Magnitude and Determinants of Dropout from Community-Based Health Insurance Among Households in Manna District, Jimma Zone, Southwest Ethiopia

Machine learning to predict unintended pregnancy among reproductive-age women in Ethiopia: evidence from EDHS 2016

BACKGROUND

An unintended pregnancy is a pregnancy that is either unwanted or mistimed, such as when it occurs earlier than desired. It is one of the most important issues the public health system is currently facing, and it comes at a significant cost to society both economically and socially. The burden of an undesired pregnancy still weighs heavily on Ethiopia. The purpose of this study was to assess the effectiveness of machine learning algorithms in predicting unintended pregnancy in Ethiopia and to identify the key predictors.

METHOD

Machine learning techniques were used in the study to analyze secondary data from the 2016 Ethiopian Demographic and Health Survey. To predict and identify significant determinants of unintended pregnancy using Python software, six machine-learning algorithms were applied to a total sample of 7193 women. The top unplanned pregnancy predictors were chosen using the feature importance technique. The effectiveness of such models was evaluated using sensitivity, specificity, accuracy, and area under the curve.

RESULT

The ExtraTrees classifier was chosen as the top machine learning model after various performance evaluations. The region, the ideal number of children, religion, wealth index, age at first sex, husband education, refusal sex, total births, age at first birth, and mother's educational status are identified as contributing factors in that predict unintended pregnancy.

CONCLUSION

The ExtraTrees machine learning model has a better predictive performance for identifying predictors of unintended pregnancies among the chosen algorithms and could improve with better policy decision-making in this area. Using these important features to help direct appropriate policy can significantly increase the chances of mother survival.

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.

Patient satisfaction and associated factors among insured and uninsured patients in Deder General Hospital, eastern Ethiopia: a facility-based comparative cross-sectional study

Background

Patient satisfaction is a crucial measure of healthcare quality, as dissatisfied patients are more likely to miss appointments, disregard treatment plans, and leave hospitals, leading to poor treatment outcomes. Therefore, the study aimed to compare levels of satisfaction with health services and associated factors among insured and uninsured patients in Deder General Hospital, eastern Ethiopia.

Methods

A comparative cross-sectional study with 532 participants was conducted from December 1-30, 2021. Data was collected through a structured questionnaire, analyzed using SPSS, and predictors assessed using a multivariate logistic regression model. Statistical significance was set at p < 0.05.

Results

Overall, patient satisfaction with health services was 65.6% (95% CI: 61.5-69.5), and the level of patient satisfaction with health services among insured and noninsured patients was 68.8% (95% CI: 62.8-74.4) and 62.4% (95% CI: 56.8-68.0), respectively. In the final model of multivariable analysis, factors such as educational status of secondary school (AOR = 4.90; 95% CI: 2.05-11.76), and a higher level (AOR = 3.08; 95% CI: 1.05-9.03), getting the entire prescribed drugs (AOR = 3.49; 95% CI: 1.43-8.54), getting some of the ordered drugs (AOR = 3.34; 95% CI: 1.61-6.94), paying less than 100 Ethiopian birrs (AOR = 4.85; 1.35-17.40) were significantly associated with patient satisfaction among insured patients. Whereas getting the entire and some prescribed drugs were (AOR = 6.28; 95% CI: 3.26-12.05), and (AOR = 3.40; 95% CI: 1.70-6.78) times more likely to be satisfied with the service among noninsured patients as compared to their counterparts, respectively.

Conclusion

The study found that about six in 10 patients in the study area were satisfied with healthcare services, with insurance patients reporting higher satisfaction. Factors such as receiving prescribed drugs, paying less than 100 Ethiopian birr, having a secondary school education, and having a higher education were associated with satisfaction.

Dropout rate and associated factors of community-based health insurance beneficiaries in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Ethiopia aims to achieve universal healthcare using health insurance. To do so, it has been implementing community-based health insurance since 2011. However, the retention of members by the scheme has not yet been evaluated nationally. The systematic review and meta-analysis aimed to evaluate the dropout rate and associated factors among the scheme's beneficiaries in Ethiopia.

