Why do rural residents in China withdraw from the health insurance system? -A qualitative study based on Y County in S Province, China

BACKGROUND

Since the 2009 healthcare reform, the Chinese government has been committed to establishing a universal healthcare system. This study aims to investigate the complex reasons behind rural residents' decision to forgo participation in the medical insurance system by examining causal relationships and interactions.

METHODS

This study employs content analysis, conducting in-depth interviews with 42 stakeholders, including government administration departments, tax departments, medical insurance departments, village committees, and residents who have withdrawn from the health insurance system.

RESULTS

The study finds that the primary reasons rural residents withdraw from the medical insurance system are fourfold: heavy economic burdens, unfair design of the medical insurance system, failure of conventional mobilization strategies, and the internet's impact on residents' cognitive biases.

CONCLUSION

The decision of rural residents in China to withdraw from the medical insurance system is influenced not only by economic factors but also by the system's design and various aspects of rural governance. Moving forward, the Chinese government should optimize the medical insurance system's design, implement more flexible mobilization and persuasion strategies, and prioritize the identification and regulation of misleading information.

Investigating membership attrition dynamics in community-based health insurance: a survival analysis of socioeconomic and program-specific determinants in the Amhara Region, Northwest Ethiopia

BACKGROUND

Despite substantial growth and increased enrollment in Ethiopia's CBHI program, achieving universal coverage and retaining members remain challenging. This study, however, focuses on the persistent issue of dropout rates, which threaten the program's sustainability, while previous research has often focused on enrollment.

METHOD

The dependent variable is"time to membership attrition,"defined as an event "Dropout,"with independent variables including socioeconomic and program factors. Using Cochran's formula, data were collected from 772 (208 failure) respondents across five administrative zones. Analysis was performed using Kaplan-Meier estimation, Cox Regression, and the Weibull AFT Model.

RESULT

Dropout rates peaked at an average membership duration of 4.09 years, with increasing hazard rates (Weibull shape parameter = 2.077, p < 0.001). The Kaplan-Meier analysis indicates safety net beneficiaries had a lower dropout rate (67.8%) than non-beneficiaries (76.6%) and longer survival (Chi-square = 4.083, p = 0.043). Respondents with 4-6 hectares had the shortest survival (5.88 years) and a higher dropout risk (B = 0.417, p = 0.042), while non-landowners had a higher attrition risk (HR = 1.266, p = 0.814), Farm owners had a lower dropout rate (70.7%) (Chi-square = 1.569, p = 0.021). Lower-middle-income members had a higher attrition risk (HR = 1.999, p = 0.042) with a mean survival of 6.28 years, compared to 6.47 years for upper-middle-income. Perceived healthcare quality influenced dropout risk, increasing it by 5.9% for fair quality than poor (HR = 3.368, p < 0.000), and significantly for good quality as well (HR = 2.284, p < 0.000). Moderate financial protection (not catastrophic spending) increased dropout risk by 7.3% compared to high protection (HR = 1.125, p = 0.040).

CONCLUSION

Dropout rates peak in the early years of membership and increase over time. Enrolling in safety nets and having smaller land sizes enhanced retention rates, while extensive landholdings and being classified as Lower-Middle Income led to higher dropout rates; however, ownership of modern amenities had minimal impact on retention. Perceived healthcare quality and financial protection significantly influence CBHI retention, while program service quality has little effect, underscoring the need for policies that prioritize improving service quality, accessibility, and affordability.

Households willingness to join and pay for community-based health insurance: implications for designing community-based health insurance based on economic Status in Ethiopia

BACKGROUND

Despite the encouraging results achieved by community-based health insurance in Ethiopia, the program faces significant challenges. Among these challenges is the current practice where premium contributions to Community Based Health Insurance are either a flat rate or based solely on family size, rather than considering households' socio-economic status The overall aim of this study was to assess households' willingness to join and pay for Community Based Health Insurance in reference to socio-economic status to design sliding scale-based Community Based Health Insurance contributions in Ethiopia.

METHODS

A community based cross-sectional study was conducted in districts from two different contexts: urban areas and agrarian areas in two major regions in Ethiopia, namely Oromia, and Amhara. A double-bounded dichotomous contingent valuation method was used to determine households' willingness to pay. Descriptive statistics were used to summarize the data. A chi-square test was used to assess background factors associated with willingness to join and pay for Community Based Health Insurance, and tobit regression analyses were conducted to identify factors that determine the amount of willingness to pay for Community Based Health Insurance. The statistical significance of all results was interpreted using an adjusted two-sided Type I error rate of 0.05.

RESULT

A total of 786 households participated in this study. Overall, 532 (67.7%) study households have ever participated in the Community Based Health Insurance scheme. The reason for never participating was unaffordability of payment (30.3%), and they stated that the service was unsatisfactory (21.7%). Generally, 647 (82.3%) of the households were willing to join Community Based Health Insurance or renew their scheme membership in the future, with higher willingness among rural and urban residents and households with food insecurity (p < 0.05. The average amount households were willing to pay was 538.2 Ethiopian Birr with mode (570.0 Ethiopian Birr). In contrast with the existing premium contribution policy, the vast majority of households preferred premium contributions that considered households' economic status (81.2%). Increased household size, better household food security, and being rural residents, increased satisfaction with the scheme; and rural households' economic status significantly predicted the value of money households are willing to contribute to Community Based Health Insurance (p < 0.05).

CONCLUSION

This study revealed a strong willingness among community members to participate in or renew their membership in the Community Based Health Insurance scheme, with a clear preference for a socio-economic-based sliding scale approach over current flat rate or family size-dependent premium systems. This preference highlights the potential for transforming towards more equitable citizen contributions. Policymakers should therefore consider household economic status, alongside factors like household food security and family size, in determining Community Based Health Insurance membership fees. Furthermore, enhancing the quality of healthcare services is essential to boosting Community Based Health Insurance member satisfaction and ensuring the program's long-term sustainability. This comprehensive approach not only improves health outcomes but also strengthens community trust and support for the Community Based Health Insurance initiative.

Predictors of community-based health insurance enrollment among reproductive-age women in Ethiopia based on the EDHS 2019 dataset: a study using SHAP analysis technique, 2024

Background

Out-of-pocket payments for health services can lead to health catastrophes and decreased service utilization. To address this issue, community-based health insurance has emerged as a strategy to provide financial protection against the costs of poor health. Despite the efforts made by the government of Ethiopia, enrollment rates have not reached the potential beneficiaries. Therefore, this study aimed to predict and identify the factors influencing community-based health insurance enrollment among reproductive-age women using SHapley Additive exPlanations (SHAP) analysis techniques.

Method

The study was conducted using the recent Demographic Health Survey 2019 dataset. Eight machine learning algorithm classifiers were applied to a total weighted sample of 9,013 reproductive-age women and evaluated using performance metrics to predict community-based health insurance enrollment with Python 3.12.2 software, utilizing the Anaconda extension. Additionally, SHAP analysis was used to identify the key predictors of community-based health insurance enrollment and the disproportionate impact of certain variables on others.

Result

The random forest was the most effective predictive model, achieving an accuracy of 91.64% and an area under the curve of 0.885. The SHAP analysis, based on this superior random forest model, indicated that residence, wealth, the age of the household head, the husband's education level, media exposure, family size, and the number of children under five were the most influential factors affecting enrollment in community-based health insurance.

Conclusion

This study highlights the significance of machine learning in predicting community-based health insurance enrollment and identifying the factors that hinder it. Residence, wealth status, and the age of the household head were identified as the primary predictors. The findings of this research indicate that sociodemographic, sociocultural, and economic factors should be considered when developing and implementing health policies aimed at increasing enrollment among reproductive-age women in Ethiopia, particularly in rural areas, as these factors significantly impact low enrollment levels.

Beneficiaries' satisfaction with health insurance and associated factors in Sub-Saharan Africa: a systematic review and meta-analysis

OBJECTIVE

Beneficiaries' satisfaction with health insurance schemes is crucial for the success of these programmes, influencing their effective implementation and reducing dropout rates. This systematic review and meta-analysis aimed to assess the proportion of beneficiaries satisfied with health insurance and identify factors associated with their satisfaction in Sub-Saharan Africa (SSA).

DESIGN

A systematic review and meta-analysis were conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines.

DATA SOURCES

PubMed/MEDLINE, African Journals Online, Cumulative Index to Nursing & Allied Health Literature and Google Scholar were searched up to 23 May 2024.

ELIGIBILITY CRITERIA

Observational and quantitative studies conducted in SSA that reported the proportion of health insurance beneficiaries satisfied with the scheme and/or determined factors associated with satisfaction were included.

DATA EXTRACTION AND SYNTHESIS

Data were extracted using Microsoft Excel and analysed with STATA V.17 software. The quality of studies was assessed using Joanna Briggs Institute checklists. A random-effects model was employed to estimate pooled outcomes. Publication bias was evaluated with a funnel plot and Egger's regression test, while heterogeneity was assessed using the I² statistic.

RESULT

The study included 29 primary studies with a total of 11,488 participants. Among the included studies, 17 (58.62%) were found to have a low risk of bias, while the remaining studies exhibited a moderate risk of bias. The findings suggested publication bias among the included studies. To address this, a trim-and-fill analysis imputed 10 hypothetical missing studies, resulting in a more symmetrical funnel plot. The pooled finding showed that 61.84% of beneficiaries were satisfied with their health insurance (95% CI: 55.14 to 68.55, (I2=98.6%, p<0.001)). Having a good knowledge of health insurance (OR=2.75, 95% CI: 1.42 to 5.34, (I2=95.3%, p<0.001)), availability of prescribed drugs (OR=5.69, 95% CI: 3.04 to 10.62, (I2=88.6%, p<0.001)) and availability of lab services (OR=4.20, 95% CI: 2.18 to 8.11, (I2=88.4%, p<0.001)) were significantly associated to higher satisfaction with health insurance.

CONCLUSION

The results of this review show that a significant number of beneficiaries are satisfied with their health insurance. The findings highlight that beneficiaries' satisfaction is significantly influenced by their knowledge of health insurance, as well as the availability of prescribed drugs and essential laboratory services. It is recommended that health insurance programmes in SSA focus on these factors to improve overall satisfaction among beneficiaries.

