Patterns of enrollment to community-based health insurance and the situations influencing utilization of the services in Southern Ethiopia: a qualitative study

Abstract

A community-based health insurance (CBHI) scheme was proposed by the World Health Organization, hoping that it would provide financial protection by reducing out-of-pocket expenditure and enhancing health-seeking behavior. The utilization of CBHI, however, is influenced by a variety of factors. Because these factors differ according to differing socio-economic contexts and understanding them in a specific context would help to improve the use of the scheme, we examined the situations influencing the utilization of CBHI in Sodo Zuria woreda, southern Ethiopia. Using a phenomenological approach, the study relied on qualitative data from 21 in-depth interviews and 4 FGDs with beneficiaries, as well as 12 key informant interviews with health professionals and kebele leaders. Audio records were first transcribed verbatim, translated to English, and transported to Atlas.ti 7 software. Transcriptions, along with field notes and memos, were coded, and subsequently, themes and sub-themes were identified. Accordingly, the study revealed that low levels of educational attainment, lack of program awareness, lack of pharmaceuticals and medical supplies, lack of adequate healthcare professionals, distance from home, and administrative complexities undermine the utilization of community-based health insurance. The situation exposes beneficiaries to out-of-pocket medical expenses, thereby negating the goal of the CBHI program. As a result, the Ministry of Health, in conjunction with other governmental and non-governmental bodies, should ensure that enough pharmaceuticals and medical supplies are provided. In addition, efforts should be made to make sure that there are enough health workers and that a convenient working procedure is established in health centers.

Keywords:

• Community-based health insurance
• utilization
• qualitative study
• Ethiopia
• healthcare system

REVIEWING EDITOR:

• Joe Thomas, Institute of Health and Management, Australia

SUBJECTS:

• Health & Society
• Public Health Policy and Practice
• Social Work and Social Policy

Introduction

More than 150 million people encounter significant health expenses every year globally, and more than 100 million treatment seekers face poverty owing to out-of-pocket payments for health care (Demissie & Atnafu, 2021; WHO, 2005). Out-of-pocket payment, which is the most common source of health-care financing in Sub-Saharan Africa, has hampered the region’s efforts to achieve universal health coverage and the Sustainable Development Goals (SDGs) (Eze et al., 2022). Furthermore, most Sub-Saharan African countries have found it difficult to acquire funds to support the delivery of an essential package of health services (Mulat et al., 2022). Financial contributions for health are considered equitable when household health expenditures are distributed based on the ability to pay rather than real expenditures paid as a result of illness (Carrin et al., 2005).

WHO (2010) underscores the urgent need for countries to move towards universal health coverage (UHC) to ensure that all individuals have access to essential health services without facing financial hardship. WHO emphasized that achieving UHC is not only a moral imperative but also a strategic investment in human capital and economic development. WHO further urged policymakers to implement reforms that prioritize UHC and address the financial barriers to healthcare access. In this regard, Kutzin (2013) argued that health financing policy is an integral part of efforts to move towards UHC, but for the policy to be aligned with the pursuit of UHC, health system reforms need to be aimed explicitly at improving coverage and the intermediate objectives linked to it, such as efficiency, equity in health resource distribution, transparency, and accountability. The movement towards achieving universal health coverage is gaining attention worldwide, and Community-Based Health Insurance (CBHI) has been instrumental in this regard (Ghimire et al., 2022). CBHI schemes refer to voluntary, nonprofit health insurance schemes organized and managed at the community level (Umeh & Feeley, 2017). It is proposed by the World Health Organization with the hope of making it an essential instrument to provide financial protection through reducing out-of-pocket expenditure and ultimately improving the health-seeking behavior of a particular community (Geferso & Sharo, 2022). The scheme is a not-for-profit type of health insurance that can be used by people in the lower social stratum to protect them against the cost of seeking medical treatment for illness (Tabor, 2005). It is mainly financed by the premiums collected from its members. Studies in Ethiopia (Alemayehu et al., 2023) and South Asia and the Pacific (Eze et al., 2023) revealed that CBHI membership is found to increase the utilization of health services and reduce the incidence of catastrophic health expenditure.