METHODS

On December 19, 2022, searches were conducted in Scopus, Hinari, PubMed, Semantic Scholar, and Google Scholar. Searches were also conducted on the general web and electronic repositories, including the Ethiopian Health Insurance Service, the International Institute for Primary Health Care-Ethiopia, and various higher education institutions. The Joanna Briggs Institute's tools and the "preferred reporting items for systematic reviews and meta-analyses 2020 statement" were used to evaluate bias and frame the review, respectively. Data were analyzed using Stata 17 and RevMan 5. To assess heterogeneity, we conducted subgroup analysis and used a random model to calculate odds ratios with a p value less than 0.05 and a 95% CI.

RESULTS

In total, 14 articles were included in the qualitative synthesis, of which 12 were selected for the quantitative analysis. The pooled estimate revealed that the dropout rate of beneficiaries from the scheme was 34.0% (95% CI: 23-44%), provided that the renewal rate was 66.0%, and was found to be influenced by socio-demographic, health status, length of enrolment, knowledge, attitude, the scheme, and health service-related variables. The southern and Oromia regions reported the lowest and highest dropout rates, with 27.0% (95% CI: 24-29%) and 48.0% (95% CI: 18-78%), respectively. The dropout rates increased from 12.3% in 2012-2015 to 34.4% in 2020-2021.

CONCLUSION

More than one-third of the scheme's beneficiaries were found to have dropped out, and this has been found to increase over time, dictating that a community-based strategy and intervention, from the supply, insurer, and demand sides, seem indispensable in minimizing this huge dropout rate.

Whether or not to enroll, and stay enrolled? A Tanzanian cross-sectional study on voluntary health insurance

Lower-middle income countries (LMICs) have invested significant effort into expanding insurance coverage as a means of improving access to health care. However, it has proven challenging to fulfill these ambitions. This study investigates to what extent variables associated with the enrollment decision (stay never-insured or enroll) differ from variables associated with the dropout decision (stay insured or drop out). A cross-sectional survey that included 722 households from rural districts in Tanzania was conducted and multinomial logistic regressions were performed to determine the associations between independent variables and membership status (never-insured, dropouts, or currently insured). Both the decision to enrollment and the decision to drop out were significantly associated with the presence of chronic disease and perceptions about the quality of services provided, insurance scheme management, and traditional healers. The effect of other variables, such as age, gender and educational level of the household head, household income, and perceptions about premium affordability and benefit-premium ratios, varied across the two groups. To improve voluntary health insurance coverage, policymakers must simultaneously increase the enrollment rate among the never-insured and reduce the dropout rate among the insured. Our conclusions suggest that policies to increase insurance scheme enrollment rates should differ for the two uninsured groups.

Causes of dropout from health insurance program: An experience from Lumbini Province, Nepal

The Health Insurance Program (HIP) in Nepal is experiencing low enrolment and high dropout rates, but the causes of these issues have remained unknown. This study aimed to explore the causes of dropouts of the HIP implemented by the Health Insurance Board, Nepal. We employed an exploratory qualitative research design. We purposefully selected the informants for the data collection who had previously enrolled and currently not renewed their insurance scheme. We gathered qualitative information from 16 in-depth interviews, four key informant interviews, and four focus group discussion in Palpa and Bardia Districts of Lumbini Province, Nepal. The qualitative data were analyzed using thematic analysis. We identified two major themes and nine drop-out-related sub-themes. These were: unnecessary health insurance; negligence to renew; unable to pay the contribution amount; poor cooperation between institutions as well as insurees and insurers; limited coverage and ceiling amount; rigid processes to receive health services; health professionals' behaviors; poor quality healthcare services; inadequate information. Dropout-related factors were associated with personal or individual factors and institutional or policy-related (process-related) factors. The major causes/reasons for dropout include lengthy procedures, poor quality and unsatisfactory services, a lack of knowledge on health insurance norms and procedures, and health professionals' behavior towards insurees during treatment. Information, education, and communication programs related to health insurance are still necessary to make the insurees familiar with the insurance systems and its processes. These factors could be taken into account by policymakers while planning interventions to minimize the low enrollment and high dropout.