PROSPERO REGISTRATION NUMBER

CRD42024496847.

A Comparative Analysis of Factors Influencing the Sustainability of the Abia State Health Insurance Agency: Insights From Rural-Urban Abia State

The goal of the Abia State Health Insurance Agency (ABSHIA) has been to increase coverage since its implementation. However, the sustainability of the scheme is crucial to continue providing affordable healthcare in the State. This study aimed to identify and compare factors that influence the sustainability of ABSHIA in rural-urban areas of Abia State. The study used a mixed-method cross-sectional design that involved collecting data through a questionnaire on enrollment, satisfaction, and willingness to renew membership. Key informant interviews and focus group discussions were also conducted to obtain qualitative data from healthcare providers and ward development committees. The collected data were analyzed using appropriate statistical tests. The results showed a higher enrollment in rural areas compared to urban areas, with no significant difference in satisfaction and willingness to renew membership between the 2 locations. The study also identified factors that positively influenced willingness to renew membership, but it was found that traveling a distance of 15 min or more decreased willingness to renew membership in urban Abia. Furthermore, poor health status was found to have a low influence on willingness to renew membership in rural Abia. Among other barriers to renewal, poor quality of care and, nonpayment of health workers' capitation was identified as significant factors. It is crucial to prioritize the sustainability of ABSHIA to achieve the sustainable development goal of health for all in the State.

Economic inequalities in health insurance subscription renewal: Evidence from Ghana's National Health Insurance Scheme

Ghana's national health insurance scheme (NHIS) is considered a major step towards achieving Universal Health Coverage (UHC) in the country. However, over the years the scheme has faced challenges, including subscription non-renewal, that threaten its sustenance. In this study, we estimate and analyse the nature of economic inequalities in NHIS subscription renewal and determine factors that contribute to the observed inequality. Data from the seventh round of the Ghana Living Standard Survey (GLSS) was used for the study. A sample of 40,170 ever insured individuals was included in the analysis comprising 18,066 males and 22,104 females. We computed concentration indices (CIs) and used linear regression techniques to decompose the CIs. The results show that NHIS renewal is pro-rich [CI = 0.126; P < 0.01] and favored males [CI = 0.110; P < 0.01] and urban dwellers [CI = 0.066; p < 0.01]. Major contributors to the observed inequality in subscription renewal include premium and processing fees payment, access to information, and economic wellbeing. The observed rural-urban and male-female differences in subscription renewal were explained by differences in premium and processing fee payments, education outcomes, employment status and access to information. The findings suggest that interventions that reduce cost barriers to NHIS subscription for the poor, improve physical access to healthcare and improve sensitization efforts should be encouraged.

The impact of community-based health insurance on universal health coverage in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Ideally health insurance aims to provide financial security, promote social inclusion, and ensure equitable access to quality healthcare services for all households. Community-based health insurance has been operating in Ethiopia since 2011. However, its nationwide impact on universal health coverage has not yet been evaluated despite several studies being conducted.

OBJECTIVE

We evaluated the impact of Ethiopia's community-based health insurance (2012-2021) on universal health coverage.

METHODS

On 27 August 2022, searches were conducted in Scopus, Hinari, PubMed, Google Scholar, and Semantic Scholar. Twenty-three studies were included. We used the Joana Briggs Institute checklists to assess the risk of bias. We included cross-sectional and mixed studies with low and medium risk. The data were processed in Microsoft Excel and analyzed using RevMan-5. The impact was measured first on insured households and then on insured versus uninsured households. We used a random model to measure the effect estimates (odds ratios) with a p value < 0.05 and a 95% CI.

RESULTS

The universal health coverage provided by the scheme was 45.6% (OR = 1.92, 95% CI: 1.44-2.58). Being a member of the scheme increased universal health coverage by 24.8%. The healthcare service utilization of the beneficiaries was 64.5% (OR = 1.95, 95% CI: 1.29-2.93). The scheme reduced catastrophic health expenditure by 79.4% (OR = 4.99, 95% CI: 1.27-19.67). It yielded a 92% (OR = 11.58, 95% CI: 8.12-16.51) perception of health service quality. The health-related quality of life provided by it was 63% (OR = 1.71, 95% CI: 1.50-1.94). Its population coverage was 40.1% (OR = 0.64, 95% CI: 0.41-1.02).

CONCLUSION

Although the scheme had positive impacts on health service issues by reducing catastrophic costs, the low universal health coverage on a limited population indicates that Ethiopia should move to a broader national scheme that covers the entire population.

Dropout rate and associated factors of community-based health insurance beneficiaries in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Ethiopia aims to achieve universal healthcare using health insurance. To do so, it has been implementing community-based health insurance since 2011. However, the retention of members by the scheme has not yet been evaluated nationally. The systematic review and meta-analysis aimed to evaluate the dropout rate and associated factors among the scheme's beneficiaries in Ethiopia.

METHODS

On December 19, 2022, searches were conducted in Scopus, Hinari, PubMed, Semantic Scholar, and Google Scholar. Searches were also conducted on the general web and electronic repositories, including the Ethiopian Health Insurance Service, the International Institute for Primary Health Care-Ethiopia, and various higher education institutions. The Joanna Briggs Institute's tools and the "preferred reporting items for systematic reviews and meta-analyses 2020 statement" were used to evaluate bias and frame the review, respectively. Data were analyzed using Stata 17 and RevMan 5. To assess heterogeneity, we conducted subgroup analysis and used a random model to calculate odds ratios with a p value less than 0.05 and a 95% CI.

RESULTS

In total, 14 articles were included in the qualitative synthesis, of which 12 were selected for the quantitative analysis. The pooled estimate revealed that the dropout rate of beneficiaries from the scheme was 34.0% (95% CI: 23-44%), provided that the renewal rate was 66.0%, and was found to be influenced by socio-demographic, health status, length of enrolment, knowledge, attitude, the scheme, and health service-related variables. The southern and Oromia regions reported the lowest and highest dropout rates, with 27.0% (95% CI: 24-29%) and 48.0% (95% CI: 18-78%), respectively. The dropout rates increased from 12.3% in 2012-2015 to 34.4% in 2020-2021.

CONCLUSION

More than one-third of the scheme's beneficiaries were found to have dropped out, and this has been found to increase over time, dictating that a community-based strategy and intervention, from the supply, insurer, and demand sides, seem indispensable in minimizing this huge dropout rate.

Whether or not to enroll, and stay enrolled? A Tanzanian cross-sectional study on voluntary health insurance

Lower-middle income countries (LMICs) have invested significant effort into expanding insurance coverage as a means of improving access to health care. However, it has proven challenging to fulfill these ambitions. This study investigates to what extent variables associated with the enrollment decision (stay never-insured or enroll) differ from variables associated with the dropout decision (stay insured or drop out). A cross-sectional survey that included 722 households from rural districts in Tanzania was conducted and multinomial logistic regressions were performed to determine the associations between independent variables and membership status (never-insured, dropouts, or currently insured). Both the decision to enrollment and the decision to drop out were significantly associated with the presence of chronic disease and perceptions about the quality of services provided, insurance scheme management, and traditional healers. The effect of other variables, such as age, gender and educational level of the household head, household income, and perceptions about premium affordability and benefit-premium ratios, varied across the two groups. To improve voluntary health insurance coverage, policymakers must simultaneously increase the enrollment rate among the never-insured and reduce the dropout rate among the insured. Our conclusions suggest that policies to increase insurance scheme enrollment rates should differ for the two uninsured groups.

Multidimensional determinants of willingness to pay for community-based health insurance in Ethiopia and its implication towards universal health coverage: A narrative synthesis

Pooling resources to pay for healthcare services and attain universal health coverage is a viable global agenda, especially for underdeveloped health systems. Ethiopia has implemented community-based health insurance (CBHI) since 2011 to improve healthcare funding. However, comprehensive evidence on the demand and determinants of health insurance in Ethiopia is lacking. Therefore, this review aimed at identifying determinants of willingness to pay (WTP) for CBHI in Ethiopia. A narrative review was conducted using search terms from PubMed, Science Direct, Scopus, African Journal Online, and Google Scholar databases. Screening process considered publication year, settings, English language, and study participants. Newcastle Ottawa tool assessed the quality of included studies. A thematic framework was applied. The review protocol was registered in PROSPERO with an ID number CRD42022296840. The review included 10 studies. The synthesis identified 25 determinants of WTP for CBHI in Ethiopia. Socio-demographic and economic, scheme-related, and health-related determinants of WTP for the CBHI were identified. Determinants of household WTP for CBHI in Ethiopia were multi-dimensional. Socio-demographic, socio-economic, scheme-related, and health-related factors are among the common determinants documented. CBHI is thus an alternative and potential source of financing for the healthcare system, primarily for people with low socioeconomic status and a fragile health system. The health system, socioeconomic leaders, and political figures play a significant role in influencing communities towards WTP for CBHI while increasing government spending on health toward UHC.

Effectiveness and impact of community-based health insurance on health service utilization in northwest Ethiopia: a quasi-experimental evaluation

Background

Addressing the health challenges of lower socioeconomic groups in Ethiopia is still a huge problem. In that regard, the government piloted the community-based health insurance (CBHI) in 2011 in a few districts and subsequently scaled up. However, the effectiveness of the program on the utilization of health services and its impact was not well explored. Thus, we aimed to evaluate the effectiveness of CBHI toward health services' utilization and its impact in northwest Ethiopia.

Methods

A quasi-experimental matched comparison group evaluation design with sequential explanatory mixed methods was employed. To evaluate the CBHI program, the effectiveness and impact dimensions from the Organization for Economic Cooperation and Development framework were used. A multistage sampling technique was used to select a total of 332 households enrolled in the CBHI program; 341 comparison households who did not enroll in the program were also randomly selected. A structured interviewer-administrated questionnaire was used to evaluate the effectiveness and impact of CBHI on health service utilization. The Propensity score matching model was employed for the estimation of the effect of the CBHI program on health service utilization. Challenges for program achievement toward health service utilization were explained through qualitative data and these were then analyzed thematically.

