What role does community-based health insurance play in the utilisation of health services among households in Ethiopia? A community-based comparative cross-sectional study.

OBJECTIVE: In Ethiopia, despite increased health service coverage, health service utilisation remains very low. However, evidence on the level of health service utilisation between insured and non-insured households in the study area was scanty. Therefore, this study aimed to assess health service utilisation and its predictors among insured and non-insured households of community-based health insurance in the East Wallaga Zone, Oromia region, Ethiopia, in 2022. METHODS: A community-based comparative cross-sectional study was employed. Data were collected using semi-structured interviewer-administered pretested questionnaire by face-to-face interviewing of heads of the households or spouse from 1 January 2022 to 30 January 2022, on 900 (450 insured and 450 non-insured). Epi-Data V.3.1 and Statistical Package for Social Science V.26 were used for data entry and analysis, respectively. The association between dependent (health service utilisation) and independent variables was analysed first using binary logistic regression. Multivariable logistic regression was used to identify potential predictor variables at a p<0.05. RESULTS: About 60.5% (95% CI 55.7% to 64.8%) of insured households had used health services compared with 45.9% (95% CI 41.4% to 50.9%) of non-insured households in the last 6 months. Family health status (Adjusted Odd Ratio (AOR) and 95% CI=2.74 (1.37 to 5.45), AOR and 95% CI=1.62 (1.01 to 3.14)); family with chronic disease (AOR and 95% CI=8.33 (5.11 to 13.57), AOR and 95% CI=4.90 (2.48 to 9.67)); perceived availability of drugs (AOR and 95% CI=0.34 (0.15 to 0.79), AOR and 95% CI=3.97 (1.69 to 9.34)); perceived transportation cost (AOR and 95% CI=0.44 (0.21 to 0.90), AOR and 95% CI=1.71 (1.00 to 2.93)); participated in indigenous community insurance (AOR and 95% CI=3.82 (1.96 to 7.45), AOR and 95% CI=0.13 (0.06 to 0.29)) and >10 km travel distance from nearby health facilities (AOR and 95% CI=1.52 (1.02 to 2.60), AOR and 95% CI=8.37 (4.54 to 15.45)) among insured and non-insured households, respectively, were predictors of health service utilisation. CONCLUSION: Insured households were more likely to utilise health services compared with non-insured households. Family health status, family with chronic disease, perceived availability of drugs, perceived transportation cost, participation in indigenous community insurance and >10 km travel were predictors of health service utilisation among insured and non-insured households. Hence, the greatest emphasis should be given to enhancing enrolment in the community-based health insurance scheme to achieve universal health coverage.

Experiences of membership in munno mubulwadde (your friend indeed) - a novel community-based health insurance scheme in Luwero district in rural central Uganda.

BACKGROUND: Community-Based Health Insurance (CBHI) schemes are recognized as an important health financing pathway to achieving universal health coverage (UHC). Although previous studies have documented CBHIs in low-income countries, the majority of these have been provider-based. Non-provider based schemes have received comparatively less empirical attention. We sought to describe a novel non-provider based CBHI munno mubulwadde (your friend indeed) comprising informal sector members in rural central Uganda to understand the structure of the scheme, the experiences of scheme members in terms of the perceived benefits and barriers to retention in the scheme. METHODS: We report qualitative findings from a larger mixed-methods study. We conducted in-depth interviews with insured members (n = 18) and scheme administrators (n = 12). Four focus groups were conducted with insured members (38 participants). Data were inductively analyzed by thematic approach. RESULTS: Munno mubulwadde is a union of ten CBHI schemes coordinated by one administrative structure. Members were predominantly low-income rural informal sector households who pay annual premiums ranging from $17 and $50 annually and received medical care at 13 scheme-contracted private health facilities in Luwero District in Central Uganda. Insured members reported that scheme membership protected them from catastrophic health expenditure during episodes of sickness among household members, and especially so among households with children under-five who were reported to fall sick frequently, the scheme enabled members to receive perceived better quality health care at private providers in the study district relative to the nearest public facilities. The identified barriers to retention in the scheme include inconvenient dates for premium payment that are misaligned with harvest periods for cash crops (e.g. maize corn) on which members depended for their agrarian livelihoods, long distances to insurance-contracted private providers, falling prices of cash crops which diminished real incomes and affordability of insurance premiums in successive years after initial enrolment. CONCLUSION: Munno mubulwadde was perceived by as a valuable financial cushion during episodes of illness by rural informal sector households. Policy interventions for promoting price stability of cash crops in central Uganda could enhance retention of members in this non-provider CBHI which is worthy of further research as an additional funding pathway for realizing UHC in Uganda and other low-income settings.

