Community-based health insurance enrollment and service experiences in Ethiopia’s Somali Region: a sequential explanatory mixed-methods study

Abstract Community-based health insurance (CBHI) is a key strategy for improving financial protection and access to healthcare in Ethiopia; however, evidence from pastoralist settings remains limited. This sequential explanatory mixed-methods study assessed CBHI enrollment, determinants, and healthcare service experiences among 600 adult patients attending three public hospitals in Ethiopia’s Somali Region between July and August 2025. Quantitative data were analyzed using descriptive statistics and multivariable logistic regression, while qualitative interviews with 12 patients and four healthcare providers were analyzed thematically to contextualize the quantitative findings. Although awareness of CBHI was nearly universal (98.3%), only 65.0% of participants were enrolled, and functional knowledge of benefit packages and referral procedures remained limited. Higher educational attainment, greater trust in CBHI management, and stronger perceived benefits were positively associated with CBHI participation, whereas perceived barriers were negatively associated. Medication shortages were the most frequently reported barrier (72.7%). Interviews further revealed that administrative complexity, medicine shortages, long waiting times, and transportation difficulties continued to undermine healthcare experiences despite insurance coverage. Although CBHI enrollment was associated with perceived improvements in healthcare access and financial protection, service experiences remained constrained by persistent health-system limitations. Policymakers should prioritize community education, simplify enrollment procedures, ensure reliable medicine availability, and strengthen CBHI governance and transparency to improve implementation and sustainability in pastoralist settings.