Results

The evaluation showed 1.3 visits per capita per year of health service utilization among CBHI members. Households enrolled in CBHI increased health service utilization by 6.9 percentage points (ATT = 0.069; 95% CI: 0.034, 0.114). There was an improvement in health service utilization after the introduction of CBHI, however, there are challenges: (i) shortage of human resources, (ii) out-of-stock of drugs and medical supplies, and (iii) long waiting times for service and reimbursement claims. These issues limit the success of the program toward health service utilization.

Conclusion

The CBHI program contributed to health service utilization improvement among CBHI members. However, the utilization rate of health services among CBHI members is still less than the target stated for the program and also the WHO recommendation. Therefore, the findings of this evaluation can be used by program implementers, policy makers, and other stakeholders to overcome the identified challenges and to increase the success of the program.

Household satisfaction and associated factors with community-based health insurance scheme in Ethiopia: systematic review and meta-analysis

BACKGROUND

Community-based health insurance (CBHI) schemes are crucial for households to avoid financial hardship, improve healthcare quality, and engage in health policies. Household satisfaction is a key indicator for assessing healthcare quality and identifying service gaps. However, research on household satisfaction with CBHI in Ethiopia is limited. Therefore, this study aimed to evaluate household satisfaction and associated factors with CBHI schemes in Ethiopia.

METHODS

A comprehensive search of relevant literature was conducted using multiple databases, including PubMed, Google Scholar, Africa Journal Online, and Ethiopian Universities' institutional open-access online repositories. The search was carried out between January 25, 2023, and February 28, 2023. Twelve primary studies, including eight published and four unpublished, were identified and included in the analysis with a total sample size of 5311 participants. A protocol with the registration number CRD20531345698 is recorded on the Prospero database. Two authors, DT and MK, independently extracted the required data using a standardized form. The extracted data were then analyzed using STATA version 17 software. Heterogeneity was assessed using the Cochrane Q-test and I2 tests. Finally, a random-effect model was employed to calculate the overall household satisfaction with CBHI and to determine the associated factors.

RESULTS

The meta-analysis showed that the overall household satisfaction with CBHI in Ethiopia was 62.26% (95% CI 53.25-71.21%). The study found regional variations in household satisfaction, with 63.40% in Oromia, 64.01% in Amhara, 49.58% in Addis Ababa, and 66.76% in SNNPs. The study identified several factors associated with household satisfaction and the CBHI scheme, including the availability of drugs (OR 2.13, 95% CI 1.47-2.78), friendly services (OR 3.85, 95% CI 1.60-6.10), affordability of premium (OR 2.80, 95% CI 1.97-3.63), and knowledge/awareness of CBHI (OR 2.52, 95% CI 1.73-3.33).

CONCLUSIONS

The study provides valuable insights into household satisfaction with CBHI in Ethiopia, with a considerable proportion of enrolees being satisfied. The finding highlights regional variations in household satisfaction and underscores the need for tailored interventions and monitoring to enhance CBHI sustainability and effectiveness. The results suggest that healthcare providers and policymakers should prioritize the availability of drugs, friendly services, affordable premiums, and education to improve household satisfaction with CBHI schemes.

Making health insurance responsive to citizens: the management of members' complaints by mutual health organisations in Kinshasa, Democratic Republic of Congo

INTRODUCTION

In moving towards universal health coverage, a number of low-income and middle-income countries have adopted community-based health insurance (CBHI) as a means to reduce both the inequity in healthcare access and the burden of catastrophic health expenditures linked to user fees. However, organisations managing CBHIs face many challenges, including a poor relationship with their members. In the Democratic Republic of the Congo, CBHI schemes are managed by mutual health organisations (MHOs) and are in the process of enhancing their accountability and responsiveness to members' needs and expectations. This study assessed how MHOs have managed member complaints and their performance in grievance redressal.

METHODS

Using a sequential mixed-methods approach, we drew insights from four types of sources: review of approximately 50 relevant documents, 25 in-depth interviews (IDIs) with CBHI managers, 9 IDIs with health facility managers, 1063 surveys of MHO members and 15 focus group discussions (FGDs) comprising an additional 153 MHO members. MHO members in this study belonged to three different MHOs (Lisanga, La Borne and Mutuelle de santé des Enseignants de l'Enseignement Primaire, Secondaire et Professionnel) in the capital, Kinshasa.

RESULTS

The document review showed that there were no clear administrative processes for the implementation of the grievance redressal arrangement measures resulting in low member awareness of these measures. These results were confirmed by the IDIs. Of 1044 members surveyed, only 240 (23%) were aware of the complaint measures, and 201 (84%) of these declared they had used the measures at some point in time, 181/201 (90%) users who had used the measures declared being satisfied with the response provided. The FGDs confirmed that most members lack knowledge on the grievance redressal procedures, but those who were aware had made use of them and were often satisfied with the response provided.

CONCLUSION

MHOs should urgently improve communication with their members on the range of redressal measures put in place to address grievances. Attention should be given to properly monitor existing arrangements, and possibly adapt them with well-documented and communicated standard operating procedures.

Determinants of enrollment in community based health insurance program among households in East Wollega Zone, west Ethiopia: Unmatched case-control study

Background

Ethiopia has launched a community-based health insurance (CBHI) since 2011, which is an innovative financing mechanism to enhance domestic resource mobilization and sustainable health financing. This study assessed determinants of CBHI enrollment among HHs (households) of East Wollega, Ethiopia, 2022.

Method and materials

Community based unmatched 1:2 case-control study design was conducted between Jan 7and Feb 5/2022 among 428 HHs (144 cases and 284 controls). Cases were selected from HHs who registered for CBHI and currently using CBHI. Controls were from those who do not registered for CBHI membership. Data collected using a semi-structured, interview administered questionnaire. Multivariable logistic regression with SPSS version 25 was employed for analysis and variables were declared statistical significant association at p-value < 0.05, 95% CI.

Result

Data from 428 (144 cases and 284 controls to CBHI) were collected; a response rate of 98.8%. Statistically lower odds of CBHI enrollment was observed among HHs who have poor knowledge [AOR = 0.48 (95% CI:0.27, 0.85)], perceived not respectful care [AOR = 0.44 (95% CI :0.24, 0.81)], unavailability of laboratory services [AOR = 0.37(95% CI:0.21, 0.66)], inappropriate time of premium payment [AOR = 0.31(95% CI:0.18, 0.52)]. In addition, medium wealth status category [AOR = 0.11(95% CI: 0.03, 0.45)]. Higher odd of CBHI enrollment observed among who have formal education [AOR = 2.39(95% CI: 1.28, 4.48)].

Conclusion and recommendation

Educational level, knowledge, time of membership payment, laboratory test availability, perception of respectful care and wealth status were significant determinants of CBHI enrollment status. Hence, the responsible bodies should discuss and decide with community on the appropriate time of premium payment collection, and enhance community education on CBHI benefit package.

Satisfaction of beneficiaries with community-based health insurance and associated factors in Legambo District, North-East Ethiopia: a cross-sectional study

Background

The fundamental concept of community-based health insurance is to strengthen the healthcare financing system to access universal healthcare by reducing costly risk-coping strategies. The scheme's sustainability and the quality of services provided by it are highly dependent on the satisfaction of its beneficiaries. Despite beneficiaries' satisfaction being the key determinant for providing evidence for policy revision and decision-making, it has often been neglected. Therefore, the study investigated the community-based health insurance beneficiaries' satisfaction and associated factors in Legambo district, North-East Ethiopia.

Methods

The study was conducted in the Legambo district with a community-based cross-sectional study design from October to November 2019. The data were collected from 838 households that had been the beneficiaries of the scheme using multi-stage and systematic random sampling. Twelve trained data collectors were employed and gathered the data using a pre-tested, structured questionnaire. We ran descriptive, bivariate, and logistic regression analyses. A value of p less than 0.05 with a 95% CI was used in multivariate logistic regression to determine the association of variables with the beneficiaries' satisfaction.

Results

The overall satisfaction level of the beneficiaries of the scheme was 58.6% and was associated with the following factors: merchandize (AOR = 1.92, 95% CI = 1.02-3.63), living in rural areas (AOR = 1.52, 95% CI = 1.02-2.27), an early office opening time (AOR = 3.81, 95% CI = 2.04-7.10), a short time interval to use benefit packages (AOR = 4.85, 95% CI = 2.08-11.31), an inexpensive membership premium (AOR =10.58, 95% CI = 3.56-31.44), availability of laboratory services (AOR =2.95, 95% CI = 1.71-5.09), presence of referral services (AOR =1.93, 95% CI = 1.33-2.80), having immediate care at health facilities (AOR = 1.73, 95% CI = 1.01-2.97) and non-compulsory enrolment (AOR = 6.31, 95% CI = 1.64-24.20).

Conclusion

The beneficiaries' satisfaction with the scheme was suboptimal and found to be determined by occupation, residence, laboratory and referral services, immediate care, office opening time, time interval to use benefit packages, premium amount, and situation of enrollment, most of which are service-related variables. Thus, to improve the satisfaction level, the stakeholders that should work hard seem to be the health insurance agency (the insurer) and the health facilities (the provider or supplier).

Enrollment of reproductive age women in community-based health insurance: An evidence from 2019 Mini Ethiopian Demographic and Health Survey

Background

Universal health coverage (UHC) is aimed at ensuring that everyone has access to high-quality healthcare without the risk of financial ruin. Community-based health insurance (CBHI) is one of the essential means to achieve the sustainable development goals (SDGs) global health priority of UHC. Thus, this study assessed health insurance enrollment and associated factors among reproductive age women in Ethiopia.

Methods

We computed the health insurance enrollment of reproductive-age women using secondary data from the recent Ethiopian Mini Demographic and Health Surveys (EMDHS) 2019. The EMDHS was a community-based cross-sectional study carried out in Ethiopia from March 21 to June 28, 2019. Cluster sampling with two stages was employed for the survey. The study comprised 8885 (weighted) reproductive-age women. STATA 14 was used for data processing and analysis. Bivariate and multivariable logistic regression analyses were conducted. Adjusted odds ratio (AOR) with 95% confidence interval (CI) was reported and statistical significance was set at a value of p < 0.05.

