Community-based Health Insurance Enrolment Research Articles

Determinants of enrollment in community based health insurance program among households in East Wollega Zone, west Ethiopia: Unmatched case-control study.

Ethiopia has launched a community-based health insurance (CBHI) since 2011, which is an innovative financing mechanism to enhance domestic resource mobilization and sustainable health financing. This study assessed determinants of CBHI enrollment among HHs (households) of East Wollega, Ethiopia, 2022. Community based unmatched 1:2 case-control study design was conducted between Jan 7and Feb 5/2022 among 428 HHs (144 cases and 284 controls). Cases were selected from HHs who registered for CBHI and currently using CBHI. Controls were from those who do not registered for CBHI membership. Data collected using a semi-structured, interview administered questionnaire. Multivariable logistic regression with SPSS version 25 was employed for analysis and variables were declared statistical significant association at p-value < 0.05, 95% CI. Data from 428 (144 cases and 284 controls to CBHI) were collected; a response rate of 98.8%. Statistically lower odds of CBHI enrollment was observed among HHs who have poor knowledge [AOR = 0.48 (95% CI:0.27, 0.85)], perceived not respectful care [AOR = 0.44 (95% CI :0.24, 0.81)], unavailability of laboratory services [AOR = 0.37(95% CI:0.21, 0.66)], inappropriate time of premium payment [AOR = 0.31(95% CI:0.18, 0.52)]. In addition, medium wealth status category [AOR = 0.11(95% CI: 0.03, 0.45)]. Higher odd of CBHI enrollment observed among who have formal education [AOR = 2.39(95% CI: 1.28, 4.48)]. Educational level, knowledge, time of membership payment, laboratory test availability, perception of respectful care and wealth status were significant determinants of CBHI enrollment status. Hence, the responsible bodies should discuss and decide with community on the appropriate time of premium payment collection, and enhance community education on CBHI benefit package.

Enrollment of reproductive age women in community-based health insurance: An evidence from 2019 Mini Ethiopian Demographic and Health Survey.

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. 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. 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. 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.

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

BackgroundEthiopia 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.MethodsData 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.ResultsResults 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.ConclusionsFindings 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.

Effects of a free health insurance programme for the poor on health service utilisation and financial protection in Senegal

IntroductionImplemented in 2013 in Senegal, the Programme National de Bourses de Sécurité Familiale (PNBSF) is a national cash transfer programme for poor households. Besides reducing household poverty and encouraging children’s...

The effects of individual and community-level factors on community-based health insurance enrollment of households in Ethiopia.

IntroductionCommunity-based health insurance (CBHI) is a type of volunteer health insurance that has been adopted all over the world in which people of the community pool funds to protect themselves from the high costs of seeking medical care and treatment for the disease. In Ethiopia, healthcare services are underutilized due to a lack of resources in the healthcare system. The study aims to identify the individual and community level factors associated with community-based health insurance enrollment of households in Ethiopia.MethodsData from the Ethiopian mini demographic and health survey 2019 were used to identify factors associated with community-based health insurance enrollment of households in Ethiopia. Multilevel logistic regression analysis was used on a nationally representative sample of 8,663 households nested within 305 communities, considering the data’s layered structure. We used a p-value<0.05 with a 95% confidence interval for the results.ResultThe prevalence of community-based health insurance enrollment in Ethiopia was 20.2%. The enrollment rate of households in the scheme was high in both Amhara (57.9), and Tigray (57.9%) regions and low (3.0%) in the Afar region. At the individual level; the age of household heads, number of children 5 and under, number of household members, has land for agriculture, has a mobile telephone, receiving cash of food from the safety Net Program, Owning livestock, and herds of farm animals, wealth index, and at the community level; the region had a significant association with community-based health insurance enrollment.ConclusionBoth individual and community-level characteristics were significant predictors of community-based health insurance enrollment in households. Furthermore, the ministry of health, health bureaus, and other concerning bodies prioritize clusters with low health insurance coverage to strengthen health system financing and intervene in factors that negatively affect the CBHI enrollment of households.