Assessing the Determinants of Compliance with Contribution Payments to the National Health Insurance Scheme among Informal Workers in Indonesia

This study aimed to investigate the determinants of compliance with contribution payments to the National Health Insurance (NHI) scheme among informal workers in Bogor Regency, West Java Province, Indonesia. Surveys of 418 informal workers in Bogor Regency from April to May 2023 were conducted. Multivariate logistic regression analyses were performed to assess the factors associated with informal workers' compliance with NHI contribution payments. The results revealed that being female, having lower secondary education or below, perceiving good health of family members, having negative attitudes toward and poor knowledge of the NHI, experiencing financial difficulties, preferring to visit health facilities other than public ones, and utilizing fewer outpatient services were significantly associated with the noncompliance of informal workers with NHI contribution payments. It was concluded that economic factors alone cannot contribute to informal workers' payment compliance and that motivational factors (knowledge, attitudes toward the insurance system, and self-related health status) also encourage them to comply with contribution payments. Improving people's knowledge, especially on the risk-sharing concept of the NHI, should be done through extensive health insurance education using methods that are appropriate for the population's characteristics.

Effectiveness and impact of community-based health insurance on health service utilization in northwest Ethiopia: a quasi-experimental evaluation

Background

Addressing the health challenges of lower socioeconomic groups in Ethiopia is still a huge problem. In that regard, the government piloted the community-based health insurance (CBHI) in 2011 in a few districts and subsequently scaled up. However, the effectiveness of the program on the utilization of health services and its impact was not well explored. Thus, we aimed to evaluate the effectiveness of CBHI toward health services' utilization and its impact in northwest Ethiopia.

Methods

A quasi-experimental matched comparison group evaluation design with sequential explanatory mixed methods was employed. To evaluate the CBHI program, the effectiveness and impact dimensions from the Organization for Economic Cooperation and Development framework were used. A multistage sampling technique was used to select a total of 332 households enrolled in the CBHI program; 341 comparison households who did not enroll in the program were also randomly selected. A structured interviewer-administrated questionnaire was used to evaluate the effectiveness and impact of CBHI on health service utilization. The Propensity score matching model was employed for the estimation of the effect of the CBHI program on health service utilization. Challenges for program achievement toward health service utilization were explained through qualitative data and these were then analyzed thematically.

Results

The evaluation showed 1.3 visits per capita per year of health service utilization among CBHI members. Households enrolled in CBHI increased health service utilization by 6.9 percentage points (ATT = 0.069; 95% CI: 0.034, 0.114). There was an improvement in health service utilization after the introduction of CBHI, however, there are challenges: (i) shortage of human resources, (ii) out-of-stock of drugs and medical supplies, and (iii) long waiting times for service and reimbursement claims. These issues limit the success of the program toward health service utilization.

Conclusion

The CBHI program contributed to health service utilization improvement among CBHI members. However, the utilization rate of health services among CBHI members is still less than the target stated for the program and also the WHO recommendation. Therefore, the findings of this evaluation can be used by program implementers, policy makers, and other stakeholders to overcome the identified challenges and to increase the success of the program.

Community-Based Health Insurance Utilization and Its Determinants among Informal Workers: Cross-Sectional Study

Background

Ethiopia has implemented a community-based health insurance (CBHI) program to provide coverage to 80% of the population and shield underprivileged individuals from the detrimental effects of exorbitant medical expenses. However, there is a paucity of data regarding its utilization and pertinent concerns. This study aimed to evaluate the utilization of CBHI and its associated factors among informal workers in Berek District.

Methods

This community-based cross-sectional study was conducted between June 15 and July 15, 2022. The sample population comprised 538 households selected using a multistage sampling approach. Data analysis was done using SPSS Version 26. Variables with P-values of less than 0.25 during the bivariate analysis were selected for multivariate analysis using binary logistic regression. The statistical significance threshold was set at a p-value of 0.05.

Results

The utilization of Community-Based Health Insurance (CBHI) was 49.8%. Age between 30 and 39 years, monthly earnings of less than 1500 Ethiopian Birr, presence of chronic illness, membership in social organization, and possessing adequate knowledge were found to have a statistically significant association with the use of CBHI.

Conclusion

The utilization of CBHI was low within the confines of this district Age, income, social group membership, and chronic illnesses were significantly associated with CBHI utilization.

