Perception of Members toward Community-Based Health Insurance (CBHI Program, in Ethiopia: Insight from customer satisfaction national survey

doi:10.21203/rs.3.rs-4970275/v1

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Research Article

Perception of Members toward Community-Based Health Insurance (CBHI Program, in Ethiopia: Insight from customer satisfaction national survey

https://doi.org/10.21203/rs.3.rs-4970275/v1

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Background

This study investigates the perceptions of Community-Based Health Insurance (CBHI) holders across various regions and demographic factors in Ethiopia, focusing on their views regarding key aspects of the CBHI program. CBHI initiatives are crucial for enhancing healthcare access and providing financial protection, especially in low- and middle-income countries. In Ethiopia (since 2011), the CBHI program has been part of broader health sector reforms aimed at reducing out-of-pocket (OOP) healthcare expenses and improving service delivery [1].

Method

This study employs data from a national customer survey and analyzes responses from CBHI members, who rated aspects such as registration, contribution rates, service efficiency, and travel costs on a five-point Likert scale. This national survey employed a correctional study design and a questionnaire as a data collection tool. Descriptive statistics, chi-square tests, and composite variable scoring were used to interpret the data.

Result

the Key findings reveal a strong positive perception of the registration process, with 91% of respondents viewing it favorably and 88% finding the contribution rates fair. These elements are crucial for member retention and the sustainability of the CBHI scheme. However, only 75% of the respondents were satisfied with the convenience of services provided under the CBHI, indicating significant areas for improvement, particularly in terms of the efficiency and quality of healthcare services. The study also highlights substantial regional differences, with Dire Dawa showing the highest positive perceptions and Benishangul Gumuz the lowest. Additionally, factors such as age, employment status, duration of CBHI membership, healthcare usage, residence, and awareness level significantly influenced members' perceptions.

Conclusion and Recommendation:

The findings underscore the need to address region-specific challenges and demographic disparities within the CBHI program. While highly positive perceptions of registration and contribution fairness are encouraging, less favorable views of service convenience and regional disparities suggest uneven program implementation. To improve CBHI effectiveness, policymakers should focus on enhancing service convenience, particularly in regions with higher negative perceptions, through better resource allocation, staff training, and infrastructure improvements. Addressing demographic disparities, particularly among rural populations, younger age groups, and lower-income households, is also essential. Future research should explore these disparities further and evaluate the long-term impact of the CBHI on healthcare access and financial protection.

Community- based health insurance (CBHI) schemes have emerged as pivotal instruments for providing financial protection and improving access to healthcare services in low- and middle-income countries (LMICs) [1]. Unlike formal health insurance systems, which often cover urban and formal sector employees, CBHI schemes are tailored to meet the needs of rural populations and informal sector workers, who are typically underserved by traditional health insurance mechanisms [2]. The primary goal of CBHI programs is to reduce out-of-pocket (OOP) healthcare expenditures, thus preventing impoverishment due to catastrophic health expenses and promoting equity in health service utilization [3].

Despite the growing implementation of CBHI schemes, there remains a significant need to understand the perceptions and satisfaction levels of members, as these are critical indicators of program success and sustainability. Positive member perceptions are essential for high enrollment rates, continuous membership renewal, and overall program viability. Conversely, negative perceptions can lead to low enrollment rates, high dropout rates, and eventual program failure [4]. As shown in a study in Tanzania, household perceptions significantly influence enrollment decisions, with factors such as convenience, healthcare quality, alternative strategies, and knowledge being the most impactful [4]. Similarly, in Ghana, perceptions of quality healthcare services were found to be a key determinant of member satisfaction, with over half of the respondents having a positive perception [5]. In Western Ethiopia, perceptions regarding health status, premium affordability, and care quality are strongly associated with CBHI enrollment [7]. In addition, a study in the Gedio zone highlighted that members with positive perceptions of healthcare quality and favorable attitudes toward the CBHI scheme were much more likely to renew their memberships [8].

This study aims to fill the evidence gap in the area by providing a detailed analysis of CBHI member perceptions in Ethiopia. By examining perception items such as the registration process, contribution fairness, service efficiency, travel time and costs, and trust in CBHI workers and officials, this study seeks to identify key areas of strength and potential improvement. Furthermore, the study explores how these perceptions vary by region, urban versus rural setting, and demographic factors such as age, sex, and membership type (paying vs. indigent).

