Willingness to join community-based health insurance among rural households of Debub Bench District, Bench Maji Zone, Southwest Ethiopia

Patient satisfaction with pharmacy services among users and non users of community based health insurance scheme at public health facilities in Gamo Zone, South Ethiopia: a comparative cross sectional study

BACKGROUND

Patient satisfaction is a crucial humanistic outcome metric in pharmacy services. There was a lack of evidence on patients' satisfaction with pharmacy services in Gamo zone among users and nonusers of the CBHI scheme. Therefore, the aim this study is to compare the level of patient satisfaction with pharmacy services among users and nonusers of community based health insurance scheme at public health facilities in Gamo zone, South Ethiopia.

METHOD

A facility based comparative cross sectional study design with mixed approach was conducted from June 1 to 30, 2023. A total of 522 study participants and 16 key informants were included as the sample size for quantitative and qualitative study, respectively. The quantitative data was gathered from the study participants who visited the outpatient pharmacy department during the study period by using a simple random sampling technique, while the purposive sampling technique was used to select clients and key informants for the qualitative study. The adjusted odds ratio (AOR) was used to measure the association between independent variables and patient satisfaction toward outpatient pharmacy services at the P values < 0.05 and 95% confidence interval (CI).

RESULTS

From the total of study participants, 195 (73.9%) of insured and 175 (67.8%) of noninsured clients were satisfied with pharmacy services offered at public health facilities. The gender of insured (95% CI = 2.00-12.36, (p 0.01)), and noninsured (95% CI = 0.658-2.881, (p 0.02)), waiting time of insured (95% CI = 0.057-0.766, (p 0.0027)), and noninsured (95% CI = 0.084-0.925, (p 0. 0021)) and premium affordability of insured (95% CI = 0.0605-4.860, (p 0.00)) were significantly associated factors with client satisfaction at p < 0.05 and 95% CI. Based on qualitative finding, as member of the CBHI scheme, the members had a greater opportunity to receive a good pharmacy services, because they were more familiar with the physicians and the institutions.

CONCLUSION

The clients with insurance perceived high level of satisfaction with pharmacy services in public health facilities than noninsured. The gender and waiting times at outpatient pharmacy department for both groups of study participants and the premium affordability for the insured groups of clients were factors affecting client satisfactions with pharmacy services.

Willingness to join community-based health insurance and its associated factors among households in Nekemte City, Ethiopia. A community-based cross-sectional study

INTRODUCTION

Ethiopia has been implementing community-based health insurance programs since 2011 to improve health care financing system. However, the prevalence of household willingness to join the community-based health insurance (CBHI) program and its associated factors are less explored in urban area. Therefore, this study was aimed to assess the prevalence of willingness to join community-based health insurance program and its associated factors among households in Nekemte City, Ethiopia.

METHODS

A community-based cross-sectional study was conducted on 422 randomly selected households in Nekemte City, Ethiopia. Bivariate and multivariable analyses were performed to see the association between the independent and outcome variables using binary logistic regression model. Association was described using an adjusted odd ratio (AOR) and a 95% confidence interval (CI). Finally, p-value < 0.05 was considered the cut-off point for declaring a significant.

RESULTS

Among 422 study participants, 320 (75.83%) [95% CI = 71.5-79.8%)] of the households were willing to join community-based health insurance program. The willingness to join for community-based health insurance was 3.11 times more likely among households who were in the richest quintile (AOR = 3.11; 95% CI = 1.08-8.93), 3.4 times more likely among those who were merchants (AOR = 3.40;1.33, 8.69), 2.52 times more likely among those who had history of chronic illness in the household (AOR = 2.52; 95% CI = 1.43-4.45), 4.09 times more likely among those who had the awareness about the scheme (AOR = 4.09; 95% CI = 1.97-8.47) and 3.29 times more likely among those who had the experience of borrow for medical care (AOR = 3.29; 95% CI = 1.48-7.30).

CONCLUSION

Nearly three fourth of the households were willing to join community-based health insurance program, however, about one fourth of households were not willing, which is a significant public health problem. Being merchant, having awareness about the scheme, being in the richest wealth quintile, having experience of borrowing for medical care, and having history of chronic illness in the household were factors found to be significantly associated with willingness to join community based health insurance in the study area. Therefore, strengthening awareness creation at community level about the benefit package and principle of the program would increase their demand for the community-based health insurance scheme.

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.

Determinants of community-based health insurance membership renewal decision among rural households in Kellem Wollega zone, Oromia regional state, Ethiopia: a community-based cross-sectional study

Background

Despite the fact that community-based health insurance (CBHI) is a promising program to achieve the goal of universal health coverage (UHC), it faces challenges that are not only due to low enrollment but also due to membership renewal decision that impact its sustainability. Hence, the study aimed to identify the determinants of CBHI membership renewal decision among rural households in Kellem Wollega zone, Ethiopia.

Methods

The study was conducted in Kellem Wollega, Ethiopia, among rural households from March 30-April 30, 2022, using a community-based cross-sectional study design. An interviewer-administered structured questionnaire through face-to-face interviews was used. Using a systematic random sampling method, 551 households were selected making 540 (98%) response rates. The data was entered into EPI Data 3.1 and analyzed using SPSS 25 software. Descriptive statistics, binary, and multiple logistic regressions were performed. Using multiple logistic regressions, a significant association between the CBHI membership renewal decision and independent variables was identified, declaring the statistical significance level using a 95% confidence interval (CI) at p < 0.05.

Results

The overall rate of CBHI membership renewal decision among households was estimated to be 365 (67.6%, 95% CI = 63.7-71.5%). The factors that significantly influenced the households' membership renewal decision were family size (AOR = 0.46, 95% CI = 0.25-0.86), low literacy status (AOR = 0.28 95% CI = 0.12-0.64), lower than middle-level of wealth index (AOR = 9.80, 95% CI = 2.75-34.92), premium affordability (AOR = 4.34, 95% CI = 2.08-9.04), unavailability of services (AOR = 0.26, 95% CI = 0.12-0.55), trusting in health facilities (AOR = 5.81, 95% CI = 2.82-11.94), favorable providers' attitude toward members (AOR = 8.23, 95% CI = 3.96-19.64), good quality of service (AOR = 4.47, 95% CI = 2.28-8.85) and health care seeking behavior (AOR =3.25, 95% CI = 1.32-7.98).

Conclusion

The overall CBHI membership dropout decision rate among rural households was high, which could affect health service provision and utilization. Therefore, the insurance scheme and contracted health facilities should consider and work on family size and wealth status when membership premiums are calculated, the education level of households when creating awareness about the scheme, building trust in the contracted health facilities by providing all promised benefit packages of health services with good quality, and improving the attitude of health care providers towards the scheme members.

Multidimensional determinants of willingness to pay for community-based health insurance in Ethiopia and its implication towards universal health coverage: A narrative synthesis

Pooling resources to pay for healthcare services and attain universal health coverage is a viable global agenda, especially for underdeveloped health systems. Ethiopia has implemented community-based health insurance (CBHI) since 2011 to improve healthcare funding. However, comprehensive evidence on the demand and determinants of health insurance in Ethiopia is lacking. Therefore, this review aimed at identifying determinants of willingness to pay (WTP) for CBHI in Ethiopia. A narrative review was conducted using search terms from PubMed, Science Direct, Scopus, African Journal Online, and Google Scholar databases. Screening process considered publication year, settings, English language, and study participants. Newcastle Ottawa tool assessed the quality of included studies. A thematic framework was applied. The review protocol was registered in PROSPERO with an ID number CRD42022296840. The review included 10 studies. The synthesis identified 25 determinants of WTP for CBHI in Ethiopia. Socio-demographic and economic, scheme-related, and health-related determinants of WTP for the CBHI were identified. Determinants of household WTP for CBHI in Ethiopia were multi-dimensional. Socio-demographic, socio-economic, scheme-related, and health-related factors are among the common determinants documented. CBHI is thus an alternative and potential source of financing for the healthcare system, primarily for people with low socioeconomic status and a fragile health system. The health system, socioeconomic leaders, and political figures play a significant role in influencing communities towards WTP for CBHI while increasing government spending on health toward UHC.

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.

Determinants of treatment satisfaction among patients with diabetes: multicentre cross-sectional study in Northwest Ethiopia

OBJECTIVE

Treatment satisfaction is a significant determinant of quality of care, especially for patients with chronic diseases such as diabetes. Identifying factors that contribute to treatment satisfaction may improve patient outcomes. This study examined treatment satisfaction and determinant factors in patients with diabetes.

DESIGN AND SETTING

A multicentre hospital-based cross-sectional study was conducted between April and July 2022 at selected hospitals in Northwest Ethiopia.

PARTICIPANTS

Eligible adult patients with diabetes were included in the study.

MAIN OUTCOME MEASURES

Treatment satisfaction was the main outcome and was measured using the Diabetes Treatment Satisfaction Questionnaire, which was valid and reliable in the current sample. A linear regression analysis was used to determine the association between treatment satisfaction scores and independent variables.

