBHI schemes in other countries, including Rwanda and Ghana. CBHI pilots, which were only initiated in 13 districts, were manageable, and the assessment and feedback on the pilot helped to scale up CBHI to more woredas.

“Implementation of the pilot first of course, CBHI scheme was really good, was very manageable because we started very small, we started with 12 districts, and then added more, so it was really manageable and it was I think a wise approach to start with [a] few districts and because it worked. There was a strong commitment from those selected districts. The government, regions, and district were happy to scale it up.” -KI 04

Major challenges for scaling up CBHI

Despite the good practices and successes of CBHI identified by interview respondents, KIs also identified a number of challenges that will need the attention of relevant bodies if CBHI is to provide UHC in Ethiopia.

Limited risk pooling and financial sustainability

More than two thirds of KIs were concerned that financial sustainability would be the most challenging issue for the further development of CBHI in Ethiopia. CBHI, by its nature, is implemented at the woreda level and beneficiaries join the scheme voluntarily. The voluntary nature of enrolment leads to a fragmented financing mechanism with limited risk pooling and reduced financial sustainability.

“I think most of the challenges will be … .ensuring that everybody is enrolled, to ensure that the risk pools are actually able to be sustainable, that at some point, there is, maybe consolidation of the various woreda level schemes to ensure that they are more viable and financially strong. And I think these are some of the things that will be ironed out as times goes, there is more people enrolled in this scheme, they will see the benefit of enrolling in the scheme.”-KI 07

Both KI 03 and KI 04 pointed out that some woredas have experienced “financial bankruptcy,” given the relatively small size of the funding pool. The factors that interviewees mentioned as being associated with financial unsustainability of CBHI included low coverage rates; coverage of mostly poor populations who cannot afford the fee and premium; and coverage with high numbers of people who use health services intensively. To improve the financial sustainability of CBHI, five KIs suggested that Ethiopia should consider increasing the level of risk pooling to improve cross-subsidization, while another four KIs argued that mandatory participation in CBHI should be considered. These options were also being discussed within the government.

“We need to establish a pooling system to influence cross subsidization between woredas and also between regions”-KI 02

“From the very beginning, CBHI was actually designed to be voluntary, but now I think there is a discussion that from our own experience and from other countries experience as well, the experience shows that CBHI is voluntary and the capacity of the scheme is challenging and there is also adverse effect of selection which actually compromises the capacity of the scheme and the objective of the scheme. That is actually being discussed currently, because there is no legal framework for CBHI and now I think the government or health insurance agency is developing a draft proclamation to make it compulsory, but still there is a debate and discussion that it should not be compulsory.”-KI 16

KIs also mentioned government subsidies as another challenge for the financial sustainability of CBHI. The CBHI pilots received subsidies from the government in a variety of formats, including human resources, administrative support and premium support for poor populations. After scaling up, it is not clear who will cover the cost of subsidies and provide administrative personnel to all the regions implementing CBHI.

“The costs, the government has to subsidize since CBHI scheme has been implemented. Not only for CBHI, but also even for the SHI as well as because currently the public health centers are highly subsidized [at] about 20%. So in CBHI, the salary and all other costs actually the government decided that. When they decided to implement health insurance in Ethiopia, in the government of Ethiopia the higher-level officials or ministry of cabinet decided that the contribution of the beneficiaries will only be used for the services that they have got, so all the other costs will covered by the government.”- KI 11

Finally, KIs argued that the operational plans for the benefit package, coverage and even premium had not been considered properly. Different elements of the CBHI scheme were not mapped out and connected with each other. For example, the scheme has not mapped actuarial projections to current premium levels and future claims pay outs, which may impact the scheme’s financial sustainability. While the premium was supposed to be affordable for most of the population, several stakeholders were concerned that the benefit package was “too generous” and cannot be afforded under current coverage rates and premium levels. Additionally, the moral hazard problem occurred whereby CBHI beneficiaries intended to use more services than the uninsured. Two stakeholders also mentioned this as another factor that could endanger the sustainability of CBHI.