Formula feeding and associated factors among mothers with infants 0-6 months old in Mettu Town, Southwest Ethiopia

Adequate nutrition during infancy is essential for children's normal development and well-being. However, the duration of breastfeeding has been declining and is being replaced by formula feeding, particularly in the urban communities of developing countries, including Ethiopia. Hence, this study aimed to assess formula feeding and its associated factors, as relatively little information is available regarding this problem in Ethiopia, particularly in Mettu Town. A community-based cross-sectional study was conducted in Mettu Town from May 17 to July 1, 2021, among 366 mothers with infants 0-6 months old. A simple random sampling technique was used in this study. Pre-tested semi-structured questionnaires were used to collect the data. Descriptive statistics and multivariable logistic regression were performed, and variables with a p-value <0.05 in the final model were declared statistically significant with formula feeding found to be 28.4% [95% CI: (24.0-33.0)]. Primiparity [AOR = 3.27, 95% CI: (1.71-6.27)], cesarean delivery [AOR = 2.62, 95% CI: (1.28-5.35)], initiation of breastfeeding after 24 h [AOR = 3.5, 95% CI: (1.74-10.0)], employed mothers [AOR = 2.4, 95% CI: (1.29-4.19)], positive attitude toward formula feeding [AOR = 2.4, 95% CI: (1.29-4.19)], and poor knowledge of formula feeding [AOR = 2.6, 95% CI (1.49-4.74)] were factors significantly associated with formula feeding. Almost one-third of the mothers were formula feeding their infants. Primiparity, maternal employment, initiation of breast milk after 24 h, cesarean delivery, poor maternal knowledge, and positive attitude toward formula feeding were among the contributing factors to this high formula-feeding practice. Hence, much effort should be invested in educating pregnant and lactating mothers to improve their knowledge of formula feeding while working on activities that change their attitude toward formula feeding.

The level of household satisfaction with community-based health insurance and associated factors in Southern Ethiopia

Background

Community-based health insurance (CBHI) is a program intended to prevent financial hardship brought on by the cost of medical care. All of Ethiopia's regions are implementing it; however, it has not yet been researched how the program is being received by the local population. This study's objective is to determine how satisfied Southern Ethiopian households are with community-based health insurance programs and connected variables.

Methods

A community-based cross-sectional study was conducted from April to May 2021. Information was gathered from 528 households (HHs) selected at random in the Gurage Zone of Southern Ethiopia using a questionnaire. Bivariate and multivariate logistic regression, as well as descriptive statistics, were applied. p values less than 0.05 was used as a cutoff point for identifying the self-determining factors.

Results

The adjusted odds ratio (AOR) for HHs with the poorest wealth status was 2.40 (95% confidence interval:1.14-4.90); for HHs with a good knowledge of the CBHI, it was 1.81 (95% CI: 1.87-3.40); and for households with illness in the past 3  months, it was 5.22 (95% CI: 2.91-9.34). Recurrent visits to the facility (AOR:5.04, 95% CI:1.18-23.44), a Model household in rural health extension program (AOR:3.21, 95% CI:1.76-5.85), being enrolled in the scheme for three years or less (AOR:0.55, 95% CI: 0.30-0.95), and having faith in the leadership of the governing board (AOR:10.53, 95% CI:4.690-23.54) and the availability of the prescribed medication (AOR:14.64, 95% CI:5.37-39.84) were the significant influencing factors.

Conclusion

This study revealed several variables that affected HHs' satisfaction with CBHI. We strongly advise all responsible parties to focus on increasing HH knowledge of the CBHI scheme, supporting HHs to serve as role models for rural health extension packages, and completing the CBHI pledged package to improve HHs' satisfaction with the CBHI scheme, which may then play a role in the sustainability of CBHI.

Determinants of household dropout from community-based health insurance program in northwest Ethiopia; A community-based case-control study

BACKGROUND

Community-Based Health Insurance (CBHI) is an evolving program for delivering financial protection against the cost of illness and enhancing access to quality health services for low-income informal households.

OBJECTIVE

The study aimed to identify determinants of household dropout from a CBHI program in Mecha district, North West Ethiopia, 2019.

METHODS

A community-based case-control study was conducted in the Mecha district from March 10 to June 10, 2018. The final sample was 634 (317 cases and 317 controls) determined by the two-population proportion formula, and these samples were selected using a multi-stage sampling technique. The collected data was entered into Epi-data version 3.1 and analyzed using R version 4.0 software. Descriptive statistics computed. A simple logistic analysis was run (at 95% CI and p-value < 0.05) to identify the determinants for the dropout from CBHI.