The insights gained from this study are intended to inform policymakers and program administrators about the factors that influence member satisfaction and to guide targeted interventions aimed at enhancing the effectiveness and sustainability of CBHI programs. By addressing region-specific challenges and demographic disparities, the goal is to ensure that CBHI schemes effectively meet the healthcare needs of all members, thereby contributing to the broader objectives of universal health coverage and health equity.

Study Design

This study used data from 4008 CBHI members extracted from a national customer satisfaction survey conducted in 2023. The survey used a cross-sectional design with quantitative data collection techniques. The survey identified study participants using 14 strata and by applying random sampling techniques. The tool used for data collection involved a structured questionnaire administered to CBHI members.

Participants

The national customer survey sample comprised CBHI members from various regions in Ethiopia and was selected through a stratified random sampling method to ensure representation across different demographic groups and geographic locations. The target population included both paying and indigent members to capture a broad spectrum of experiences and perceptions.

Data collection

The data collected via a national survey through a structured questionnaire included perception items on a five-point Likert scale ranging from "strongly disagree" to "strongly agree." The questionnaire covered key aspects of the CBHI program, including the following

Registration Process: Assessing the ease and accessibility of CBHI registration.
Contribution fairness: Evaluating members' perceptions of the fairness of contribution rates.
Out-of-Pocket (OOP) Expenses: Measuring the perceived effectiveness of CBHI in reducing OOP healthcare costs.
Service Efficiency: Gauging satisfaction with the efficiency and quality of healthcare services provided under the CBHI, which usually affects perceptions.
Travel Time and Costs: Assessing the burden of travel time and costs associated with accessing healthcare services.
Trust in CBHI Officials: Evaluating the level of trust in CBHI workers and officials.

Data analysis

The data were analyzed via descriptive statistics, chi-square tests, and composite variable scoring. Perception levels were categorized as favorable or unfavorable based on scores above or below the mean value of the composite variable. Regional differences and demographic associations were examined via statistical tests to identify significant variations and trends.

The CBHI members’ perception level is measured via a composite variable created by summing the individual scores of the participants on a five-point Likert scale across the nine perception items. The value of the composite variable is a maximum of 45 and a minimum of 9 for each participant. Hence, the mean value of the composite variable was found to be 35.35 (adjusted for sampling weight) and was used to categorize the participants into two groups. Study participants with individual scores above the mean value of the composite variable were labeled as having a “positive perception”, whereas those below the mean value were labeled as having a “negative perception”. Accordingly, 58.1% of the CBHI members scored above the mean value and were considered to have a “positive or favorable perception”, whereas the remaining participants (41.9%) scored below the mean value and were considered to have a “negative or unfavorable perception”.

The combined responses of "agree" and "strongly agree" for each perception item, as illustrated in Fig. 2, were the highest perception reported for the suitability of the CBHI registration process (91%), followed by the fairness of contribution rates (88%) and the potential for reducing out-of-pocket (OOP) expenses (86%). The favorability of the perception of travel cost was the lowest at 75%. These findings indicate that while members appreciate the ease of enrollment and equitable contribution requirements, there are complaints regarding the efficiency of service delivery.

Predictors of perception

The multivariate analysis revealed that the perceptions of members toward the CBHI program are significantly influenced by factors such as the age of the participants, employment status, duration of CBHI membership, ever use of health services, residence and level of awareness.

Age of the participants

Older age groups were significantly more likely to have positive perceptions than younger (18–29 years) participants were. Members who were 66 years and above were 1.91 times more likely to have a positive perception than the youngest, with a significant value of P < 0.05. This may suggest that older members are usually exposed to diseases, mainly chronic cases, and could drive them to value the financial risk protection and improved access to healthcare that the CBHI program provides.

Employment

Compared with self-employed individuals, those employed by others (66.9%) are 1.56 times more likely to have favorable perceptions of the CBHI program. Students, unemployed individuals, and homemakers are more likely to have positive perceptions than self-employed individuals are, with a significant P value < 0.05.