RESULTS

Out of the 422 patients approached, 402 (95.3%) participated in the study. Overall, the mean treatment satisfaction score was 17.13 (±3.3) out of 30. Most of the participants had a lower degree of satisfaction with the current treatment (>52%) and its convenience (>63%). More than half of the participants (51.2%) perceived hyperglycaemia most of the time and hypoglycaemia some of the time (64.9%). Treatment satisfaction was influenced by body mass index (BMI) (p<0.01), number of medical conditions and medications (p<0.001), hyperglycaemia perception (p<0.001), healthcare cost coverage (p<0.001), monthly salary (p<0.001), self-monitoring blood glucose (SMBG) (p=0.017), lifestyle modification status (p<0.01), and comorbidity and/or complications (p<0.001).

CONCLUSION

Treatment satisfaction was low among patients with a higher BMI, a higher number of medical conditions and medications, comorbidities and/or complications, a frequent perception of hyperglycaemia and a lower monthly salary. Interventions addressing specific independent variables might enhance treatment satisfaction.

Effects of the level of household access to water, sanitation and hygiene on the nutritional status of children under five, Benin

BACKGROUND

Whether or not the Water, Sanitation and Hygiene (WASH) conditions in which children under five live determine their nutritional status is still under discussion. The work aimed to study the effects of household WASH conditions to which children under five are exposed on their nutritional status in Benin.

METHODS

The study utilized a cross-sectional design and consisted of secondary analyses using datasets from the fifth Demographic and Health Survey (DHS-V) conducted in Benin. Stunting, wasting and underweight were the dependent variables. The WASH conditions in which children live were evaluated in the immediate environment, i.e., at the level of their households. After describing the study variables, the relationships between the dependent variables and the exposures were checked using multivariate logistic regression. Data analysis was performed with Stata 15 and took into account the survey's sampling design.

RESULTS

The prevalence of stunting, wasting and underweight was 31.15% (95% CI = 29.90-32.42), 4.79% (95% CI = 4.33-5.31) and 15.82% (95% CI = 14.92-16.76), respectively. The stunting odds were 1.35 (95% CI = 1.15-1.59) and 1.27 (95% CI = 1.01-1.59) times higher for children from households with no water and sanitation services, respectively, compared to children living in households with basic water and sanitation services. Children under five from households with no hygiene facilities and using limited hygiene services had 1.31 (95% CI = 1.05-1.63) and 1.35 (95% CI = 1.10-1.67) times the odds of being stunted, respectively, compared to children covered by basic hygiene facilities. There is no evidence of a significant relationship between household access to WASH and wasting in children under five. The odds of being underweight were 1.33 (95% CI = 1.02-1.72) times higher among children under five from households with limited hygiene facilities than among children from households with basic hygiene facilities.

CONCLUSION

Interventions to fight malnutrition in children under five should include a WASH dimension.

Household satisfaction with a pilot community-based health insurance scheme and associated factors in Addis Ababa

Background

Many countries introduce CBHI as their healthcare financing system to ensure healthcare access. Understanding the level of satisfaction and factors associated with it is essential to ensure the sustainability of the program. Therefore, this study aimed to assess household satisfaction with a CBHI scheme and its associated factors in Addis Ababa.

Design and methods

Institutional-based cross-sectional study was conducted in the 10 health centers found in the 10 sub-cities of Addis Ababa. Both quantitative and qualitative methods were used. Logistic regression analysis was carried out to identify its associated factors and thematic analysis was used for qualitative data. Finally, variables with a p-value of <0.05 have been considered statistically significant.

Results

In this study, the overall satisfaction level of households with CBHI was 46.3%. Satisfaction was associated with valid CBHI management regulations (AOR = 1.96, 95% CI: 1.12, 3.46), participants who received the right drug (AOR = 1.77, 95% CI: 1.08, 2.93), households who got immediate care (AOR = 4.95, 95% CI: 2.72, 8.98), those who agreed with the adequacy of medical equipment (AOR = 1.65, 95% CI: 1.02, 2.69), and households who agreed with qualification of health personnel (AOR = 1.89, 95% CI: 1.12, 3.20) were more satisfied with the scheme than their counterparts. The challenges mentioned by the discussants were the shortage of drugs, poor attitude of health professionals, absence of kenema pharmacy, lack of laboratory services, lack of awareness about the CBHI scheme, and tight payment schedule.

Conclusions

the satisfaction level of households was low. To achieve a better result, the concerned bodies should work to improve the availability of medication, and medical equipment and improve the attitude of healthcare workers.

Differentials in the Prevalence of Acute Respiratory Infections Among Under-Five Children: An Analysis of 37 Sub-Saharan Countries

Objective

We investigated the prevalence and risk factors of ARI in children under 5 years old in 37 SSA countries.

Methods

Data from Demographic and Health Survey (DHS) of 37 African countries was examined in this analysis. Data from children under the age of 5 years old were examined. Forest plot was used to identify disparities in the occurrence of ARIs across SSA countries.

Results

We observed a higher prevalence of ARI among children under 5 in Uganda, Kenya, Sao Tome and Principe (9% each), Gabon, Chad, Eswatini (8% each), Burundi, Ethiopia, Congo Democratic Republic (7.0% each). The prevalence of ARI among under-five children who sought medical advice/treatment from health facility was higher in South Africa (88%), Sierra Leone (86%), Tanzanian (85%), Guinea (83%) and Uganda (80%). The prevalence rate of ARI among under-five children who received antibiotics was higher in Tanzania (61%), Sao Tome and Principe (60%), Rwanda and Congo (58% each), Angola (56.0%), Mozambique (54.0%), Kenya (53.0%), Namibia (52.0%) and Gabon (50.0%). This study found that the household wealth index, maternal education, and urban residence were significantly associated with ARI (p <0.001). A higher prevalence of ARI was observed among urban residents, low income families, and those with mothers with lower education.

Conclusion

ARI prevalence could be reduced by improving household socioeconomic status, child nutrition and community awareness of indoor and outdoor pollution. Interventions and programs focused on early diagnosis, treatment and prevention of ARIs are crucial in reducing ARIs particularly in developing countries.

Teachers' Willingness to Pay for Social Health Insurance and Its Determinant Factors at Harar Region, Ethiopia, 2021

Background

Most developing nations lag behind in maintaining their populations' health. These nations are characterized by under-financing, low health cost protection mechanisms for the poor, and lack of risk pooling and cost sharing methods. To tackle this challenge, Ethiopia proposed social health insurance in 2010 even though its implementation was delayed. Hence, the purpose of this study was to assess teachers' willingness to pay for the newly proposed social health insurance and its associated factors.

Methods

A cross-sectional study was conducted and a stratified sampling technique was used to select government and private schools. After data were collected using a semi-structured self-administered questionnaire, binary and multivariate logistic regressions were done to examine determinants of willingness to pay for social health insurance.

Results

Among participants who faced illness six months prior to the study, 85.7% reported that they paid "out of their pocket". About 59.2% and 54% of the teachers had a positive attitude and good knowledge toward health insurance schemes respectively. Of the total study respondents, 89.5% were willing to pay for the suggested insurance scheme. Forty eight percent of participants agreed to pay greater than or equal to 4% of their monthly salary. Willingness to pay was more likely among those who taught in secondary schools, had a positive attitude and good knowledge.

Conclusion

Nearly three fourths of the teachers showed willingness to pay for social health insurance. Participants with good knowledge, a positive attitude and from primary schools were more likely to be willing to pay for social health insurance. Equipping all public facilities' employees with necessary knowledge of social health insurance is essential to reduce catastrophic health care costs. Future researchers need to consider qualitative studies to support these findings.

Factors Associated with Willingness to Pay for Cost-Sharing under Universal Health Coverage Scheme in Yogyakarta, Indonesia: A Cross-Sectional Survey

BACKGROUND

National Health Insurance (NHI) in Indonesia requires an appropriate cost-sharing policy, particularly for diseases that require the largest financing. This study examined factors that influence willingness to pay (WTP) for cost-sharing under the universal health coverage scheme among patients with catastrophic illnesses in Yogyakarta, Indonesia.

METHODS

This was a cross-sectional study using structured questionnaires through direct interviews. The factors related to the WTP for cost-sharing under the NHI scheme in Indonesia were identified by a bivariable logistic regression analysis.

RESULTS

Two out of every five (41.2%) participants had willingness to pay for cost-sharing. Sex [AOR = 0.69 (0.51, 0.92)], education [AOR = 1.54 (0.67, 3.55)], family size [AOR = 1.71 (1.07, 2.73)], occupation [AOR = 1.35 (0.88, 2.07)], individual income [AOR = 1.50 (0.87, 2.61)], household income [AOR = 1.47 (0.90, 2.39)], place of treatment [AOR = 2.54 (1.44, 4.45)], a health insurance plan [AOR = 1.22 (0.87, 1.71)], and whether someone receives an inpatient or outpatient service [AOR = 0.23 (0.10, 0.51)] were found to affect the WTP for a cost-sharing scheme with p < 0.05.