Enrollment and clients' satisfaction with a community-based health insurance scheme: a community-based survey in Northwest Ethiopia.

BACKGROUND: Although the Ethiopian government has implemented a community-based health insurance (CBHI) program, community enrollment and clients' satisfaction have not been well investigated in Gondar Zuria district, Northwest Ethiopia. This study assessed CBHI scheme enrollment, clients' satisfaction, and associated factors among households in the district. METHODS: A community-based cross-sectional survey assessed CBHI scheme enrollment and clients' satisfaction among households in Gondar Zuria district, Northwest Ethiopia, from May to June 2022. A systematic random sampling method was used to select the study participants from eligible households. A home-to-home interview using a structured questionnaire was conducted. Data were analysed using the statistical packages for social sciences version 26. Logistic regression was used to identify variables associated with enrollment and clients' satisfaction. A p-value < 0.05 was considered statistically significant. RESULTS: Out of 410 participants, around two-thirds (64.9%) of the participants were enrolled in the CBHI scheme. Residency status (AOR = 1.38, 95% CI: 1.02-5.32; p = 0.038), time taken to reach a health facility (AOR = 1.01, 95% CI: 1.00-1.02; p = 0.001), and household size (AOR = 0.77, 95% CI: 0.67-0.88; p < 0.001) were significantly associated with CBHI scheme enrollment. Two-thirds (66.5%) of enrolled households were dissatisfied with the overall services provided; in particular, higher proportions were dissatisfied with the availability of medication and laboratory tests (88.7%). Household size (AOR = 1.31, 95% CI: 1.01-2.24; p = 0.043) and waiting time to get healthcare services (AOR = 3.14, 95% CI: 1.01-9.97; p = 0.047) were predictors of clients' satisfaction with the CBHI scheme services. CONCLUSION: Although a promisingly high proportion of households were enrolled in the CBHI scheme, most of them were dissatisfied with the service. Improving waiting times to get health services, improving the availability of medications and laboratory tests, and other factors should be encouraged.

Percepções dos gestores e profissionais de saúde sobre os desafios e estratégias para a provisão médica na Estratégia Saúde da Família (ESF) no município de Francisco Morato (SP) / Perceptions of managers and health professionals about the challenges and strategies for medical provision in the Family Health Strategy (ESF) in the municipality of Francisco Morato (SP)

O estudo objetiva identificar as percepções dos gestores em saúde do município de Francisco Morato (SP) e dos gestores de Unidades Básicas de Saúde (UBS), além de médicos atuantes nessas unidades, sobre os desafios e estratégias para a provisão médica na Estratégia Saúde da Família (ESF). A coleta dessas percepções foi realizada, por intermédio de entrevistas semiestruturadas. O trabalho pôde indicar uma tendência à escassez de médicos e demais profissionais da saúde, como consequência da ausência de materiais, baixa infraestrutura, da sobrecarga dos profissionais e financiamento inadequado, fatores agravados no período da pandemia e pela revisão de parâmetros de alocação de profissionais a partir do Programa mais Médicos pelo Brasil. Dentre as estratégias para lidar com esse cenário, os entrevistados relataram utilizar estratégias externas como a retomada do Programa Federal Mais Médicos (PMM) e estratégias internas de gestão. Conclui-se com o estudo a importância de usar no município moratense, algumas estratégias propostas pela Organização Mundial da Saúde (OMS), para minimizar a escassez de profissionais da saúde.

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.

Determinants of willingness to pay for community-based health insurance scheme among households in rural community of southern Ethiopia.