Duration of CBHI Membership

Participants with more than 3 years of CBHI membership duration are less likely to perceive positive CBHI membership duration than those with less than 3 years of membership duration, which is statistically significant, with a p value < 0.05. This suggests that over time, some members may become dissatisfied with aspects of the program or encounter challenges that reduce their positive perception.

Ever use of health services

Participants who had ever utilized their CBHI membership to access healthcare services (58.9%) reported 1.6 times more favorable perceptions than never did. This underlines the importance of program usage in shaping perceptions, which are strongly associated with a statistically significant p value of 0.000.

Awareness level of the participants

Participants with good awareness had more positive perceptions than did those with poor awareness, with statistically significant p values < 0.005 and ORs of 1.138. Enhancing community-level awareness and understanding of the program's benefits may therefore be an important strategy.

Residence

Urban residents (60.6%) were more likely to have positive perceptions of the CBHI program than rural residents were, with a significant p value (0.003) and an odds ratio (OR) of 1.203, which may indicate that urban residents are more prone to chronic diseases such as hyperattention and diabetes.

Other Factors

Demographic Factors

The proportion of members with a positive perception differed by region (Fig. 3), type of membership (paying vs. indigent), sex, and age group. There was a significant association between age and perception level (Χ2 = 12.7, p = 0.005) and between perception level and renewal decision (Χ2 = 87.527, p = 0.000). These associations suggest that demographic factors play a critical role in shaping members' attitudes toward the CBHI program.

Regional differences

The perception levels of CBHI members significantly vary across regions (Fig. 3). Dire Dawa scored the highest for reducing OOP expenses (93.3%), whereas Benishangul Gumuz scored the lowest (77.2%) for this perception item. The perception of relief from unexpected health expenditures was highest in Dire Dawa (94%) and lowest in SWEP (73%). Trust in CBHI workers and officials varied widely, with high levels of trust reported in Oromia, Addis Ababa, Dire Dawa, and Harari (90–97%) and low levels of trust reported in Amhara and Benishangul-Gumuz (75%). These regional differences suggest that localized factors significantly impact members' perceptions and experiences with the CBHI program.

Educational Status Illiterate

The findings show that participants with higher education levels have more positive perceptions, ranging from 57.2% with primary education to 64.4% with diploma and above, with an OR of 1.35.

Accessibility and Affordability. The affordability of contributions compared with income was perceived positively in regions such as Dire Dawa (93.7%) and Harari (96.2%) but less favorably in Addis Ababa (64.1%) and SWEP (82%). This finding indicates that geographical disparities influence how members perceive the cost and accessibility of healthcare under the CBHI scheme.

In general, CBHI members with good awareness, living in urban areas, being older, having a higher education level, and being employed are more likely to have positive perceptions that drive participants toward continuation and a willingness for renewal.

The findings highlight significant regional and demographic variations in the perceptions of CBHI programs. Positive perceptions are associated with better perceived accessibility, affordability, and trust in CBHI workers. The high levels of satisfaction with the registration process and fairness of contribution rates suggest that the CBHI program is well structured in these aspects. However, the lower perceptions of service efficiency and travel costs indicate areas needing improvement.

The marked regional differences in perceptions underscore the importance of context-specific interventions. For example, the high perception scores in Dire Dawa may be attributed to better healthcare infrastructure and administrative efficiency, whereas the lower scores in Benishangul Gumuz and Gambella could reflect logistical and infrastructural challenges.

The significant associations between perception levels and demographic factors, such as age and renewal decisions, indicate that older and middle-aged members tend to have more favorable perceptions. Urban members were generally more satisfied with the program than their rural counterparts were, with a significant difference in perception levels. The greater positive perception of older and urban residents may be associated with and derived from their greater risk of disease, mostly chronic. The higher renewal rates among members with positive perceptions of ever-used health services emphasize the importance of maintaining trust and improving service quality to ensure sustained membership. Household income was positively associated with satisfaction, with higher-income households reporting better perceptions of the registration process and fairness of contribution rates.

The pronounced regional disparities in perception levels underscore the importance of tailoring the CBHI program's implementation to the specific needs and challenges of different regions. For example, regions with lower satisfaction levels may require additional support in terms of resources and capacity building to enhance the effectiveness of the program. Furthermore, the significant variation in trust among CBHI officials suggests that efforts to improve transparency, communication, and accountability could enhance member satisfaction and trust in the program. These findings are consistent with those of previous studies that emphasized the importance of good governance and member engagement in the success of CBHI schemes.