“CBHI was a very good model of bringing all [different levels of government and beneficiaries] together but what I found is operationally it has not [been] designed well yet. It is [at] a very initial stage managing the operation part of the scheme because how we are going to reach out to people, how the premium is going to be collected, how providers are to be paid … how the Ethiopian health insurance agency will treat between the public and private sector … I think that is something where I see a gap in EHI [Ethiopian Health Insurance] agency.”-KI 01

“We have made a promise of a very extensive and elaborate package of services, which might not be feasible in real term [s] so, therefore, a lot of empirical analysis needs to be done.” KI-10

Lack of legal framework and poor institutional accountability

Most KIs stated that the lack of a proclamation (legal framework) presents institutional and structural barriers to implementation of CBHI and it makes accountability challenging. A legal framework would clarify the institutional and structural arrangements for CBHI, which would help implementation; KIs argued that such a framework is urgently needed.

“Okay, the first one is the legal framework. We need to have legal framework, we need have the proclamation approved before we scale it up because that legal framework will correct and will address some of the challenges like the pooling, the voluntarily vs compulsory kind of issues of debate and that will address actually through that proclamation and there is also discussion to build the pooling at regional level and that needs to be addressed through the legal framework.”–KI 16

KIs argued that implementation of CBHI is hindered by the separation of regulatory bodies and implementers. The Ethiopian Health Insurance Agency (EHIA) was established at national level to lead the overall development of CBHI, with branch offices at regional level. However, the woreda administrators or woreda health offices are accountable for the establishment, operation and management of the CBHI. There is no effective coordination between EHIA and woreda, and KIs expressed their concern that this lack of coordination would be even worse after the scaling up of CBHI. Moreover, district-level management structures are costly to replicate across the country and potentially not effective. CBHI is managed at the woreda level, with three dedicated staff members, computers and other equipment installed in woreda health or administrative offices.

“Currently we have a critical challenge: when the agency (the Ethiopian health insurance agency) was established to manage and to lead health insurance throughout the country, but if you see Community-Based Health Insurance scheme, the scheme was established at woreda level and in some woredas, they are accountable for woreda administrators and in some regions, they are accountable for woreda health offices. So, there is no direct accountability line between the woreda and the branch office of the agency (the Ethiopian health insurance agency and its branches).” -KI 02

Weak health service delivery system and limited engagement with private sector

Most KIs (15 out of 18) worried that the health service delivery system is not ready to provide proper care for CBHI beneficiaries. The current management, said the KIs, is unable to hold providers accountable for providing cost-effective, quality care and services are reimbursed on a fee for service basis without checks in place to control costs or quality. Many facilities provide low quality services and providers differ in their readiness to deliver quality care due to problems in staffing, medicines, laboratory facilities, reception, and outpatient services.

“In terms of providers of services, the major area of concern is readiness of facilities, which is beyond the capacity of the providers. When we say readiness, it is infrastructure. Some of them do not have power, some of them do not have electricity, so the ability of the facilities to provide respectful care, responsive care, sometimes is limited.”-KI 03

Most respondents raised weak supply chain management as one of the root causes of poor quality of services. The supply side constraints, they argued, in the areas of pharmaceutical and medical supplies procurement, transportation and distribution need much attention. Additionally, the implementation of CBHI has raised the expectations of the population in terms of better availability of services, especially access to pharmaceuticals.

“The other [problem] is the availability of medicines. Medicines availability has highly improved in Ethiopia but still there is inequitability in Addis Ababa: you can find a lot of medicines and public facilities having majority of pre-essential drugs that are expected to be availed in the facilities based on the regulatory agencies standard guideline, but you can rarely find [these medicines] when you go to the health facilities. The availability of medicines is scarcely available.” -KI 09

Eight KIs explained that while engagement with the private sector was encouraged and implemented at the federal level, this practice was not reflected at the regional level. CBHI is often affiliated with woredas and/or regional health bureaus at the regional level, making the public sector the dominant service provider for CBHI beneficiaries. Due to a lack of policies supporting public and private sector collaboration, private providers considered CBHI as a “threat” because CBHI has promoted service use at public sector facilities. Private providers were also excluded from the decision-making process of CBHI. The limited engagement from the private sector at the regional level further reduced the competition between public and private provision.

