Enrollment and clients’ satisfaction with a community-based health insurance scheme: a community-based survey in Northwest Ethiopia

Health insurance continues to become one of the most important health financing programs and has been used as a complementary or substitute source of healthcare financing in the developing world [1]. Community-based health insurance (CBHI) schemes are often voluntary and applied by pooling funds from community members to protect themselves against the significant cost of pursuing medical care and treatment for medical conditions [2, 3]. Inability to afford out-of-pocket (OOP) expenditures has been one of the foremost obstacles to getting healthcare, especially for poor individuals and the vulnerable population at large [4]. Thus, CBHI has been implemented as a health financing tool and part of health transformation programs and policies in most low- and middle-income countries aimed at providing operational and proficient healthcare for citizens, most particularly for the poor and vulnerable [1, 5].

Though health insurance has been initiated in many countries, the majority of the population in developing countries suffers from financial devastation, and about 100 million are forced into poverty due to high OOP payments for healthcare services globally [6‐8]. However, health insurance schemes in many low- and middle-income (LMIC) countries are still in their early stages of implementation, especially in most African countries, with the goal of universal coverage of the population in the health sector [9‐12]. OOP payment to get health care is regressive as it limits admission to healthcare services for poor individuals, and it has contributed to the impoverishment of families due to having to pay for unexpected healthcare services at the time of illness [13].

There are many factors contributing to the enrollment and satisfaction of households with CBHI programs. Studies report that residency status, educational status, occupational status, household size, time taken to reach a health facility, and provided service qualities contribute to the enrollment of individuals or households in the healthcare services of CBHI [14‐16]. On the other hand, the satisfaction of enrolled clients with the CBHI service was determined by the availability of medications and laboratory services, the qualification of healthcare service providers, and the waiting time to access health services [12, 17].

CBHI in Ethiopia is currently voluntary; individuals have the choice to enroll or not, and OOP has been a major means of financing health expenditures for several decades since the introduction of modern healthcare services [18, 19]. Nevertheless, recently, the Ethiopian government has developed a mutual health insurance strategy and a new policy for the CBHI schemes targeting employees from the rural and informal sectors through the Federal Ministry of Health (FMOH) of Ethiopia [20]. It has brought some improvements to the population’s health and the financing structure of healthcare [21]. The Ethiopian Health Insurance Service (EHIS) has been working to improve risk pooling among different groups of the population, such as between rich and poor, healthy and sick [22, 23]. CBHI packages in Ethiopia include all necessary family health services and curative care for disease conditions, which are part of the primary health packages, excluding dental and optical care and out-of-country referrals [22]. A high percentage of families registered in CBHI might be an indicator of the program's overall appeal and a gauge of how long it has been in place. More households will be able to ensure access to care when needed and avoid the financial burden of expensive treatments as more people join health insurance. However, in practice, CBHI frequently falls short of its potential, mainly due to low levels of involvement [24]. The commitment of authorities to support the program, and the attitude and awareness of the community towards the importance of health insurance services determine the enrollment and inclusion of individuals in the scheme [25‐28]. Financial constraints and informal sector and economy dominance are also posing a problem of enrollment in the CBHI scheme because it is challenging to reach them through traditional enrollment channels. Subsidising premiums, information campaigns, and leveraging the informal sector are among the solutions.

Although EHIS’s initiatives have been practiced throughout the country and studies have been conducted regarding enrollment [16, 22] and clients’ satisfaction [12, 17, 29], the existing evidence focuses on either enrollment or clients' satisfaction in enrolled households. In addition, because of differences in community engagement with the CBHI scheme and variations in administrative and healthcare service provider facilities across different areas of the country, investigating the current study area is crucial to providing tailored insights because little is known about the extent of utilization of health insurance by households and the level of client satisfaction among CBHI scheme users in the study area. Furthermore, the clients’ level of utilization of and satisfaction with the CBHI scheme could be assessed in terms of individuals' perceptions of, expectations, and experiences with service delivery [30‐32]. Consequently, the current study assessed the enrollment of households in CBHI, the level of clients’ satisfaction, and associated factors in Gondar Zuria, District, Northwest Ethiopia. The findings from the study may help to understand the extent of community involvement in CBHI and the level of satisfaction among individuals enrolled in the scheme. Besides, the findings serve as a baseline for further research and as input for improving the program outcomes by concerned authorities and stakeholders.

This community-based survey aimed to assess the enrollment of households in the CBHI scheme and the level of client satisfaction with the services provided by the program. Consequently, this study showed that most participants were enrolled in the CBHI scheme, and two-thirds (66.5%) of the enrolled participants were dissatisfied with the services of the program. Residency status, time taken to health facilities, and household size were factors associated with the enrollment of the CHBI scheme, while household size and waiting time to get healthcare services were variables significantly associated with enrolled clients’ level of satisfaction with the CBHI scheme.