RESULTS

Poor perceived quality of care (AOR = 3.66; 95%CI: 2.35, 5.69), low knowledge of community-based health insurance (AOR = 6.02; 95%CI: 2.97, 12.26), no active community communication (AOR = 5.41; 95%CI: 3.29, 8.90) no chronic illness (AOR = 10.82; 95%CI: 5.52, 21.21) premium fee is not affordable (AOR = 2.35; 95%CI: 1.47, 3.77), and out of pocket money not reimbursed (AOR = 9.37; 95%CI: 4.44, 19.77) were the determinants for the dropout from CBHI.

CONCLUSIONS

Poor perceived quality of care, low knowledge of CBHI, no active community participation, no chronic illness, premium fees are not affordable, and out-of-pocket money not reimbursed were the determinants for the dropout from CBHI.

Dropout Analysis of a National Social Health Insurance Program at Pokhara Metropolitan City, Kaski, Nepal

BACKGROUND

Nepal's national social health insurance (SHI) program, which started in 2016, aims to achieve universal health coverage (UHC), but it faces severe challenges in achieving adequate population coverage. By 2018, enrolment and dropout rates for the scheme were 9% and 38% respectively. Despite government's efforts, retaining the members in SHI scheme remains a significant challenge. The current study therefore aimed to assess the factors associated with SHI program dropout in Pokhara, Nepal.

METHODS

A cross-sectional household survey of 355 households enrolled for at least one year in the national SHI program was conducted. Face-to-face interviews with household heads were conducted using a structured questionnaire. Data was entered in Epi-Data and analysed using SPSS. The factors associated with SHI program dropout were identified using bivariate and multiple logistic regression analyses.

RESULTS

The findings of the study revealed a dropout prevalence of 28.2% (95% CI: 23.6%-33.2%). Households having more than five members (adjusted odds ratio [aOR]: 2.19, 95% CI: 1.22-3.94), belonging to underprivileged ethnic groups (Dalit/Janajati) (aOR: 2.36, 95% CI: 1.08-5.17), living on rented homes (aOR: 4.53, 95% CI: 1.87-10.95), absence of chronic illness in family (aOR: 1.95, 95% CI: 1.07-3.59), perceived good health status of the family (aOR: 4.21, 95% CI: 1.21-14.65), having private health facility as first contact point (aOR: 3.75, 95% CI: 1.93-7.27), poor availability of drugs (aOR: 4.75, 95% CI: 1.19-18.95) and perceived unfriendly behaviour of service providers (aOR: 3.09, 95% CI: 1.01-9.49) were statistically significant factors associated with SHI dropout.

CONCLUSION

In Pokhara, more than one-fourth of households have dropped out of the SHI scheme, which is a significant number. Dropping out of SHI is most commonly associated with a lack of drugs, followed by rental housing, family members' reported good health status and unfriendly service provider behaviour. Efforts to reduce SHI dropout must focus on addressing drugs availability issues and improving providers' behaviour towards scheme holders. Increasing insurance awareness, including provisions to change first contact points, may help to reduce dropouts among rented households, which make up a sizable proportion of the Pokhara metropolitan area.

Perceived quality of care among households ever enrolled in a community-based health insurance scheme in two districts of northeast Ethiopia: a community-based, cross-sectional study

OBJECTIVES

To examine how clients perceived the quality of healthcare they received and identify associated factors both at the individual and facility levels.

DESIGN

A community-based, cross-sectional study.

SETTING

Two rural districts of northeast Ethiopia, Tehulederie and Kallu.

PARTICIPANTS

1081 rural households who had ever been enrolled in community-based health insurance and visited a health centre at least once in the previous 12 months. Furthermore, 194 healthcare providers participated in the study to provide cluster-level data.

OUTCOME MEASURES

The outcome variable of interest was the perceived quality of care, which was measured using a 17-item scale. Respondents were asked to rate the degree to which they agreed on 5-point response items relating to their experiences with healthcare in the outpatient departments of nearby health centres. A multilevel linear regression analysis was used to identify predictors of perceived quality of care.