A mixed methods study of community-based health insurance enrollment trends and underlying challenges in two districts of northeast Ethiopia: A proxy for its sustainability.

The term "community-based health insurance" refers to a broad range of nonprofit, prepaid health financing models designed to meet the health financing needs of disadvantaged populations, particularly those in the rural and informal sectors. Due to their voluntary nature, such initiatives suffer from persistently low coverage in low- and middle-income countries. In Ethiopia, the schemes' membership growth has not been well investigated so far. This study sought to examine the scheme's enrollment trend over a five-year period, and to explore the various challenges that underpin membership growth from the perspectives of various key stakeholders. The study employed a mixed methods case study in two purposively selected districts of northeast Ethiopia: Tehulederie and Kallu. By reviewing the databases of health insurance schemes, quantitative data were collected retrospectively from 2017 to 2021 to examine enrollment trends. Trends for each performance indicator were analyzed descriptively for the period under study. Face-to-face interviews were conducted with nine community members and 19 key informants. Study participants were purposely selected using the maximum variation technique. Interviews were audio recorded, transcribed verbatim, and translated into English. Thematic analysis was employed with both deductive and inductive coding approaches. Over the course of the study period, enrollment in the scheme at both districts exhibited non-linear trends with both positive and negative growth rates being identified. Overall, the scheme in Tehulederie has a relatively higher population coverage and better membership retention, which could be due to the strong foundation laid by a rigorous public awareness campaign and technical support during the pilot phase. The challenges contributing to the observed level of performance have been summarized under four main themes that include quality of health care, claims reimbursement for insurance holders, governance practices, and community awareness and acceptability. The scheme experienced negative growth ratios in both districts, indicating that it is not functionally viable. It will fail to meet its mission unless relevant stakeholders at all levels of government demonstrate political will and commitment to its implementation, as well as advocate for the community. Interventions should target on the highlighted challenges in order to boost membership growth and ensure the scheme's viability.

Towards universal health coverage: The level and determinants of enrollment in the Community-Based Health Insurance (CBHI) scheme in Ethiopia: A systematic review and meta-analysis.

Community-based health insurance (CBHI) is a risk-pooling approach that tries to disperse health expenditures across families with varying health profiles to provide greater access to healthcare services by allowing cross-subsidies from wealthy to poor populations. It is crucial to assess the level of CBHI enrolment and its determinants in Ethiopia, where government health spending is limited to less than 5% of GDP, far below the Alma Ata Declaration's benchmark of 15%. Although various epidemiological studies on CBHI enrolment status and its determinants have been undertaken in Ethiopia, the results have been inconsistent, with significant variability. However, no nationwide study assessing the pooled estimates exists today. Furthermore, the estimated strength of association at the country level varied and was inconsistent across studies. Hence, this systematic review and meta-analysis aimed at estimating the pooled prevalence of CBHI enrolment and its determinants in Ethiopia. A comprehensive search of studies was done by using PubMed, EMBASE, Science Direct, HINARI, Scopus, Web of Science, and the Cochrane Library. The database search was complemented by google scholar and some repositories for grey literature. The search was carried out from February 11 to March 12, 2022. The relevant data were extracted using a Microsoft Excel 2013 spreadsheet and analyzed using STATATM Version 16. Studies reporting the level and determinants of CBHI enrolment in Ethiopia were considered. A weighted DerSimonian Laired random effect model was applied to estimate the pooled national prevalence of CBHI enrolment. The Cochrane Q test statistics and I2 tests were used to assess the heterogeneity of the included studies. A funnel plot, Begg's and Egger's tests, were used to check for the presence of publication bias. Fifteen studies were eligible for this systematic review and meta-analysis with a total of 8418 study participants. The overall pooled prevalence of CBHI enrolment in Ethiopia was 45.5% (95% CI: 32.19, 58.50). Affordability of premium for the scheme[OR = 2.58, 95% CI 1.68, 3.47], knowledge of respondents on the CBHI scheme[OR = 4.35, 95% CI 2.69, 6.01], perceived quality of service[OR = 3.21, 95% CI 2.04, 4.38], trust in the scheme[OR = 2.32, 95% CI 1.57, 3.07], and the presence of a person with a chronic disease in the household [OR = 3.58, 95% CI 2.37, 4.78] were all found to influence CBHI enrolment. Community health workers (CHWs) need to make a high effort to improve knowledge of CBHI in rural communities by providing health education. To deal with the issue of affordability, due emphasis should be placed on building local solidarity groups and strengthening local initiatives to aid poor members. Stakeholders in the health service delivery points need to focus on the dimensions of high service quality. The financial gap created by the adverse selection of households with chronically ill members should be rectified by implementing targeted subsidies with robust plans.