CONCLUSION

Healthcare (place of treatment, health insurance plan, and whether someone receives an inpatient or outpatient service) and individual socioeconomic (sex, educational, family size, occupational, income) factors were significantly related to the WTP for cost-sharing.

Rural residents' willingness to participate in basic medical insurance and influential factors: A survey of three provinces in China

Background

Rural residents' participation in medical insurance has a significant relationship to the affordability of their medical care. This study aims to investigate the willingness of rural residents to participate in basic medical insurance for urban and rural residents and its determinants so as to enhance their willingness to participate in medical insurance.

Methods

Data were obtained from 1,077 validated questionnaires from rural residents. Chi-square test and multiple logistic regression analysis were adopted to analyze determinants of rural residents' willingness to participate in basic medical insurance for urban and rural residents.

Results

94.3% of respondents were willing to participate in basic medical insurance for urban and rural residents and this was associated with the familiarity with the medical insurance policies [OR = 2.136, 95% CI (1.143, 3.989)], the reasonability of medical insurance premiums [OR = 2.326, 95% CI (0.998, 5.418)], the normality of doctors' treatment behavior [OR = 3.245, 95% CI (1.339, 7.867)] and the medical insurance's effectiveness in reducing the economic burden of disease [OR = 5.630, 95% CI (2.861, 11.079)].

Conclusion

Even though most respondents were willing to participate in basic medical insurance for urban and rural residents, some aspects need to be improved. The focus should be on promoting and regulating the behavior of medical staff. Financing policies and reimbursement of treatment costs need to be more scientifically developed. A comprehensive basic healthcare system needs to be optimized around the core function of "hedging financial risks".

Willingness to pay for community-based health insurance and associated factors in Ethiopia: A systematic review and meta-analysis

In Ethiopia, there is low enrollment and a wide discrepancy in willingness to pay for community-based health insurance schemes, and there is a lack of nationally representative data on willingness to pay for community-based health insurance. Thus, this systematic review and meta-analysis aimed to estimate the pooled prevalence of willingness to pay for community-based health insurance and associated factors in Ethiopia. This was developed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Databases such as PubMed/Medline, CINAHL, African Journals Online, and Google Scholar searches were performed to retrieve available published and unpublished studies from December 15 to May 17, 2022. Two independent reviewers screened the retrieved articles. Critical quality appraisal was performed using the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument. To investigate the sources of heterogeneity, subgroup analysis and meta-regression were performed based on region, study setting (rural/urban), and sample size. RevMan software and STATA 14 software were used for the statistical analysis. A random-effect model was used to estimate the effect size at a 95% confidence interval. A total of 190 studies were retrieved, and six studies were included in the final meta-analysis. The pooled prevalence of willingness to pay for community-based health insurance was 78 (95% confidence interval: 74, 81). A subgroup analysis by region indicated the lowest proportion of willingness to pay community-based health insurance in the Oromia region, 76% (95% confidence interval: 68, 84), and the highest in the Amhara region, 79% (95% confidence interval: 77, 81). Nearly three in four households were willing to pay for community-based health insurance in Ethiopia. Thus, awareness of willingness to pay community-based health insurance is mandatory to improve the implementation of community-based health insurance.

Is Ethiopian community-based health insurance affordable? Willingness to pay analysis among households in South Central, Ethiopia

Background

Community-based Health Insurance (CBHI) is a voluntary prepayment mechanism that guarantees the provision of basic healthcare services without financial barriers to underserved segments of the population in developing countries. The Government of Ethiopia launched the CBHI program to protect the community from high out-of-pocket health expenditure and improve health service utilization a decade ago. However, to improve the quality of healthcare services delivery in health facilities and cover the changing costs of healthcare, the government should revise the contribution of the CBHI scheme. Therefore, we determined the willingness to pay for a CBHI scheme and associated factors among rural households of Lemu and Bilbilo district, South Central Ethiopia.

Methods

We conducted a community-based cross-sectional study design to assess willingness to pay for the CBHI scheme and its associated factors among households in Lemu and Bilbilo districts, South Central Ethiopia. We used a double bounded contingent valuation method to elicit households’ willingness to pay for the CBHI scheme. Data were coded, cleaned, entered into Statistical Package for Social Science (SPSS) version 25, and exported to STATA 16 for analysis. A logistic regression analysis was conducted to determine the presence of statistically significant associations between the willingness to pay for the CBHI scheme and independent variables at a p-value <0.05 and Adjusted odds ratio (AOR) values with 95% CI. Finally, we checked the fitness of the model using Hosmer and Lemeshow’s goodness-of-fit test.

Results

Of the 476 study participants, 82.9% (95% CI: 79.2%, 86.01%) were willing to pay for the CBHI scheme and only 62% of them can afford the average amount of 358.32ETB ($7.68) per household per annum. Primary education (AOR = 3.17; 95% CI: 1.74–5.80), secondary and above education (AOR = 4.13; 95% CI: 1.86–9.18), large family size (AOR = 2.75; 95% CI: 1.26–5.97), monthly income of 500-1000ETB (AOR = 3.75; 95% CI: 1.97–7.13) and distance to public health facilities (AOR = 2.14, 95% CI: 1.04–4.39 were significantly associated with willingness to pay for the CBHI scheme.

Conclusion

In this study, around 83% of respondents were willing to pay for the CBHI and meet the government expectation for 2020. The study also revealed that educational status, family size, monthly income, and distance from the health facilities were significant factors associated with WTP for the CBHI scheme. In addition, we found that a large number of the respondents couldn’t afford the average amount of money that the participants were willing to pay for the CBHI scheme. So, the government should consider the economic status of the communities while revising the CBHI scheme premium not to miss those who cannot afford the contribution.

Community-Based Health Insurance Membership Renewal Rate and Associated Factors among Households in Gedeo Zone, Southern Ethiopia

Background

Community-based health insurance (CBHI) scheme is an emerging strategy to achieve universal health coverage and protect communities in developing countries from catastrophic financial expenditure at the service delivery point. However, high membership discontinuation from the CBHI scheme remained the challenge to progress toward universal financial protection in resource-constrained countries. Therefore, this study assessed the community-based health insurance membership renewal rate and associated factors in the Gedeo zone, Southern Ethiopia.

Methods

We conducted a community-based cross-sectional study among households in the Yirga Chafe district, Gedeo zone, Southern Ethiopia, from September 10 to 30, 2021. We used a multistage simple random sampling to recruit 537 respondents. We entered data into Epi-Info 7 and exported it to SPSS version 25 for analysis. We used a logistic regression model to determine factors associated with the CBHI scheme membership renewal. Variables with a P value of <0.05 and a 95% confidence level were considered to be significantly associated with the outcome variable.

Results

We found the respondents' CBHI membership renewal rate was 82.68%. Those who enrolled in the CBHI scheme >3years (AOR = 3.12; 95% CI: 1.40–6.97), having illnesses in the last three months (AOR = 2.97; 95% CI: 1.47–5.99), the CBHI premium affordability (AOR = 12.64; 95% CI: 3.25–49.38), good knowledge of the CBHI scheme (AOR = 21.11; 95% CI: 10.63–41.93), perceived quality of health service (AOR = 4.21; 95% CI: 1.52–11.68), and favorable attitude towards the CBHI scheme (AOR = 3.89, 95% CI: 1.67–9.04) were significantly associated with the CBHI program membership renewal rate.

Conclusion

In our study, we found the magnitude of CBHI members who discontinued their CBHI scheme membership was high. Besides, we found that the affordability of the CBHI premium, respondents' attitude, and knowledge of the CBHI program were predictor factors for dropout from the CBHI membership. Therefore, the government should consider the economic status of communities during setting the CBHI program contribution. Moreover, awareness creation through health education should be provided to improve participants' knowledge and perception of the CBHI program.

Medication adherence and its impact on glycemic control in type 2 diabetes mellitus patients with comorbidity: A multicenter cross-sectional study in Northwest Ethiopia

BACKGROUND

Medication nonadherence in patients with chronic diseases, particularly in type 2 diabetes mellitus (T2DM) with comorbidity, has continued to be the cause of treatment failure. The current study assessed medication adherence and its impact on glycemic control in T2DM patients with comorbidity.

METHODS

An institutional-based multicenter cross-sectional study was conducted among T2DM patients with comorbidity at the selected hospitals in Northwest Ethiopia. Medication adherence was measured using a structured questionnaire of the General Medication Adherence Scale (GMAS). A logistic regression model was used to identify predictors of the level of medication adherence and glycemic control. P < 0.05 at 95% confidence interval (CI) was statistically significant.