The Ethiopian health-care system was heavily reliant on out-of-pocket spending, exposing many households to financial difficulty as a result of high health-care costs, particularly in rural Ethiopia (Asfaw et al., 2022). Because of this, the Ethiopian government implemented two types of insurance schemes. The first one is ‘social health insurance’ for formal sector employees, which is funded by both employees and employers, while the second one is a ‘CBHI scheme,’ which aims to protect low-income communities in society from the impoverishing effects of catastrophic health expenditures, increasing demand for health service utilization, and broadening the income source for the health care sector from domestic sources (Asfaw et al., 2022; Demissie & Atnafu, 2021; Mulat et al., 2022). To accelerate progress towards UHC, the government of Ethiopia piloted CBHI in 13 woredas (districts) between 2011 and 2013, and based on the encouraging results of CBHI pilots, the government scaled up the scheme to over 350 woredas in 2017 (Mulat et al., 2022). As a result, more than 14.5 million people had health insurance coverage through CBHI in 2017.

The enrollment in CBHI is influenced by a variety of factors. Gender, family size, annual income, and occupation were found to influence CBHI utilization in several studies (e.g., Fite et al., 2021; Geferso & Sharo, 2022; Moyehodie et al., 2022). In addition, Moyehodie et al. (2022) and Negash et al. (2019) found that the more educated people are, the more likely they are to use CBHI. This has been attributed to the influence of education on people’s understanding, attitude, and behavior regarding the significance of CBHI healthcare service consumption, as insurance may be a new notion. Other factors include satisfaction with health professionals and perceived quality of healthcare services, persons with chronic diseases in the family, prescriptions and availability of drugs, the rapidity of treatment results, perceived premium affordability and registration fees, perceived health status, preference of modern healthcare over the traditional, household’s health status, previous illnesses, and track records of health care utilization (Fite et al., 2021; Geferso & Sharo, 2022; Ghimire et al., 2022; Mirach et al., 2019; Negash et al., 2019; Yechale, 2014).

According to Demissie and Atnafu (2021), the barriers to joining community-based health insurance in rural Amhara Region, North West Ethiopia, were a high premium, a poor perception of the quality of services, and a lack of trust. Furthermore, a lack of understanding and knowledge of the concept of health insurance has contributed to a low level of participation in voluntary health insurance schemes (Bantie et al., 2020; Demissie & Atnafu, 2021). The emphasis during sensitization and awareness creation for health insurance interventions is typically on the amount of premium that potential enrollees are expected to pay, i.e., less emphasis is placed on explaining concepts such as solidarity, risk pooling, moral hazard, and adverse selection, which is a limitation (Obse et al., 2015). Yismaw Jembere (2018) also discovered that households were subject to additional healthcare expenses even though they were members of the CBHI scheme due to reimbursement issues and a lack of information about the procedure for service utilization, which could result in scheme dropouts. According to Ashagrie et al. (2020), the CBHI dropout rate was significant in the Dera district of Northwest Ethiopia owing to frequent health facility visits for treatment, distance of health facilities, lack of knowledge of the CBHI scheme, and length of enrollment.

Although CBHI appears to be the most appropriate insurance model for employees of informal sectors and households in rural areas, Bantie et al. (2020) discovered that informal workers in Northern Ethiopia had low awareness and attitudes towards CBHI. Negash et al. (2019) also found that CBHI utilization was low among the same group of people, i.e. informal workers in Western Ethiopia. However, Ahmed et al. (2016) revealed that a high majority of informal workers in Bangladesh were willing to pay for CBHI. However, Asfaw et al. (2022) noted that CBHI boosted service utilization, decreased per-capita health expenditure, and enhanced overall household wellbeing in Northern Ethiopia.

Despite having widespread application throughout the nation, CBHI schemes in Ethiopia have not yet been thoroughly examined. Furthermore, the bulk of CBHI studies carried out in Ethiopia, such as those by Mirach et al. (2019), Yismaw Jembere (2018), Bantie et al. (2020), Negera and Abdisa (2022), Moyehodie et al. (2022), Negash et al. (2019), Asfaw et al. (2022), Fite et al. (2021), and Geferso and Sharo (2022), among others, were geographically restricted to Ethiopia’s northern, central, and western areas. The phenomenon of CBHI in the southern regions of the nation is therefore understudied. Moreover, the majority of previous studies also used quantitative research methods with the aim of generating statistics that would explain the characteristics of a particular community. Hence, we have employed the qualitative method due to its capacity to yield in-depth insights that extend beyond numerical data. This approach enables a comprehensive exploration of prevailing attitudes, social dynamics, and experiences related to CBHI. As a result, this study investigated the situations influencing CBHI enrollment in Sodo Zuria woreda, southern Ethiopia, using a qualitative research method.