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.

The interaction of healthcare service quality and community-based health insurance in Ethiopia.

Community-based health insurance (CBHI) as a demand-side intervention is presumed to drive improvements in health services quality, and the quality of health services is an important supple-side factor in motivating CBHI enrollment and retention. There is, however, limited evidence on this interaction. This study examined the interaction between quality of health services and CBHI enrollment and renewal. A mixed-method comparative study was conducted in four agrarian regions of Ethiopia. The study followed the Donabedian model to compare quality of health services in health centers located in woredas/districts that implemented CBHI with those that did not. Data was collected through facility assessments, client-exit interviews, and key informant interviews. In addition to manual thematic analysis of qualitative data, quantitative descriptive and inferential analyses were done using SPSS vs 25. The process related (composite index including provider-client interpersonal communication) and outcome related (client satisfaction) measures of service quality in CBHI woreda/districts differed significantly from non-CBHI woredas/districts, but there were no significant differences in overall measures of structural quality between the two. The study found better diagnostic test capacity, availability of tracer drugs, provider interpersonal communication, and service quality standards in CBHI woredas. A higher proportion of clients at CBHI health centers gave high ratings of overall satisfaction with services. Individual and household factors including family size, age, household health care-related expenditures, and educational status, played a more significant role in CBHI enrollment and renewal decisions than health service quality. Key-informants reported in interviews that participation in the scheme increased accountability of health facilities in CBHI woredas/districts, because they promised to provide quality services using the CBHI premium collected at the beginning of the year from all enrolled households. This study indicates a need for follow-up research to understand the nuanced linkages between quality of care and CBHI enrollment.

Factors affecting enrollment status of households for community based health insurance in a resource-limited peripheral area in Southern Ethiopia. Mixed method.

Despite the efforts made by the government of Ethiopia, the community-based health insurance (CBHI) enrollment rate failed to reach the potential beneficiaries. Therefore, this study aimed to assess the enrollment status of households for community-based health insurance and associated factors in peripheral areas of Southern Ethiopia. We conducted a community based cross-sectional study design with both quantitative and qualitative methods. Systematic random sampling was employed to select 820 households from 27, April to 12 June 2018. A pretested structured questionnaire, in-depth interview, and focus group discussion guiding tool were used to obtain information. A binary logistic regression model was used to assess the association between independent and outcome variables. A P-Value of less than 0.05 was taken as a cutoff to declare association in multivariable analysis. Qualitative data were analyzed manually using the thematic analysis method. Out of 820 households, 273[33.30%; 95% CI: 29.9-36.20] were enrolled in the community based health insurance scheme. Having good knowledge [AOR = 13.97, 95%CI: 8.64, 22.60], having family size of greater than five [AOR = 1.88, 95% CI: 1.15, 3.06], presence of frequently ill individual [AOR = 3.90, 95% CI: 2.03, 7.51] and presence of chronic illness [AOR = 3.64, 95% CI: 1.67, 7.79] were positively associated with CBHI enrollment. In addition, poor quality of care, lack of managerial commitment, lack of trust and transparency, unavailability of basic logistics and supplies were also barriers for CBHI enrollment. The study found that lower community based health insurance enrollment status. A higher probability of CBHI enrollment among higher health care demanding population groups was observed. Poor perceived quality of health care, poor managerial support and lack of trust were found to be barriers for non-enrollment. Therefore, wide-range awareness creation strategies should be used to address adverse selection and poor knowledge. In addition, trust should be built among communities through transparent management. Furthermore, the quality of care being given in public health facilities should be improved to encourage the community to be enrolled in CBHI.