BACKGROUND: Community-based health insurance programs are being acknowledged as effective strategies to attain universal health coverage and mitigate the financial catastrophic shock of the community. Even though Ethiopia has been focusing on the implementation and expansion of a community-based health insurance (CBHI) program since 2011, only a small number of people are enrolled, which might be attributed to a lack of willingness towards the program. The purpose of this study is to determine the willingness to pay for community-based health insurance and associated factors among households in the rural community of Gombora District, Hadiya Zone, southern Ethiopia. METHODS: Using the multistage systematic random sampling technique, a sample of 421 households was chosen for a community-based cross-sectional study. The desired information was gathered using a pre-tested, structured, interviewer-administered questionnaire. The data was entered using Epi-Data V3.1 and exported to SPSS version 24.0 for statistical analysis. Bivariable and multivariable logistic regression analyses were performed to determine the variables associated with the willingness to pay for community-based health insurance. RESULTS: The study showed that 67.1% of respondents expressed a willingness to pay for community-based health insurance. The mean amount of money they are willing to pay for the scheme is 178.41 (± 57.21) Ethiopian Birr (ETB), or 6.43 (± 2.06) USD per household per annum in 2020. Based on multiple logistic regression analysis, belonging to Rich household compared to poor (AOR: 2.78, 95% CI: 1.54, 5.03), having a household head who can read and write (AOR: 2.90, 95% CI: 1.39, 6.05), family size greater than five (AOR: 1.76, 95% CI: 1.06, 2.92), indigenous community insurance (iddir) participation (AOR: 2.83, 95% CI: 1.61, 4.96), and the presence of chronic illness (AOR: 1.94, 95% CI: 1.21, 3.12), were significantly associated with the willingness to pay for a CBHI scheme. CONCLUSION: Households' willingness to pay for a CBHI scheme was found to be significantly influenced by poor household wealth status, household heads who cannot read and write, households with less than or equal to five family members, households who participate in greater or equal to two indigenous community insurance participations, and the absence of chronic illness within the household. Therefore, factors affecting households' willingness to pay should be considered and massive community mobilization needs to be done to strengthen and increase household membership during the implementation of the CBHI scheme, especially in rural areas.

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.

Willingness to enroll and pay for community-based health insurance, decision motives, and associated factors among rural households in Enugu State, Southeast Nigeria.

Background: Over 70% of Nigeria's population is poor and rural, and most lack financial risk protection against ill health. Community-based health insurance (CBHI) may be an essential intervention strategy for ensuring that quality healthcare reaches the informal and rural populations. Aim: This article explores the willingness to enroll (WTE) and willingness to pay (WTP) for CBHI by community members, their decision considerations, and associated factors in Enugu State, Nigeria. Materials and Methods: We adopted a cross-sectional survey design with a multi-stage sampling approach. A validated and pre-tested questionnaire was used to elicit information from the respondents. WTE and WTP for CBHI was determined using the bid contingent valuation method. A test of correlation/association (Chi-square and ordinary least square regression) was conducted to ascertain the relationship between WTP for CBHI and other variables at a 95% confidence interval. The socioeconomic status index was generated using principal component analysis. A test of association was conducted between the demographic characteristics and WTE and WTP variables. Key Findings: A total of 501 household heads or their representatives were included in the study which yielded a return rate of 98.2%. The finding showed that most (92.4%) of the respondents indicated a WTE in CBHI. 86.6% indicated a willingness to pay cash for CBHI, while 84.4% indicated a willingness to pay other household members for CBHI. There was a significant association between gender, marital status, education, location, and willingness to pay. The study shows that 81.6% of the respondent stated that qualified staff availability motivates their WTE/WTP for CBHI, while 78.1% would be willing to enroll and pay for CBHI if services were provided free, and 324 (74.6%) stated that proximity to a health facility would encourage them to enroll and pay for the CBHI. Conclusion: This community demand analysis shows that rural and peri-urban community members are open to using a contributory mechanism for their health care, raising the prospect of establishing CBHI. To achieve universal health coverage, policy measures need to be taken to promote participation, provide financial and non-financial incentives and ensure that the service delivery mechanism is affordable and accessible. Further studies are needed to explore ways to encourage participation and enrollment in CBHI and other contributory schemes among under-served populations and improve access to and utilization of healthcare services.

The level of household satisfaction with community-based health insurance and associated factors in Southern Ethiopia.