Methods and materials

Study design

Using a qualitative research design, we collected data from key informants and members of the local community in southern Ethiopia using in-depth interviews, focus group discussions (FGDs), and key informant interviews (KIIs). This is because, as stated in the background, the issue calls for a detailed qualitative assessment, as many studies conducted before were highly reliant on the quantitative method.

Methods and procedures of data collection

With the aim of enriching the data, we have collected rich qualitative data from members of the CBHI using in-depth interviews and substantiated it with key informant interviews and FGDs. Using unstructured interview guides, the third author conducted in-depth interviews with members of the scheme in Sodo zuriya woreda in southern Ethiopia in the local ‘Wolaitta’ language. For the sake of convenience and privacy, the in-depth interviews were conducted face-to-face in private locations around their residential area, and each interview took on average 30–40 minutes. In addition to the in-depth interviews, we have also conducted key informant interviews (KIIs) with health professionals and local government administrative units (kebeles) in their offices. Furthermore, data from the two sources was complemented by four focus group discussions (FGDs) with CBHI member local communities, each group comprising six participants. The goal of conducting those FGDs was to ensure data richness and understand common concerns, attitudes, and expectations related to CBHI. The participants for the FGD were different from those approached for in-depth interviews. Accordingly, we have tried to maintain maximum variation in the data by considering the perspectives of diverse groups of participants, including health professionals, the local community, and kebele¹ leaders. Semi-structured questions were used in the process of in-depth interviews, key informant interviews, and focus group discussions while simultaneously allowing room for evolving themes throughout the duration of data collection. In the process of the interview, we have tried to be flexible, and the checklist was updated during the interview sessions to account for new difficulties that emerged (Ryan et al., 2009). Moreover, there were no other people present for the interviews apart from the participants and the researchers.

Sampling techniques

Based on the information obtained from Sodo Zuria Woreda’s Health Center, which is one of the healthcare facilities where members of the CBHI get services, kebeles (the lowest administrative unit in Ethiopia) from Sodo Zuria Woreda, particularly Dalbo Atuwaro, Dalbo Wogane, Zala Shasha, Waja Kero, Waja Shoya, and Kuto Sorfela, were identified. Whereas participants in in-depth interviews and FGDs who were beneficiaries of the community-based health insurance program were selected using the snowball sampling technique, key informants—medical professionals and kebele leaders—were chosen purposefully based on their knowledge of the issue under consideration. The sample size was determined by counting interviews up until a level of data saturation was reached, which was the point at which the researchers concluded they had collected enough data and no new information had been uncovered (Fusch & Ness, 2015; Saunders et al., 2018). As a result, 21 individuals have participated in the in-depth interviews, 24 people participated in the FGDs, and 12 key informants who were thought to be more knowledgeable about the CBHI scheme—of which six were health professionals and the other six were kebele leaders—were chosen for key informant interviews. Based on the consents of the research participants, interviews were tape-recorded and kept in a separate folder on the third author’s computer until the transcription of the data started. Because the third author was able to speak the local language of the study area, the data were collected in the local language and later translated by him into the English language.

Method of data analysis

After gathering the data, the researchers first transcribed and translated the tape recordings, field notes, and memos from the local language to English. The transcribed data were then transported to Atlas.ti version 9 qualitative data analysis software, where it was coded. The data were then categorized and divided into manageable units to discover sub-themes. Then, three overarching themes—household-level factors that influence community-based health insurance utilization, scheme-related factors that influence community-based health insurance utilization and limitations of scheme training affecting the utilization of community-based health insurance—were identified, and all other significant issues were examined as subthemes under these themes.

