Combining social protection interventions for better food security: Evidence from female-headed households in Amhara region, Ethiopia.

Ethiopia introduced its flagship poverty-targeted social protection program, the Productive safety net program (PSNP), in 2005 and Community-Based Health Insurance (CBHI) in 2011. Although both programs operate in several districts with some overlaps, evidence is scarce on how these large-scale programs jointly affect the food security of vulnerable groups. This study examines the impacts of a combination of these programs on food security outcomes among female-headed households in a chronically food-insecure and drought-prone district. Cross-sectional data were collected from 365 female-headed households selected through multi-stage sampling technique and analyzed using Inverse-probability-weighted regression adjustment (IPWRA) strategy to assess the effect of the programs on food security. The results show that while 63.6% of sample households are enrolled in CBHI and 48.8% are beneficiaries of PSNP's conditional cash transfer (CCT) component, membership in both social protection programs was 38.9%. The IPWRA analysis finds that inclusion in the CCT combined with CBHI, on average, increased dietary diversity score by 0.918 (95% CI 0.779-1.057) and food consumption score by 0.576 (95% CI 0.464-0.688). It also reduced household food insecurity access scale by 8.658 (95% CI -9.775 - -7.541). In all assessments, a combination of CBHI and CCT always produced results of a larger magnitude than each of CBHI and CCT alone. The findings provide evidence of the potentials of integrating social protection programs to increase food security outcomes among the most vulnerable and marginalized groups in a developing country. In addition, the results have also useful implications to achieve sustainable development goals related to ending hunger and achieving food security among vulnerable groups.

Farmers' willingness to pay for metal silo cereal storage technology in northeast Ethiopia.

In Ethiopia, cereal crops play a significant role in food security and income for most smallholder farmers. In the Gubalafto district, the environment is ideal for growing vital cereal crops such as sorghum, maize, and teff. However, various factors such as weevils, rodents, mold infestation, and lack of suitable storage materials were blamed for a post-harvest loss of cereal at the storage stage in the district. Hence, this research study was intended to identify factors affecting households' willingness to pay for metal silo cereal storage technology and the maximum willingness to pay for the technology. The study used both primary and secondary sources to gather the data. A total of 385 sample households were selected using a systematic random sampling technique. The semi-structural questionnaire was used to collect the primary data during a face-to-face interview, and double-bounded questions were also followed by open-ended questions. Combinations of data analysis methods such as descriptive, inferential statistics, and econometrics models were used. a binary probit regression model was used to identify factors that influenced farmers' willingness to pay for metal silo cereal storage technology. A bivariate probit regression model was also used to estimate the household's willingness to pay for metal silo cereal storage technology. The survey results showed that the majority (71.69%) of the sample households were willing to pay for metal silo cereal storage technology due to the severity of cereal post-harvest loss. Moreover, the binary probit model results revealed that household educational status, total household annual income, market accessibility, and extension service positively and significantly affected the household's willingness to pay decisions. The mean willingness to pay of households in open-ended and double-bounded methods was 4157 Ethiopian birr and 5147 Ethiopian Birr (ETB), respectively. In general, the result of the study revealed that farmers were more willing to adopt metal silo cereal storage technology due to its high-storage quality. Therefore, as a part of the recommendations, there should be great integration among farmers, metal manufacturing factories, local and regional governments to supply and offer metal silos technology for farmers at a reasonable price and time. Moreover, training should be arranged on how to use the metal silo technology to prevent post-harvesting loss during the storage time.

Impact of community-based health insurance on health services utilisation among vulnerable households in Amhara region, Ethiopia.

BACKGROUND: Ethiopia piloted community-based health insurance in 2011, and as of 2019, the programme was operating in 770 districts nationwide, covering approximately 7 million households. Enrolment in participating districts reached 50%, holding promise to achieve the goal of Universal Health Coverage in the country. Despite the government's efforts to expand community-based health insurance to all districts, evidence is lacking on how enrolment in the programme nudges health seeking behaviour among the most vulnerable rural households. This study aims to examine the effect of community-based health insurance enrolment among the most vulnerable and extremely poor households participating in Ethiopia's Productive Safety Net Programme on the utilisation of healthcare services in the Amhara region. METHODS: Data for this study came from Amhara pilot integrated safety net programme baseline survey in Ethiopia and were collected between December 2018 and February 2019 from 5,398 households. We used propensity score matching method to estimate the impacts of enrolment in community-based health insurance on outpatient, maternal, and child preventive and curative healthcare services utilisation. RESULTS: Results show that membership in community-based health insurance increases the probabilities of visiting health facilities for curative care in the past month by 8.2 percentage points (95% CI 5.3 to 11.1), seeking care from a health professional by 8.4 percentage points (95% CI 5.5 to 11.3), and visiting a health facility to seek any medical assistance for illness and check-ups in the past 12 months by 13.9 percentage points (95% CI 10.5 to 17.4). Insurance also increases the annual household per capita health facility visits by 0.84 (95% CI 0.64 to 1.04). However, we find no significant effects of community-based health insurance membership on utilisation of maternal and child healthcare services. CONCLUSIONS: Findings that community-based health insurance increased outpatient services utilisation implies that it could also contribute towards universal health coverage and health equity in rural and informal sectors. The absence of significant effects on maternal and child healthcare services may be due to the free availability of such services for everyone at the public health facilities, regardless of insurance membership. Outpatient services use among insured households is still not universal, and understanding of the barriers to use, including supply-side constraints, will help improve universal health coverage.

