Community-Based Health Insurance in Ethiopia: ENROLLMENT, MEMEBRSHIP RENEWAL, AND EFFECTS ON HEALTH SERVICE UTILIZATION

Abstract

Community-Based Health Insurance in Ethiopia: Enrollment, Membership Renewal, and Effects on Health Service Utilization Ayalneh Asmamaw Atnafu Dept. of Health Care Management and Policy The Graduate School of Public Health Seoul National University

Background: Community-Based Health Insurance (CBHI) received a considerable attention as a mechanism of health care financing and a potential alternative for a user fee in many low and middle-income countries. The Ethiopian government has introduced different measures to implement pre-payment schemes including CBHI as of 2010. In this dissertation, three sub-studies were designed and implemented to explore 1) The determinants of CBHI enrollment, 2) the magnitude and factors associated with CBHI membership renewal, and 3) the association between CBHI enrollment and health service utilization in Northwest Ethiopia. Methods: The main research design of the study was a case-comparison community based cross-sectional household survey linked to the health facility survey supplemented with a concurrent qualitative component. The study populations were all eligible households for CBHI in 15 selected clusters in five districts. A multi-stage cluster sampling was employed to obtain a representative sample for the three sub-studies. Applying a structured questionnaire, 2,008 households and 7 health centers were surveyed. Additionally, 8 focus group discussions (four with CBHI members and four with non-members) and 5 in-depth interviews were conducted to supplement the quantitative findings. A classical multivariate logistic regression, mixed-effect logistic regression, and bivariate-probit regression along with a thematic analysis of the qualitative data were used for the data analysis. Results: The findings from the enrollment study showed that household-related factors such as age, education, self-rated health status, perceived quality of health services, household size, knowledge and information (awareness) about CBHI were the main influential factors affecting enrollment into CBHI in the study area. Additionally, participation in informal associations, such as local credit associations, and health facility factors in terms of availability of laboratory tests significantly influence probability of enrollment. The findings from the membership renewal study showed that 36% of the participants were not willing to renew their membership for the next period. The results confirmed that once the households are enrolled in CBHI, factors related to institutional trusts, such as trust in public health facilities and trust in CBHI schemes, and inconvenience of the premium collection were the main influential factors to renew membership. Moreover, poor self-rated health status and perceived quality of healthcare services are correlated with membership renewal. Hence, there is a possibility of adverse selection with regard to CBHI enrollment and membership renewal in the study area. The third study revealed that CBHI enrollment is positively associated with adult outpatient use, inpatient care, and sick children health services visits. CBHI membership shows 0.50 (50%), 0.22 (22%), and 0.44 (44%) points higher probability of health service visits for adult outpatient, inpatient, and sick childrens health problem in the study area, respectively. Conclusion and recommendation: The study results in this thesis demonstrated important factors affecting CBHI enrollment and membership renewal. Moreover, it also revealed the link between CBHI enrollment and health service utilization. Therefore, multifaceted policy interventions need to be considered before the nationwide rollout of CBHI and implementation of Social Health Insurance (SHI) in Ethiopia. Strategies such as compulsory enrollment, differential premiums, and group enrollment are essential to tackle adverse selection. Provision of continuous education and social marketing activities to increase enrollment and maintain the sustainability of the schemes are crucial. Policy interventions that enhance the capacity of health facilities and CBHI schemes to provide the promised services to the members and build trust are also necessary. Benefit package expansion and other supply-side interventions are required to strengthen the positive effect of CBHI on health care utilization. Keywords: Adverse selection, Bivariate probit model, CBHI enrollment, Ethiopia, Health care use, Institutional trust, Membership renewal, Mixed-effect model, Mixed method Student number: 2014-31499