Ethical considerations

It is agreed that researchers should respect the privacy and safety of study participants during the research process (Creswell, 2009). First, a letter of cooperation was obtained from the department of sociology, Wolaita Sodo University. We have also obtained a support letter from the administration of Sodo Zuria woreda. The objectives and significance of the study were then explained to the participants. They were also informed that all information was confidential and that they might refuse to answer any questions if they felt uncomfortable. After receiving verbal consent from all of them, data were finally collected in a private location and at a convenient time for participants. Above all, we were extremely careful not to identify the participants when quoting their answers from the interviews. As a result, the confidentiality of the data was maintained along with the privacy of research participants.

Results

This section presents the data gathered using qualitative methods in accordance with the study’s objectives. The findings of the study are categorized into three themes: household-level factors that affect the utilization of community-based health insurance, scheme-related factors influencing community-based health insurance utilization, and limitations of scheme training affecting the service utilization of community-based health insurance.

Household level issues that affect utilization of Community based health insurance

Level of education

Rural households with a better educational level were found to consistently take part in the CBHI scheme than those with a lower level of education. It is obvious in Ethiopia that the majority of rural households lack formal education, but those headed by individuals with a little formal education are more likely than those headed by individuals with no formal education to sign up for health insurance coverage. One of our key informants explained this as follows:

‘Based on our cluster experience, we have observed that households with a minimum of formal education voluntarily enroll in the scheme. This is because those who have a little formal education quickly decide to join the CBHI scheme when they are informed about it. However, it can be difficult for households where no one has received formal education to accept.’ (KII, 42, Zala Shasa)

Another interviewee also made the following statement regarding education level and household service usage:

‘When it (CBHI scheme) was started as a pilot program in our cluster, the health extension workers have taught us the advantages of the insurance and most households that became members of the scheme at that time were those with better education, and after being members for themselves, they also taught the others to become members’ (IDI, 40, Waja Shoya).

It is evident that households with at least some formal educations are more likely to actively participate in the scheme. This is attributed to the fact that individuals with limited formal education are more inclined to readily comprehend the benefits of the CBHI scheme and make informed decisions about enrollment once they are properly informed about it. On the other hand, households without any formal education face challenges in accepting and understanding the concept of the CBHI scheme, potentially leading to reluctance in participation.

Household size

In our focus group discussions, the community members voiced a strong preference for community-based health insurance due to its fair payment system. One participant put it simply, saying,

‘No matter how big our families are, we all pay the same amount, and that feels fair to us. I am even more concerned about what I would do if this system were not in place. We all know the costs of medical expenses these days, especially in private clinics. The burden is so unimaginable if something were to happen for someone like me with many family members’ (FGD, Dalbo Wogane)

This sentiment was equally shared among participants for the FGD, showing that they found the idea of everyone contributing equally regardless of family size to be really fair. Another participant shared a relatable example, saying,

‘In our community, we have families of all sizes, from big extended ones to smaller ones. With community-based insurance, everyone chips in the same amount, no matter the family size, and that feels fair and inclusive. This shows that no matter our family setups, we all matter equally when it comes to getting the treatment we need. It really brings us together as a community, looking out for each other’s well-being, regardless of our family size or financial situation’ (FGD, Dalbo Wogane)

The data indicate a shared belief in the fairness and inclusivity that community-based health insurance brings among beneficiaries of the service. KIIs with healthcare professionals in Dalbo Kebele also revealed that the majority of the beneficiaries of CBHI are those high household members, stating,

‘I would say most of the beneficiaries in this scheme are families with many members. The beneficiaries have a kind of membership ID card or book with pictures of all the families in it. So, if you randomly check the cards, you will see a lot of pictures. Some with 4, 5, or 6 pictures’ (KII)

This indicates that the community-based health insurance scheme is perceived as crucial among households with large family sizes and the utilization of the service is higher among households with large family sizes.

Scheme-related factors affecting the utilization of community-based health insurance

Unavailability of drugs and medical supplies

The more drugs are unavailable, the fewer services are available to members of community-based health insurance schemes at the institutional level. Health professionals revealed during an interview that the lack of medications in the store is influencing effective service delivery in the study area. The problem is escalating as each day goes by and people are shifting their attention to getting services through out-of-pocket expenditures.