Background: Community-based health insurance (CBHI) is a program intended to prevent financial hardship brought on by the cost of medical care. All of Ethiopia's regions are implementing it; however, it has not yet been researched how the program is being received by the local population. This study's objective is to determine how satisfied Southern Ethiopian households are with community-based health insurance programs and connected variables. Methods: A community-based cross-sectional study was conducted from April to May 2021. Information was gathered from 528 households (HHs) selected at random in the Gurage Zone of Southern Ethiopia using a questionnaire. Bivariate and multivariate logistic regression, as well as descriptive statistics, were applied. p values less than 0.05 was used as a cutoff point for identifying the self-determining factors. Results: The adjusted odds ratio (AOR) for HHs with the poorest wealth status was 2.40 (95% confidence interval:1.14-4.90); for HHs with a good knowledge of the CBHI, it was 1.81 (95% CI: 1.87-3.40); and for households with illness in the past 3 months, it was 5.22 (95% CI: 2.91-9.34). Recurrent visits to the facility (AOR:5.04, 95% CI:1.18-23.44), a Model household in rural health extension program (AOR:3.21, 95% CI:1.76-5.85), being enrolled in the scheme for three years or less (AOR:0.55, 95% CI: 0.30-0.95), and having faith in the leadership of the governing board (AOR:10.53, 95% CI:4.690-23.54) and the availability of the prescribed medication (AOR:14.64, 95% CI:5.37-39.84) were the significant influencing factors. Conclusion: This study revealed several variables that affected HHs' satisfaction with CBHI. We strongly advise all responsible parties to focus on increasing HH knowledge of the CBHI scheme, supporting HHs to serve as role models for rural health extension packages, and completing the CBHI pledged package to improve HHs' satisfaction with the CBHI scheme, which may then play a role in the sustainability of CBHI.

Impact of community-based health insurance in low- and middle-income countries: A systematic review and meta-analysis.

BACKGROUND: To systematically evaluate the empirical evidence on the impact of community-based health insurance (CBHI) on healthcare utilization and financial risk protection in low- and middle-income countries (LMIC). METHODS: We searched PubMed, CINAHL, Cochrane CENTRAL, CNKI, PsycINFO, Scopus, WHO Global Index Medicus, and Web of Science including grey literature, Google Scholar®, and citation tracking for randomized controlled trials (RCTs), non-RCTs, and quasi-experimental studies that evaluated the impact of CBHI schemes on healthcare utilization and financial risk protection in LMICs. We assessed the risk of bias using Cochrane's Risk of Bias 2.0 and Risk of Bias in Non-randomized Studies of Interventions tools for RCTs and quasi/non-RCTs, respectively. We also performed a narrative synthesis of all included studies and meta-analyses of comparable studies using random-effects models. We pre-registered our study protocol on PROSPERO: CRD42022362796. RESULTS: We identified 61 articles: 49 peer-reviewed publications, 10 working papers, 1 preprint, and 1 graduate dissertation covering a total of 221,568 households (1,012,542 persons) across 20 LMICs. Overall, CBHI schemes in LMICs substantially improved healthcare utilization, especially outpatient services, and improved financial risk protection in 24 out of 43 studies. Pooled estimates showed that insured households had higher odds of healthcare utilization (AOR = 1.60, 95% CI: 1.04-2.47), use of outpatient health services (AOR = 1.58, 95% CI: 1.22-2.05), and health facility delivery (AOR = 2.21, 95% CI: 1.61-3.02), but insignificant increase in inpatient hospitalization (AOR = 1.53, 95% CI: 0.74-3.14). The insured households had lower out-of-pocket health expenditure (AOR = 0.94, 95% CI: 0.92-0.97), lower incidence of catastrophic health expenditure at 10% total household expenditure (AOR = 0.69, 95% CI: 0.54-0.88), and 40% non-food expenditure (AOR = 0.72, 95% CI: 0.54-0.96). The main limitations of our study are the limited data available for meta-analyses and high heterogeneity persisted in subgroup and sensitivity analyses. CONCLUSIONS: Our study shows that CBHI generally improves healthcare utilization but inconsistently delivers financial protection from health expenditure shocks. With pragmatic context-specific policies and operational modifications, CBHI could be a promising mechanism for achieving universal health coverage (UHC) in LMICs.

Family Circle and Willingness to Subscribe to Community-based Health Insurance (CBHI) for the Elderly in a Rural Community in South-South Nigeria.