Results

Of the 8,885 study participants, 3,835 (43.2, 95% CI; 42.1, 44.2%) of women had health insurance. Women aged 20-24 years, 25-29 years, and 30-34 years less likely to enroll in health insurance compared to their younger counterparts (15-19 years). Women living in rural areas, had greater than five family sizes, living with a female household head, and having more than five living children were negatively associated with enrollment in health insurance. Besides, health insurance enrollment among reproductive-age women is significantly affected by region and religious variation.

Conclusion

The overall CBHI enrolment among reproductive-age women in Ethiopia was low. To achieve the SDGs of reducing maternal mortality ratio and neonatal mortality, improving reproductive-age women's access to health insurance is essential. The national, regional, and local officals, policymakers, NGOs, program planners, and other supporting organizations working on improving health insurance enrollment of reproductive age women need to create awareness and support them based on these significant factors.

Teachers' Willingness to Pay for Social Health Insurance and Its Determinant Factors at Harar Region, Ethiopia, 2021

Background

Most developing nations lag behind in maintaining their populations' health. These nations are characterized by under-financing, low health cost protection mechanisms for the poor, and lack of risk pooling and cost sharing methods. To tackle this challenge, Ethiopia proposed social health insurance in 2010 even though its implementation was delayed. Hence, the purpose of this study was to assess teachers' willingness to pay for the newly proposed social health insurance and its associated factors.

Methods

A cross-sectional study was conducted and a stratified sampling technique was used to select government and private schools. After data were collected using a semi-structured self-administered questionnaire, binary and multivariate logistic regressions were done to examine determinants of willingness to pay for social health insurance.

Results

Among participants who faced illness six months prior to the study, 85.7% reported that they paid "out of their pocket". About 59.2% and 54% of the teachers had a positive attitude and good knowledge toward health insurance schemes respectively. Of the total study respondents, 89.5% were willing to pay for the suggested insurance scheme. Forty eight percent of participants agreed to pay greater than or equal to 4% of their monthly salary. Willingness to pay was more likely among those who taught in secondary schools, had a positive attitude and good knowledge.

Conclusion

Nearly three fourths of the teachers showed willingness to pay for social health insurance. Participants with good knowledge, a positive attitude and from primary schools were more likely to be willing to pay for social health insurance. Equipping all public facilities' employees with necessary knowledge of social health insurance is essential to reduce catastrophic health care costs. Future researchers need to consider qualitative studies to support these findings.

Determinants of household dropout from community-based health insurance program in northwest Ethiopia; A community-based case-control study

BACKGROUND

Community-Based Health Insurance (CBHI) is an evolving program for delivering financial protection against the cost of illness and enhancing access to quality health services for low-income informal households.

OBJECTIVE

The study aimed to identify determinants of household dropout from a CBHI program in Mecha district, North West Ethiopia, 2019.

METHODS

A community-based case-control study was conducted in the Mecha district from March 10 to June 10, 2018. The final sample was 634 (317 cases and 317 controls) determined by the two-population proportion formula, and these samples were selected using a multi-stage sampling technique. The collected data was entered into Epi-data version 3.1 and analyzed using R version 4.0 software. Descriptive statistics computed. A simple logistic analysis was run (at 95% CI and p-value < 0.05) to identify the determinants for the dropout from CBHI.

RESULTS

Poor perceived quality of care (AOR = 3.66; 95%CI: 2.35, 5.69), low knowledge of community-based health insurance (AOR = 6.02; 95%CI: 2.97, 12.26), no active community communication (AOR = 5.41; 95%CI: 3.29, 8.90) no chronic illness (AOR = 10.82; 95%CI: 5.52, 21.21) premium fee is not affordable (AOR = 2.35; 95%CI: 1.47, 3.77), and out of pocket money not reimbursed (AOR = 9.37; 95%CI: 4.44, 19.77) were the determinants for the dropout from CBHI.

CONCLUSIONS

Poor perceived quality of care, low knowledge of CBHI, no active community participation, no chronic illness, premium fees are not affordable, and out-of-pocket money not reimbursed were the determinants for the dropout from CBHI.

Dropout Analysis of a National Social Health Insurance Program at Pokhara Metropolitan City, Kaski, Nepal

BACKGROUND

Nepal's national social health insurance (SHI) program, which started in 2016, aims to achieve universal health coverage (UHC), but it faces severe challenges in achieving adequate population coverage. By 2018, enrolment and dropout rates for the scheme were 9% and 38% respectively. Despite government's efforts, retaining the members in SHI scheme remains a significant challenge. The current study therefore aimed to assess the factors associated with SHI program dropout in Pokhara, Nepal.

METHODS

A cross-sectional household survey of 355 households enrolled for at least one year in the national SHI program was conducted. Face-to-face interviews with household heads were conducted using a structured questionnaire. Data was entered in Epi-Data and analysed using SPSS. The factors associated with SHI program dropout were identified using bivariate and multiple logistic regression analyses.

RESULTS

The findings of the study revealed a dropout prevalence of 28.2% (95% CI: 23.6%-33.2%). Households having more than five members (adjusted odds ratio [aOR]: 2.19, 95% CI: 1.22-3.94), belonging to underprivileged ethnic groups (Dalit/Janajati) (aOR: 2.36, 95% CI: 1.08-5.17), living on rented homes (aOR: 4.53, 95% CI: 1.87-10.95), absence of chronic illness in family (aOR: 1.95, 95% CI: 1.07-3.59), perceived good health status of the family (aOR: 4.21, 95% CI: 1.21-14.65), having private health facility as first contact point (aOR: 3.75, 95% CI: 1.93-7.27), poor availability of drugs (aOR: 4.75, 95% CI: 1.19-18.95) and perceived unfriendly behaviour of service providers (aOR: 3.09, 95% CI: 1.01-9.49) were statistically significant factors associated with SHI dropout.

CONCLUSION

In Pokhara, more than one-fourth of households have dropped out of the SHI scheme, which is a significant number. Dropping out of SHI is most commonly associated with a lack of drugs, followed by rental housing, family members' reported good health status and unfriendly service provider behaviour. Efforts to reduce SHI dropout must focus on addressing drugs availability issues and improving providers' behaviour towards scheme holders. Increasing insurance awareness, including provisions to change first contact points, may help to reduce dropouts among rented households, which make up a sizable proportion of the Pokhara metropolitan area.

"Magnitude of community-based health insurance utilization and associated factors in Bassona Worena District, North Shoa Zone, Ethiopia: a community-based cross-sectional study"

INTRODUCTION

The health insurance system has been proven to offer effective and efficient health care for the community, particularly community-based health insurance is expected to ensure health care access for people with low economic status and vulnerable groups. Despite the significance of evidence-based systems and implementation, there is a limited report about the magnitude of CBHI utilization. Therefore, this study was done to assess factors associated with community-based health insurance utilization in Basona Worena District, North Shewa Zone, Ethiopia.

METHOD

A community-based cross-sectional study was employed. We have included 530 households from 6 randomly selected kebeles. The data was entered using Epi-Data V 3.1 and exported to SPSS version 20.0 for statistical analysis. Bi-variable and multivariable logistic regression analyses were computed to determine factors associated with community-based health insurance utilization.

RESULT

The study finding shows that 58.6% of the respondents were members of community-based health insurance. Respondents who had primary and secondary education levels were 2 times more likely to be members than those who had no formal education. As compared to those who had awareness, respondents who had no awareness about CBHI were 0.27 times less likely to be insured. Respondents who did not experience illness were 0.27 times less likely to be members than respondents who experienced illness.

CONCLUSION

Educational status, awareness about CBHI, perception of CBHI scheme and illness experience of family influence CBHI utilization. There is a need to strengthen awareness creation to improve the CBHI utilization.

Factors Associated with Willingness to Pay for Cost-Sharing under Universal Health Coverage Scheme in Yogyakarta, Indonesia: A Cross-Sectional Survey

BACKGROUND

National Health Insurance (NHI) in Indonesia requires an appropriate cost-sharing policy, particularly for diseases that require the largest financing. This study examined factors that influence willingness to pay (WTP) for cost-sharing under the universal health coverage scheme among patients with catastrophic illnesses in Yogyakarta, Indonesia.

METHODS

This was a cross-sectional study using structured questionnaires through direct interviews. The factors related to the WTP for cost-sharing under the NHI scheme in Indonesia were identified by a bivariable logistic regression analysis.

RESULTS

Two out of every five (41.2%) participants had willingness to pay for cost-sharing. Sex [AOR = 0.69 (0.51, 0.92)], education [AOR = 1.54 (0.67, 3.55)], family size [AOR = 1.71 (1.07, 2.73)], occupation [AOR = 1.35 (0.88, 2.07)], individual income [AOR = 1.50 (0.87, 2.61)], household income [AOR = 1.47 (0.90, 2.39)], place of treatment [AOR = 2.54 (1.44, 4.45)], a health insurance plan [AOR = 1.22 (0.87, 1.71)], and whether someone receives an inpatient or outpatient service [AOR = 0.23 (0.10, 0.51)] were found to affect the WTP for a cost-sharing scheme with p < 0.05.

CONCLUSION

Healthcare (place of treatment, health insurance plan, and whether someone receives an inpatient or outpatient service) and individual socioeconomic (sex, educational, family size, occupational, income) factors were significantly related to the WTP for cost-sharing.

The effects of individual and community-level factors on community-based health insurance enrollment of households in Ethiopia

Introduction

Community-based health insurance (CBHI) is a type of volunteer health insurance that has been adopted all over the world in which people of the community pool funds to protect themselves from the high costs of seeking medical care and treatment for the disease. In Ethiopia, healthcare services are underutilized due to a lack of resources in the healthcare system. The study aims to identify the individual and community level factors associated with community-based health insurance enrollment of households in Ethiopia.

Methods

Data from the Ethiopian mini demographic and health survey 2019 were used to identify factors associated with community-based health insurance enrollment of households in Ethiopia. Multilevel logistic regression analysis was used on a nationally representative sample of 8,663 households nested within 305 communities, considering the data’s layered structure. We used a p-value<0.05 with a 95% confidence interval for the results.

Result

The prevalence of community-based health insurance enrollment in Ethiopia was 20.2%. The enrollment rate of households in the scheme was high in both Amhara (57.9), and Tigray (57.9%) regions and low (3.0%) in the Afar region. At the individual level; the age of household heads, number of children 5 and under, number of household members, has land for agriculture, has a mobile telephone, receiving cash of food from the safety Net Program, Owning livestock, and herds of farm animals, wealth index, and at the community level; the region had a significant association with community-based health insurance enrollment.

