Barriers and facilitators to health services utilization among households with free community-based health insurance enrolment in Ethiopia: A qualitative study

To build an integrated social protection programme, Ethiopia introduced a pilot initiative that facilitated community-based health insurance (CBHI) premium exemptions for permanent direct support (PDS) beneficiaries. This study sought to explore the factors that influence access and utilization of health services among PDS beneficiaries following free CBHI enrolment. We conducted an exploratory qualitative inquiry using semi-structured interviews with 22 key informants and 22 PDS beneficiaries (focus group discussions and in-depth interviews) in two sub-cities of Addis Ababa where a pilot intervention was implemented. Thematic analysis was used to analyse the data. CBHI has facilitated timely access to healthcare services by reducing financial barriers for PDS beneficiaries. However, challenges related to the quality of health services, such as the shortages of commodities and attitudes of health professionals, have hindered optimal use. These challenges often lead to some beneficiaries returning to traditional sources or foregoing formal healthcare services altogether, as their cash transfers are insufficient for the ancilliary out-of-pocket health payments. Inadequate social support, lack of education about health services and insurance use are also key factors that have affected service uptake. A person-centred approach involving greater engagement with social workers could provide awareness and support for beneficiaries to maximize health services utilization. After free enrolment in health insurance, it is crucial to address barriers to accessing healthcare services that are faced by vulnerable populations. There is a need for strengthening social services and primary health care systems and ensuring that health professionals are competent in caring for indigents.