BACKGROUND: The older people in most rural communities depend on family members to provide resources for their healthcare. However, such payments for health services are mostly out of pocket. In trying to protect the health of elderly persons who by nature are prone to high morbidity, other younger family members may be contacted for financial support for their healthcare through contributions to the Community based Health Insurance (CBHI). This study assessed the willingness of the significant other in the family to subscribe to the CBHI for the elderly person within the family. METHODS: A cross-sectional survey was used to study 358 elderly people, and their significant other (identified by using the family circle tool). The respondents were selected by a multistage sampling technique from nine clusters of villages within the community. The data were generated with an interviewer-administered semi-structured questionnaire. For the significant other that lived outside the community phone call was used for the interview. Descriptive and inferential analyses were done using SPSS 22. RESULTS: Majority of the significant others (97.8%) were aged less than 60 years and mostly female (67.9%) and had attained the tertiary level of education (75.4%). Most of the significant others were civil servants (83.0%); 94.7% were Christians; 87.4% were married, and 83.2% lived in urban locations. Only 7.5% were aware of CBHI and 56.7% were willing to buy N10,000 (naira) subscriptions for CBHI. Socio-demographic characteristics that were significantly associated with willingness to subscribe for CBHI were age < 60 years (p=0.040), tertiary education (p<0.001), occupation (p<0.001), religion (p=0.008), marital status (p<0.001), place of residence (p<0.001) and monthly income (p<0.001). CONCLUSION: There is a need to create awareness of CBHI in communities, as the majority of the significant others identified in this study were ready to subscribe to CBHI for the elderly members of their families at a convenient cost.

CONTEXTE: Dans la plupart des communautés rurales, les personnes âgées dépendent des membres de leur famille pour financer leurs soins de santé. Cependant, ces paiements pour les services de santé se font le plus souvent de leur poche. En essayant de protéger la santé des personnes âgées qui, par nature, sont sujettes à une morbidité élevée, d'autres membres plus jeunes de la famille peuvent être contactés pour obtenir un soutien financier pour leurs soins de santé par le biais d'une contribution à l'assurance maladie communautaire (CBHI). Cette étude a évalué la volonté de l'autre membre de la famille de souscrire à l'assurance maladie communautaire pour la personne âgée de la famille. MÉTHODES: Une enquête transversale a été menée auprès de 358 personnes âgées et de leur proche (identifié à l'aide de l'outil du cercle familial). Les personnes interrogées ont été sélectionnées par une technique d'échantillonnage à plusieurs degrés dans neuf groupes de villages au sein de la communauté. Les données ont été générées à l'aide d'un questionnaire semi-structuré administré par un enquêteur. Pour la personne significative qui vivait en dehors de la communauté, un appel téléphonique a été utilisé pour l'entretien. Les analyses descriptives et inférentielles ont été effectuées à l'aide de SPSS 22. RÉSULTATS: La majorité des personnes interrogées (97,8 %) étaient âgées de moins de 60 ans, principalement des femmes (67,9 %) et avaient atteint un niveau d'éducation supérieur (75,4 %). La plupart des personnes interrogées étaient des fonctionnaires (83 %), 94,7 % étaient chrétiennes, 87,4 % étaient mariées et 83,2 % vivaient en milieu urbain. Seuls 7,5 % connaissaient l'existence de la CBHI et 56,7 % étaient prêts à souscrire un abonnement de 10 000Naira pour la CBHI. Les caractéristiques sociodémographiques significativement associées à la volonté de souscrire un abonnement à la CBHI étaient l'âge < 60 ans (p=0,040), l'enseignement supérieur (p<0,001), la profession (p<0,001), la religion (p=0,008), la situation matrimoniale (p<0,001), le lieu de résidence (p<0,001) et le revenu mensuel (p<0,001). CONCLUSION: Il est nécessaire de sensibiliser les communautés à l'initiative CBHI, car la majorité des proches identifiés dans cette étude étaient prêts à souscrire à l'initiative CBHI pour les membres âgés de leur famille à un coût raisonnable. Mots-clés: Cercle familial, Volonté, Assurance maladie communautaire, Personnes âgées, Communauté rurale.

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).

The feasibility analysis of integrating community-based health insurance schemes into the national health insurance scheme in Uganda.