One of the key informants (a health professional from Dalbo kebelle) stated the following about drug unavailability:

‘While we have been providing CBHI services in our health center in a good manner for the past two years, we are currently unable to properly treat the members because of a lack of medications in our store due to funding issues, particularly from NGOs. Furthermore, organizations like the Woreda health office do not buy medications when there is shortage because of financial issues; in this case, we were unable to provide the service as intended.’

Furthermore, a kebele leader in Lasho kebelle stated,

‘When this program was first introduced in our cluster, we were all excited, but now the service provision at health centers demoralizes us because most of the time when we go to them, they order us to buy drugs from private drug centers. This demonstrates that they do not have enough drugs in their store to provide the necessary service on their own. Members are dissatisfied with the insurance service as a result, but the poor still use it, and those with money now prefer private clinics by canceling their membership’.

The above quote indicates that there was enthusiasm surrounding the program initially, but the current state of service provision at health centers has led to disillusionment among the community. The practice of directing members to purchase drugs from private drug centers due to inadequate stock at the health centers has resulted in dissatisfaction among members. This disillusionment has led those with financial means to opt for private clinics by canceling their membership, while those with limited financial resources continue to rely on the service, albeit with dissatisfaction.

Shortage of healthcare workers

Lack of adequate human resource in health centers has a profound impact on delivering CBHI services effectively. This was demonstrated in the following statement made by a key informant:

‘We don’t have enough medical staff to properly provide CBHI services since our health center is in a rural area. Because the majority of professionals are not interested in working in rural areas, there is a fluctuation in the number of professionals. As a result, they are moving away from the area in search of towns, particularly Sodo town. Additionally, the woreda Health Office does not have the responsibility of finding a replacement for a departing health professional. In this situation, we delay hiring the new professional for even a year after reporting to the zone health office. (KII, 42, Dalbo)

Similar to that, another key informant explained how a lack of human resources affects the delivery of services, as follows:

‘Regarding human resources, we do not have enough people, even at the Woreda level. The majority of professionals have a diploma education level, and the majority of them graduated from private colleges without having the necessary knowledge. Because of this, health centers don’t offer many services.’ (KII, 37, CBHI focal person)

It can be inferred from the data that shortage of qualified professionals, coupled with their reluctance to work in rural areas, poses a serious obstacle to ensuring consistent and quality healthcare delivery within the context of the CBHI program.

Challenges related with payment modality

The existence of high administrative complexities also makes the institutional CBHI service provision weaker. Challenge associated with the payment modality of the premium is the main administrative hurdle mentioned by key informants when implementing the CBHI scheme. One key informant described the problem associated with the payment modality of the premium as follows:

‘Our method requires us to collect the annual premium once, which makes it more challenging for households. When asked to pay the annual premium in a lump sum, households felt uncomfortable and needed the payment to be spread out over the year because they felt the one payment was burdensome. As a result, fewer households are interested in signing up for the CBHI scheme, which in turn affects how our health center provides services’ (KII,37, Lasho).

Another key informant explained how administrative complexities affected the CBHI program as follows:

‘Rural households face additional difficulties with the timing of premium collection because they are required to pay the premium during the harvest season, when crop prices are at their lowest. Because rural households are also required to pay for other contributions like Red Cross, sports, and political party membership fees, the payment schedule should be changed, and it is preferable if the premium is collected after harvest time (KII, 42, Waja Kero).’

The above data indicate the adverse effects of the premium payment structure on household participation in the CBHI scheme and the subsequent impact on the delivery of healthcare services. These perspectives from interviewees underscore the importance of aligning premium collection practices with the financial realities and preferences of households to ensure equitable access to health insurance and healthcare services.

Distance between health facilities and household homes

Households who enrolled into the CBHI program also take into account the hospital’s distance from their residence. As distance increases, households become more exposed to additional transportation costs as well as other associated expenses like accommodation and meals, which lowers their interest in using the program.

FGDs with households participating in the CBHI program revealed the following:

‘I am willing to continue being a member of the CBHI scheme, but the health center that provides care for us is located outside of our kebele; it would take more than 6 kilometers to go from my house to the Lasho Health Center. As a result, I have decided to end my membership if the government does not offer any other options. I have gone to private clinics more than twice since joining the CBHI program because of the distance’ (FGD, 36, Waja shoya).