“ … there is not enough competition in the health sector as I said before, so they [CBHI] have mentioned that the public facilities are included in the system and the scheme has not even included the private sector. So, essentially, they [providers of CBHI, i.e., the public sector] are characterized by poor services for the customers”-KI 12

Three KIs reported that health workers also complained about an increased workload after the implementation of CBHI and a lack of incentives for taking on additional responsibilities. Despite the increase in health service use due to the increase in enrolment and coverage of the health services under CBHI, health providers were still receiving the same payment without compensation for the increased workload.

“One of the major unintended effects on CBHI probably is overload for health workers... I think work overloads were not expected, particularly in good facilities. Although the health providers think that they are overloaded and hence should get incentives, the government insisted that this is the health provider’s normal duty … “KI 03

All these factors, said the KIs, led to poor quality of health services or limited availability of medicines or medical supplies. Two interviewees pointed out that if these issues are not handled properly, CBHI beneficiaries would abandon the scheme.

“If the people [CBHI beneficiaries] are paid for the services, they [beneficiaries] are serious about the premium and scheme. We have to be sure that the quality of services is available at the service delivery point.”-KI 15

“ … If you are a CBHI member and if services are not around, the insured community members started directly going to the districts administrators and say, “I am paying my money, where is the doctor? Where is the health provider? ”-KI 04

Absence of political commitment at the sub-national level

Over half of informants stated that although political support for CBHI was very high at the federal level, there were significant variations in political commitment between regions and woredas. Even though representatives from woredas were invited to the discussion on CBHI, in most cases the level of engagement was low. Additionally, collection of CBHI premiums was regarded as a “demanding” task by the woredas, and without delegated efforts from the woreda level administration, resources at community level could not be fully mobilized and posed a major bottleneck for the scaling up of CBHI.

“They [woreda representatives] are invited to discuss on sector strategies. I mean they don’t actively engage although there were many invitations so as to get all the partners to be engaged in the discussion, we have to invite them twice, maybe sometimes you have to invite them more. So, they are invited by the Ethiopian health ministry but actually honestly they are not engaged.”-KI 11

“Leadership commitments at all levels including the regional level, have been a challenge. There is a good commitment at federal level, but when you go to the woreda level, there is a difference, significant difference between woredas. Some of the woredas are able to achieve 100% [coverage], but there are woredas who only gained 20% coverage because of leadership commitment, so that they [woredas] are important.” -KI 02

Constrained implementation capacity, especially at the woreda level

Half of the KIs argued that lack of human and institutional capacity of the regional health and finance bureaus and woredas was a barrier to scaling up CBHI. The Ethiopian health insurance system needs further capacity in terms of its human resources, clear management structure and system building. Citing examples of how investments in other countries significantly contributed to health sector improvement, most respondents felt that capacity building and training were crucial to improving the implementation of CBHI in Ethiopia.

“ … The capacity challenge is not only in terms of skills but also quantity of the required staffing at the lower level. Supporting capacity building of the government at woreda level is particularly important. For example, there is only one person who is responsible for the kebele [neighborhood] working as a focal person for the scheme who is usually kebele manager who is only supported by the kebele’s community. He is in charge of all the activities in that particular kebele … ”-KI 13

Respondents mentioned that there is a lack of human resource capacity at lower levels, including limited ability at the woreda level to manage risks through clinical and financial auditing and through cash management. Providers also faced challenges in processing claims. In addition, variations in the commitment of the local management officials raised concerns about the sustainability of the schemes, as CBHI implementation depends heavily on the woreda administrative staff.

