Community based health insurance uptake and utilisation of healthcare in Ethiopia

Abstract

Background: Community-Based Health Insurance (CBHI) is widely recognized as a key strategy for improving healthcare access and financial protection among lowincome populations. In Ethiopia, despite sustained efforts to expand CBHI coverage, enrolment remains below the national target of 80%. By 2020, only 49% of eligible households enrolled in Shaggar City, Oromia Region, Ethiopia. This limited coverage continues to expose many households to out-of-pocket healthcare costs, delays in seeking care, and poor health outcomes, thereby constraining broader socioeconomic development. Purpose: This study aimed to investigate the factors influencing CBHI uptake and healthcare utilization and to develop sustainable, evidence-based intervention strategies to enhance enrolment, renewal, and effective service use. Methods: A convergent mixed-methods design, guided by the Socio-Ecological Model (SEM), was employed across six sub-cities of Shaggar City, Oromia Region. The quantitative component involved a cross-sectional survey of 406 households, analyzed using SPSS (version 26) through descriptive statistics and multivariable logistic regression. The qualitative component comprised in-depth interviews with health leaders, CBHI officials, experts, healthcare providers, and community representatives, and was analyzed thematically. Findings from both strands were integrated and further refined using the APEASE framework (Affordability, Practicability, Effectiveness, Acceptability, Safety, and Equity). Results: CBHI enrolment showed a substantial improvement over time. While national and earlier evidence indicated that only 49% of eligible households were enrolled by 2020, the findings of this study revealed that enrolment had increased to 98% among eligible households in the study area by 2025. Despite this significant progress in coverage, both CBHI uptake and healthcare utilization were influenced by interconnected factors operating at multiple levels. Key determinants included individual awareness, perceived quality of healthcare services, household economic status, community trust, and institutional capacity. Qualitative insights further enriched these findings by highlighting persistent challenges related to service quality, limited access to reliable information, and gaps in system responsiveness. Drawing on the integrated evidence, the study developed the Comprehensive Integrated CBHI Uptake and Utilization (CICU) strategy, which focuses on strengthening awareness, improving service delivery, and enhancing sustained community engagement. Conclusion: This study makes a meaningful contribution to the field of health financing by offering an empirically grounded and theoretically informed framework for strengthening the implementation of Community-Based Health Insurance. The proposed Comprehensive Integrated CBHI Uptake and Utilization (CICU) strategy provides practical and context-sensitive guidance for policymakers and practitioners to enhance enrolment, improve service utilization, and address system-level challenges. By promoting more equitable and sustained access to quality healthcare, the study also supports Ethiopia’s ongoing efforts toward achieving Universal Health Coverage (UHC) and Sustainable Development Goal 3 (SDG 3). Keywords: Community-Based Health Insurance, CBHI uptake, healthcare utilization, socio-ecological model, health financing, Shaggar City, Oromia Region, Ethiopia