Knowledge of and access to frontline workers among poor, rural households in Amhara region, Ethiopia: a mixed-methods study.

BACKGROUND: Social protection programmes have effectively reduced poverty and improved food security. However, the effects of poverty require an intersectoral approach to adequately address poor nutrition and health. Identifying gaps in knowledge and access to frontline workers who oversee these integrations is critical for understanding the potential for integrated social protection programming to improve these outcomes. We measured levels of social protection programme participants' knowledge of and interaction with social workers (SWs) and health extension workers (HEWs) in rural Ethiopia. METHODS: This mixed-methods study uses cross-sectional data from the baseline survey of a quasi-experimental impact evaluation among a sample of 5,036 households participating in Ethiopia's Productive Safety Net Programme. Qualitative interviews include key informant interviews, in depth interviews and focus group discussions with caregivers, community members, frontline agents, and stakeholders. Using data from household questionnaires administered to household heads, quantitative analyses include univariate and bivariate descriptive statistics as well as mutually-adjusted multivariable logistic regression analyses to estimate adjusted odds ratios and 95% confidence intervals for household sociodemographic characteristics associated with 1) knowledge of SWs and HEWs and 2) interaction with SWs and HEWs in their communities. Qualitative data were analysed using thematic analysis combining both a fluid and more structured coding processes to unpack the important topics within the data supported by illustrative quotes. RESULTS: Our results show that knowledge of and interaction with SWs is limited while many knew of and interacted with HEWs quite regularly. Interactions with SWs were negatively associated with increased household size and living in Dewa Chefa. Factors associated with increased knowledge of and interaction with HEWs include having children under the age of 5 years in the household, having health insurance, and having a formal education. Qualitative analyses suggest that SWs are limited by overwhelming caseloads, limited resources to carry out their work, and high staff turnover. However, SWs are considered highly valuable in the communities where they work. CONCLUSIONS: While most of the participants reported knowing their HEW, there is room for improvement, especially around household engagement with HEWs. Although SWs support the ISNP in the treatment districts only and not formally incorporated into the structure in the region, our findings highlight a need to provide greater support to SWs to effectively facilitate improvements in health and nutritional outcomes among vulnerable households. TRIAL REGISTRATION: Pan African Clinical Trial Registry (PACTR201902876946874) and the Registry for International Development Impact Evaluations (RIDIE-STUDY-ID-5bf27eb0404a0).

Impact of conditional cash transfers on enrolment in community-based health insurance among female-headed households in south Gondar zone, Amhara region, Ethiopia.

Ethiopia has been implementing its flagship social protection programme, Productive Safety Net Programme (PSNP), since 2005, mainly in drought prone and chronically food insecure woredas. In 2011, the country also launched Community-Based Health Insurance (CBHI). However, the two large-scale social protection programmes are not integrated well. This study examines the impact of participation in the conditional cash transfer (CCT) component of the PSNP (Public Works or PW) on enrolment in the CBHI among female-headed households in Amhara region. Data for the study generated through a cross-sectional survey collected from 365 PW-participating and non-participating female-headed households in south Gondar zone, Ebinat woreda (district). Inverse-probability-weighted regression adjustment (IPWRA) estimator is used to evaluate the impact of participating in PW component on CBHI enrolment decisions. Enrolment in CBHI among female-headed households is 63.6%. Data also show that 61.2% of insured and 27.1% of non-insured households receive CCTs. The study finds that participating in PSNP's CCT component increases the probability of CBHI enrolment among female-headed households by 16.3 percentage points. The finding informs efforts in integrating social protection programmes among most vulnerable households in rural Ethiopia. It also gives useful insights on the role of PSNP's CCT component to achieving universal health coverage through increasing insurance enrolment among most vulnerable households in Ethiopia.

Linking poverty-targeted social protection and Community Based Health Insurance in Ethiopia: Enrolment, linkages, and gaps.