BACKGROUND: Uganda has a draft National Health Insurance Bill for the establishment of a National Health Insurance Scheme (NHIS). The proposed health insurance scheme is to pool resources, where the rich will subsidize the treatment of the poor, the healthy will subsidize the treatment of the sick, and the young will subsidize the treatment of the elderly. However, there is still a lack of evidence on how the existing community-based health insurance schemes (CBHIS) can fit within the proposed national scheme. Thus, this study aimed at determining the feasibility of integrating the existing community-based health financing schemes into the proposed National Health Insurance Scheme. METHODS: In this study, we utilized a multiple-case study design involving mixed methods. The cases (i.e., units of analysis) were defined as the operations, functionality, and sustainability of the three typologies of community-based insurance schemes: provider-managed, community-managed, and third party-managed. The study combined various data collection methods, including interviews, survey desk review of documents, observation, and archives. FINDINGS: The CBHIS in Uganda are fragmented with limited coverage. Only 28 schemes existed, which covered a total of 155,057 beneficiaries with an average of 5,538 per scheme. The CBHIS existed in 33 out of 146 districts in Uganda. The average contribution per capita was estimated at Uganda Shillings (UGX) 75,215 = equivalent to United States Dollar (USD) 20.3, accounting for 37% of the national total health expenditure per capita UGX 51.00 = at 2016 prices. Membership was open to everyone irrespective of socio-demographic status. The schemes had inadequate capacity for management, strategic planning, and finances and lacked reserves and reinsurance. The CBHIS structures included promoters, the scheme core, and the community grass-root structures. CONCLUSION: The results demonstrate the possibility and provide a pathway to integrating CBHIS into the proposed NHIS. We however recommend implementation in a phased manner including first providing technical assistance to the existing CBHIS at the district level to address the critical capacity gaps. This would be followed by integrating all three elements of CBHIS structures. The last phase would then involve establishing a single fund for both the formal and informal sectors managed at the national level.

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.

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.

In Ethiopia's Kutaber district, does community-based health insurance protect households from catastrophic health-care costs? A community- based comparative cross-sectional study.

OBJECTIVE: Every health system needs to take action to shield households from the expense of medical costs. The Ethiopian government implemented community-based health insurance (CBHI) to protect households from catastrophic health care expenditure (CHE) and enhance the utilization of health care services. The impact of CBHI on CHE with total household expenditure and non-food expenditure measures hadn't been studied, so the study aimed to evaluate the impact of CBHI on CHE among households in Kutaber district, Ethiopia. METHODS: A total of 472 households (225 insured and 247 uninsured) were selected by multistage sampling techniques. Households total out-of-pocket (OOP) health payments ≥10% threshold of total household expenditure or ≥40% threshold of household non-food expenditure categorized as CHE. The co-variants for participation in the CBHI scheme were estimated by using a probit regression model. A propensity score matching analysis was used to determine the impact of CBHI on CHE. A Chi-square (χ2) test was computed to compare CHE between insured and uninsured households. RESULTS: The magnitude of CHE was 39.1% with total household expenditure and 1.8% with non-food expenditure measures among insured households. Insured households were 46.3% protected from CHE when compared to uninsured households with total household expenditure measures and 24.2% to 25% with non-food expenditure measures. CONCLUSION: The magnitude of CHE was lower among CBHI-enrolled households. CBHI is an effective means of financial protection benefits for households as a share of total household expenditure and non-food expenditure measures. Therefore, increasing the upper limits of benefit packages, minimizing exclusions, and CBHI scale-up to uninsured households is essential.

Effect of community-based health insurance on catastrophic health expenditure among chronic disease patients in Asella referral hospital, Southeast Ethiopia: a comparative cross-sectional study.

BACKGROUND: Chronic disease-related catastrophic health spending is frequent in Ethiopia affecting several households, particularly the poorest ones. A community-based health insurance (CBHI) scheme has been in place in Ethiopia since 2011. The scheme aims to provide financial protection against health expenditure but there is little evidence of how well it protects chronic patients financially. OBJECTIVE: The objective of the study was to evaluate the effect of community-based health insurance in reducing the incidence of catastrophic health expenditure among patients attending chronic disease follow-up departments in Asella referral hospital, Southeast Ethiopia. METHOD: A health facility-based comparative cross-sectional study was conducted in Asella referral hospital from March 2022 to May 2022. Systematic random sampling was used to select 325 chronic patients. Data were collected using an open data kit (ODK) collect app and then imported to STATA version 16 for analysis. Propensity score matching was used to evaluate the effect of community-based health insurance on catastrophic health expenditure. RESULT: The study enrolled a total of 325 chronic patients (157 insurance members and 168 nonmembers). More than 30% of the study participants incurred health spending that could be catastrophic based on the 15% nonfood threshold. Catastrophic health expenditure was found in 31% of insured and 47% of uninsured participants. Overshoot and mean positive overshoot were 10% and 33% for insured members, respectively and the corresponding figures were 18% and 39% for nonmembers. Community-based health insurance contributes to a 19% ((ATT = -0.19, t = -2.97)) reduction in the incidence of catastrophic health expenditure among chronic patients. This result is found to be consistent for alternative measurements of the outcome variable and the use of alternative matching algorithms. CONCLUSION: Chronic patients, particularly those in uninsured households, had a high incidence and intensity of catastrophic health expenditure. Hence, it is relevant to expand community-based health insurance to provide financial protection for people suffering from chronic conditions.