Conclusion

Both individual and community-level characteristics were significant predictors of community-based health insurance enrollment in households. Furthermore, the ministry of health, health bureaus, and other concerning bodies prioritize clusters with low health insurance coverage to strengthen health system financing and intervene in factors that negatively affect the CBHI enrollment of households.

Factors influencing drop-out of households from community based health insurance membership in rural districts of Gurage Zone, Southern Ethiopia: Community based case-control study

Background

Financial risk-sharing through community-based health insurance is a critical component of universal health coverage. However, its development is a great challenge, not only due to low enrollment but also due to the high dropout rate of members from the program, which threatens its sustainability. So far, the few existing studies in this area have focused on household enrollment into community-based health insurance, rather than on the number of members dropping out. This study aims to identify factors influencing households to drop out of community-based health insurance membership in rural districts of the Gurage Zone, Southern Ethiopia.

Methods

A community-based case-control study was carried out from May to July 2021. Supplemented by qualitative focus group discussions. Multi-stage sampling was employed. An interviewer-administered prearranged tool was used for collecting data. Epi-data version 3.1 and SPSS version 21 were used for data entry and analysis. The association between factor and outcome variable was determined using binary logistic regression analysis at p < 0.05 and 95% CI. Qualitative data were analyzed thematically and triangulated.

Results

From 525 (175 cases and 350 controls) rural household heads 171 cases and 342 controls responded, yielding a response rate of 97.7%. Of those, 73.1 and 69.0% were males in cases and controls, respectively. The statistically significant influencing factors associated with dropout from community-based health insurance were: highest wealth status (adjusted odds ratio [AOR] = 2.36, 95% confidence interval [CI]:1.14-4.87), unfavorable attitude toward CBHI (AOR: 1.81, 95% CI: 1.87-3.37), no illness experienced in the last 3 months (AOR: 5.21, 95% CI: 2.90-9.33). no frequent health facility visits (AOR:5.03, 95% CI:1.17-23.43), no exposure to indigenous community insurance (AOR:0.10, 95% CI: 0.03-0.37), not graduated in the model household (AOR: 3.20, 95% CI:1.75-5.83), being a member in the program for more than 3 years (AOR:0.55, 95% CI: 0.29-0.94), not trusting governing bodies (AOR:10.52, 95% CI:4.70-23.53), the ordered drug was not available in the contractual facility (AOR:14.62, 95% CI:5.37-39.83), waiting time was >3 h (AOR:4.26, 95% CI:1.70-10.66), and poor perception of service quality (AOR:12.38, 95%CI:2.46-62.24).

Conclusion

The findings of this study illustrated various factors which positively and negatively influenced households to drop out from CBHI: wealth status, attitude toward CBHI, perceived poor provider attitude toward CBHI members, illness experience in the household, the experience of frequent health facility visits, model household graduation status, trust on CBHI committee (governing bodies), availability of a prescribed drug in the contractual health facility, waiting time and perceived quality of health service from the contractual facility, exposure to any of the indigenous insurance (IDIR and/or IQUB) and length of membership in program. We strongly recommend all responsible stakeholders give strong attention to promoting the community, and for providers to project a favorable attitude toward community-based health insurance, to achieve model household graduation, and improve quality of service by addressing the basic quality-related areas like waiting time, and drug availability).

Community-Based Health Insurance Membership Renewal Rate and Associated Factors among Households in Gedeo Zone, Southern Ethiopia

Background

Community-based health insurance (CBHI) scheme is an emerging strategy to achieve universal health coverage and protect communities in developing countries from catastrophic financial expenditure at the service delivery point. However, high membership discontinuation from the CBHI scheme remained the challenge to progress toward universal financial protection in resource-constrained countries. Therefore, this study assessed the community-based health insurance membership renewal rate and associated factors in the Gedeo zone, Southern Ethiopia.

Methods

We conducted a community-based cross-sectional study among households in the Yirga Chafe district, Gedeo zone, Southern Ethiopia, from September 10 to 30, 2021. We used a multistage simple random sampling to recruit 537 respondents. We entered data into Epi-Info 7 and exported it to SPSS version 25 for analysis. We used a logistic regression model to determine factors associated with the CBHI scheme membership renewal. Variables with a P value of <0.05 and a 95% confidence level were considered to be significantly associated with the outcome variable.

Results

We found the respondents' CBHI membership renewal rate was 82.68%. Those who enrolled in the CBHI scheme >3years (AOR = 3.12; 95% CI: 1.40–6.97), having illnesses in the last three months (AOR = 2.97; 95% CI: 1.47–5.99), the CBHI premium affordability (AOR = 12.64; 95% CI: 3.25–49.38), good knowledge of the CBHI scheme (AOR = 21.11; 95% CI: 10.63–41.93), perceived quality of health service (AOR = 4.21; 95% CI: 1.52–11.68), and favorable attitude towards the CBHI scheme (AOR = 3.89, 95% CI: 1.67–9.04) were significantly associated with the CBHI program membership renewal rate.

Conclusion

In our study, we found the magnitude of CBHI members who discontinued their CBHI scheme membership was high. Besides, we found that the affordability of the CBHI premium, respondents' attitude, and knowledge of the CBHI program were predictor factors for dropout from the CBHI membership. Therefore, the government should consider the economic status of communities during setting the CBHI program contribution. Moreover, awareness creation through health education should be provided to improve participants' knowledge and perception of the CBHI program.

A mixed methods study of community-based health insurance enrollment trends and underlying challenges in two districts of northeast Ethiopia: A proxy for its sustainability

Background

The term "community-based health insurance" refers to a broad range of nonprofit, prepaid health financing models designed to meet the health financing needs of disadvantaged populations, particularly those in the rural and informal sectors. Due to their voluntary nature, such initiatives suffer from persistently low coverage in low- and middle-income countries. In Ethiopia, the schemes’ membership growth has not been well investigated so far. This study sought to examine the scheme’s enrollment trend over a five-year period, and to explore the various challenges that underpin membership growth from the perspectives of various key stakeholders.

Methods

The study employed a mixed methods case study in two purposively selected districts of northeast Ethiopia: Tehulederie and Kallu. By reviewing the databases of health insurance schemes, quantitative data were collected retrospectively from 2017 to 2021 to examine enrollment trends. Trends for each performance indicator were analyzed descriptively for the period under study. Face-to-face interviews were conducted with nine community members and 19 key informants. Study participants were purposely selected using the maximum variation technique. Interviews were audio recorded, transcribed verbatim, and translated into English. Thematic analysis was employed with both deductive and inductive coding approaches.

Results

Over the course of the study period, enrollment in the scheme at both districts exhibited non-linear trends with both positive and negative growth rates being identified. Overall, the scheme in Tehulederie has a relatively higher population coverage and better membership retention, which could be due to the strong foundation laid by a rigorous public awareness campaign and technical support during the pilot phase. The challenges contributing to the observed level of performance have been summarized under four main themes that include quality of health care, claims reimbursement for insurance holders, governance practices, and community awareness and acceptability.

Conclusions

The scheme experienced negative growth ratios in both districts, indicating that it is not functionally viable. It will fail to meet its mission unless relevant stakeholders at all levels of government demonstrate political will and commitment to its implementation, as well as advocate for the community. Interventions should target on the highlighted challenges in order to boost membership growth and ensure the scheme’s viability.

Exploring heterogeneity of national health insurance scheme enrolment among persons in the informal sector

The Ghanaian government began implementing the National Health Insurance Scheme (NHIS) in 2005, anchored on the universal health coverage principle. However, informal sector workers contribute to the low enrolment into the scheme. This paper examines the factors that influence enrolment status in Ghana's NHIS among individuals in the informal sector. The study employed the fixed-effects logit model, using the Ghana Socioeconomic Panel Survey datasets. The findings revealed that gender, age, education, marital status, household size, physical activity, income, savings and subjective social welfare determine enrolment decisions of persons in the informal sector. Drivers of NHIS enrolment for male and female household heads were secondary education and household size. Heterogeneously, age, Junior High School education, married, physical activity, subjective social welfare and savings influenced only male-headed households' enrolment status. The study shows differences in enrolment status among rural and urban residents, as age, education, marital status, household size, and physical activity influenced rural residents, while for urban inhabitants', savings determined their NHIS enrolment decisions. However, gender, obesity, income and subjective social welfare predicted enrolment decisions for rural and urban residents. Finally, two variables, gender (male) and physical activity predicted the NHIS enrolment decision among the poor, whereas subjective social welfare and savings influenced the wealthiest enrolment decisions. For Ghana to achieve the Sustainable Development Goals of universal health coverage, the study recommends enhanced public education on NHIS benefits among informal workers to promote enrolment.

Financial viability of a community-based health insurance scheme in two districts of northeast Ethiopia: a mixed methods study

BACKGROUND

Community-based health insurance initiatives in low- and middle-income countries encountered a number of sustainability challenges due to their voluntary nature, small risk pools, and low revenue. In Ethiopia, the schemes' financial viability has not been well investigated so far. This study examined the scheme's financial viability and explored underlying challenges from the perspectives of various key stakeholders.

METHODS

This study employed a mixed methods case study in two purposively selected districts of northeast Ethiopia. By reviewing financial reports of health insurance schemes, quantitative data were collected over a seven years period from 2014 to 2020 to examine trends in financial status. Trends for each financial indicator were analyzed descriptively for the period under review. Interviews were conducted face-to-face with nine community members and 19 key informants. We used the maximum variation technique to select the study participants. Interviews were audio recorded, transcribed verbatim, and translated into English. Thematic analysis was applied with both inductive and deductive coding methods.

RESULTS

Both schemes experienced excess claims costs and negative net income in almost all the study period. Even after government subsidies, the scheme's net income remained negative for some reporting periods. The challenges contributing to the observed level of financial performance have been summarized under five main themes, which include adverse selection, moral hazard behaviors, stockout of medicines, delays in claims settlement for service providers, and low insurance premiums.

