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

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          Abstract

          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.

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          Most cited references39

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          Qualitative research methods: when to use them and how to judge them.

          M S Kirkman, K Hammarberg, S de Lacey (2016)
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            Dropping out of Ethiopia's community-based health insurance scheme.

            Robert Sparrow, Getnet Alemu, Arjun S Bedi … (2015)
            Low contract renewal rates have been identified as one of the challenges facing the development of community-based health insurance (CBHI) schemes. This article uses longitudinal household survey data gathered in 2012 and 2013 to examine dropout in the case of Ethiopia's pilot CBHI scheme. We treat dropout as a function of scheme affordability, health status, scheme understanding and quality of care. The scheme saw enrolment increase from 41% 1 year after inception to 48% a year later. An impressive 82% of those who enrolled in the first year renewed their subscriptions, while 25% who had not enrolled joined the scheme. The analysis shows that socioeconomic status, a greater understanding of health insurance and experience with and knowledge of the CBHI scheme are associated with lower dropout rates. While there are concerns about the quality of care and the treatment meted out to the insured by providers, the overall picture is that returns from the scheme are overwhelmingly positive. For the bulk of households, premiums do not seem to be onerous, basic understanding of health insurance is high and almost all those who are currently enrolled signalled their desire to renew contracts.
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              Barriers and facilitators to implementation, uptake and sustainability of community-based health insurance schemes in low- and middle-income countries: a systematic review

              Racha Fadlallah, Fadi El-Jardali, Nour Hemadi … (2018)
              Background Community-based health insurance (CBHI) has evolved as an alternative health financing mechanism to out of pocket payments in low- and middle-income countries (LMICs), particularly in areas where government or employer-based health insurance is minimal. This systematic review aimed to assess the barriers and facilitators to implementation, uptake and sustainability of CHBI schemes in LMICs. Methods We searched six electronic databases and grey literature. We included both quantitative and qualitative studies written in English language and published after year 1992. Two reviewers worked in duplicate and independently to complete study selection, data abstraction, and assessment of methodological features. We synthesized the findings based on thematic analysis and categorized according to the ecological model into individual, interpersonal, community and systems levels. Results Of 15,510 citations, 51 met the eligibility criteria. Individual factors included awareness and understanding of the concept of CBHI, trust in scheme and scheme managers, perceived service quality, and demographic characteristics, which influenced enrollment and sustainability. Interpersonal factors such as household dynamics, other family members enrolled in the scheme, and social solidarity influenced enrollment and renewal of membership. Community-level factors such as culture and community involvement in scheme development influenced enrollment and sustainability of scheme. Systems-level factors encompassed governance, financial and delivery arrangement. Government involvement, accountability of scheme management, and strong policymaker-implementer relation facilitated implementation and sustainability of scheme. Packages that covered outpatient and inpatient care and those tailored to community needs contributed to increased enrollment. Amount and timing of premium collection was reported to negatively influence enrollment while factors reported as threats to sustainability included facility bankruptcy, operating on small budgets, rising healthcare costs, small risk pool, irregular contributions, and overutilization of services. At the delivery level, accessibility of facilities, facility environment, and health personnel influenced enrollment, service utilization and dropout rates. Conclusion There are a multitude of interrelated factors at the individual, interpersonal, community and systems levels that drive the implementation, uptake and sustainability of CBHI schemes. We discuss the implications of the findings at the policy and research level. Trial registration The review protocol is registered in PROSPERO International prospective register of systematic reviews (ID = CRD42015019812). Electronic supplementary material The online version of this article (10.1186/s12939-018-0721-4) contains supplementary material, which is available to authorized users.
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                Author and article information

                Contributors
                Gavin Yamey: gavin.yamey@duke.edu
                Journal
                Journal ID (nlm-ta): BMC Health Serv Res
                Journal ID (iso-abbrev): BMC Health Serv Res
                Title: BMC Health Services Research
                Publisher: BioMed Central (London )
                ISSN (Electronic): 1472-6963
                Publication date (Electronic): 10 April 2022
                Publication date PMC-release: 10 April 2022
                Publication date Collection: 2022
                Volume: 22
                Electronic Location Identifier: 473
                Affiliations
                [1 ]Kilimanjaro Consulting, 341 Code1110 Addis Ababa, Ethiopia
                [2 ]GRID grid.26009.3d, ISNI 0000 0004 1936 7961, The Center for Policy Impact in Global Health, , Duke Global Health Institute, Duke University, ; 310 Trent Dr, Durham, NC 27705 USA
                Article
                Publisher ID: 7889
                DOI: 10.1186/s12913-022-07889-4
                PMC ID: 8994817
                PubMed ID: 35399058
                SO-VID: 65af9704-a09e-4a11-92c5-3ff2d53d54ff
                Copyright © © The Author(s) 2022
                License:

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

                History
                Date received : 29 July 2021
                Date accepted : 28 March 2022
                Categories
                Subject: Research
                Custom metadata
                issue-copyright-statement © The Author(s) 2022

                ScienceOpen disciplines: Health & Social care
                Keywords: health financing,health insurance,community-based health insurance,ethiopia
                Data availability:
                ScienceOpen disciplines: Health & Social care
                Keywords: health financing, health insurance, community-based health insurance, ethiopia

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