DETERMINANTS OF DROPOUT FROM COMMUNITY-BASED HEALTH INSURANCE AMONG HOUSEHOLDS IN RAYA KOBO DISTRICT AND KOBO TOWN, NORTH WOLLO ZONE, NORTH EAST ETHIOPIA, 2024

Background: Community-Based Health Insurance (CBHI) programs play a crucial role in improving access to health services, particularly in low-resource settings. However, research on CBHI programs in Ethiopia is limited, and there is a lack of comprehensive understanding regarding the factors contributing to participant dropout. Addressing these challenges could significantly improve the effectiveness of the region's healthcare system.<br> Objectivities: To identify the determinants of dropout from Community-Based Health Insurance among households in Raya Kobo District and Kobo Town.<br> Methods: A case-control study design using a simple random sampling technique was conducted in Raya Kobo District and Kobo Town from September 10, 2024, to December 10, 2024. A total of 422 participants (211 cases and 211 controls) from seven rural kebeles (in Raya Kobo District) and two urban kebeles (in Kobo Town) were selected through random sampling to participate in the study. Descriptive statistics, such as proportions, mean scores, total scores, frequency, and percentage were employed to describe the categorical variables. A univariable and multivariable binary logistic regression model was computed to identify the possible predictors of dropout status among CBHI users.<br> Results: About 39.34% of the cases acknowledged the availability of medications; however, around 97.61% of participants exhibited a significant lack of awareness regarding the health benefits provided by Community-Based Health Insurance (CBHI). Participants also showed a favorable perception regarding the accuracy of medical diagnoses, their trust in CBHI, and the risk pooling associated with CBHI, with mean scores of 3.94, 3.85, and 3.61, respectively. Being aged 30–39 years (AOR = 0.199; 95% CI: 0.052–0.757) and 40–49 years (AOR = 0.145; 95% CI: 0.036–0.578) were associated with reduced odds of dropout to CBHI. Conversely, divorced marital status (AOR = 9.815; 95% CI: 2.067–46.601) substantially increased dropout likelihood, while being unmarried (AOR = 0.103; 95% CI: 0.013–0.827) was protective. Individuals who can read and write (AOR = 3.811; 95% CI: 1.188–24.481), have completed primary education (AOR = 4.990; 95% CI: 1.098–22.666), and have a household size exceeding five members (AOR = 2.856; 95% CI: 1.821–9.089) also found as significant predictors of dropout. At the contextual level, participants exhibited increased dropout rates associated with the distance from health services: those living 30 minutes to 1 hour away showed an AOR of 6.571(95% CI: 2.289-18.864), while those residing more than 1 hour away had an AOR of 5.13(95% CI: 2.442-115.23). Furthermore, contextual factors significantly associated with CBHI dropout included receiving information about the CBHI program from kebele mobilizers (AOR = 0.009; 95% CI: 0.002–0.032), perceiving the CBHI payment process as inconvenient (AOR = 0.106; 95% CI: 0.028-0.391), and experiencing inadequate follow-up (AOR = 0.257; 95% CI: 0.107–0.612).<br> Conclusion and Recommendations: Control participants had a better understanding toward the CBHI service compared to case participants. Inadequate service quality, high annual premiums, and unavailability of ordered medications at the health center were the main reasons for participants dropping out from the service. Community health outreach programs should prioritize individuals who are literate, have only primary education, are divorced or unmarried, and belong to households with more than five members, as these groups were identified as being at high risk of dropping out in the study. It is critical to implement tailored awareness campaigns and behavior-change interventions targeting dropout cases. Improving service quality, and drug availability at health centers, and reducing annual premiums will be important for increasing participant retention in the package. Furthermore, collaboration with district health extension workers is necessary to enhance the accessibility of health services for participants.