The findings of this study have important implications for policymakers and program administrators. To increase the overall effectiveness of the CBHI program, targeted strategies should be developed to address specific regional challenges and demographic disparities. Improvements in service efficiency, reductions in travel costs, and increased trust in CBHI officials are critical areas for intervention. By addressing these issues, the CBHI program can better meet the healthcare needs of its members, thereby contributing to the broader goals of universal health coverage and health equity.

Future research could further explore the impact of demographic factors on CBHI perceptions and investigate the long-term outcomes of the program in terms of healthcare access, financial protection, and health outcomes. Additionally, longitudinal studies could provide insights into how member perceptions evolve over time and how changes in program implementation affect satisfaction levels. Such research would be valuable in informing ongoing efforts to refine and scale up the CBHI program in Ethiopia and other low- and middle-income countries

CBHI

Community-based health insurance

LMICs

Low- and middle-income countries

NCS

National Customer Satisfaction Survey

OOP

Out-of-Pocket

Odds ratio

SWEP

Southwest Ethiopia people

Consent and ethical considerations

The study was conducted in accordance with ethical guidelines and approved by the relevant institutional review boards. Informed consent was obtained from all participants, and confidentiality and anonymity were maintained throughout the research process. The authors have full authority for the publication

Competing interests:

No competing interest

Funding:

The study was financially supported by the Ethiopian health insurance service, but the authors declare that they have no conflicts of interest for publication.

Author Contribution

Adamu Wondimtekahu, Hilina Faye, Wudalew Meselu, Teklu Debebe, Alemayehu Bedassa, Bereket Habte, Geremew Tesgera, Tigist Yoseph, and Kidist Dereje played pivotal roles in the initial stages of the project, contributing significantly to the proposal preparation. They were also deeply involved in the data collection and analysis, ensuring that the research was conducted rigorously and accurately. Their efforts laid a strong foundation for the subsequent phases of the study.Dereje Mengistu, Wodaje Gietaneh, Adamtachew Beyene, Mekonen Ararso, and Fikru Teshome took the lead in the critical task of analyzing the collected data. They meticulously examined the data, drawing meaningful insights that were essential for the report. Additionally, they were responsible for drafting the report, translating the data analysis into a coherent and comprehensive document that effectively communicated the study’s findings.Yamerot Andualem, Frehiwot Abebe, and Muluken Aragaw provided overall leadership and guidance throughout the entire project. From the inception of the proposal to the final dissemination of the results, they ensured that all activities were conducted smoothly and aligned with the project’s objectives. Their leadership was instrumental in coordinating the team’s efforts, maintaining the project’s focus, and ensuring the successful completion of all stages, culminating in the effective sharing of the study’s outcomes with relevant stakeholders.

Acknowledgments:

The authors would like to express our sincere gratitude to all those who contributed to the completion of this research. First and foremost, we extend our heartfelt thanks to the EHIS management and technical working groups (TWGs) assigned for this work, whose guidance, insights, and unwavering support have been invaluable throughout this journey. We are particularly grateful for their patience and encouragement, which have been instrumental in shaping this work.

Availability of data and materials:

The authors confirm the availability of full data and material.

Ethiopian Health Insurance Service. Annual Performance Report. 2023 (2015 Ethiopian Fiscal Year).
WHO), World Health Organization. Community Based Health Insurance, Key Facts. https://www.who.int/news-room/fact-sheets/detail/community-based-health-insurance-2020. 2020.
Abebe Sorsa Badacho, Kora Tushune, Yohannes Ejigu, and Tezera Moshago Berheto,. Household Satisfaction with a community-based health insurance scheme in Ethiopia. BMC Research Notes: DOI 10.1186/s13104-016-2226-9. 2016.
Do household perceptions influence enrollment decisions into community-based health insurance schemes in Tanzania? Alphoncina Kagaigai, Amani Anaeli, Amani Thomas Mori and Sverre Grepperud. Tanzania : s.n., 2021.
Utilization of the Ghana National Health Insurance Scheme and its association with patient perceptions on healthcare quality. HAW, NEL JASON L. Ghana : s.n., 2018
Mebratie A.D. et al. Impact of Ethiopian Pilot Community-Based Health Insurance Scheme on Health-Care Utilization: A Household Panel Data Analysis. The Lancet Global Health, 3(3). 2015
Derseh A, Sparrow R, Debebe ZY, Alemu G, Bedilu B, Mekonnen Y. [Online] 2018
Community‐Based Health Insurance Membership Renewal Rate and Associated Factors among Households in Gedeo Zone, Southern Ethiopia - Kaso - 2022 - Journal of Environmental and Public Health - Wiley Online Library