The current study has shown that around two-thirds of the participants were enrolled in the CBHI scheme. This figure indicates a better enrollment rate than the report by EHIS, which indicated a national rate of 58% [20]. This implies the existence of factors that motivate residents in the study area to enroll in the program. However, it could still be encouraged to engage the communities in the program. It has an important implication for healthcare financing by protecting citizens from catastrophic health expenditures. Consistent with previous studies [14, 15], the current findings revealed that residence, household size, and time taken from home to healthcare facility were predictor variables for CBHI scheme enrollment among households. Consequently, rural residents and participants who travelled a longer distance from home to healthcare facilities were found to have lower enrollment in the CBHI scheme compared with urban residents and participants who travelled a shorter distance, respectively. This might be because of lower awareness, poor knowledge regarding the programs and services, and a lack of information about how they engage with the health insurance systems. Rural residents and those who live at a longer distance from health facilities may not have better knowledge and access to information about health insurance systems and services. This intern decreases their enrollment in the insurance scheme. Therefore, rural communities living a longer distance from home to health facilities may need attention. The service providers must design policies or evaluate their implementation to better accommodate rural communities. This study also demonstrated that participants with a larger family size were more inclined to join in the CBHI scheme. This could be the case because people with larger families might not be able to afford the OOP expenses associated with receiving healthcare. As a result, individuals are free to select health insurance plans, enlist in the program, and go via the CBHI for only the best pre-paid coverage.

This study revealed that, despite the fact that most of the community had enrolled in the CBHI, a lower proportion (33.5%) of the clients were satisfied with the services of the program. This finding is much lower than the previous studies [9, 12, 35, 36]. The finding implies that the CBHI scheme office may not go through the way it is designed to because of different reasons. This can compromise the service of the program and lead to clients’ dissatisfaction. For instance, in this study, a significantly higher proportion of participants were not satisfied with the overall quality of services, and more than 80% of the participants were dissatisfied with the availability of medications and laboratory tests. This may contribute to the overall dissatisfaction of the clients. The clients also reported that they were forced to leave refereed health facilities without receiving healthcare access because of the inability of the district to recover the costs from the previous one and two years; this in turn affects the clients’ satisfaction with the overall services. However, more than half of the participants reported that they were satisfied and/or very satisfied with the respectful care of healthcare providers, the cleanliness of the healthcare facilities, and the referee services when the program recovered the costs for healthcare facilities. The finding may suggest that the health insurance system should adhere to the interests of clients in its implementation.

In this study, satisfaction levels among different participants were significantly different. Thus, the findings showed that there was a significant satisfaction difference between different household size members, different waiting times to get healthcare services, different educational statuses, and different occupational types. Consequently, participants with larger household sizes were found to have significantly lower satisfaction scores compared to those with lower household family members. This might be partially justified because clients with larger family sizes could pay a higher pre-paid cost of coverage proportionally to their household size, which in turn affects their perceptions and satisfaction with the services of the program. The association of household size and clients’ satisfaction in this study also showed that participants who had smaller household sizes were found to be more likely to have higher satisfaction with the CBHI scheme services compared to those with larger household families. This might be because households with large families might be reluctant to pay for their pre-paid cost coverage based on their family size. This can contribute to a lower perceived service quality. Thus, the compromised healthcare service may make them dissatisfied, in contrast to their expectations.

This study also revealed that participants who waited a shorter time to get healthcare access at the health facility had a high satisfaction score. An impact of waiting time on the satisfaction level also uncovered that patients who were waiting a shorter time were found to be more likely to be satisfied compared with participants who were awaiting a longer time to get healthcare services from health facilities. This finding agrees with a previous study conducted by Haile et al [12]. The finding indicates that healthcare providers should be encouraged to provide healthcare for the clients as early as possible on their referral or admission to the health facility.

There is also a significant satisfaction mean score difference among different participants regarding their educational status and occupational types. The finding revealed that college and university-graduated participants had significantly higher satisfaction mean scores compared to participants who were unable to read and write and who could read and write. This could be because those participants with higher educational levels may have better awareness and knowledge regarding how the services of the program can be implemented, making them more likely to adhere to the services that can result in high satisfaction scores compared to participants with lower educational status. Additionally, in terms of occupational characteristics of study participants, merchants had significantly higher satisfaction mean scores than farmers on CBHI scheme services. This might be related to their level of awareness, knowledge, and information regarding the service in general, which can affect their level of involvement and their level of satisfaction with the service. However, this study did not show a statistically significant association between the educational status and occupation of participants and their level of satisfaction.

Generally, the study highlighted the level of household engagement with the CBHI scheme and clients’ satisfaction in Northwest Ethiopia. The findings showed that the services provided by the program should be encouraged. The ultimate goal for which every health system should strive is to achieve and maintain client satisfaction and increase the provision of service to customers. Therefore, the commitment of the district authorities to support the scheme through the implementation of cost recovery would have a great value in improving clients’ satisfaction. Additionally, healthcare facilities could implement the CBHI services based on the aim, which is to maintain the healthcare financial balance of individuals and the community at large.

This study concluded that a significant proportion of households in the district were enrolled in the CBHI scheme, but most of these participants were dissatisfied with the program's services. Significantly, a higher proportion of participants were not satisfied with the overall quality of services and/or the availability of medications and laboratory tests. Household family size and waiting time to get healthcare access were predictors clients’ satisfaction with the CBHI scheme services. Therefore, the CBHI services need to be monitored and audited based on its objectives, in particular the overall quality of service and availability of medications, and laboratory tests should need special attentions.