A key informant further explained the connection between distance and the usage of CBHI services as follows:

‘Households in our kebele are interested in community-based health services, but the main issue that concerns them is the distance between our kebele and the Lasho health center. Even after we get to the main asphalt route from Gungo to Sodo, we are still required to pay 5 birr for a car and 10 birr for a motorcycle.² We are also faced with additional expenses, such as lunch in Lasho town’ (KII, 40, Kuto Sorfela).

In general, these quotes underscore the critical importance of accessibility and proximity of healthcare facilities in the successful implementation and uptake of community-based health services. They point to the potential impact of geographical barriers and associated costs on individuals’ decisions regarding their participation in health insurance programs and their healthcare-seeking behavior.

Limitations of scheme training affecting service the utilization of community-based health insurance

Lack of adequate awareness creation regarding the scheme

The entire kebeles of Sodo Zuria Woreda were piloted by the CBHI program, according to data from the Sodo Zuria Woreda health office report, (2019). Meetings and trainings with a focus on participation were also held, and it was claimed that these programs helped people learn more about the community-based health insurance program.

However, there are concerns about whether the concerned bodies accurately informed the program’s participants about its objectives, procedures, significance, and potential effects on the CBHI scheme’s service delivery. This is so because informants frequently mentioned the fact that they don’t have adequate awareness about the CBHI scheme. In this regard, key informant from healthcare professionals disclosed that:

‘We are required to inform members about the type and qualities of the services we offer, but health extension workers are typically responsible for educating households about CBHI services. However, they are not willing to speak with every household because they lack the dedication to endure the ups and downs of going through different kebeles. Due to this, the majority of households are unaware of the benefits and drawbacks of community-based health insurance, making it impossible to provide the service to them’ (KII, 37, CBHI focal person).

In the same way, the FGDs with member households of the community-based health insurance scheme in Waja Kero kebele revealed that:

‘Our community is willing to take advantage of the service offered by the CBHI scheme, but for those households who live in remote kebeles, like Damota Village, the health extension workers do not want to travel to the area to raise awareness of the service and the majority of the time they say "climbing the mountain is old fashion". Due to this, households are also impacted by a lack of understanding of how the community-based health insurance scheme provides services’

The data shows that the reluctance of health extension workers to engage with households and communities, compounded by their unwillingness to navigate challenging terrains, further exacerbates the lack of understanding among households regarding the services offered by the CBHI scheme. Consequently, this situation not only hinders the delivery of CBHI services to remote areas but also impedes the community’s ability to make informed decisions about enrolling in the insurance program, thereby limiting their access to essential healthcare services.

Discussion

The study investigated the situations influencing the utilization of CBHI scheme membership in Sodo Zuria Woreda, southern Ethiopia. Educational status, distance from the health facility, awareness of CBHI, unavailability of pharmaceuticals and medical supplies, administrative complexity, and limited human resources have all been found to influence CBHI enrollment.

The results of the study revealed that low levels of educational attainment can have a substantial impact on households’ decisions to utilize CBHI schemes in southern Ethiopia. This suggests that households with a little formal education are more likely to be enrolled in the program. The finding is consistent with studies conducted in Ethiopia, such as Bayked et al. (2021); Fite et al. (2021); Minyihun et al. (2019), which found that those with a high level of awareness of the CBHI scheme were more likely to enroll in it than those with a low level of awareness. This finding is backed by studies in Rwanda (Schneider & Diop, 2001), Tanzania (Macha et al., 2014), Bangladesh (Ahmed et al., 2016), and West Africa (Chankova et al., 2008). This could be because people with more information are more likely to inquire about the services and gain a better understanding of the benefits that motivate them to join CBHI. This means that enhancing community knowledge could aid in the scheme’s successful implementation.

In regards to distance, our study found that households located far from the health care institution were less likely to utilize CBHI health care services than families located near the health care institution. This study supported previous research (Acharya et al., 2013; Asfaw et al., 2022; Atnafu, 2018; Moyehodie et al., 2022), which found that the distance between a home and the nearest health institution had a substantial impact on CBHI enrollment. This could be because of the great distance between the community and the health center, which could result in significant transportation and accommodation costs. It should also be noted that because Ethiopian society is more egalitarian in nature, where most individuals from a given community frequently travel to hospitals to visit sick people and sick people enjoy the company of others, remote health institutions may not be preferred.