BACKGROUND: Community-Based Health Insurance (CBHI) has received increasing attention in low and middle-income countries as a pathway toward universal health coverage. In 2011, the government of Ethiopia piloted CBHI and subsequently integrated CBHI with its flagship social protection programme, the Productive Safety Net Program (PSNP) which was established in 2005. We examined enrolment decisions by PSNP households, including, understanding of the programme, reasons for non-coverage, and factors associated with enrolment decisions. METHODS: Cross-sectional data for this study come from an Integrated Safety Net Program (ISNP) baseline survey implemented in four rural woredas in Amhara region, Ethiopia between December 2018 and February 2019. We collected data from 5398 PSNP beneficiary households, categorized as either Public Work (PW) or Permanent Direct Support (PDS) types. We used descriptive methods to characterize sample households and fitted binary logistic regression to identify factors associated with households' CBHI enrolment decisions. RESULTS: Current CBHI enrolment is higher among PW households (70.1 %) than PDS clients (50.3 %). The most common reason for not enrolling in both PW and PDS households is cost. Results further show that the following characteristics are positively associated with CBHI enrolment: the number of children and working-age adults in the household, older household head, female household head, married household head, having been food insecure in the previous 12 months, heads having experienced illness in the past month, and increasing household wealth status. CONCLUSION: While demographic factors are important in households' decisions to enrol in CBHI, various mechanisms could be used to increase enrolment among vulnerable households such as PDS clients. In this regard, while better communication about CBHI could increase enrolment for some households, other poor and vulnerable households will need fee waivers to induce enrolment.

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.

Impact of community-based health insurance on utilisation of preventive health services in rural Uganda: a propensity score matching approach.

The effect of voluntary health insurance on preventive health has received limited research attention in developing countries, even when they suffer immensely from easily preventable illnesses. This paper surveys households in rural south-western Uganda, which are geographically serviced by a voluntary Community-based health insurance scheme, and applied propensity score matching to assess the effect of enrolment on using mosquito nets and deworming under-five children. We find that enrolment in the scheme increased the probability of using a mosquito net by 26% and deworming by 18%. We postulate that these findings are partly mediated by information diffusion and social networks, financial protection, which gives households the capacity to save and use service more, especially curative services that are delivered alongside preventive services. This paper provides more insight into the broader effects of health insurance in developing countries, beyond financial protection and utilisation of hospital-based services.

Impact of voluntary community-based health insurance on child stunting: Evidence from rural Uganda.

While community-based health insurance increasingly becomes part of the health financing landscape in developing countries, there is still limited research about its impacts on health outcomes. Using cross-sectional data from rural south-western Uganda, we apply a two-stage residual inclusion instrumental variables method to study the impact of insurance participation on child stunting in under-five children. We find that one year of a household's participation in community-based health insurance was associated with a 4.3 percentage point less probability of stunting. Children of two years or less dominated the effect but there were also statistically significant benefits of enrolling in insurance after a child's birth. The expansion of community-based health insurance might have more dividends to improving health, in addition to financial protection and service utilisation in rural developing countries.

Determinants of Enrolment and Renewing of Community-Based Health Insurance in Households With Under-5 Children in Rural South-Western Uganda.

BACKGROUND: The desire for universal health coverage in developing countries has brought attention to communitybased health insurance (CBHI) schemes in developing countries. The government of Uganda is currently debating policy for the national health insurance programme, targeting the integration of existing CBHI schemes into a larger national risk pool. However, while enrolment has been largely studied in other countries, it remains a generally under-covered issue from a Ugandan perspective. Using a large CBHI scheme, this study, therefore, aims at shedding more light on the determinants of households' decisions to enrol and renew membership in these schemes. METHODS: We collected household data from 464 households in 14 villages served by a large CBHI scheme in southwestern Uganda. We then estimated logistic and zero-inflated negative binomial (ZINB) regressions to understand the determinants of enrolment and renewing membership in CBHI, respectively. RESULTS: Results revealed that household's socioeconomic status, husband's employment in rural casual work (odds ratio [OR]: 2.581, CI: 1.104-6.032) and knowledge of health insurance premiums (OR: 17.072, CI: 7.027-41.477) were significant predictors of enrolment. Social capital and connectivity, assessed by the number of voluntary groups a household belonged to, was also positively associated with CBHI participation (OR: 5.664, CI: 2.927-10.963). More positive perceptions on insurance (OR: 2.991, CI: 1.273-7.029), access to information were also associated with enrolment and renewing among others. Burial group size and number of burial groups in a village, were all significantly associated with increased the likelihood of renewing CBHI. CONCLUSION: While socioeconomic factors remain important predictors of participation in insurance, mechanisms to promote inclusion should be devised. Improving the participation of communities can enhance trust in insurance and eventual coverage. Moreover, for households already insured, access to correct information and strengthening their social network information pathways enhances their chances of renewing.