RESULTS

The mean perceived quality of care was 70.28 (SD=8.39). Five dimensions of perceived quality of care were extracted from the factor analysis, with the patient-provider communication dimension having the highest mean score (M=77.84, SD=10.12), and information provision having the lowest (M=64.67, SD=13.87). Wealth status, current insurance status, perceived health status, presence of chronic illness and time to a recent health centre visit were individual-level variables that showed a significant association with the outcome variable. At the cluster level, the work experience of healthcare providers, patient volume and an interaction term between patient volume and staff job satisfaction also showed a significant association.

CONCLUSIONS

Much work remains to improve the quality of care, especially on information provision and access to care quality dimensions. A range of individual-level and cluster-level characteristics influence the perceived quality of care. For a better quality of care, it is vital to optimise the patient-provider ratio and enhance staff job satisfaction.

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

Introduction

Community-based health insurance (CBHI) is a type of volunteer health insurance that has been adopted all over the world in which people of the community pool funds to protect themselves from the high costs of seeking medical care and treatment for the disease. In Ethiopia, healthcare services are underutilized due to a lack of resources in the healthcare system. The study aims to identify the individual and community level factors associated with community-based health insurance enrollment of households in Ethiopia.

Methods

Data from the Ethiopian mini demographic and health survey 2019 were used to identify factors associated with community-based health insurance enrollment of households in Ethiopia. Multilevel logistic regression analysis was used on a nationally representative sample of 8,663 households nested within 305 communities, considering the data’s layered structure. We used a p-value<0.05 with a 95% confidence interval for the results.

Result

The prevalence of community-based health insurance enrollment in Ethiopia was 20.2%. The enrollment rate of households in the scheme was high in both Amhara (57.9), and Tigray (57.9%) regions and low (3.0%) in the Afar region. At the individual level; the age of household heads, number of children 5 and under, number of household members, has land for agriculture, has a mobile telephone, receiving cash of food from the safety Net Program, Owning livestock, and herds of farm animals, wealth index, and at the community level; the region had a significant association with community-based health insurance enrollment.

Conclusion

Both individual and community-level characteristics were significant predictors of community-based health insurance enrollment in households. Furthermore, the ministry of health, health bureaus, and other concerning bodies prioritize clusters with low health insurance coverage to strengthen health system financing and intervene in factors that negatively affect the CBHI enrollment of households.

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.

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

Background

The term "community-based health insurance" refers to a broad range of nonprofit, prepaid health financing models designed to meet the health financing needs of disadvantaged populations, particularly those in the rural and informal sectors. Due to their voluntary nature, such initiatives suffer from persistently low coverage in low- and middle-income countries. In Ethiopia, the schemes’ membership growth has not been well investigated so far. This study sought to examine the scheme’s enrollment trend over a five-year period, and to explore the various challenges that underpin membership growth from the perspectives of various key stakeholders.

Methods

The study employed a mixed methods case study in two purposively selected districts of northeast Ethiopia: Tehulederie and Kallu. By reviewing the databases of health insurance schemes, quantitative data were collected retrospectively from 2017 to 2021 to examine enrollment trends. Trends for each performance indicator were analyzed descriptively for the period under study. Face-to-face interviews were conducted with nine community members and 19 key informants. Study participants were purposely selected using the maximum variation technique. Interviews were audio recorded, transcribed verbatim, and translated into English. Thematic analysis was employed with both deductive and inductive coding approaches.

Results

Over the course of the study period, enrollment in the scheme at both districts exhibited non-linear trends with both positive and negative growth rates being identified. Overall, the scheme in Tehulederie has a relatively higher population coverage and better membership retention, which could be due to the strong foundation laid by a rigorous public awareness campaign and technical support during the pilot phase. The challenges contributing to the observed level of performance have been summarized under four main themes that include quality of health care, claims reimbursement for insurance holders, governance practices, and community awareness and acceptability.

Conclusions

The scheme experienced negative growth ratios in both districts, indicating that it is not functionally viable. It will fail to meet its mission unless relevant stakeholders at all levels of government demonstrate political will and commitment to its implementation, as well as advocate for the community. Interventions should target on the highlighted challenges in order to boost membership growth and ensure the scheme’s viability.