Table 1

Renewal Decision of CBHI Members by Perception Status in 2023
Renewal Decision	Perception Status		Total
Renewal Decision	Negative Perception	Positive Perception	Total
Yes	1650 (40.4%)	2434 (59.6%)	4084
No	136 (75.6%)	44 (24.4%)	180

Table 2

Results of the bivariate analysis of factors influencing the level of perception of the CBHI program
Perception Items	Category	Positive Perception	P Value	COR	95% C.I. for EXP(B)		AOR	95% C.I for EXP (B)		P value
Perception Items	Category	Positive Perception	P Value	COR	Lower	Upper	AOR	Lower	Upper	P value
Residence	Rural	56.1%
Residence	Urban	60.6%	0.003	1.203	1.06	1.35
Age	18–29	53.6%	0.005							0.00
	30–49	59.0%	0.02	1.245	1.03	1.49	1.36	1.126	1.654	0.00
	50–65	56.7%	0.225	1.134	0.92	1.38	1.30	1.056	1.619	0.01
	66 and above	65.1%	0.001	1.613	1.21	2.14	1.91	1.414	2.59	0.00
Educational Status	Illiterate	57.2%	0.299
	Writ Read Primary	57.8%	0.735	1.025	0.88	1.18
	Secondary TVET	58.7%	0.497	1.063	0.89	1.26
	Diploma & Above	64.4%	0.062	1.351	0.98	1.85
Sex	Male	58.3%
Sex	Female	57.9%	0.818	0.986	0.87	1.11
Family Size	0–4	58.1%	0.236
	5–7	59.1%	0.588	1.038	0.90	1.18
	8 and above	55.5%	0.231	0.897	0.75	1.07
Marital Status	Married	58.7%	0.038							0.00
	Single	63.6%	0.269	1.228	0.85	1.76	1.27	0.864	1.877	0.22
	Divorced or Widow	54.0%	0.026	0.826	0.69	0.97	0.72	0.602	0.864	0.00
Employment status	Self employed	55.6%	0.00							0.00
	Employed by others	66.9%	0.00	1.611	1.32	1.95	1.59	1.295	1.967	0.00
	Housewife	59.9%	0.06	1.193	0.99	1.43	1.20	0.999	1.455	0.05
	Student & No job	62.1%	0.019	1.309	1.04	1.64	1.29	1.008	1.654	0.04
Duration of CBHI membership	</= 3years	59.3%
Duration of CBHI membership	> 3 years	54.6%	0.008	0.828	0.72	0.95	0.79	0.689	0.922	0.00
Membership type	Paying Member	57.8%
Membership type	Indigent	60.8%	0.219	1.13	0.93	1.37
Ever used health service	No	47.0%
Ever used health service	Yes	58.9%	0.00	0.621	0.48	0.79	1.62	1.261	2.08	0.00
Overall Awareness	Poor Awareness	56.0%
Overall Awareness	Good Awareness	59.2%	0.047	1.138	1.00	1.29	1.14	1.006	1.307	0.04

No competing interests reported.

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You are reading this latest preprint version

Perception of Members toward Community-Based Health Insurance (CBHI Program, in Ethiopia: Insight from customer satisfaction national survey

Status:

Version 1

Abstract

Background

Method

Result

Conclusion and Recommendation:

Figures

Introduction

Methodology

Results

Predictors of perception

Other Factors

Discussion

Conclusion

Abbreviations

Declarations

Consent and ethical considerations

Competing interests:

Funding:

Author Contribution

Acknowledgments:

Availability of data and materials:

References

Tables

Additional Declarations

Status:

Version 1