&lt;p&gt;Community-Based Health Insurance and Associated Factors in North-Western Ethiopia. The Case of Bahir Dar City&lt;/p&gt;

BackgroundHealth insurance provides access to health care with financial risk protection. Knowledge and attitude have been found to influence enrolment in community-based health insurance, which avoids catastrophic health-care expenditure. However, knowledge and attitude levels towards health insurance are not well studied. The objective of this study was to determine the knowledge and attitude level of the informal workers of the Bahir Dar city towards community-based health insurance.MethodsA community-based cross-sectional study was conducted with systematically selected 335 informal workers. We conducted structured face-to-face interviews using a newly developed and validated questionnaire. The collected data were coded and then entered into Epi data and exported to SPSS software for analysis. Logistic regression analysis was used to identify potential associations between the study variables.ResultsOut of 325 informal workers, 51% of them had good knowledge of community-based health insurance, while 56% of participants had a favorable attitude towards community-based health insurance. Being single (AOR=3.4, 95% CI; 1.3, 9.0), daily laborer (AOR=2.73, 95% CI; 1.36, 5.48), attending secondary education (AOR=0.29; 95% CI: 0.12, 0.71), and obtaining information from television (AOR=0.31, 95% CI; 0.14, 0.71) were found to be statistically associated with knowledge. While being single (AOR=0.23, 95% CI: 0.08, 0.67), married (AOR=0.29, 95% CI: 0.11, 0.73), daily laborer (AOR=2.84, 95% CI: 1.37. 5.88), getting information from television (AOR= 3.09, 95% CI: 1.37, 6.93) and family (AOR= 2.63, 95% CI: 1.23, 5.61) were found to be statistically associated with the attitude towards community-based health insurance.ConclusionThe knowledge and attitude level of the informal workers towards community-based health insurance were low. Therefore, community-based health insurance should be promoted to ensure the accessibility of health care to all.

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

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.

Community-Based Health Insurance Enrollment and Child Health Service Utilization in Northwest Ethiopia: A Cross-Sectional Case Comparison Study.

PurposeUtilization of primary healthcare services in the rural communities of Ethiopia is very low. The Ethiopian government has introduced community-based health insurance (CBHI) to improve the health service utilization of the rural community. Thus, this study was conducted to examine the association between CBHI enrollment and child health service utilization in northwest Ethiopia.Patients and MethodsA cross-sectional case comparison study among CBHI enrolled and unenrolled households was conducted. A total of 226 sick children from 2008 surveyed households were included in the study. Bivariate-probit regression analysis was employed to account the endogenous nature of insurance enrollment and child health services utilization.ResultsThe results showed that the overall sick child healthcare visit in the CBHI enrolled group was about 0.44 (44%) point more compared to those unenrolled households. CBHI enrolled households in the poorest wealth group have a higher probability of visiting healthcare facilities for their sick children (coefficient: 0.13, SD: 0.07, 95% CI: −0.01, 0.27), whereas CBHI enrolled households with older age household head have a lower probability of visiting healthcare facilities for their sick children (coefficient: −0.16, SD: 0.08, 95% CI: −0.32, 0.01).ConclusionA promising positive effect on sick children’s health services utilization among CBHI enrolled was noticed. Moreover, households in the poorest wealth status and older age head affect the use of sick children’s healthcare services among those CBHI enrolled. Therefore, policy measures to expand benefit packages and supply-side interventions are essential to enhance the effects of CBHI on different health service utilization.

