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

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.

Trust in the integrity of a micro health insurance scheme and its determinants in two rural districts of Ethiopia

BACKGROUND

Mistrust in community-based health insurance schemes is a significant deterrent to enrollment and renewal decisions. Despite its significance, there is little evidence on the level of community trust in such schemes. This study examined the level of trust in the integrity of a community-based health insurance scheme and its determinants in two rural districts of northeast Ethiopia.

METHODS

A community-based cross-sectional study was carried out on 1,232 randomly selected rural households who had been registered in a community-based health insurance scheme. The data were collected through face-to-face interviews using an electronic data collection platform. Multivariable ordinal logistic regression analysis was performed using the partial proportional odds model to examine predictors of trust. The degree of association was assessed using odds ratios, and statistical significance was determined at a 95% confidence interval.

RESULTS

The mean score of the five trust dimensions was 5.86 on a scale of 0-10, ranging from 5.06 to 7.65. In the multivariable regression analysis, age (AOR = 1.58; 95% CI: 1.10, 2.29), female gender (AOR = 2.05; 95% CI: 1.29, 3.25), education (AOR = 1.36; 95% CI: 1.03, 1.80), insurance membership status (AOR = 2.68; 95% CI: 1.89, 3.80), membership duration (AOR = 1.51; 95% CI: 1.19, 1.92), value for solidarity (AOR = 1.71; 95% CI: 1.20, 2.45), perceived risk protection (AOR = 3.35; 95% CI: 2.27, 4.96), and perceived quality of care (AOR = 1.78; 95% CI: 1.34, 2.37) were positive predictors of trust in the integrity of the scheme, while wealth index (AOR = 0.33; 95% CI: 0.23, 0.47), and hospitalization history (AOR = 0.62; 95% CI: 0.48, 0.82) were negative predictors of trust.

CONCLUSIONS

Trust in the integrity of the scheme received mediocre scores, with some trust dimensions having lower ratings, indicating specific areas of focus to be considered in trust-building. Scheme administrators and health authorities need to devise strategies to improve people's understanding of the basic principles of health insurance and promote access to high-quality care while minimizing expenditures at the point of receiving care.

Determinants of community-based health insurance membership renewal decision among rural households in Kellem Wollega zone, Oromia regional state, Ethiopia: a community-based cross-sectional study

Background

Despite the fact that community-based health insurance (CBHI) is a promising program to achieve the goal of universal health coverage (UHC), it faces challenges that are not only due to low enrollment but also due to membership renewal decision that impact its sustainability. Hence, the study aimed to identify the determinants of CBHI membership renewal decision among rural households in Kellem Wollega zone, Ethiopia.

Methods

The study was conducted in Kellem Wollega, Ethiopia, among rural households from March 30-April 30, 2022, using a community-based cross-sectional study design. An interviewer-administered structured questionnaire through face-to-face interviews was used. Using a systematic random sampling method, 551 households were selected making 540 (98%) response rates. The data was entered into EPI Data 3.1 and analyzed using SPSS 25 software. Descriptive statistics, binary, and multiple logistic regressions were performed. Using multiple logistic regressions, a significant association between the CBHI membership renewal decision and independent variables was identified, declaring the statistical significance level using a 95% confidence interval (CI) at p < 0.05.

Results

The overall rate of CBHI membership renewal decision among households was estimated to be 365 (67.6%, 95% CI = 63.7-71.5%). The factors that significantly influenced the households' membership renewal decision were family size (AOR = 0.46, 95% CI = 0.25-0.86), low literacy status (AOR = 0.28 95% CI = 0.12-0.64), lower than middle-level of wealth index (AOR = 9.80, 95% CI = 2.75-34.92), premium affordability (AOR = 4.34, 95% CI = 2.08-9.04), unavailability of services (AOR = 0.26, 95% CI = 0.12-0.55), trusting in health facilities (AOR = 5.81, 95% CI = 2.82-11.94), favorable providers' attitude toward members (AOR = 8.23, 95% CI = 3.96-19.64), good quality of service (AOR = 4.47, 95% CI = 2.28-8.85) and health care seeking behavior (AOR =3.25, 95% CI = 1.32-7.98).

Conclusion

The overall CBHI membership dropout decision rate among rural households was high, which could affect health service provision and utilization. Therefore, the insurance scheme and contracted health facilities should consider and work on family size and wealth status when membership premiums are calculated, the education level of households when creating awareness about the scheme, building trust in the contracted health facilities by providing all promised benefit packages of health services with good quality, and improving the attitude of health care providers towards the scheme members.

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.

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.