CONCLUSIONS

The health insurance scheme in both districts spent more than it received for claims settlement in almost all the period under the study, and experienced heavy losses in these periods, implying that it is not financially viable for the period in question. The scheme is also unable to fulfill its purpose of protecting members against out-of-pocket expenses at the point of health care. Interventions should target on the highlighted challenges to restore financial balance and enhance the scheme's viability.

Towards universal health coverage: The level and determinants of enrollment in the Community-Based Health Insurance (CBHI) scheme in Ethiopia: A systematic review and meta-analysis

BACKGROUND

Community-based health insurance (CBHI) is a risk-pooling approach that tries to disperse health expenditures across families with varying health profiles to provide greater access to healthcare services by allowing cross-subsidies from wealthy to poor populations. It is crucial to assess the level of CBHI enrolment and its determinants in Ethiopia, where government health spending is limited to less than 5% of GDP, far below the Alma Ata Declaration's benchmark of 15%. Although various epidemiological studies on CBHI enrolment status and its determinants have been undertaken in Ethiopia, the results have been inconsistent, with significant variability. However, no nationwide study assessing the pooled estimates exists today. Furthermore, the estimated strength of association at the country level varied and was inconsistent across studies. Hence, this systematic review and meta-analysis aimed at estimating the pooled prevalence of CBHI enrolment and its determinants in Ethiopia.

METHODS

A comprehensive search of studies was done by using PubMed, EMBASE, Science Direct, HINARI, Scopus, Web of Science, and the Cochrane Library. The database search was complemented by google scholar and some repositories for grey literature. The search was carried out from February 11 to March 12, 2022. The relevant data were extracted using a Microsoft Excel 2013 spreadsheet and analyzed using STATATM Version 16. Studies reporting the level and determinants of CBHI enrolment in Ethiopia were considered. A weighted DerSimonian Laired random effect model was applied to estimate the pooled national prevalence of CBHI enrolment. The Cochrane Q test statistics and I2 tests were used to assess the heterogeneity of the included studies. A funnel plot, Begg's and Egger's tests, were used to check for the presence of publication bias.

RESULTS

Fifteen studies were eligible for this systematic review and meta-analysis with a total of 8418 study participants. The overall pooled prevalence of CBHI enrolment in Ethiopia was 45.5% (95% CI: 32.19, 58.50). Affordability of premium for the scheme[OR = 2.58, 95% CI 1.68, 3.47], knowledge of respondents on the CBHI scheme[OR = 4.35, 95% CI 2.69, 6.01], perceived quality of service[OR = 3.21, 95% CI 2.04, 4.38], trust in the scheme[OR = 2.32, 95% CI 1.57, 3.07], and the presence of a person with a chronic disease in the household [OR = 3.58, 95% CI 2.37, 4.78] were all found to influence CBHI enrolment.

CONCLUSION

Community health workers (CHWs) need to make a high effort to improve knowledge of CBHI in rural communities by providing health education. To deal with the issue of affordability, due emphasis should be placed on building local solidarity groups and strengthening local initiatives to aid poor members. Stakeholders in the health service delivery points need to focus on the dimensions of high service quality. The financial gap created by the adverse selection of households with chronically ill members should be rectified by implementing targeted subsidies with robust plans.

Spatial distribution and associated factors of community based health insurance coverage in Ethiopia: further analysis of Ethiopian demography and health survey, 2019

Background

Community-Based Health Insurance is an emerging concept for providing financial protection against the cost of illness and improving access to quality health services for low-income households excluded from formal insurance and taken as a soft option by many countries. Therefore, exploring the spatial distribution of health insurance is crucial to prioritizing and designing targeted intervention policies in the country.

Methods

A total of 8,663 households aged 15–95 years old were included in this study. The Bernoulli model was used by applying Kulldorff methods using the SaTScan software to analyze the purely spatial clusters of community based health insurance. ArcGIS version 10.3 was used to visualize the distribution of community-based health insurance coverage across the country. Mixed-effect logistic regression analysis was also used to identify predictors of community-based health insurance coverage.

Results

Community based health insurance coverage among households had spatial variations across the country by regions (Moran’s I: 0.252, p < 0.0001). Community based health insurance in Amhara (p < 0.0001) and Tigray (p < 0.0001) regions clustered spatially. Age from 15–29 and 30–39 years (Adjusted Odds Ratio 0.46(AOR = 0.46, CI: 0.36,0.60) and 0.77(AOR = 0.77, CI: 0.63,0.96), primary education level 1.57(AOR = 1.57, CI: 1.15,2.15), wealth index of middle and richer (1.71(AOR = 1.71, CI: 1.30,2.24) and 1.79(AOR = 1.79, CI: 1.34,2.41), family size > 5, 0.82(AOR = 0.82, CI: 0.69,0.96),respectively and regions Afar, Oromia, Somali, Benishangul Gumuz, SNNPR, Gambella, Harari, Addis Ababa and Dire Dawa was 0.002(AOR = 0.002, CI: 0.006,0.04), 0.11(AOR = 0.11, CI: 0.06,0.21) 0.02(AOR = 0.02, CI: 0.007,0.04), 0.04(AOR = 0.04, CI: 0.02,0.08), 0.09(AOR = 0.09, CI: 0.05,0.18),0.004(AOR = 0.004,CI:0.02,0.08),0.06(AOR = 0.06,CI:0.03,0.14), 0.07(AOR = 0.07, CI: 0.03,0.16) and 0.03(AOR = 0.03, CI: 0.02,0.07) times less likely utilize community based health insurance than the Amhara region respectively in Ethiopia.

Conclusion

Community based health insurance coverage among households in Ethiopia was found very low still. The government needs to develop consistent financial and technical support and create awareness for regions with lower health insurance coverage.

Pooled coverage of community based health insurance scheme enrolment in Ethiopia, systematic review and meta-analysis, 2016-2020

BACKGROUND

Community Based Health Insurance (CBHI) is a type of health insurance program that provides financial protection against the cost of illness and improving access to health care services for communities engaged in the informal sector. In Ethiopia, the coverage of CBHI enrolment varies across regions and decision of household enrolment is affected by different factors. There are pocket studies on CBHI scheme with different coverage in Ethiopia and there is no pooled study on CBHI enrolment coverage in Ethiopia for better understanding the scheme and decision making. The aim of this systematic review and meta-analysis was to identify the pooled coverage of CBHI enrolment in Ethiopia to understand its policy implications.

METHODS

The systematic review and meta-analysis was done by adhering the PRISMA guideline with exhaustive search in PubMed/Medline, HINARI, SCOPUS and Google scholar complemented by manual search. Two authors independently selected studies, extracted data, and assessed quality of studies. The I2 test statistic was used to test heterogeneity among studies. The overall coverage of CBHI scheme was estimated by using random-effects model.

RESULT

Among 269 identified, 17 studies were included in this meta-analysis and the overall coverage of CBHI scheme was 45% (95% CI 35%, 55%) in Ethiopia. The sub-group analysis shows higher enrolment rate 55.97 (95%CI: 41.68, 69.77) in earlier (2016-2017) studies than recent 37.33 (95%CI: 24.82, 50.77) studies (2018-2020).

CONCLUSION

The pooled coverage of CBHI enrolment is low in Ethiopia compared the national target of 80% set for 2020. It is also concentrated in only major regions of the country. The finding of the study helps national decision making for CBHI scheme service improvement. Due attention to be given to improving geographic expansion of CBHI and to the declining coverages with in the CBHI implementing regions by addressing the main bottlenecks restraining coverages.

TRIAL REGISTRATION

The protocol of this systematic review and meta-analysis was published in PROSPERO with registration number: CRD42021252762 .

Community-based health insurance, healthcare service utilization and associated factors in South Gondar Zone Northwest, Ethiopia, 2021: A comparative cross-sectional study

INTRODUCTION

Community-based health insurance schemes are becoming increasingly recognized as a potential strategy to achieve universal health coverage in developing countries. Ethiopia has implemented community-based health insurance in piloted regions of the country. The scheme aims to improve the utilization of healthcare services by removing financial barriers. There is a dearth of literature regarding the effect of the insurance scheme on the utilization of healthcare services.

METHODS

A community-based comparative cross-sectional study was conducted in the south Gondar Zone. Six hundred fifty-eight participants were selected using a systematic random sampling method. Data were entered into EPI data version 4.4.1 and exported to SPSS version 25 for analysis. Binary logistic regression was used to measure the association of factors with the outcome variable. The result of the final model was expressed in terms of Adjusted Odd Ratios (AOR) and 95% CI.

RESULT

Two hundred twenty-three (67.8%) and 111 (33.7%) of the respondents reported that their family members went to health institutions within three months among CBHI users and non-users respectively. The presence of under-five children (AOR = 2, 95% CI = 1.6-2.4), CBHI scheme membership times (AOR = 3, 95% CI = 2.6-3.4), household wealth index rich (AOR = 4, 95% CI = 2.3-6.3), household wealth index medium (AOR = 3, 95% CI = 1.8-5.8) and presence of chronic illness (AOR = 0.5, 95% CI = 0.2-0.8) was associated with health care service utilization. Households who were enrolled in CBHI were more likely to use healthcare services than households who were not enrolled.

CONCLUSION AND RECOMMENDATION

Households who were enrolled in CBHI were more likely to use healthcare services than households who were not enrolled. Therefore, health sector leaders and managers in the study area should strengthen their efforts for increasing the enrollment of the community into CBHI.

Contributions and challenges of healthcare financing towards universal health coverage in Ethiopia: a narrative evidence synthesis

Background

High burden of healthcare expenditure precludes the poor from access to quality healthcare services. In Ethiopia, a significant proportion of the population has faced financial catastrophe associated with the costs of healthcare services. The Ethiopian Government aims to achieve universal health coverage (UHC) by 2030; however, the Ethiopian health system is struggling with low healthcare funding and high out-of-pocket (OOP) expenditure despite the implementation of several reforms in health care financing (HCF). This review aims to map the contributions, successes and challenges of HCF initiatives in Ethiopia.

Methods

We searched literature in three databases: PubMed, Scopus, and Web of science. Search terms were identified in broader three themes: health care financing, UHC and Ethiopia. We synthesised the findings using the health care financing framework: revenue generation, risk pooling and strategic purchasing.