RESULTS

A total of 403 samples were included in the final study. This study showed that more than three-fourths (76.9%) of the participants were under a low level of medication adherence. Source of medication cost coverage [AOR = 10.593, 95% CI (2.628-41.835; P = 0.003], monthly income (P < 0.00), self-monitoring of blood glucose (SMBG) practice [AOR = 0.266, 95% CI (0.117-0.604); P = 0.002], number of medications [AOR = 0.068, 95% CI (0.004-0.813); P = 0.014] and medical conditions [AOR = 0.307, 95% CI (0.026-0.437); P = 0.018] were found to be significant predictors of medication adherence. Significantly, majority (74.7%) of participants had poor levels of glycemic control. Patients who had a high level of medication adherence [AOR = 0.003, 95% CI (0.000-0.113); P = 0.002] were found less likely to have poor glycemic control compared with patients who were low adherent to their medications.

CONCLUSION

The current study concluded that medication adherence was low and significantly associated with poor glycemic control. Number of medical conditions and medications were found to be associated with medication adherence. Management interventions of T2DM patients with comorbidity should focus on the improvement of medication adherence.

Rate of glycaemic control and associated factors in patients with type 2 diabetes mellitus treated with insulin-based therapy at selected hospitals in Northwest Ethiopia: a multicentre cross-sectional study

OBJECTIVES

This study was aimed to determine the level of glycaemic control and associated factors in patients with type 2 diabetes mellitus (T2DM) treated with insulin-based therapy.

DESIGNS

Institutional-based multicentre cross-sectional study design was employed to conduct this study.

SETTINGS

The diabetes follow-up clinics of selected hospitals in Northwest Ethiopia.

PARTICIPANTS

Adult patients with T2DM treated with insulin-based therapy at the selected hospitals who met the eligibility criteria were the study participants.

MAIN OUTCOME MEASURES

Good glycaemic control; when fasting blood glucose (FBG) level ranged from 70 to 130 mg/dL, and FBG <70 and >130 mg/dL was considered poor glycaemic control. A logistic regression model was used to identify determinants of poor glycaemic control. A p<0.05 at 95% CI was statistically significant.

RESULTS

Of 403 study participants, 54.8% were males with a mean age of 55.03±10.8 years. Though patients with T2DM were treated with insulin-based therapy, most of the participants (72.5%) could not achieve the target FBG. The overall mean FBG was 177.1±54.3, and far from the target glucose level. Patients who could not practise self-monitoring of blood glucose were found more likely to have poor glycaemic control compared with those who practised self-monitoring (p<0.001). Whereas patients who had a normal body mass index (p=0.011) and who were treated with premixed insulin-based therapy (p=0.04) were found less likely to have poor glycaemic control compared with patients with obesity and who received NPH insulin based-regimens, respectively.

CONCLUSION

This study demonstrated that a significant proportion of the study samples could not achieve glycaemic targets and the average blood glucose was far higher than the recommended glycaemic target level. Insulin initiation and titration, considering the determinants of glycaemic control, could be recommended to achieve target glycaemic levels.

Predictors of Community-Based Health Insurance in Ethiopia via Multilevel Mixed-Effects Modelling: Evidence from the 2019 Ethiopia Mini Demography and Health Survey

Background

The World Health Organization has endorsed a community-based health insurance scheme (CBHIS) as a shared financing plan to improve access to health services and ensure universal coverage of the healthcare delivery system. Such a contributory scheme is the most likely option to provide health insurance coverage when governments cannot offer direct health care support. Despite improvements in access to current healthcare services, Ethiopia’s healthcare delivery remained low, owing to the country’s underdeveloped healthcare finance system. As a result, the present study assessed CBHIS coverage and its predictors in Ethiopia at the individual and community level.

Methods

The availability of CBHIS was checked via a criterion: at least one of the cluster respondents had to be enrolled in CBHIS. This study was based on secondary data from the Ethiopia Mini Demography and Health Survey (EMDHS) 2019 and included 7724 respondents. The study population was described using percentage and frequency. Four multilevel mixed-effects logistic regression modelling stages were performed to control for variations due to heterogeneity across clusters, and determinant predictors of CBHIS enrollment were outplayed.

Results

The prevalence of CBHIS enrollment in Ethiopia was 33.13%. Rural residents were 3.218 times (AOR = 3.218; 95% CI: 1.521, 6.809), male household heads were 1.574 times (AOR = 1.574, 95% CI: 1.105, 2.241), getting funds from the safety net program were times 2.062 (AOR = 2.062, 95% CI: 1.297, 3.279), attending the primary educational level was 1.686 times (AOR = 1.686, 95% CI: 1.007, 2.821), bank accounts were 1.373 times (AOR = 1.373, 95% CI: 1.052, 1.792), and wealth index was 1.356 times (AOR = 1.356, 95% CI: 1.001, 1.838) more likely associated with CBHIS coverage, whereas the regions, the other religions, and women aged 20–24 had lower odds of CBHIS coverage.

Conclusion

In Ethiopia, regional healthcare expenditure per capital, religious affiliation, women age range, residents, sex of household head, funds from the safety net program, formal educational level, and having bank accounts were associated with community-based health insurance scheme coverage.

Willingness to pay for social health insurance among public civil servants: A cross-sectional study in Dessie City Administration, North-East Ethiopia

Background

The readiness to pay for health insurance has an impact on universal health care. This study investigated the willingness of public civil servants in Dessie City Administration, North-East Ethiopia, to pay for social health insurance and associated factors.

Methods

From April to May 2021, a cross-sectional study was undertaken. The sectors from which the samples were proportionately allocated were chosen using a multistage sampling procedure. Using their payroll list as a sampling frame, simple random sampling was done to recruit them. A semi-structured self-administered questionnaire was used to collect data. Epi Data version 3.1 was used to enter, code, and clean the data, which was then exported to SPSS version 23 for analysis. To determine relationships, bi-variable and multivariable analyses were utilized. Candidates for multivariable analysis were variables with a p-value ≤ 0.3 in bi-variable analysis. AOR with a 95% CI was used to determine the strength and direction of association. Statistical significance was defined at p-value < 0.05.

Results

A total of 796 employees took part in the study, with a 94.42% response rate. Overall, 29.60% of them were willing to pay for the scheme (95% CI: 26.4, 33%). The decision to pay was influenced by favorable perception (AOR = 2.43, 95% CI: 1.72, 3.44), household income < Birr 5,000 (AOR = 0.26, 95% CI: 0.14, 0.48), acute illness (AOR = 0.48, 95% CI: 0.32, 0.72), bachelor level education (AOR = 0.44, 95% CI: 0.28, 0.70), master and above level education (AOR = 0.26, 95% CI: 0.14, 0.49), and age 25–29 years (AOR = 1.97, 95 % CI: 1.08, 3.57).

Conclusion

The willingness of the civil servants to pay for social health insurance was low, and it was influenced by their attitudes toward the scheme, the occurrence of severe illness, income level, educational status, and age.

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

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.

Willingness to join community based health insurance among households in South Wollo, Northeast Ethiopia: A community-based cross-sectional study

BACKGROUND

Poor health care financing remains a major challenge to health service utilization among the lower socioeconomic society. Consequently, countries have designed different health insurance programs to overcome financial barriers against health services utilization. Similarly, Ethiopia has been implementing community-based health insurance programs since 2011 to improve health care financing system. However, only a small number of people are enrolled which might be attributed to lack of willingness towards the program and the reasons for this remained under reported. This study was intended to examine willingness to join the community-based health insurance program and its associated factors in South Wollo, Northeast Ethiopia.

METHOD

A community-based cross-sectional study was conducted among 421 households. A multistage systematic random sampling technique was employed to recruit the study households. Data were entered into EpiData version 3.1 and was exported into SPSS version 24.0 for analysis. Bivariable and multivariable logistic regression analysis with a backward elimination method was performed to identify the determinants of willingness to join community-based health insurance. Finally, a statistically significant level was declared at a p-value of less than 0.05.

RESULTS

Two hundred and ninety-three [73.6% (95%CI:68.8%-77.9%)] households were willing to join community-based health insurance programs. Being male headed household (AOR:0.2, 95%CI: 0.07-0.58), being a member of Idir (AOR:0.46, 95%CI: 0.25-.84), absence of chronic illness in the household (AOR: 0.31, 95%CI: 0.13-0.77), and family size < 4 (AOR: 0.18, 95% CI:0.08-0.41) were barriers to join community-based health insurance program whereas rural residency (AOR:1.9, 95% CI: 1.09-3.32), perceived quality health services (AOR:2.96, 95%CI:1.4-6.24), and having positive attitude (AOR:4.1, 95%CI:2.32-7.22) and good knowledge to programs (AOR:2.62, 95%CI:1.43-4.8) were enabling factors.

CONCLUSION

Nearly three-fourths of the households were willing to join community-based health insurance programs. However, different household and health service-related factors affected their willingness. The ministry of health with the regional and woreda health offices should work towards improving the quality of health services, conduct program advocacy and community sensitization towards the program, and build trust with the community.

