Impact of Ethiopian pilot community-based health insurance scheme on health-care utilisation: a household panel data analysis

Abstract

Summary Background In recent years, there has been a proliferation of community-based health insurance (CBHI) schemes designed to provide financial protection against the costs of health care and expand access to modern health-care services to the informal and rural sectors. In 2011, a pilot CBHI scheme was introduced in Ethiopia. This study aims to rigorously evaluate the effect of the scheme on access to health-care services and financial protection. Methods The study was conducted in 12 CBHI pilot districts and four control districts in four mail regions (Tigray, Amhara, Oromiya, and SNNPR) of Ethiopia. The control areas were selected on the basis of the same criteria used to select the intervention districts. In these districts, sample households were randomly selected before the introduction of the pilot scheme. The participants of the study were people in the informal sector. The sample covers 1203 randomly selected households from intervention districts and 429 households from non-intervention districts. About 41% (489 of 1203) of the sample households from the CBHI districts were members of the scheme. This study investigates the effect of CBHI on the outcomes of interest. The primary outcomes of the study are outpatient visits and inpatient days spent in modern health-care providers. In order to properly address the proposed issues, this study uses a mixed approach (quantitative and qualitative). The econometrics models used in the analysis include ordinary least-square and fixed-effect regressions. Moreover, for the sake of sensitivity checks, propensity-score-adjusted fixed-effect estimates were also employed. Findings The multivariate analysis provides robust evidence that the pilot scheme increases outpatient care services from modern providers. The mean number of outpatient care use per insured household member (0·19) was higher by 0·074 visits than the visits per non-insured household member (0·11; p=0·01). On the other hand, there was no significant difference in the size of inpatient care use that could be attributed to the pilot scheme (p=0·63). Among different groups of the population, the benefit of the scheme in terms of creating access to care is more pronounced for the rich than for the poor. Interpretation CBHI intervention could play a supportive role in creating access to cheaper outpatient care instead of relatively expensive inpatient care for the population in the informal sector. Funding The Netherlands Organisation for Scientific Research, grant number W07.45.103.00.