“Opening [CBHI] branch offices is not difficult, you can open branch offices, you can install the required infrastructure and so on, but if the country doesn’t have adequately trained officials who can manage, administer, and lead the process … .The health service will not be able to catch up all expectations of the community” -KI 04

To address the capacity issue, many stakeholders advocated for changes in the capacity building system such as the system of training and transferring skills from the federal to the lower levels. For example, professionals should have the chance to attend various trainings and learning opportunities to incorporate lessons and experiences of other countries in their health financing and health insurance practices.

“ … There needs to be an in-built system at all levels, especially from the federal level, to share the experiences they learnt from abroad and really ramping up its effort towards training all the way down to the regional and woreda levels. I think the big challenge is down at the woreda and kebele levels. So, the capacity building is usually very difficult to maintain and constantly sustain it. But it is important to cascade that information to the lower levels to bring comprehensive changes in the system.”- KI 06

Weak information systems to support daily operation and informed decision

Nearly half of all interviewees (7 out of 18) raised concerns about the health information system. The dependence on manual systems for the operations of CBHI led to reduced efficiency in core operations such as enrollment, claims management, and auditing. Digitalization and information technology (IT) systems will need to be adopted to manage the huge volumes of claims and to improve service provision if the scheme is to be scaled up to the national level. KIs argued that the lack of good information systems is a challenge at the central, regional and woreda levels for tracking progress and addressing problems in CBHI in a timely, transparent and reliable manner.

“ … The Government needs to work closely with the relevant stakeholders in order develop the information system so that they collect accurate and reliable data related to the premium collection, claims management and disbursements related to health insurance at all levels and analyse them for better decision-making.” -KI 05

Our qualitative study with key informants from Ethiopia identified several good practices and successes in scaling up CBHI, but also several challenges. The key informants argued that the implementation of CBHI in Ethiopia was a result of a political drive towards self-reliance and UHC, and was informed by lessons from other countries and the results of the domestic pilot scheme. Positive impacts of CBHI, including resource mobilization, improved service use and financial risk protection, have in turn encouraged enrolment into the CBHI scheme. However, the respondents also identified major barriers that need to be addressed in order to successfully scale up CBHI nationwide.

Stakeholders in our study suggested that Ethiopia had done well to adopt three “good practices” in the initial phase of its CBHI implementation. First, global efforts towards UHC and concerns about future donor exits from Ethiopia pushed the government of Ethiopia to seek alternative health financing approaches and to provide a strong political commitment to CBHI. The two “policy windows” of UHC and donor exits were fully leveraged and transformed into strong political commitment, and helped to create policy momentum and support for mobilizing resources for CBHI in Ethiopia.

Second, Ethiopia’s CBHI drew lessons from experiences of other countries and widely engaged with stakeholders for additional technical support. The lessons from the initial CBHI pilots in select districts also helped to improve the design and further development of the program.

Third, Ethiopia managed to mobilize domestic resources through CBHI, which creates a pathway to achieve UHC goals and objectives with broader scale-up efforts. The increasing community participation improved the responsiveness of the health delivery system and improved health service use. The scheme also had a positive impact on women’s health seeking behaviour and their participation in decision making. This can lead to empowerment of women and improved financial protection, which in turn can help to improve community support for scaling up the scheme. Stakeholders in our qualitative study also argued that CBHI has increased service use and reduced the financial burden for CBHI beneficiaries. Other studies, including those with quantitative designs, have had similar findings. For example, in a cross-sectional study, Atnafu and colleagues observed that CBHI beneficiaries had almost double the service use of the uninsured population—the rate of healthcare use was 50.5% in insured households versus 29.3% in uninsured households [ 25 ]. In another cross-sectional study, Mekonen et al. found that less than 5% of households with CBHI experienced catastrophic health expenditure compared with over 15% of uninsured families [ 29 ].