Client satisfaction on community based health insurance scheme and associated factors at Boru Meda Hospital, Northeast, Ethiopia: institutional based cross-sectional study

Background

Community-based health insurance systems are usually voluntary and characterized by community members pooling funds and protecting themselves against the high costs of seeking medical care and treatment for illness. Client satisfaction with health service provision during the implementation of health insurance schemes has often been neglected. This study aimed to determine client satisfaction with the community-based health insurance scheme and associated factors.

Methods

An institutional-based cross-sectional study design was applied from February 22–March 11 /2019. A total of 420 study participants were included in the study using a systematic random sampling technique. Data were collected using a pretested semi-structured interviewer-administered questionnaire with a patient exit interview. Bivariate and multivariate logistic regression analyses were used to identify factors associated with Community-based Health Insurance of client satisfaction. Statistical significance was decided at a p-value less than 0.05.

Result

A total of 420 community-based health insurance clients of health service users participated in the study with a 100% response rate. The overall client satisfaction was 80% at 95% Cl (76.1, 83.9), respondents who have perceived that partially or none availability of prescribing drugs were 0.09 times less likely satisfied as compared to full availability of prescribing drugs (AOR =0.09; 95% Cl: (0.04, 0.19)). Besides, study participants waiting time to consult service providers within 30 min were more satisfied than those who were delayed 60 min and above (AOR =3.16; 95% Cl: (1.19, 8.41)).

Conclusion

Community-based health insurance client satisfaction provided in the present study was 80% indicating low proportion. Full availability of prescribing drugs, clients renewed their community-based health insurance membership, and preference of clients to use the hospital for future health care need were positively associated with client satisfaction while the perception of waiting time before physician consultation negatively affected client’s satisfaction. Therefore, the hospital management members and service providers need to give attention to reduce waiting time preceding consultation, improve drug availability, and sustain the hospital preference by the client.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSION AND RECOMMENDATION

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.

Willingness to Enroll for Community-Based Health Insurance and Associated Factors in Simada District, North-West, Ethiopia, 2020:A Community-Based Cross-Sectional Study

Background

Community-based health insurance is a not-for-profit type of health insurance that has been used by poor people to protect themselves against the high costs of seeking medical care and treatment for illness. This study aimed to assess communities’ willingness to enroll for community-based health insurance (CBHI) and its associated factors in Simada district, Northwest, Ethiopia.

Methods

A community-based mixed cross-sectional study design was conducted. Multistage simple random and purposive sampling techniques were used for quantitative and qualitative studies, respectively. Data were coded and entered into Epi info version 7.2.0.1 and exported to SPSS 20.0 for data analysis. Inferential statistics were done to determine an association between the outcome and independent variables. Statistically significant variables in binary logistic regression analysis with p-value <0.2 were entered for multivariable binary logistic regression analysis and P-value ≤0.05 was considered as statistically significant. Hosmer and Lemeshow’s goodness of fitness test was fitted and qualitative data were analyzed by using thematic analysis.

Results

Among 510 study participants, 454 (89%) [CI: (86.5%-91.6%)] were willing to enroll for community-based health insurance. Members of social capital [AOR: 7.6 (3.78–15.5)], distance from health facilities [AOR: 10.8 (4.9–23.5)], the experience of chronic illness in the family [AOR: 4.6 (1.88–11.4)], medium family wealth status [AOR: 3.1 (1.3–7.5)], and the number of family members [AOR: 2.25 (1.11–4.6)] were significantly associated with willingness to enroll for community-based health insurance.

Conclusion

Willingness to enroll in community-based health insurance in the study area is high. Members of social capital, the experience of chronic illness in the family, distance from a health facility, the number of family members, and medium family wealth status were factors found to be associated with willingness to enroll for the scheme. Therefore, emphasizing redesigning and planning strategies for better expanding the scheme accordingly.

Perceived Quality of Healthcare and Availability of Supplies Determine Household-Level Willingness to Join a Community-Based Health Insurance Scheme in Amhara Region, Ethiopia

Purpose

The Ethiopian health system has been challenged by a shortage of funds and is heavily reliant on foreign donation. However, voluntary community-based health insurance (CBHI) has been implemented to reach and cover the very large agricultural sector since 2010. Thus, the level of acceptability of the scheme needs to be regularly assessed through households’ willingness to join before the nationwide rollout of the scheme. This study was intended to assess the level of willingness to join in community-based health insurance and associated factors in northwest Ethiopia.

Patients and Methods

Using a pretested structured questionnaire, a cross-sectional community-based study was conducted in 2017 in Amhara Region, northwest Ethiopia. Using a multi-stage sampling method, from 15 clusters in which CBHI was implemented, 1,179 households without CBHI membership were included as a sample for the study. Bivariable and multivariable logistic regression was fitted to assess the association between predictor variables and the outcome of interest.

Results

Out of the total (1,179) participants, 60.5% (713) were willing to join the scheme. Households’ occupation (AOR=2.26; 95% CI:=1.12–5.07), perceived good (AOR=2.21; 95% CI:=1.53−3.21), and medium (AOR=1.44; 95% CI=1.22–2.0) healthcare quality and richer wealth status (AOR=1.72; 95% CI=1.08–2.73) were associated with higher odds of willingness to join the scheme.

Conclusion

As The study revealed that level of willingness to join is lower compared to other studies. Therefore, social protection activities for the low-income population and enhancement of the capacity of health facilities are crucial.

Willingness to Pay for Community-Based Health Insurance Scheme and Associated Factors Among Rural Communities in Gemmachis District, Eastern Ethiopia

Background

In sub-Saharan Africa, out-of-pocket expenditures constitute approximately 40% of total healthcare expenditures, imposing huge financial burdens on the poor. To tackle the effects of out-of-pocket payment for healthcare services, Ethiopia has been focusing on implementation and expansion of a community-based health insurance (CBHI) program since 2011. This study assessed willingness to pay for CBHI scheme and associated factors among rural communities in Gemmachis district, eastern Ethiopia.

Methods

Community-based cross-sectional study was conducted among 446 randomly selected participants in Gemmachis district from April 1 to April 30, 2019. Data were collected from participants using pretested structured questionnaires through face-to-face interview. Data were entered into EpiData version 3.1 and analyzed using SPSS version 24. Bivariable and multivariable logistic regression analyses were conducted to identify factors associated with willingness to pay for CBHI.

Results

A total of 440 (98.7%) participants were involved in the study. Three in every four (74.8%) participants were willing to pay for CBHI (95% CI: 70.7%, 78.9%). Primary education (AOR=5.1, 95% CI: 2.4, 11.1), being merchant (AOR=0.23, 95% CI: 0.10, 0.51), housewife (AOR=3.8, 95% CI: 1.3, 11.0), poor (AOR=2.5, 95% CI: 1.3, 4.7), illness in the last one year (AOR=3.1, 95% CI, 1.9, 5.2), good knowledge about CBHI (AOR=2.3, 95% CI: 1.5, 3.6) and access to public health facility (AOR=2.0,95% CI: 1.1, 3.7) were all significantly associated with willingness to pay for CBHI.

Conclusion

A significant proportion of participants were willing to pay for CBHI scheme. Education, occupation, wealth status, illness in the last one year, knowledge about CBHI and access to healthcare facility were factors significantly associated with willingness to pay for CBHI. If the scheme is to serve as a means to provide access to health service, the premium for membership should be tailored and customized by individual socioeconomic factors.

Acceptance of the proposed social health insurance among government-owned company employees in Northwest Ethiopia: implications for starting social health insurance implementation

BACKGROUND

Ethiopia is currently planning to introduce Social Health Insurance (SHI) that will lead to universal health coverage and assist a country to achieve its health system's objectives and to prevent the catastrophic health expenditure. But there is no evidence until now about the level of acceptance of the proposed SHI among government-owned companies' employees. Therefore, this study was intended to assess the acceptance of SHI and associated factors among government-owned companies' employees in northwest Ethiopia.

METHODS

An institution-based cross-sectional study was conducted from February 1 to April 30, 2019. A randomly selected 541 government-owned companies' employees were participated in the study. A pretested self-administered structured questionnaire was used that consisted sociodemographic and economic, health status-related factors, attitude (measured by 12 items), organizational related factors and knowledge about SHI (measured by 11 items). Finally, binary logistic regression analysis was performed and in the multivariable logistic regression analysis, a significant level at a p-value of < 0.05 and Adjusted Odds Ratio (AOR) with 95% confidence interval (CI) were used to identify factors statistically associated with SHI acceptance.

RESULTS

Overall, 32% (95% CI: 27.7-36.2) of the government-owned companies' employees accepted the proposed Ethiopian SHI scheme. Self-perceived health status (AOR: 8.55, 95% CI: 2.69-27.13), heard about SHI (AOR: 1.69, 95% CI: 1.12-2.54), coverage of medical healthcare cost (AOR: 0.60, 95% CI: 0.39-0.92), work experience (AOR: 0.49, 95% CI: 0.26-0.89) and quality of healthcare service at the facilities (AOR: 0.17, 95% CI: 0.04-0.71) were significantly associated with acceptance of SHI among government-owned companies' employees.