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

BACKGROUND: Evidence on the effectiveness of community-based health insurance (CBHI) in low-income countries is inconclusive. This study assessed the impact of CBHI on health service utilization and financial risk protection in Ethiopia. METHODS: We conducted a comparative cross-sectional study nested within a larger national household survey in 2020. Data was collected from three groups of households-CBHI member households (n = 1586), non-member households from CBHI implementing woredas (n = 1863), and non-member households from non-CBHI implementing woredas (n = 789). Indicators of health service utilization, out-of-pocket health spending, catastrophic health expenditure, and impoverishment due to health spending among CBHI members were compared with non-members from CBHI implementing woredas and households from non-CBHI implementing woredas. Propensity score matching (PSM) was used to account for possible selection bias. RESULTS: The annual number of OPD visits per capita among CBHI member households was 2.09, compared to 1.53 among non-member households from CBHI woredas and 1.75 among households from non-CBHI woredas. PSM estimates indicated that CBHI members had 0.36 (95% CI: 0.25, 0.44) and 0.17 (95% CI: -0.04, 0.19) more outpatient department (OPD) visits per capita per year than their matched non-member households from CBHI-implementing and non-CBHI implementing woredas, respectively. CBHI membership resulted in a 28-43% reduction in annual OOP payments as compared to non-member households. CBHI member households were significantly less likely to incur catastrophic health expenditures (measured as annual OOP payments of more than 10% of the household's total expenditure) compared to non-members (p < 0.01). CONCLUSION: CBHI membership increases health service utilization and financial protection. CBHI proves to be an important strategy for promoting universal health coverage. Implementing CBHI in all woredas and increasing membership among households in woredas that are already implementing CBHI will further expand its benefits.

Determinants of trust in healthcare facilities among community-based health insurance members in the Manna district of Ethiopia.

BACKGROUND: Low-income countries, including Ethiopia, face substantial challenges in financing healthcare services to achieve universal health coverage. Consequently, millions of people suffer and die from health-related conditions. These can be efficiently managed in areas where community-based health insurance (CBHI) is properly implemented and communities have strong trust in healthcare facilities. However, the determinants of community trust in healthcare facilities have been under-researched in Ethiopia. OBJECTIVE: To assess the determinants of trust in healthcare facilities among community-based health insurance members in the Manna District of Ethiopia. METHODS: A community-based cross-sectional study was conducted from March 01 to 30, 2020 among 634 household heads. A multistage sampling technique was used to recruit the study participants. A structured interviewer-administered questionnaire was used to collect the data. Descriptive statistics were computed as necessary. Multivariable linear regression analyses were performed, and variables with a p-value < 0.05 were considered to have a significant association with households' trust in healthcare facilities. RESULTS: In total, 617 households were included in the study, with a response rate of 97.0%. Household age (ß=0.01, 95% CI:0.001, 0.0013), satisfaction with past health services (ß=0.13, 95% CI:0.05, 0.22), perceived quality of services (ß= -0.47, 95% CI: -0.64, -0.29), perceived provider's attitude towards CBHI members (ß = -0.68, 95% CI: -0.88, -0.49), and waiting time (ß= -0.002, 95% CI:- 0.003, -0.001) were determinants of trust in healthcare facilities. CONCLUSION: This study showed that respondents' satisfaction with past experiences, older household age, long waiting time, perceived poor quality of services, and perceived unfavorable attitudes of providers towards CBHI members were found to be determinants of trust in healthcare facilities. Thus, there is a need to improve the quality of health services, care providers' attitudes, and clients' satisfaction by reducing waiting time in order to increase clients' trust in healthcare facilities.