However, our study also found that there are many challenges that need to be addressed to improve the sustainability of CBHI. The key informants described three key obstacles. The first and most substantial challenge is the risk pooling mechanism. A fragmented fund pool is one of the most significant limitations of CBHI. The voluntary nature of CBHI is also inevitably threatened by adverse selection—sicker people are more likely to join the scheme, thus making it harder to achieve financial sustainability of the insurance fund. To address these challenges, it will be crucial to establish regional and national risk pooling mechanisms to increase cross-subsidization and to improve the capacity to share risk among various groups. Innovative solutions are needed to address adverse selection, such as encouraging family enrollment or even complementary insurance. A legal framework for CBHI should be adopted to give explicit guidance on the establishment of a pooling system to influence cross subsidization between woredas and between regions. This framework would also clearly guide what type of health structures are going to be implemented at woreda, zonal, regional, and national levels, and would clarify the roles and responsibilities of Federal and Regional Health Bureaus and local/woreda administrations with respect to health insurance schemes.

A second challenge that the KIs identified is the readiness of health facilities to be included in the CBHI scheme. Previous research has had similar findings. For example, Abazinab et al. conducted a facility-based cross-sectional study in Ethiopia’s Jimma zone [ 24 ]. They found that: “More than nine out of ten facilities did not fulfill the criteria for providing healthcare services for insurance beneficiaries and are not ready to provide general services according to the standard.” These findings echo the concerns expressed by stakeholders in our study.

KIs in our study provided insights on the factors that led to the poor performance of providers in the CBHI scheme, including the weak health system delivery system and lack of engagement with the private sector. Access to quality care is critical to expand and maintain enrollment of the population. Therefore, addressing poor quality should be the top priority for the government before scaling up the scheme to make sure all facilities have the required medicines, skilled professionals and good governance. This requirement calls for broader reform or policy changes in Ethiopia, including to ensure mobilization of the private sector and NGOs to improve their participation, especially at sub-national levels. A broader liberalization reform effort by the government is needed to enhance competition between the public and private sectors. Providing proper incentives to health providers should also be an important agenda to improve the overall responsiveness and quality of health services.

Third, the success of the CBHI scheme hinges on continued political commitment and engagement of governments at all levels. Given the weak domestic revenue mobilization capacity, the challenges created by the COVID-19 pandemic, and the socio-political conflicts in certain parts of the country, continued commitment and political will is going to be crucial to sustain the scheme. The Second Health Sector Transformation plan (HSTP II) for the period 2020–2025 reiterates Ethiopia’s commitment towards UHC. Among the key HSTP II strategic areas, the plan aims to increase financial protection through the CBHI scheme and aims to cover 80% of the informal sector in 85% of woredas by 2025, including the poor, women, and children. The HSTP II also emphasizes ‘woreda transformation’ to align national and regional priorities, and strengthen the capacity of woredas to achieve the country’s UHC goals [ 4 ]. Looking ahead, Ethiopia’s ambitious health sector agenda will need to be accompanied by strong reform, accountability, and a political movement to transform goals into actions and outcomes.

Finally, transition from a manual to an automated system is also necessary to improve the efficiency of the operation of CBHI and to inform improved decision making. The government should work closely with the relevant stakeholders in order to develop the information system to collect and analyze accurate and reliable data related to premium collection, claims management and disbursements at all levels for better decision-making.

While the scheme has yielded some good results, our study has also pointed to ways in which its performance can be improved. Recent studies of the implementation of Ethiopia’s CBHI and the satisfaction of enrollees suggest moderate satisfaction among beneficiaries with the scheme, with scheme awareness, premium payments, quality service provision, and scheme management being important determinants for improved provision [ 19 , 30 , 37 ]. A systematic review of the barriers to and enablers of CBHI in low- and middle-income countries identified family and socio-cultural factors, favorable political and policy environment, service accessibility, timing and amount of premiums, sustainable contributions and government budgets for successful enrollment and delivery [ 38 ]. These are echoed in the findings of our study, and need to be considered for further scale up and improved scheme performance and sustainability.