CONCLUSIONS

One-third of the study participants accepted the proposed Ethiopian SHI scheme. Self-perceived health status, quality of healthcare service at health facilities, coverage of the medical cost by their organization, heard about SHI and work experience were the factors that affect acceptance of the proposed SHI among the government-owned company employees. Therefore, policymakers should devise a plan to promote the benefit packages of SHI for the formal sector employees to start the implementation.

Determinants of enrollment in community based health insurance among Households in Tach-Armachiho Woreda, North Gondar, Ethiopia, 2019

BACKGROUND

Recently in Ethiopia, there is an increasing movement to implement community based health insurance scheme as integral part of health care financing and remarkable movements has resulted in the spread of the scheme in different parts of the country. Despite such increasing effort, recent empirical evidence shows enrolment has remained low. To identify determinants of enrollment in community based health insurance among households in Tach-Armachiho Woreda, North Gondar, Ethiopia, 2019.

METHODS

A community based unmatched case control study was conducted Tach-Armachiho Woreda from March to May 2019 among 262 participants (88 cases and 174 controls with case control ratio of 1:2). Study subjects were selected using multi-stage sampling technique. Data were collected using a pretested, structured interviewer administered questioner. Data were entered to Epi-info 7 and exported to SPSS version 20 for analysis. Bivariable and multivariable logistic regression model were used to see the determinants of enrollment in community based health insurance. Adjusted odds ratio with 95% CI at p-value <0.05 in multivariable logistics regression analysis factors were identified as statistically significantly associated.

RESULT

Female headed households (AOR = 2.79, 95% CI = 1.16, 6.69), Increase in Age (AOR = 1.09, 95% CI = 1.05, 1.13) and negative perception towards community based health insurance (AOR = 0.062, 95% CI = .030, .128) were found to be significant predictors.

CONCLUSION

This study provides evidence that the decision to enroll in the scheme is shaped by age and a combination of household head sex and perception towards community based health insurance. Implementers aimed at enhancing enrolment ought to act on the bases of this findings.

Enrollment in community based health insurance program and the associated factors among households in Boricha district, Sidama Zone, Southern Ethiopia; a cross-sectional study

Background

In absence of any form of health insurance, out-of-pocket payments for health care lead to decreased use of health services and catastrophic health expenditures. Community-based health insurances has been promised financial model for informal sectors to reduce these problems in many countries. When this comes down to Ethiopia, in the South Nation Nationality People’s Region of the country established 52 schemes including Boricha district, the study area However, there has been little evidence about the enrollment status and the associated factors in the study area in particular elsewhere in general.

Objective

The study aims to assess the current enrollment status of households in community based health insurance and the associated factors in Boricha district of Sidama Zone, Southern Ethiopia.

Methods and materials

A community based cross-sectional study design was employed from February 01, 2019 to March 31, 2019, using a sample of 632 households. Data were collected using interviewer-administered pre-tested questionnaire and entered into EPI-Info 7and transported to SPSSversion20 for analysis. Multi-variable logistic regression analysis along with odds ratio and the corresponding 95% CI was conducted and significance was declared at P-value <0.05.

Results

Current enrollment status of households in community based health insurance was found to be 81 (12.8%). According to this study, educational status; secondary school& above[AOR = 2.749, 95%CI(1.142, 6.618)], timing of collecting premium [AOR = 0.433; 95% CI (0.196, 0.958)], family size ≥5, [AOR = 4.16;95%CI (1.337, 12.944)], no trust on scheme management[AOR = 0.272; 95%CI (0.140, 0.528)], lack of information [AOR = 0.086; 95%CI (0.026, 0.288)], dissatisfaction with health care service received[AOR = 0.303; 95%CI (0.171, 0.537)], no chronic illness in the family[AOR = 0.259; 95%C.I.(0.137, 0.488)] were factors significantly associated with current enrollment status in CBHI.

Conclusions

Households head’s education status, timing of premium collection, family size, no trust on scheme management, lack of information, services dissatisfaction and chronic illness in the family member were the identified factors associated with enrollment in CBHI in the study area. Therefore, to enhance the enrollment and sustainability of CBHI in the study area awareness creation, improving timing of premium collection, strengthening scheme management, improving quality of service are the areas that decision makers needs to intervene.

Willingness to Join and Pay for Community-Based Health Insurance Among Rural Households of Selected Districts of Jimma Zone, Southwest Ethiopia

BACKGROUND

Globally, millions of people suffer and die because they do not have the money to pay for health care. A voluntary health insurance scheme is a prepayment mechanism to overcome the financial hardship of poor households. There is a high demand to determine the enrolment rate and ability to pay before scale-up of the scheme by the government to be sure of its feasibility and sustainability.

OBJECTIVE

To determine willingness to join and pay for a community-based health insurance scheme and associated factors among rural households of selected districts in Jimma Zone, 2018.

METHODS

A community-based cross-sectional study design was employed in selected districts of Jimma Zone, Ethiopia. Multistage simple random sampling was used to select 422 households. Data were collected using a semi-structured interviewer-administered questionnaire. A double bounded contingent valuation method was applied to elicit households' willingness to pay for the scheme. Data were entered into Epi-Data 3.1 and analyzed with SPSS V.23. A binary logistic regression model was fitted to determine the presence of statistically significant associations between the dependent and independent variables at p-value <0.05 and AOR values with 95% CI.

RESULTS

Of 422 sampled respondents, 389 participated in this study with a response rate of 92%. Of these, 305 (78%) were willing to join and 274 (90%) of them were willing to pay. The average amount of money the households were willing to pay per household per annum was 228 ETB (8.27 USD), with a range of 100-500 ETB. The older age groups, poor households, and experience of local risk-sharing schemes were found to be determinants for willingness to join the community-based health insurance. Similarly, having a large family size, and low economic and education status of households were significant predictors of willingness to pay for this scheme.

CONCLUSION

A high proportion of households were willing to join and pay for the CBHI scheme. The average amount of money they were willing to pay for the scheme was very slightly lower than what is planned by the government. Thus, the government of Ethiopia should strengthen efforts to scale up this scheme in the rural areas of the country specifically to districts not yet enrolled, to reduce direct out-of-pocket payment at service delivery points. This will also contribute to guaranteeing dwellers of rural areas access to quality health services without facing financial hardship, to achieve universal health coverage for all by the end of 2035.

Prevalence and determinants of Acute Lower Respiratory Infections among children under-five years in sub-Saharan Africa: Evidence from demographic and health surveys

Acute Lower Respiratory Infections (ALRIs) account for 5.8 million deaths globally and 50% of these deaths occur in sub-Saharan Africa. In this paper, we examined the prevalence and determinants of ALRIs among children under-five years in 28 sub–Saharan African countries. We used data from the most recent (2011–2016) Demographic and Health Surveys of the 28 countries. Women aged 15–49 (N = 13,495) with children under-five years participated in the study. Data were extracted and analysed using STATA version 14.2. Bivariate and multivariate analyses were done to establish associations between the outcome and explanatory variables. The prevalence of ALRI for all the countries was 25.3%. Congo (39.8%), Gabon (38.1%), Lesotho (35.2%), and Tanzania (35.2%) were the countries with the highest prevalence of ALRIs. The results from the multivariate analyses showed that children aged 24–59 months (AOR = 1.15; 95% CI = 1.04–1.28), and children who received intestinal parasite in the 6 months preceding the survey (AOR = 1.11; 95% CI = 1.02–1.22) had higher odds of developing ALRIs. However, children whose mothers were employed (AOR = 0.77; 95% CI = 0.64–0.94) and those whose households used improved toilet facilities (AOR = 0.72; 95% CI = 0.64–0.97) had lower odds of contracting ALRIs. Our findings underscore the need for stakeholders in health in the various sub-Saharan African countries, especially those worst affected by ALRIs to implement programmes and develop policies at different levels aimed at reducing infections among children under-five years. Such strategies should specifically focus on improving the administration of medications for intestinal worms, health education to mothers with children under five on ALRIs and improving the sanitation situations of households through the provision of improved toilet facilities.

•

We examined the prevalence and determinants of Acute Lower Respiratory Infections (ALRIs) among children under-five years in sub–Sahara Africa.

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ALRIs account for 5.8 million deaths globally.

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The prevalence of ALRI is 25.3% in sub-Sahara Africa.

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Children aged 24–59 months had higher odds of developing ALRIs.

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Employed mothers and improved toilet facility are protective factors against ALRIs.

Moving towards universal health coverage for mental disorders in Ethiopia

BACKGROUND

People with mental disorders in low-income countries are at risk of being left behind during efforts to expand universal health coverage.

AIMS

To propose context-relevant strategies for moving towards universal health coverage for people with mental disorders in Ethiopia.