According to studies in Ethiopia (Geferso & Sharo, 2022; Kebede, 2014; Minyihun et al., 2019; Mirach et al., 2019; Negera & Abdisa, 2022), those with a higher socioeconomic status are more likely to enroll. The same result has been documented in Tanzania (Macha et al., 2014). However, the findings of our study demonstrated that household income has no discernible impact on households’ willingness to utilize CBHI systems. This could be related to people in the research area believing that the premium is affordable for the majority of them.

We have found in the present study that households with large members are more likely to utilize the CBHI services. This is analogous with several studies in Ethiopia (Minyihun et al., 2019; Mirach et al., 2019; Negera & Abdisa, 2022), Nigeria (Babatunde & Akande, 2012), and China (Wang et al., 2005), who discovered that households with larger family sizes were more willing to pay for and use community-based health insurance. This is because the contribution (premium) is collected from homes at a predetermined flat rate, which means that a similar amount of payment is charged to every household regardless of their household characteristics (Tahir et al., 2022). As a result, it is expected that households with several members will utilize CBHI to reduce excessive health costs under the out-of-pocket mechanism.

Among scheme-related factors, drug unavailability was the first subtheme to emerge as a deterrent to persons using and renewing CBHI memberships, followed by the availability of health care providers. The primary goal of joining the CBHI scheme is to obtain high-quality health care at a low cost (Mirach et al., 2019). As a result, it is critical for a healthcare institution implementing CBHI to guarantee that appropriate medications and healthcare personnel are available so that the scheme can be executed effectively and dropout rates are reduced. According to the findings of our study, members were dissatisfied with the lack of appropriate professionals, as they frequently relocated to urban areas in pursuit of better opportunities, and with the absence of drugs at the health facility. This finding is consistent with those from Ethiopia, such as Fufa and Yasin (2021), who found that the most unsatisfactory aspects of CBHI service were a lack of skilled personnel and the availability of drugs at health facilities; and Bayked et al. (2021), who found that the availability of medical equipment and laboratory services could encourage people to pay for, enroll in, and utilize CBHI. However, this contradicts the findings of a study conducted by Geferso and Sharo (2022), which discovered that members were satisfied with the availability of drugs and medical supplies. This could be due to differences in methodology and geography.

Although participants in this study regarded the payment as affordable, the time of premium collection looks to be difficult, particularly for rural households. This is because members believe they are obligated to pay the annual premium during the harvest season, when crop prices are at their lowest and payments for other services are also anticipated. This study is consistent with a study in Ethiopia (Atnafu, 2018), which revealed that the inconvenience of premium collection was the most influential factor in renewing CBHI membership, and a study in India (Sinha et al., 2006), which revealed that barriers related to scheme design and management (for example, lack of clarity among scheme staff regarding the validity of their claims) affect scheme take-up decisions and access to benefits. According to Hussien et al. (2022), despite CBHI’s attempts to increase health care access for its members, particularly high-risk individuals living with chronic diseases, the organization lacks the ability to protect them from financial challenges while getting health care. This means that the scheme may be unable to produce sufficient funds to meet its members’ health-care demands.

The current study also found that there was a lack of awareness regarding CBHI services in the study area, owing to a lack of adequate information dissemination on the part of healthcare professionals and a lack of understanding of the program by its members. This finding is congruent with the findings of Obse et al. (2015), who claimed that members had insufficient knowledge of the concept and parts of health insurance and that several concepts, such as risk pooling and sharing, were poorly understood by study participants. They viewed health insurance as merely a prepayment mechanism with no risk sharing among scheme members. Other Ethiopian research (Bantie et al., 2020; Demissie & Atnafu, 2021; Negera & Abdisa, 2022) demonstrated a lack of awareness and misconceptions about community-based health insurance. A study conducted in Tanzania by Macha et al. (2014) also revealed that a lack of understanding of risk pooling discouraged people from joining the scheme and was the primary cause for not renewing membership.