Effects of community-based health insurance on modern family planning utilization in Ethiopia

Background: Community-based health insurance (CBHI) has been established in a number of developing countries to expand access to modern health care service. However, few studies have focused on health care utilization of CBHI members in Ethiopia. Accordingly, the aim of this study was to assess the effect of CBHI on modern family planning (FP) utilization as part of its routine outcome monitoring activities. Methods: The USAID Transform: Primary Health Care project, conducted a continuous monitoring follow up visit using a multistage sampling technique in its four major targeted regions. A total of 3433 households were selected and 3313 women of reproductive age (15-49 years) were interviewed. The questionnaire captured the CBHI status of each household and FP use data from randomly selected women. Microsoft Access database was used to enter the data, which was then transferred to SPSS Version 20 for further analysis. Results: 49% of women (aged 15-49 years) were found to be enrolled in CBHI scheme. Half of the women (50.2%) use any family planning method, of which 49% of them used modern family planning method in project-supported areas. Over half of women (57%) who are exposed to CBHI schemes utilized family planning method which is statistically significant Conclusions: Modern FP utilization among insured women was higher compared with uninsured women. While FP methods are provided for free, CBHI enrollment improves FP use among women of child-bearing age. Women who have access to CBHI may frequently visit health facilities seeking services for themselves and their families, during which they may be introduced to FP services. This in turn may improve their awareness and attitude towards FP. The results will increase awareness for program implementer's of the benefits of CBHI schemes in FP programming, particularly in rural settings, and provide an opportunity to increase lifelong returns in Ethiopia.

Effects of community-based health insurance on modern family planning utilization in Ethiopia

Background: Community-based health insurance (CBHI) has been established in a number of developing countries to expand access to modern health care service. However, few studies have focused on health care utilization of CBHI members in Ethiopia. Accordingly, the aim of this study was to assess the effect of CBHI on modern family planning (FP) utilization as part of its routine outcome monitoring activities. Methods: The USAID Transform: Primary Health Care project, conducted a continuous monitoring follow up visit using a multistage sampling technique in its four major targeted regions. A total of 3433 households were selected and 3313 women of reproductive age (15-49 years) were interviewed. The questionnaire captured the CBHI status of each household and FP use data from randomly selected women. Microsoft Access database was used to enter the data, which was then transferred to SPSS Version 20 for further analysis. Results: In total 50.8% of married women (aged 15-49 years) were found to be enrolled in CBHI. Current modern FP use is 47.5% among married women in project-supported areas. Modern FP use is 50.9% among married women who are exposed to CBHI schemes, versus 44.1% among women who are not exposed to CBHI which is statistically significant. Conclusions: Modern FP utilization among insured women was higher compared with uninsured women. While FP methods are provided for free, CBHI enrolment improves FP use among women of child-bearing age. Women who have access to CBHI may frequently visit health facilities seeking services for themselves and their families, during which they may be introduced to FP services. This in turn may improve their awareness and attitude towards FP. The results will increase awareness for program implementers of the benefits of CBHI schemes in FP programming, particularly in rural settings, and provide an opportunity to increase lifelong returns in Ethiopia.

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

While community-based health insurance (CBHI) becomes increasingly integrated into health systems in developing countries, there is still limited research and evidence on its probable health impacts beyond its functions for health financing or for facilitating access to services. Using a cross-sectional data from rural south-west Uganda, we apply a two-stage residual inclusion instrumental variables method to study the impact of community health insurance on stunting in children under five years. Results indicate that each year a household was enrolled in insurance was causally associated with a reduction in the probability of stunting of 5.7 percentage points. Predictive marginal effects show that children in households which have had insurance for at least 5 years had a probability of stunting of only 0.353 compared to 0.531 for children in households with no insurance. Households in CBHI were more likely to attend more free antenatal and postnatal care visits and report fewer illnesses and reported less health expenditures. Moreover, CBHI enrolment was also associated with reduced health costs. We recommend that developing countries should facilitate the expansion of community health insurance scheme not only for their contribution to health financing but even more for mortality and morbidity aversion.

