Revealing the Barriers and Enablers of Retention in Community‐Based Health Insurance: A Dual Approach Using Partial Least Squares Structural Equation Modeling and Multinomial Logistic Regression in the Amhara Region, Ethiopia

ABSTRACT CBHI programs are critical initiatives to improve healthcare access and provide financial protection despite substantial efforts to increase enrollment; previous studies have focused predominantly on initial participation, leaving a gap in understanding the factors influencing retention and exit. Data were collected from 772 (rural 450 and urban 322) and (610 current and 162 former members) purposefully selected from 27 regional districts using Cochran's formula in stratified sampling. This study combined PLS‐SEM and MLR using SMART PLS 4 and STATA 17 Versions. In PLS‐SEM results, Public Involvement ( β = 0.341, p < 0.001) and Quality of Care ( β = 3.835, p < 0.001) were the most influential factors in determining members’ commitment, excellence in Care and Services played a dual role. The MLR results in Job Occupation were a significant predictor, with merchants more likely to retain ( B = 0.163, p < 0.001, Exp(B) = 1.177) compared to other occupational groups and daily laborers less likely to remain enrolled ( B = −0.324, p < 0.001, Exp(B) = 0.723). Females exhibited a higher likelihood of retention than males ( B = −0.227, p < 0.001, Exp(B) = 0.797) rural residents were less likely to retain ( B = −0.398, p < 0.001, Exp(B) = 0.672); the extent of Social Cohesion and Accessibility Perception emerged as crucial drivers of retention, coupled with strong public involvement ( B = 0.524, p < 0.001, Exp(B) = 1.689). Findings highlight the pivotal roles of service quality, public involvement, and socioeconomic factors in influencing CBHI membership retention and exit.