Pooled coverage of community based health insurance scheme enrolment in Ethiopia, systematic review and meta-analysis, 2016-2020

BACKGROUND

Community Based Health Insurance (CBHI) is a type of health insurance program that provides financial protection against the cost of illness and improving access to health care services for communities engaged in the informal sector. In Ethiopia, the coverage of CBHI enrolment varies across regions and decision of household enrolment is affected by different factors. There are pocket studies on CBHI scheme with different coverage in Ethiopia and there is no pooled study on CBHI enrolment coverage in Ethiopia for better understanding the scheme and decision making. The aim of this systematic review and meta-analysis was to identify the pooled coverage of CBHI enrolment in Ethiopia to understand its policy implications.

METHODS

The systematic review and meta-analysis was done by adhering the PRISMA guideline with exhaustive search in PubMed/Medline, HINARI, SCOPUS and Google scholar complemented by manual search. Two authors independently selected studies, extracted data, and assessed quality of studies. The I2 test statistic was used to test heterogeneity among studies. The overall coverage of CBHI scheme was estimated by using random-effects model.

RESULT

Among 269 identified, 17 studies were included in this meta-analysis and the overall coverage of CBHI scheme was 45% (95% CI 35%, 55%) in Ethiopia. The sub-group analysis shows higher enrolment rate 55.97 (95%CI: 41.68, 69.77) in earlier (2016-2017) studies than recent 37.33 (95%CI: 24.82, 50.77) studies (2018-2020).

CONCLUSION

The pooled coverage of CBHI enrolment is low in Ethiopia compared the national target of 80% set for 2020. It is also concentrated in only major regions of the country. The finding of the study helps national decision making for CBHI scheme service improvement. Due attention to be given to improving geographic expansion of CBHI and to the declining coverages with in the CBHI implementing regions by addressing the main bottlenecks restraining coverages.

TRIAL REGISTRATION

The protocol of this systematic review and meta-analysis was published in PROSPERO with registration number: CRD42021252762 .

Contributions and challenges of healthcare financing towards universal health coverage in Ethiopia: a narrative evidence synthesis

Background

High burden of healthcare expenditure precludes the poor from access to quality healthcare services. In Ethiopia, a significant proportion of the population has faced financial catastrophe associated with the costs of healthcare services. The Ethiopian Government aims to achieve universal health coverage (UHC) by 2030; however, the Ethiopian health system is struggling with low healthcare funding and high out-of-pocket (OOP) expenditure despite the implementation of several reforms in health care financing (HCF). This review aims to map the contributions, successes and challenges of HCF initiatives in Ethiopia.

Methods

We searched literature in three databases: PubMed, Scopus, and Web of science. Search terms were identified in broader three themes: health care financing, UHC and Ethiopia. We synthesised the findings using the health care financing framework: revenue generation, risk pooling and strategic purchasing.

Results

A total of 52 articles were included in the final review. Generating an additional income for health facilities, promoting cost-sharing, risk-sharing/ social solidarity for the non-predicted illness, providing special assistance mechanisms for those who cannot afford to pay, and purchasing healthcare services were the successes of Ethiopia’s health financing. Ethiopia's HCF initiatives have significant contributions to healthcare infrastructures, medical supplies, diagnostic capacity, drugs, financial-risk protection, and healthcare services. However, poor access to equitable quality healthcare services was associated with low healthcare funding and high OOP payments.

Conclusion

Ethiopia's health financing initiatives have various successes and contributions to revenue generation, risk pooling, and purchasing healthcare services towards UHC. Standardisation of benefit packages, ensuring beneficiaries equal access to care and introducing an accreditation system to maintain quality of care help to manage service disparities. A unified health insurance system that providing the same benefit packages for all, is the most efficient way to attain equitable access to health care.

