The Effect of Ethiopia's Community-Based Health Insurance Scheme on Revenues and Quality of Care.

Zemzem Shigute,Arjun S Bedi,Getnet Alemu,Robert Sparrow,Anagaw D Mebratie

doi:10.3390/ijerph17228558

Abstract

Ethiopia’s Community-Based Health Insurance (CBHI) scheme was established with the objectives of enhancing access to health care, reducing out-of-pocket expenditure (OOP), mobilizing financial resources and enhancing the quality of health care. Previous analyses have shown that the scheme has enhanced health care access and led to reductions in OOP. This paper examines the impact of the scheme on health facility revenues and quality of care. This paper relies on a difference-in-differences approach applied to both panel and cross-section data. We find that CBHI-affiliated facilities experience a 111% increase in annual outpatient visits and annual revenues increase by 47%. Increased revenues are used to ameliorate drug shortages. These increases have translated into enhanced patient satisfaction. Patient satisfaction increased by 11 percentage points. Despite the increase in patient volume, there is no discernible increase in waiting time to see medical professionals. These results and the relatively high levels of CBHI enrollment suggest that the Ethiopian CBHI has been able to successfully negotiate the main stumbling block—that is, the poor quality of care—which has plagued similar CBHI schemes in Sub-Saharan Africa.

Highlights

In June 2011, motivated by the limited increase in health care utilization, despite substantial supply-side investments in the country’s health care infrastructure [1], the Ethiopian Government introduced a pilot voluntary Community-Based Health Insurance (CBHI) scheme
With regard to government revenues, there is a decline for health centers affiliated to the CBHI but this is more than compensated through revenues accruing from insurance payments
The revenues are the only aspect in which the CBHI and the non-CBHI group show initial differences, as CBHI facilities have higher revenues from government budget and drug sales in 2011. This suggests that the fixed effects approach is justified, since cross-section differences would overestimate the impact of CBHI

Summary

Introduction

In June 2011, motivated by the limited increase in health care utilization, despite substantial supply-side investments in the country’s health care infrastructure [1], the Ethiopian Government introduced a pilot voluntary Community-Based Health Insurance (CBHI) scheme. The main objectives of the scheme are to increase demand for health care services, enhance financial protection and generate revenues from domestic sources for the health care sector [2]. Several reviews of the CBHI literature [3,4,5,6] show that while such voluntary insurance schemes have had some success in enhancing financial protection and enabling access to health care, they struggle to expand enrollment and to retain clients. In the case of the Nouna district scheme in Burkina Faso, depending on the year, the dropout rate ranged between 31 and

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