Community-Based Health Insurance Enrollment and Determinants in Addis Ababa: Insights from Behavioral Economics and Discrete Choice Experiments

Community-based health insurance target those employed in the rural and informal sector in urban by pooling risks and protect households from out-of-pocket expenditures when receiving health facility services. However, Ethiopian community-based health insurance is schemes characterized by low enrollment. The aim of this study is to analyze the determinants of community-based health insurance enrollment in Addis Ababa from behavioral economics and discrete choice experiment insights. A total of 222 households from ten pilot woredas were selected for the study using a simple random sampling technique. A simple social experiment is used to examine the significance of behavioral biases. A discrete choice experiment conducted across three attributes and conditional logit model used to determine the relative importance of the selected attributes and willingness-to-pay for those attributes. In addition, the binary logit regression model is used to estimate the probability of households enrollment in community-based health insurance. The study result indicates that households have the highest willingness to pay for only private health service providers (Birr 1849.6/year) compared to status-quo level. Non-member households’ willingness to pay for comprehensive health service package Birr 2271.7/year. Moreover, this study revealed loss-aversion bias, over-optimistic bias, and herding bias had significantly affected the household decision on community-based health insurance enrollment. The study suggests that behavioral biases affect Community-based health insurance enrollment. The study finding also reveals that respondent households are willingness to pay more for comprehensive health service package and for health insurance scheme that includes private health service providers. In addition, the study concludes eligible household enrollment decision varied based on their socio-demographic and household characteristic. This study recommends the need to consider mandatory community-based health insurance schemes and apply targeting intervention (coverage) to the particular group.

Impact of Community-Based Health Insurance on Child Health Outcomes: Evidence on Stunting from Rural Uganda

While community-based health insurance (CBHI) becomes increasingly integrated into health systems in developing countries, there is still limited research and evidence on its probable health impacts beyond its functions for health financing or for facilitating access to services. Using a cross-sectional data from rural south-west Uganda, we apply a two-stage residual inclusion instrumental variables method to study the impact of community health insurance on stunting in children under five years. Results indicate that each year a household was enrolled in insurance was causally associated with a reduction in the probability of stunting of 5.7 percentage points. Predictive marginal effects show that children in households which have had insurance for at least 5 years had a probability of stunting of only 0.353 compared to 0.531 for children in households with no insurance. Households in CBHI were more likely to attend more free antenatal and postnatal care visits and report fewer illnesses and reported less health expenditures. Moreover, CBHI enrolment was also associated with reduced health costs. We recommend that developing countries should facilitate the expansion of community health insurance scheme not only for their contribution to health financing but even more for mortality and morbidity aversion.

Factors affecting the willingness to join community‐based health insurance (CBHI) scheme: A case study survey from Savannakhet Province, Lao P.D.R.

Community-based health insurance (CBHI) targets independent worker (self-employed) is currently struggling with inadequate size of risk pooling, low enrollment, and high dropout rate as well as financial sustainability. The objective of this study is to find out the factors that significantly affect the CBHI enrollment incentive. The study applied cross-sectional study design to perform situation analysis, in which the Andersen behavioral model was used as a guideline to identify preliminary characteristics that involved with enrolling incentive. The model found that existence of both outpatient department (OPD) and inpatient department (IPD) health service utilization had significant impact on the CBHI enrollment, this statement is strongly related to adverse selection issues. Households resides in Kaysone Phomvihane district had higher probability of joining the scheme in comparison with relatively less-developed Champhone district. Households with no CBHI knowledge were also more likely to enroll the scheme. Occupation was also found to be a significant factors; of which farmers and laborers had lower possibility enrollment. Economic condition of the district has a significant impact on enrolment. However, the increase in personal income does not directly enhance the desire for enrolment. Most of the high-income households prefer to use a local, private clinic, and foreign hospitals in Thailand or Vietnam. Households with unemployed heads had the highest possibility of enrolling. The reason is the unemployed respondents include the elderly who stay at home without performing major tasks in exchange for their living. That group of people has the highest probability of either OPD or IPD.

Community-based health insurance and healthcare service utilisation, North-West, Ethiopia: a comparative, cross-sectional study

ObjectivesThe objective of this study was to compare differences in healthcare utilisation between community-based health insurance member households and non-member households and to identify factors for community-based health insurance enrolment...