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.

Keywords: Community-based health insurance; Ethiopia; Health financing; Health insurance.

© 2022. The Author(s).

Conflict of interest statement

All authors declare no competing interests.

Similar articles

Kakama AA, Namyalo PK, Basaza RK. Kakama AA, et al. BMC Health Serv Res. 2020 Jul 17;20(1):662. doi: 10.1186/s12913-020-05525-7. BMC Health Serv Res. 2020. PMID: 32680506 Free PMC article.

Habte A, Tamene A, Ejajo T, Dessu S, Endale F, Gizachew A, Sulamo D. Habte A, et al. PLoS One. 2022 Aug 18;17(8):e0272959. doi: 10.1371/journal.pone.0272959. eCollection 2022. PLoS One. 2022. PMID: 35980888 Free PMC article.

Alemayehu YK, Dessie E, Medhin G, Birhanu N, Hotchkiss DR, Teklu AM, Kiros M. Alemayehu YK, et al. BMC Health Serv Res. 2023 Jan 23;23(1):67. doi: 10.1186/s12913-022-09019-6. BMC Health Serv Res. 2023. PMID: 36683041 Free PMC article.

Debalkie Atnafu D, Assefa Alemu Y. Debalkie Atnafu D, et al. Prev Med Rep. 2023 Oct 18;36:102474. doi: 10.1016/j.pmedr.2023.102474. eCollection 2023 Dec. Prev Med Rep. 2023. PMID: 38116251 Free PMC article. Review.

Tahir A, Abdilahi AO, Farah AE. Tahir A, et al. Health Econ Rev. 2022 Jul 12;12(1):38. doi: 10.1186/s13561-022-00386-8. Health Econ Rev. 2022. PMID: 35819505 Free PMC article. Review.

Cited by

Tsega Y, Alemu HT, Geberu DM, Hagos A, Jejaw M, Abera KM, Tiruneh MG, Demissie KA, Asmare L, Endawkie A, Negash WD, Workie AM, Yohannes L, Getnet M, Worku N, Belay AY. Tsega Y, et al. Front Public Health. 2024 Jul 29;12:1361793. doi: 10.3389/fpubh.2024.1361793. eCollection 2024. Front Public Health. 2024. PMID: 39145179 Free PMC article.

Deressa HD, Abuye H, Adinew A, Ali MK, Kebede T, Habte BM. Deressa HD, et al. Glob Health Res Policy. 2024 Apr 7;9(1):12. doi: 10.1186/s41256-024-00352-3. Glob Health Res Policy. 2024. PMID: 38584277 Free PMC article.

Szlamka Z, Ahmed I, Genovesi E, Kinfe M, Hoekstra RA, Hanlon C. Szlamka Z, et al. BMC Health Serv Res. 2023 Dec 15;23(1):1420. doi: 10.1186/s12913-023-10428-4. BMC Health Serv Res. 2023. PMID: 38102602 Free PMC article.

Balcha BA, Endeshaw M, Mebratie AD. Balcha BA, et al. J Public Health Res. 2023 Apr 13;12(2):22799036231163382. doi: 10.1177/22799036231163382. eCollection 2023 Apr. J Public Health Res. 2023. PMID: 37065469 Free PMC article.

Handebo S, Demie TG, Woldeamanuel BT, Biratu TD, Gessese GT. Handebo S, et al. Front Public Health. 2023 Mar 30;11:1067773. doi: 10.3389/fpubh.2023.1067773. eCollection 2023. Front Public Health. 2023. PMID: 37064679 Free PMC article.

References

    1. WHO . Tracking universal health coverage: first global monitoring report. Geneva: World Health Organization; 2015.
    1. Tetteh EK. Responding to the challenges of social health insurance in African countries. Dev South Afr. 2012;29(5):657–680. doi: 10.1080/0376835X.2012.730964. - DOI
    1. WHO . Global Health Expenditure Database. 2017.
    1. FMOH . Health sector transformation plan (HSTP) II 2015/16–2019/20. Addis Ababa: Federal Democratic Republic of Ethiopia Ministry of Health; 2015.
    1. WHO . WHO | the Abuja declaration: ten years on. WHO. World Health Organization; 2011.