The Impact of Community-Based Health Insurance on Household's Welfare in Chilga District, Amhara Regional State, Ethiopia

Household welfare is depleted by catastrophic health expenditure by forcing families to reduce the consumption of necessary goods and services, underutilization of health services, and of finally falling into the poverty trap. To mitigate such problem, the Government of Ethiopia launched CBHI schemes. Therefore, this study investigates the household welfare impact of Community based health insurance (CBHI) in the Chilga district. A multi-stage sampling technique was used to select 531 households (of which 356 were treated and 175 control groups). Probit and propensity score matching (PSM) were used to analyze the data. Probit model revealed the following: Level of education, access to credit, chronic disease, insurance premium, awareness, distance to health service, and health service waiting time are significant determinates for being insured in CBHI. The PSM method revealed that the insured households associated with visits increased by 2.6 times, reduced per-capita health expenditure by 17–14% points, increased the per-capita consumption of non-food items by 12–14% points, increased the per-capita consumption of food items by 12–13% points in a given matching algorithm compared to the counterparts. Therefore, CBHI has enhanced service utilization by reducing per-capita health expenditure and increasing consumption per-capita, in general, it improved household welfare. To this end, the results of this study suggested that the government (ministry of health) and concerned bodies (such as NGOs) should extend the coverage and accessibility of CBHI schemes, create aware to the society about CBHI, and subsidize premium costs of the poor.

Factors Associated with the Implementation of an Improved Community Health Fund in the Ubungo Municipality Area, Dar es Salaam Region, Tanzania

Community-based health insurance schemes help households to afford healthcare services. This paper describes healthcare facilities and community factors that are associated with the Improved Community Health Fund (iCHF) scheme in the Ubungo district of Tanzania. A cross-sectional descriptive study was conducted using online questionnaires that were completed by healthcare providers and community members in public-owned healthcare facilities in the Ubungo Municipal Council district of Dar es Salaam, Tanzania, between October and November 2021. The data were analyzed using descriptive statistics and the chi-squared test of association. We found a statistically significant relationship between income level and satisfaction with the iCHF scheme. For community-related factors, income level was statistically significant in the level of involvement in iCHF implementation among local leaders. Further, income level was statistically significant in relation to community behavior/culture toward the iCHF. Occupation was statistically significant in iCHF implementation, iCHF premiums, and iCHF membership size. A statistically significant relationship was also found between income, iCHF membership size, and iCHF premiums. Moreover, people would be willing to pay the required premiums if the quality of the healthcare services under the iCHF scheme improves. Therefore, the government should allocate resources to reduce the challenges that are facing iCHF implementation, such as the preference for a user fee scheme over the iCHF, the issues that are faced by enrollment officers, and inadequate iCHF premiums and membership size.

Continued adherence to community-based health insurance scheme in two districts of northeast Ethiopia: application of accelerated failure time shared frailty models

Background

The sustainability of a voluntary community-based health insurance scheme depends to a greater extent on its ability to retain members. In low- and middle-income countries, high rate of member dropout has been a great concern for such schemes. Although several studies have investigated the factors influencing dropout decisions, none of these looked into how long and why members adhere to the scheme. The purpose of this study was to determine the factors affecting time to drop out while accounting for the influence of cluster-level variables.

Methods

A community-based cross-sectional study was conducted among 1232 rural households who have ever been enrolled in two community-based health insurance schemes. Data were collected using an interviewer-administered questionnaire via a mobile data collection platform. The Kaplan–Meier estimates were used to compare the time to drop out among subgroups. To identify predictors of time to drop out, a multivariable analysis was done using the accelerated failure time shared frailty models. The degree of association was assessed using the acceleration factor (δ) and statistical significance was determined at 95% confidence interval.

Results

Results of the multivariable analysis revealed that marital status of the respondents (δ = 1.610; 95% CI: 1.216, 2.130), household size (δ = 1.168; 95% CI: 1.013, 1.346), presence of chronic illness (δ = 1.424; 95% CI: 1.165, 1.740), hospitalization history (δ = 1.306; 95% CI: 1.118, 1.527), higher perceived quality of care (δ = 1.322; 95% CI: 1.100, 1.587), perceived risk protection (δ = 1.218; 95% CI: 1.027, 1.444), and higher trust in the scheme (δ = 1.731; 95% CI: 1.428, 2.098) were significant predictors of time to drop out. Contrary to the literature, wealth status did not show a significant correlation with the time to drop out.

Conclusions

The fact that larger households and those with chronic illness remained longer in the scheme is suggestive of adverse selection. It is needed to reconsider the premium level in line with household size to attract small size households. Resolving problems related to the quality of health care can be a cross-cutting area of ​​intervention to retain members by building trust in the scheme and enhancing the risk protection ability of the schemes.