METHODS

We conducted a situational analysis to inform a SWOT analysis of coverage of mental health services and financial risk protection, health system characteristics and the macroeconomic and fiscal environment. In-depth interviews were conducted with five national experts on health financing and equity and analysed using a thematic approach. Findings from the situation analysis and qualitative study were used to develop recommended strategies for adequate, fair and sustainable financing of mental health care in Ethiopia.

RESULTS

Opportunities for improved financing of mental health care identified from the situation analysis included: a significant mental health burden with evidence from strong local epidemiological data; political commitment to address that burden; a health system with mechanisms for integrating mental health into primary care; and a favourable macro-fiscal environment for investment in human capabilities. Balanced against this were constraints of low current general government health expenditure, low numbers of mental health specialists, weak capacity to plan and implement mental health programmes and low population demand for mental health care. All key informants referred to the under-investment in mental health care in Ethiopia. Respondents emphasised opportunities afforded by positive rates of economic growth in the country and the expansion of community-based health insurance, as well as the need to ensure full implementation of existing task-sharing programmes for mental health care, integrate mental health into other priority programmes and strengthen advocacy to ensure mental health is given due attention.

CONCLUSION

Expansion of public health insurance, leveraging resources from high-priority SDG-related programmes and implementing existing plans to support task-shared mental health care are key steps towards universal health coverage for mental disorders in Ethiopia. However, external donors also need to deliver on commitments to include mental health within development funding. Future researchers and planners can apply this approach to other countries of sub-Saharan Africa and identify common strategies for sustainable and equitable financing of mental health care.

Willingness to pay for community-based health insurance and associated factors among rural households of Bugna District, Northeast Ethiopia

OBJECTIVE

Community based health insurance schemes are becoming recognized as powerful method to achieve universal health coverage and reducing the financial catastrophic shock of the community. Therefore, this study aimed to assess willingness to pay for community-based health insurance and associated factors among rural households of Bugna District, Ethiopia.

RESULTS

A total of 532 study participants were included in the study. The finding indicated that 77.8% of the households were willing to pay for the community-based health insurance. The average amount of money the households were willing to pay per household per annum was 233 ETB ($11.12 USD). The result of the study also revealed that attending formal education[ß = 3.20; 95% CI = 1.87, 4.53], history of illness [ß = 2.52; 95% CI = 1.29, 3.75], household size [ß = 0.408; 95% CI = 0.092, 0.724], awareness about the scheme [ß = 2.96; 95% CI = 1.61, 4.30], and wealth status [ß = 5.55; 95% CI = 4.19, 6.90] were factors significantly associated with willingness to pay. Therefore, enhancing awareness of the community about the scheme, considering the amount of premium as per household family size and wealth status might increase household's willingness to pay for community-based health insurance.

Willingness to join community based health insurance and its determinants in East Gojjam zone, Northwest Ethiopia

Objective

The main purpose of this research was to determine the magnitude of willingness to join to community based health insurance (CBHI) and to identify factors associated with it.

Results

A total of 604 study participants responded for the interviews, making the response rate 98.2%. All in all, 492 (81.5%) of the study participant households were willing to join the CBHI scheme. Households which had experience of borrowing for medical expenses within the last 12 months prior to the study were 2.7 times more likely to join CBHI scheme than those who didn’t have borrowed (AOR = 2.65; 95% CI 1.03, 6.83). Female headed households were 2.7 times more likely to take up the scheme compare to male headed households (AOR = 2.74; 95% CI 1.18, 6.37). High proportion of households was willing to join the CBHI scheme in the study area. Educational status of household head, experience of borrowing for medical expenses, sex of household head, household animal asset as measured by tropical livestock unit were factors found to be associated with willingness to take up CBHI scheme.

Willingness to pay for social health insurance and its determinants among public servants in Mekelle City, Northern Ethiopia: a mixed methods study

Background

Owing to lack of adequate healthcare financing, access to at least the basic health services is still a problem in Ethiopia. With the intention of raising funds and ensuring universal health coverage, a mandatory health insurance scheme has been introduced. The Community Based Health Insurance has been implemented in all regions of the country, while implementation of social health insurance was delayed mainly due to resistance from public servants. This study was, therefore, aimed to assess willingness to pay for social health insurance and its determinant factors among public servants in Mekelle city, Northern Ethiopia.

Methods

A concurrent mixed approach of cross-sectional study design using double bound dichotomous choice contingent valuation method and qualitative focus group discussions was employed. A total 384 public servants were recruited from randomly selected institutions and six focus group discussions (n = 36) were carried out with purposively selected respondents. Participants’ mean willingness to pay (WTP) and independent predictors of WTP were identified using an interval data logit model. Qualitative data were analyzed using thematic analysis.

Results

From the 384 participants, 381 completed the interview, making a response rate of 99.2%. Among these respondents 85.3% preferred social health insurance and were willing to pay for the scheme. Their estimated mean WTP was 3.6% of their monthly salary. Lack of money to pay (42.6%) was the major stumbling block to enrolling in the scheme. Respondents’ WTP was significantly positively associated with their level of income but their WTP decreased with increasing age and educational status. On the other hand, a majority of focus group discussion participants were not willing to pay the 3% premium set by the government unless some preconditions were satisfied. The amount of premium contribution, benefit package and poor quality of health service were the major factors affecting their WTP.

Conclusion

The majority of the public servants were willing to be part of the social health insurance scheme, with a mean WTP of 3.6% of their monthly salary. This was greater than the premium proposed by the government (3%). This can pave the way to start the scheme but attention should focus on improving the quality of health services.

Electronic supplementary material

The online version of this article (10.1186/s12962-019-0171-x) contains supplementary material, which is available to authorized users.

Adverse selection and supply-side factors in the enrollment in community-based health insurance in Northwest Ethiopia: A mixed methodology

BACKGROUND

Since 2010, the Ethiopian government introduced different measures to implement community-based health insurance (CBHI) schemes to improve access to health service and reduce the catastrophic effect of health care costs.

OBJECTIVES

The aim of this study was to examine the determinants of enrollment in CBHI in Northwest Ethiopia.

METHODS

In this study, we utilized a mix of quantitative (multivariate logistic regression applied to population survey linked with health facility survey) and qualitative (focus group discussion and in-depth interview) methods to better understand the factors that affect CBHI enrollment.

RESULTS

The study revealed important factors, such as household, informal association, and health facility, as barriers to CBHI enrollment. Age and educational status, self-rated health status, perceived quality of health services, knowledge, and information (awareness) about CBHI were among the characteristics of individual household head, affecting enrollment. Household size and participation in an informal association, such as local credit associations, were also positively associated with CBHI enrollment. Additionally, health facility factors like unavailability of laboratory tests were the main factor that hinders CBHI enrollment.

CONCLUSIONS

This study showed a possibility of adverse selection in CBHI enrollment. Additionally, perceived quality of health services, knowledge, and information (awareness) are positively associated with CBHI enrollment. Therefore, policy interventions to mitigate adverse selection as well as provision of social marketing activities are crucial to increase enrollment in CBHI. Furthermore, policy interventions that enhance the capacity of health facilities and schemes to provide the promised services are necessary.

An in-depth investigation of the causes of persistent low membership of community-based health insurance: a case study of the mutual health organisation of Dar Naïm, Mauritania

BACKGROUND

Persistent low membership is observed in many community-based health insurance (CBHI) schemes in Africa. Causes for low membership have been identified and solutions suggested, but this did not result in increased membership. In this case study of the mutual health organisation of Dar Naïm in Mauritania we explore the underlying drivers that may explain why membership continued to stagnate although several plans for change had been designed.

METHODS

We used a systems approach focussed on processes, underlying dynamics and complex interactions that produce the outcomes, to delve into 10 years of data collected between 2003 and 2012. We used qualitative research methods to analyse the data and interpret patterns.

RESULTS

Direct causes of stagnation and possible solutions had been identified in the early years of operations, but most of the possible solutions were not implemented. A combination of reasons explains why consecutive action plans were not put into practice, showing the complexity of implementation and the considerable management capacity required, as well as the challenges of integrating a novel organisational structure into exiting social structures.

CONCLUSIONS

For any CBHI project aiming at high membership, skilled professional management seems essential, with capacity to question and adapt routine procedures and interpret interactions within the wider society. Countries that include community-based health insurance in their strategic plan towards universal coverage will have to pay more attention to management capacity and the minutiae of implementation.

Community-based health insurance and communities' scheme requirement compliance in Thehuldere district, northeast Ethiopia: cross-sectional community-based study

BACKGROUND

Community-based health insurance (CBHI) is becoming a prominent and promising concept in tackling financial health care issues confronting the poor rural communities in developing countries. Ethiopia endorsed and constituted CBHI schemes in 13 pilot "woredas" in 2010/11. This study aimed to assess the compliance of the community to CBHI scheme requirements in Thehuledere district, northeast Ethiopia.

