Background:

Since 2011, the government of Ethiopia introduced a community-based health insurance (CBHI) scheme offering voluntary health insurance to rural households and to semi-urban households not employed within the formal sector. The Ethiopian Ministry of Health has taken steps to improve quality of health service by granting health facilities autonomy to retain and invest the revenue that they collect from user fees and other sources, for health care service quality improvement. Introduction of CBHI is presumed to improve service quality, and quality of health service might play a role in CBHI enrollment and retention; however, there is limited evidence on this interaction. This study examined the relationship between quality of health service and CBHI enrollment and renewal, and tried to answer two specific research questions: (i) Has the introduction and implementation of CBHI improved quality of health services? and (ii) Does quality of care affect enrollment in and renewal to CBHI schemes?

Methods

A mixed-method comparative study was done in four agrarian regions of Ethiopia [Amhara; Oromia; the Southern Nations, Nationalities, and Peoples’ Region (SNNPR); and Tigray]. Following the Donabedian model of health service quality to assess structural, process, and outcome quality, the study compared quality of health service in health centers located in woredas/districts that implemented CBHI with those that did not. Data was collected through facility assessment, client-exit interviews, and key-informant interviews. Quantitative descriptive and inferential analysis were done using SPSS vs20, and used 90% level of significancy. Thematic analysis was used for qualitative data.

Results

Availability of diagnostic test capacity and tracer drug were better in CBHI woredas/districts. However, there was no statistically significant difference between overall structural quality in CBHI and non-CBHI health centers (p=0.9) and a significant difference in process quality. The outcome quality between health centers in woredas/districts with and without CBHI: A higher proportion of clients at CBHI health centers gave high ratings of overall satisfaction with the services in a health center (p<0.001). Further analysis of the main drivers of individual client’s satisfaction in both CBHI and non-CBHI woredas/districts showed individual perception of quality was determined based on factors such as their perception of interpersonal relation, perception of proper procedure was followed by providers and facilities adhere to standards of care. CBHI enrollment was associated with individual-level factors including family size, age, household health-care- related expenditures, and educational status. Households with more than one member were more likely to enroll in and renew CBHI, and likelihood of enrollment and renewal increased with age. Health-service quality did not have a statistically significant association with CBHI enrollment and renewal.

Conclusion

The process and outcome related measure of service quality in CBHI woreda/district showed significant difference compared to non-CBHI woredas/districts, but the overall measures of structural quality were not significantly different between CBHI and non-CBHI. However, availability of diagnostic test capacity and tracer drug were better in CBHI woredas/districts than the counterpart. The second section of the study summarized, individual and household factors played a significant role in CBHI enrollment and renewal decision. However, health-service quality was not shown to have a significant impact on CBHI enrollment or renewal.