Determinants and Challenges of Enrollment in Community-Based Health Insurance in Southern Ethiopia

Since 2011, Ethiopia has been implementing the Community-Based Health Insurance (CBHI) scheme in various regions to enhance universal health coverage by reducing out-of-pocket expenses for low-income families and to promote healthcare access for poorer households. The purpose of this study is to examine household enrollment and non-enrollment decisions, as well as the main challenges in implementing the program. A multi-stage sampling process was employed to select the participating households. Study subjects were chosen through simple random selection based on population proportions (PPS). Primary data was gathered using a pretested questionnaire. To support the quantitative findings, interviews with CBHI specialists and focus group discussions (FGDs) with both members and non-members of CBHI were conducted. Data analysis was performed using STATA version 15 and SPSS version 20, employing both descriptive and inferential statistics. Of the total respondents, 42.7% were enrolled in the CBHI program, while 57.3% were not. To understand the primary determinants of CBHI enrollment, 15 variables were identified. Factors such as residence, illness, family size, occupation, attitude, awareness, information, payment fairness, service quality, and drug availability were found to be significant in relation to CBHI enrollment in the multivariable analysis (P < 0.05). The main challenges identified in the program include poor service delivery and long waiting times, among others. The study revealed the factors influencing enrollment and non-enrollment in the CBHI scheme, as well as its key implementation challenges. It is essential for the government to collaborate with relevant organizations to address the barriers faced by low income households in enrolling in the program and to find solutions to the challenges of its implementation.