Strengths and weakness of the study

One strength of our study is that is has been able to identify root factors that enable or impede the further improvement of CBHI in Ethiopia. It has also highlighted good practices identified through interviews with key stakeholders that provide a strong rationale to improve and build upon the early achievements to scale up CBHI. We interviewed a wide range of informants across different sectors and reached theoretical saturation, so it is likely that we captured most of the key views about CBHI among country policymakers.

Nevertheless, as with any qualitative study of this kind, our study also had a number of limitations—we highlight two in particular. All interviews were conducted in English, which is a widely spoken foreign language in Ethiopia. Language proficiency may have restricted the interviewees expressing their nuanced opinions, which in turn could have led us to having a limited picture of their full views. However, given how widespread spoken English is in Ethiopia, we believe language proficiency is unlikely to have had a discernible impact on our key findings and conclusions. Second, time, funding, and capacity constraints meant that we did not include subnational policy makers, implementers, service providers or CBHI beneficiaries as key informants. Therefore, our findings only captured the opinions of the national stakeholders who we interviewed; our study did not capture the views of subnational stakeholders. Further research, including interviewing a more diverse group of stakeholders is needed to fully explore issues around CBHI.

Conclusions

The financial sustainability of CBHI will depend on efforts by the government to scale up domestic revenues and gradually increase the level of risk pooling. Improving health service quality and the availability of medicines should be the priority to reach a wider and sustained population coverage. Engaging different stakeholders, including healthcare providers, lower level policy makers, and the private sector, would mobilize more resources for the development of CBHI. Training for operational staff and a strong information system would improve the implementation of CBHI and provide evidence to inform decision.

Availability of data and materials

To follow the IRB protocol for this study, neither interview records or transcripts will be available. However, we are happy to share an anonymized, de-identified summary of the interview transcripts. Please contact Dr. Gavin Yamey for details.

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Acknowledgements

We thank all the key informants that participated in the interviews and provided valuable insights.

Patient and public involvement statement

The development of the research question and the design of this study were not related to patients’ priorities, experience, or preferences. Therefore, there is no patient or public involvement in the design, recruitment or conduct of this study. The results of this study will be disseminated to study participants as an academic paper and a policy blog.

This study was funded by a grant from Joanne Kagle to the Center for Policy Impact in Global Health to support the mid-career fellows’ program. The funder has not been involved in study design, conducting interviews, data analysis or manuscript preparation.

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Addis Kassahun Mulat and Wenhui Mao contributed equally to this work.

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Addis Kassahun Mulat & Rahel Belete Balkew

The Center for Policy Impact in Global Health, Duke Global Health Institute, Duke University, 310 Trent Dr, Durham, NC, 27705, USA

Addis Kassahun Mulat, Wenhui Mao, Ipchita Bharali & Gavin Yamey

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Contributions

GY and AKM conceptualized this study and AKM conducted all of the interviews in English by telephone with assistance from RBB for transcribing. AKM and WM developed the code book and AKM, WM, IB coded all the interviews. All authors contributed to, reviewed and agreed to the submission of this manuscript.

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Correspondence to Gavin Yamey .

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The study protocol for involving humans was in accordance with national and international guidelines and the Declaration of Helsinki. The study protocol was reviewed by Duke University’s Institutional Review Board (IRB) and was determined as not being human subjects research, thus it received a waiver from full IRB review. Written informed consent form was obtained from each interview participant ahead of the interview and oral consent was obtained from all participants prior to the interview. If the participant consented to being audio-recorded, interviews were audio-recorded and de-identified. To protect key informants’ confidentiality, we have included no identifying information about them in this paper. Participants were not compensated for their participation in the study.

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Mulat, A.K., Mao, W., Bharali, I. et al. Scaling up community-based health insurance in Ethiopia: a qualitative study of the benefits and challenges. BMC Health Serv Res 22 , 473 (2022). https://doi.org/10.1186/s12913-022-07889-4

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Received : 29 July 2021

Accepted : 28 March 2022

Published : 10 April 2022

DOI : https://doi.org/10.1186/s12913-022-07889-4

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