METHODS

A community-based cross-sectional study was conducted among 530 respondents between April and June 2015 in Thehuledere District, South Wollo Zone, northeast Ethiopia. A systematic random sampling technique was deployed to select the study participants. A self-administered, structured, pre-tested questionnaire was used to collect the data. Bivariate and multivariate logistic regression analyses were used to identify factors associated with CBHI compliance.

RESULTS

A total of 511 study participants were included in the study. Approximately 77.9% of the study population complied with CBHI requirements: members' age (AOR = 0.74, 95% CI: 0.62-0.8), premium fee affordability (AOR: 2.66, 95% CI: [1.13-4.42]), members' occupation (AOR = 0.14, 95% CI: 0.04-0.45), members' attitude toward CBHI management (AOR = 2.11 [1.14-3.90]), and CBHI members' knowledge (AOR = 0.24, 95% CI: [0.13-0.42]) were found to be major predictors of community compliance to CBHI requirements.

CONCLUSION

CBHI requirement compliance at the early stage was relatively high. We observed that members' age, premium fee affordability, occupation, attitude, and knowledge were significant predictors. CBHI management's involvement in awareness creation and training on requirements of the CBHI scheme would contribute to better outcomes and success.

Inequitable Access to Health Care by the Poor in Community-Based Health Insurance Programs: A Review of Studies From Low- and Middle-Income Countries

The poor lack equitable access to health care in community-based health insurance schemes. Flexible installment payment plans, subsidized premiums, and elimination of co-pays can increase enrollment and use of health services by the poor.

Background:

Out-of-pocket payments for health care services lead to decreased use of health services and catastrophic health expenditures. To reduce out-of-pocket payments and improve access to health care services, some countries have introduced community-based health insurance (CBHI) schemes, especially for those in rural communities or who work in the informal sector. However, there has been little focus on equity in access to health care services in CBHI schemes.

Methods:

We searched PubMed, Web of Science, African Journals OnLine, and Africa-Wide Information for studies published in English between 2000 and August 2014 that examined the effect of socioeconomic status on willingness to join and pay for CBHI, actual enrollment, use of health care services, and drop-out from CBHI. Our search yielded 755 articles. After excluding duplicates and articles that did not meet our inclusion criteria (conducted in low- and middle-income countries and involved analysis based on socioeconomic status), 49 articles remained that were included in this review. Data were extracted by one author, and the second author reviewed the extracted data. Disagreements were mutually resolved between the 2 authors. The findings of the studies were analyzed to identify their similarities and differences and to identify any methodological differences that could account for contradictory findings.

Results:

Generally, the rich were more willing to pay for CBHI than the poor and actual enrollment in CBHI was directly associated with socioeconomic status. Enrollment in CBHI was price-elastic—as premiums decreased, enrollment increased. There were mixed results on the effect of socioeconomic status on use of health care services among those enrolled in CBHI. We found a high drop-out rate from CBHI schemes that was not related to socioeconomic status, although the most common reason for dropping out of CBHI was lack of money to pay the premium.

Conclusion:

The effectiveness of CBHI schemes in achieving universal health coverage in low- and middle-income countries is questionable. A flexible payment plan where the poor can pay in installments, subsidized premiums for the poor, and removal of co-pays are measures that can increase enrollment and use of CBHI by the poor.

Barriers and facilitators to enrollment and re-enrollment into the community health funds/Tiba Kwa Kadi (CHF/TIKA) in Tanzania: a cross-sectional inquiry on the effects of socio-demographic factors and social marketing strategies

BACKGROUND

Introduction of a health insurance scheme is one of the ways to enhance access to health care services and to protect individuals from catastrophic health expenditures. Little is known on the influence of socio-demographic and social marketing strategies on enrollment and re-enrollment in the Community Health Fund/Tiba Kwa Kadi (CHF/TIKA) in Tanzania.

METHODS

This cross-sectional study employed quantitative methods for data collection between November 2014 and March 2015 in Singida and Shinyanga regions. Relationship between variables was obtained through Chi-square test and multivariate logistic regression.

RESULTS

We recruited 496 participants in the study. Majority (92.7%) of participants consented to participate, with 229 (49.8%) and 231 (50.2%) members and non members of CHF/TIKA respectively. Majority (90.9%) were aware of CHF/TIKA. Majority of CHF/TIKA members and non-members (90% and 68.3% respectively) reported health facility-based sensitization as the most common social marketing approach employed to market the CHF/TIKA. The most popular marketing strategies in the country including traditional dances, football games, radio, television, news papers, and mosques/church were reported by few CHF and non CHF members. Multivariate Logistic regression models revealed no significant association between social marketing strategies and enrollment, but only socio-demographics; including marital status (AOR = 2.0, 95% CI 1.1-3.8) and family size (household with ≥ 6 members) (AOR = 1.5, 95% CI 1.0-2.5), were significant factors associated with enrollment/re-enrollment rate.

CONCLUSIONS

This study indicated that low level of utilization of available social marketing strategies and socio-demographic factors are the barriers for attracting members to join the schemes. There is a need for applying various social marketing strategies and considering different facilitating and impending socio-demographic factors for the growth and sustainability of the scheme as we move towards universal health coverage.

A socio-ecological perspective of access to and acceptability of HIV/AIDS treatment and care services: a qualitative case study research

Background

Access to healthcare is an essential element of health development and a fundamental human right. While access to and acceptability of healthcare are complex concepts that interact with different socio-ecological factors (individual, community, institutional and policy), it is not known how these factors affect HIV care. This study investigated the impact of socio-ecological factors on access to and acceptability of HIV/AIDS treatment and care services (HATCS) in Wolaita Zone of Ethiopia.

Method

Qualitative case study research was conducted in six woredas (districts). Focus group discussions (FGDs) were conducted with 68 participants in 11 groups (six with people using antiretroviral therapy (ART) and five with general community members). Key informant interviews (KIIs) were conducted with 28 people involved in HIV care, support services and health administration at different levels. Individual in-depth interviews (IDIs) were conducted with eight traditional healers and seven defaulters from (ART). NVIVO 10 was used to assist qualitative content data analysis.

Results

A total of 111 people participated in the study, of which 51 (45.9 %) were male and 60 (54.1 %) were female, while 58 (53.3 %) and 53 (47.7 %) were urban and rural residents, respectively. The factors that affect access to and acceptability of HATCS were categorized in four socio-ecological units of analysis: client-based factors (awareness, experiences, expectations, income, employment, family, HIV disclosure and food availability); community-based factors (care and support, stigma and discrimination and traditional healing); health facility-based factors (interactions with care providers, availability of care, quality of care, distance, affordability, logistics availability, follow up and service administration); and policy and standards (healthcare financing, service standards, implementation manuals and policy documents).

Conclusions

A socio-ecological perspective provides a useful framework to investigate the interplay among multilevel and interactive factors that impact on access to and acceptability of HATCS such as clients, community, institution and policy. Planners, resource allocators and implementers could consider these factors during planning, implementation and evaluation of HATCS. Further study is required to confirm the findings.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-2830-6) contains supplementary material, which is available to authorized users.

Willingness-to-Pay for Community-Based Health Insurance among Informal Workers in Urban Bangladesh

INTRODUCTION

Reliance on out-of-pocket payment for healthcare may lead poor households to undertake catastrophic health expenditure, and risk-pooling mechanisms have been recommended to mitigate such burdens for households in Bangladesh. About 88% of the population of Bangladesh depends on work in the informal sector. We aimed to estimate willingness-to-pay (WTP) for CBHI and identify its determinants among three categories of urban informal workers rickshaw-pullers, shopkeepers and restaurant workers.

METHODS

The bidding game version of contingent valuation method was used to estimate weekly WTP. In three urban locations 557 workers were interviewed using a structured questionnaire during 2010 and 2011. Multiple-regression analysis was used to predict WTP by demographic and household characteristics, occupation, education level and past illness.

RESULTS

WTP for a CBHI scheme was expressed by 86.7% of informal workers. Weekly average WTP was 22.8 BDT [Bangladeshi Taka; 95% confidence interval (CI) 20.9-24.8] or 0.32 USD and varied significantly across occupational groups (p = 0.000) and locations (p = 0.003). WTP was highest among rickshaw-pullers (28.2 BDT or 0.40 USD; 95% CI: 24.7-31.7), followed by restaurant workers (20.4 BDT 0.29 USD; 95% CI: 17.0-23.8) and shopkeepers (19.2 BDT or 0.27 USD; 95% CI: 16.1-22.4). Multiple regression analysis identified monthly income, occupation, geographical location and educational level as the key determinants of WTP. WTP increased 0.196% with each 1% increase in monthly income, and was 26.9% lower among workers with up to a primary level of education versus those with higher than primary, but less than one year of education.

CONCLUSION

Informal workers in urban areas thus are willing to pay for CBHI and socioeconomic differences explain the magnitude of WTP. The policy maker might think introducing community-based model including public-community partnership model for healthcare financing of informal workers. Decision making regarding the implementation of such schemes should consider worker location and occupation.