Towards universal health coverage: The level and determinants of enrollment in the Community-Based Health Insurance (CBHI) scheme in Ethiopia: A systematic review and meta-analysis

Abstract

Background Community-based health insurance (CBHI) is a risk-pooling approach that tries to disperse health expenditures across families with varying health profiles to provide greater access to healthcare services by allowing cross-subsidies from wealthy to poor populations. It is crucial to assess the level of CBHI enrolment and its determinants in Ethiopia, where government health spending is limited to less than 5% of GDP, far below the Alma Ata Declaration’s benchmark of 15%. Although various epidemiological studies on CBHI enrolment status and its determinants have been undertaken in Ethiopia, the results have been inconsistent, with significant variability. However, no nationwide study assessing the pooled estimates exists today. Furthermore, the estimated strength of association at the country level varied and was inconsistent across studies. Hence, this systematic review and meta-analysis aimed at estimating the pooled prevalence of CBHI enrolment and its determinants in Ethiopia. Methods A comprehensive search of studies was done by using PubMed, EMBASE, Science Direct, HINARI, Scopus, Web of Science, and the Cochrane Library. The database search was complemented by google scholar and some repositories for grey literature. The search was carried out from February 11 to March 12, 2022. The relevant data were extracted using a Microsoft Excel 2013 spreadsheet and analyzed using STATATM Version 16. Studies reporting the level and determinants of CBHI enrolment in Ethiopia were considered. A weighted DerSimonian Laired random effect model was applied to estimate the pooled national prevalence of CBHI enrolment. The Cochrane Q test statistics and I2 tests were used to assess the heterogeneity of the included studies. A funnel plot, Begg’s and Egger’s tests, were used to check for the presence of publication bias. Results Fifteen studies were eligible for this systematic review and meta-analysis with a total of 8418 study participants. The overall pooled prevalence of CBHI enrolment in Ethiopia was 45.5% (95% CI: 32.19, 58.50). Affordability of premium for the scheme[OR = 2.58, 95% CI 1.68, 3.47], knowledge of respondents on the CBHI scheme[OR = 4.35, 95% CI 2.69, 6.01], perceived quality of service[OR = 3.21, 95% CI 2.04, 4.38], trust in the scheme[OR = 2.32, 95% CI 1.57, 3.07], and the presence of a person with a chronic disease in the household [OR = 3.58, 95% CI 2.37, 4.78] were all found to influence CBHI enrolment. Conclusion Community health workers (CHWs) need to make a high effort to improve knowledge of CBHI in rural communities by providing health education. To deal with the issue of affordability, due emphasis should be placed on building local solidarity groups and strengthening local initiatives to aid poor members. Stakeholders in the health service delivery points need to focus on the dimensions of high service quality. The financial gap created by the adverse selection of households with chronically ill members should be rectified by implementing targeted subsidies with robust plans.

The uptake of WHO-recommended birth preparedness and complication readiness messages during pregnancy and its determinants among Ethiopian women: A multilevel mixed-effect analyses of 2016 demographic health survey

“…Thus, enrolling in health insurance schemes allows them to become more familiar with existing service delivery points. The finding lends support to the notion that removing direct financial barriers through health insurance schemes may increase maternal healthcare utilization in Ethiopia [ 66 , 68 , 69 ]. In addition to maternal care issues, health insurance may act as a pro-poor equalizing agent in health financing by increasing access to health care [ 69 ].…”

“…The finding lends support to the notion that removing direct financial barriers through health insurance schemes may increase maternal healthcare utilization in Ethiopia [ 66 , 68 , 69 ]. In addition to maternal care issues, health insurance may act as a pro-poor equalizing agent in health financing by increasing access to health care [ 69 ]. Hence, the local administrative authorities should make efforts to make households enroll in health insurance schemes.…”

Innovations in mutuality: challenges and learnings for the Universal Health Insurance Plan in Mali

“…The paralleling of these two programmes, in perspective with other experiences in Rwanda, Ghana, Ethiopia44 45 and soon in Benin, to better integrate mutuality into a broader national health financing mechanism, shows that technical and institutional solutions exist and are proven. In Ghana, the NHIS (National Health Insurance Scheme) programme ‘was the subject of a presidential review in 2017.…”

The impact of community-based health insurance on universal health coverage in Ethiopia: a systematic review and meta-analysis

“…Based on the concepts of UHC, the qualitative findings of the included studies were thematized into five categories. PC : The PC of the CBHI has gradually been expanded [ 38 , 41 , 42 ]. HSU : CBHI improved HSU [ 36 , 43–56 ], such as antenatal care (ANC) visits [ 43 ]; child healthcare visits [ 44 , 47 ]; seeking treatment for malaria [ 46 ]; in-patient [ 36 ] and outpatient [ 49 , 50 ] attendances; frequency of visits [ 49 , 53 ]; and family planning [ 53 ].…”

“…The pooled UHC by CBHI was found to be 45.6%. Regarding PC, according to the three national studies included in this review, 40.10% of the households were found to be covered by the scheme, with the lowest, medium, and highest coverages being 28% [ 38 ], 45% [ 42 ], and 45.5% [ 41 ], respectively. Coming to the impact of CBHI on HSU, the pooled report of the 13 included studies showed that the HSU among CBHI members was 64.5%.…”