Broader insights

Although the findings are not directly related to our results, a number of studies provided interesting broader insights regarding the utilization of CBHI services. A study conducted in Uganda by Nshakira-Rukundo et al. (2019) and Nshakira-Rukundo et al. (2021) emphasizes the role of informal social support networks, such as burial groups, in disseminating health information and renewing CBHI membership. They argued that as burial group size and the number of burial groups in a village rise, so does the possibility of renewing CBHI. Mirach et al. (2019) also found that social capital, specifically community solidarity, was substantially connected with CBHI scheme enrollment, indicating that families that believed there was good community solidarity were more likely to join than those who believed there was weak community solidarity. The results of a study in Senegal by Mladovsky et al. (2014) ostensibly suggest that CBHI schemes should build on bridging social capital to increase coverage, for example, by enrolling households through community associations. Likewise, Negera and Abdisa (2022) found that membership in any association enhances the likelihood of willingness to pay for the CBHI scheme. Moreover, perceptions and beliefs are often influential in the adoption of health practices because behavioral change is anchored in community social systems (Nshakira-Rukundo et al., 2019). Individuals’ perceptions of various aspects of health insurance play a significant role in their decisions to enroll in and utilize services.

Conclusions

The purpose of this study was to assess the circumstances influencing the patterns of utilizing community-based health insurance schemes among households in southern Ethiopia. The findings of the study revealed that low levels of educational attainment, a lack of pharmaceuticals, medical supplies, and healthcare professionals, the distance between the houses of households and the health centers, and lack of program awareness among people contribute to underutilization of the CBHI scheme’s services. These factors were found to discourage members of the local communities from enrolling in the scheme and utilizing healthcare services, which exposes them to out-of-pocket medical expenses and a financial crisis, thereby negating the goal of the CBHI program. As a result, the Ministry of Health, in conjunction with other governmental and non-governmental bodies, should ensure that enough pharmaceuticals and medical supplies are provided, that there are enough health workers available, and that a convenient working procedure is established in health centers. Above all, the lack of awareness about the scheme and its impact on patterns of utilization of CBHI indicates the need for advocacy and awareness-raising campaigns for community members.

Limitations of the study

The present research has several limitations. Firstly, the study primarily gathered information from CBHI members in the community. However, it would have been beneficial to include non-CBHI community members and conduct a comparison between these two groups. This approach would have aided in understanding why households aren’t joining the program and in identifying overall differences in attitudes and perceptions toward the CBHI program. Secondly, an examination of households in various woredas (districts) and socio-cultural settings would have provided more comprehensive information about service uptake and determinants in different contexts. Finally, the study would have greatly benefited from the combination of qualitative and quantitative methods.

Acknowledgements

We wish to convey our sincere gratitude to the study participants for their time and willingness to share their perspectives. Additionally, we extend our heartfelt appreciation to the reviewers who generously dedicated their time to meticulously review the manuscript and provide invaluable suggestions for its improvement.

Disclosure statement

The authors report there are no competing interests to declare.

Data availability statement

The data used to support the analysis for this study can be obtained from the corresponding author upon reasonable request.

Additional information

Notes on contributors

Getahun Siraw

Getahun Siraw is a senior lecturer of sociology at Dilla University, Ethiopia. He is dedicated to teaching and mentoring students while also conducting cutting edge sociological researches. His research interests are in important societal issues, with public health, gender, marginalization and IDPs attracting his attention and has published several research findings.

Bewunetu Zewude

Bewunetu Zewude studied of sociology at Addis Ababa University, Ethiopia. He has rich experience in teaching, advising and examining undergraduate and postgraduate students of higher education institutions in Ethiopia. In addition to consulting social affairs, Bewunetu has always been undertaking studies on the health and welbeing of children, youth women and other vulnerable groups. He has also published several articles in peer reviewed journals.

Muluken Meshesha

Muluken Meshesha is currently working as a community research officer in Wolaita zonal administration. He received his MA degree in sociology from Wolaita Sodo University.

Notes

1 Kebele is the lowest administrative unit of the government in Ethiopia.

2 Since recent times, motorcycle has become the most commonly used mode of transportation in most rural and some urban areas in Ethiopia.