Results

A total of 52 articles were included in the final review. Generating an additional income for health facilities, promoting cost-sharing, risk-sharing/ social solidarity for the non-predicted illness, providing special assistance mechanisms for those who cannot afford to pay, and purchasing healthcare services were the successes of Ethiopia’s health financing. Ethiopia's HCF initiatives have significant contributions to healthcare infrastructures, medical supplies, diagnostic capacity, drugs, financial-risk protection, and healthcare services. However, poor access to equitable quality healthcare services was associated with low healthcare funding and high OOP payments.

Conclusion

Ethiopia's health financing initiatives have various successes and contributions to revenue generation, risk pooling, and purchasing healthcare services towards UHC. Standardisation of benefit packages, ensuring beneficiaries equal access to care and introducing an accreditation system to maintain quality of care help to manage service disparities. A unified health insurance system that providing the same benefit packages for all, is the most efficient way to attain equitable access to health care.

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

Background

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.

Methods

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.

Results

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.

Conclusion

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.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07889-4.

Willingness to join community based health insurance among households in South Wollo, Northeast Ethiopia: A community-based cross-sectional study

BACKGROUND

Poor health care financing remains a major challenge to health service utilization among the lower socioeconomic society. Consequently, countries have designed different health insurance programs to overcome financial barriers against health services utilization. Similarly, Ethiopia has been implementing community-based health insurance programs since 2011 to improve health care financing system. However, only a small number of people are enrolled which might be attributed to lack of willingness towards the program and the reasons for this remained under reported. This study was intended to examine willingness to join the community-based health insurance program and its associated factors in South Wollo, Northeast Ethiopia.

METHOD

A community-based cross-sectional study was conducted among 421 households. A multistage systematic random sampling technique was employed to recruit the study households. Data were entered into EpiData version 3.1 and was exported into SPSS version 24.0 for analysis. Bivariable and multivariable logistic regression analysis with a backward elimination method was performed to identify the determinants of willingness to join community-based health insurance. Finally, a statistically significant level was declared at a p-value of less than 0.05.

RESULTS

Two hundred and ninety-three [73.6% (95%CI:68.8%-77.9%)] households were willing to join community-based health insurance programs. Being male headed household (AOR:0.2, 95%CI: 0.07-0.58), being a member of Idir (AOR:0.46, 95%CI: 0.25-.84), absence of chronic illness in the household (AOR: 0.31, 95%CI: 0.13-0.77), and family size < 4 (AOR: 0.18, 95% CI:0.08-0.41) were barriers to join community-based health insurance program whereas rural residency (AOR:1.9, 95% CI: 1.09-3.32), perceived quality health services (AOR:2.96, 95%CI:1.4-6.24), and having positive attitude (AOR:4.1, 95%CI:2.32-7.22) and good knowledge to programs (AOR:2.62, 95%CI:1.43-4.8) were enabling factors.

CONCLUSION

Nearly three-fourths of the households were willing to join community-based health insurance programs. However, different household and health service-related factors affected their willingness. The ministry of health with the regional and woreda health offices should work towards improving the quality of health services, conduct program advocacy and community sensitization towards the program, and build trust with the community.

Continued adherence to community-based health insurance scheme in two districts of northeast Ethiopia: application of accelerated failure time shared frailty models

Background

The sustainability of a voluntary community-based health insurance scheme depends to a greater extent on its ability to retain members. In low- and middle-income countries, high rate of member dropout has been a great concern for such schemes. Although several studies have investigated the factors influencing dropout decisions, none of these looked into how long and why members adhere to the scheme. The purpose of this study was to determine the factors affecting time to drop out while accounting for the influence of cluster-level variables.

Methods

A community-based cross-sectional study was conducted among 1232 rural households who have ever been enrolled in two community-based health insurance schemes. Data were collected using an interviewer-administered questionnaire via a mobile data collection platform. The Kaplan–Meier estimates were used to compare the time to drop out among subgroups. To identify predictors of time to drop out, a multivariable analysis was done using the accelerated failure time shared frailty models. The degree of association was assessed using the acceleration factor (δ) and statistical significance was determined at 95% confidence interval.

Results

Results of the multivariable analysis revealed that marital status of the respondents (δ = 1.610; 95% CI: 1.216, 2.130), household size (δ = 1.168; 95% CI: 1.013, 1.346), presence of chronic illness (δ = 1.424; 95% CI: 1.165, 1.740), hospitalization history (δ = 1.306; 95% CI: 1.118, 1.527), higher perceived quality of care (δ = 1.322; 95% CI: 1.100, 1.587), perceived risk protection (δ = 1.218; 95% CI: 1.027, 1.444), and higher trust in the scheme (δ = 1.731; 95% CI: 1.428, 2.098) were significant predictors of time to drop out. Contrary to the literature, wealth status did not show a significant correlation with the time to drop out.

Conclusions

The fact that larger households and those with chronic illness remained longer in the scheme is suggestive of adverse selection. It is needed to reconsider the premium level in line with household size to attract small size households. Resolving problems related to the quality of health care can be a cross-cutting area of ​​intervention to retain members by building trust in the scheme and enhancing the risk protection ability of the schemes.

Client satisfaction on community based health insurance scheme and associated factors at Boru Meda Hospital, Northeast, Ethiopia: institutional based cross-sectional study

Background

Community-based health insurance systems are usually voluntary and characterized by community members pooling funds and protecting themselves against the high costs of seeking medical care and treatment for illness. Client satisfaction with health service provision during the implementation of health insurance schemes has often been neglected. This study aimed to determine client satisfaction with the community-based health insurance scheme and associated factors.

Methods

An institutional-based cross-sectional study design was applied from February 22–March 11 /2019. A total of 420 study participants were included in the study using a systematic random sampling technique. Data were collected using a pretested semi-structured interviewer-administered questionnaire with a patient exit interview. Bivariate and multivariate logistic regression analyses were used to identify factors associated with Community-based Health Insurance of client satisfaction. Statistical significance was decided at a p-value less than 0.05.

Result

A total of 420 community-based health insurance clients of health service users participated in the study with a 100% response rate. The overall client satisfaction was 80% at 95% Cl (76.1, 83.9), respondents who have perceived that partially or none availability of prescribing drugs were 0.09 times less likely satisfied as compared to full availability of prescribing drugs (AOR =0.09; 95% Cl: (0.04, 0.19)). Besides, study participants waiting time to consult service providers within 30 min were more satisfied than those who were delayed 60 min and above (AOR =3.16; 95% Cl: (1.19, 8.41)).

Conclusion

Community-based health insurance client satisfaction provided in the present study was 80% indicating low proportion. Full availability of prescribing drugs, clients renewed their community-based health insurance membership, and preference of clients to use the hospital for future health care need were positively associated with client satisfaction while the perception of waiting time before physician consultation negatively affected client’s satisfaction. Therefore, the hospital management members and service providers need to give attention to reduce waiting time preceding consultation, improve drug availability, and sustain the hospital preference by the client.

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

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.

Dropping out of voluntary community-based health insurance in rural Uganda: Evidence from a cross-sectional study in rural south-western Uganda

AIM

Community Based Health Insurance (CBHI) schemes have become central to health systems financing as avenues of achieving universal health coverage in developing countries. Yet, while emphasis in research and policy has mainly concentrated on enrolment, very little has been apportioned to high rates of dropping out after initial enrolment. The main aim of this study is to understand the factors behind CBHI dropping out through a cross-sectional quantitative research design to gain insights into curtailing the drop out of CBHI in Uganda.

METHODS

The survey for the quantitative research component took place between August 2015 and March 2016 covering 464 households with under-5 children in south-western Uganda. To understand the factors associated with dropping out of CBHI, we employ a multivariate logistic regression on a subsample of 251 households who were either currently enrolled or had enrolled at one time and later dropped out.

RESULTS

Overall, we find that 25.1 percent of the households that had ever enrolled in insurance reported dropping out. Household socioeconomic status (wealth) was one of the key factors that associated with dropping out. Larger household sizes and distance from the hospital were significantly associated with dropping out. More socially connected households were less likely to drop out revealing the influence of community social capital in keeping households insured.

CONCLUSION

The findings have implications for addressing equity and inclusion concerns in community-based health insurance programmes such as one in south-western Uganda. Even when community based informal system aim for inclusion of the poorest, they are not enough and often the poorest of the poor slip into the cracks and remain uninsured or drop out. Moreover, policy interventions toward curtailing high dropout rates should be considered to ensure financial sustainability of CBHI schemes.

Barriers to uptake of community-based health insurance in sub-Saharan Africa: a systematic review

In the past two decades, community-based Health Insurance (CBHI) is expanding in most of sub-Saharan African countries with the aim of improving equitable access to health services for the informal sector population. However, population enrolment into CBHI and membership renewals thereafter remains stubbornly low. The purpose of this systematic review is to generate an evidence to better understand barriers to uptake of CBHI in sub-Saharan African countries. We systematically searched for relevant studies from databases: PubMed, Scopus, Cumulative Index of Nursing and Allied Health Literature (CINAHL), PsychInfo, ProQest, Excerpta Medica dataBASE (EMBASE) and Africa-Wide Information. The search strategy combined detailed terms related to (i) CBHI, (ii) enrolment/renewal and (iii) sub-Saharan African countries. A narrative synthesis of findings was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The protocol for this systematic review was registered with International Prospective Register of Systematic Reviews (PROSPERO) (ref: CRD42020183959). The database search identified 4055 potential references from which 15 articles reporting on 17 studies met the eligibility criteria. The findings revealed that barriers to uptake of CBHI in sub-Saharan Africa were multidimensional in nature. Lack of awareness about the importance of health insurance, socio-economic factors, health beliefs, lack of trust towards scheme management, poor quality of health services, perceived health status and limited health benefit entitlements were reported as barriers that affect enrolments into CBHI and membership renewals. The methodological quality of studies included in this review has been found to be mostly suboptimal. The overall findings of this systematic review identified major barriers of CBHI uptake in sub-Saharan African countries which may help policymakers to make evidence-informed decisions. Findings of this review also highlighted that further research with a robust methodological quality, depth and breadth is needed to help better understand the factors that limit CBHI uptake at individual, societal and structural levels in sub-Saharan Africa.

The failure of community-based health insurance schemes in Tanzania: opening the black box of the implementation process

BACKGROUND

Globally, there is increased advocacy for community-based health insurance (CBHI) schemes. Like other low and middle-income countries (LMICs), Tanzania officially established the Community Health Fund (CHF) in 2001 for rural areas; and Tiba Kwa Kadi (TIKA) for urban population since 2009. This study investigated the implementation of TIKA scheme in urban districts of Tanzania.

METHODS

A descriptive qualitative case study was conducted in four urban districts in Tanzania in 2019. Data were collected using semi-structured interviews, focus group discussions and review of documents. A thematic approach was used to analyse the data.

RESULTS

While TIKA scheme was important in increasing access to health services for the poor and other disadvantaged groups, it faced many challenges which hindered its performance. The challenges included frequent stock-out of drugs and medical supplies, which frustrated TIKA members and hence contributed to non-renewal of membership. In addition, the scheme was affected by poor collections and management of the revenue collected from TIKA members, limited benefit packages and low awareness of the community.

CONCLUSIONS

Similar to rural-based Community Health Fund, the TIKA scheme faced structural and operational challenges which subsequently resulted into low uptake of the schemes. In order to achieve universal health coverage, the government should consider integrating or merging Community-Based Health Insurance schemes into a single national pool with decentralised arms to win national support while also maintaining local accountability.

Barriers and Facilitators of Community-Based Health Insurance Policy Renewal in Low- and Middle-Income Countries: A Systematic Review

PURPOSE

A growing number of low- and middle-income countries are implementing small-scale community-based health insurance schemes to tackle the burdens posed by direct out-of-pocket payments. Apart from a few successful experiences, such schemes suffer from the problem of persistent low membership which could be attributed to either initial low enrollment or low renewal rate. However, there is a lack of comprehensive information on the factors that influence subscribers' policy renewal decisions. Hence, we systematically synthesize information to answer the review question "what are the barriers and facilitators of community-based health insurance policy renewal in low and middle-income countries?".

METHODS

We searched PubMed, Scopus, and Hinari electronic databases in line with the PRISMA guidelines. Our search was limited to studies published from January 2005 to February 2020 in the English language. Additional studies and grey literature were searched using Google Scholar. We included quantitative, qualitative, and mixed-method studies in the review. We assessed the methodological quality of the studies using standardized appraisal tools. The findings were synthesized inductively using a thematic analysis approach.

RESULTS

Our searches retrieved 2386 records among which 27 were included in the review. The thematic synthesis identified six major themes that influence the decision to renew scheme policy: socio-demographic factors; scheme-related awareness and understanding; participation in scheme and other voluntary groupings, need and benefit factors; health-care quality; and scheme operation and policy.

CONCLUSION

Lower socioeconomic status, poor quality of health care, lack of benefit from the scheme, lack of trust in scheme management, and dissatisfaction with scheme services are important barriers for community-based health insurance policy renewal. Better education, understanding the principles of the scheme, active participation in the scheme, and long-term illness experience of member households facilitate renewal decisions. These are important areas of intervention for governments and other relevant stakeholders to retain members and maintain the sustainability of the schemes.

REGISTRATION

The review protocol was registered in PROSPERO international prospective register of systematic reviews (ID = CRD42020168971).

Who will drop out of voluntary social health insurance? Evidence from the New Cooperative Medical Scheme in China

Although public voluntary health insurance (VHI) has been adopted in many low- and middle-income countries to improve access to care for the population, a common issue with VHI is its high dropout rate. Using the New Cooperative Medical Scheme (NCMS)-a public VHI in China-as a case study, this article employs a fixed-effects negative binomial regression model combining the difference-in-difference-in-differences approach and multivariate distance matching to examine the factors associated with dropping out and the impact of dropout on outpatient care utilization among middle-aged and older people in rural China. Drawing data from the China Health and Retirement Longitudinal Study, our results showed that healthy people, vulnerable people and people who use less healthcare tended to drop out. Dropout had a significant negative impact on outpatient care utilization, especially for those with worse health statuses and those living in poorer provinces. We also found that the impact of dropout on outpatient utilization was more pronounced at secondary and tertiary hospitals than at primary care clinics. We urge policymakers to rethink the design of the NCMS by waiving premiums for the most vulnerable people.

Factors affecting enrollment status of households for community based health insurance in a resource-limited peripheral area in Southern Ethiopia. Mixed method

BACKGROUND

Despite the efforts made by the government of Ethiopia, the community-based health insurance (CBHI) enrollment rate failed to reach the potential beneficiaries. Therefore, this study aimed to assess the enrollment status of households for community-based health insurance and associated factors in peripheral areas of Southern Ethiopia.

METHODS

We conducted a community based cross-sectional study design with both quantitative and qualitative methods. Systematic random sampling was employed to select 820 households from 27, April to 12 June 2018. A pretested structured questionnaire, in-depth interview, and focus group discussion guiding tool were used to obtain information. A binary logistic regression model was used to assess the association between independent and outcome variables. A P-Value of less than 0.05 was taken as a cutoff to declare association in multivariable analysis. Qualitative data were analyzed manually using the thematic analysis method.

RESULTS

Out of 820 households, 273[33.30%; 95% CI: 29.9-36.20] were enrolled in the community based health insurance scheme. Having good knowledge [AOR = 13.97, 95%CI: 8.64, 22.60], having family size of greater than five [AOR = 1.88, 95% CI: 1.15, 3.06], presence of frequently ill individual [AOR = 3.90, 95% CI: 2.03, 7.51] and presence of chronic illness [AOR = 3.64, 95% CI: 1.67, 7.79] were positively associated with CBHI enrollment. In addition, poor quality of care, lack of managerial commitment, lack of trust and transparency, unavailability of basic logistics and supplies were also barriers for CBHI enrollment.

CONCLUSION AND RECOMMENDATION

The study found that lower community based health insurance enrollment status. A higher probability of CBHI enrollment among higher health care demanding population groups was observed. Poor perceived quality of health care, poor managerial support and lack of trust were found to be barriers for non-enrollment. Therefore, wide-range awareness creation strategies should be used to address adverse selection and poor knowledge. In addition, trust should be built among communities through transparent management. Furthermore, the quality of care being given in public health facilities should be improved to encourage the community to be enrolled in CBHI.

Willingness to Enroll for Community-Based Health Insurance and Associated Factors in Simada District, North-West, Ethiopia, 2020:A Community-Based Cross-Sectional Study

Background

Community-based health insurance is a not-for-profit type of health insurance that has been used by poor people to protect themselves against the high costs of seeking medical care and treatment for illness. This study aimed to assess communities’ willingness to enroll for community-based health insurance (CBHI) and its associated factors in Simada district, Northwest, Ethiopia.

Methods

A community-based mixed cross-sectional study design was conducted. Multistage simple random and purposive sampling techniques were used for quantitative and qualitative studies, respectively. Data were coded and entered into Epi info version 7.2.0.1 and exported to SPSS 20.0 for data analysis. Inferential statistics were done to determine an association between the outcome and independent variables. Statistically significant variables in binary logistic regression analysis with p-value <0.2 were entered for multivariable binary logistic regression analysis and P-value ≤0.05 was considered as statistically significant. Hosmer and Lemeshow’s goodness of fitness test was fitted and qualitative data were analyzed by using thematic analysis.

Results

Among 510 study participants, 454 (89%) [CI: (86.5%-91.6%)] were willing to enroll for community-based health insurance. Members of social capital [AOR: 7.6 (3.78–15.5)], distance from health facilities [AOR: 10.8 (4.9–23.5)], the experience of chronic illness in the family [AOR: 4.6 (1.88–11.4)], medium family wealth status [AOR: 3.1 (1.3–7.5)], and the number of family members [AOR: 2.25 (1.11–4.6)] were significantly associated with willingness to enroll for community-based health insurance.

Conclusion

Willingness to enroll in community-based health insurance in the study area is high. Members of social capital, the experience of chronic illness in the family, distance from a health facility, the number of family members, and medium family wealth status were factors found to be associated with willingness to enroll for the scheme. Therefore, emphasizing redesigning and planning strategies for better expanding the scheme accordingly.

Magnitude and Determinants of Dropout from Community-Based Health Insurance Among Households in Manna District, Jimma Zone, Southwest Ethiopia

Background

Community-based health insurance (CBHI) is a prepayment method of financial contributions for healthcare which aims to risk pooling, avoidance of catastrophic and impoverishing health expenditure. However, a high dropout from the scheme remains the biggest challenge to effective and sustainable progress towards universal financial protection in low- and middle-income countries. While large literature had examined initial enrollment and factors associated with it, only a few studies dealt with dropout. So the study aimed to assess the magnitude and determinants of dropout from community-based health insurance among households in Manna district, Jimma zone, Oromia Regional State, Ethiopia.

Methods

A community-based cross-sectional study design was employed to collect data from 634 household heads from March 1 to 30, 2020. A multistage sampling technique was carried out and interviewer-administered questionnaires were used to collect data. Descriptive statistics and multivariable logistic regression analyses were performed, and variables with a P-value<0.05 were considered as having a statistically significant association with the dropout from the CBHI.

Results

Magnitude of dropout from CBHI was 31.9% with 95% confidence interval (CI)=28.2–35.8% and relatively older age [adjusted odds ratio (AOR) (95% CI)=0.26 (0.10–0.78)], educational level [AOR (95% CI)=0.16 (0.06–0.41)], family size [AOR (95% CI)=0.36 (0.19–0.66)], poor perceived quality of service [AOR (95% CI)=5.7 (2.8–11.8)], trust in health facility [AOR (95% CI)=0.43 (0.3–0.61)], trust in the scheme [AOR (95% CI)=0.61 (0.45–0.84)], providers’ attitude [AOR (95% CI)=10 (4.0–25.4)], and benefit package [AOR (95% CI)=4.9 (2.4–9.9)] were statistically significant determinants associated with dropout.

Conclusion

Dropout from CBHI in this study area was high. Household heads’ age, educational level, family size, perceived quality of service, providers’ attitude, a benefits package, trust in the contracted health facility, and the scheme were the significant predictors of dropout. We strongly recommend that greater efforts should be made toward the providers’ attitude, promised benefit package, and quality of services.