Towards universal health coverage: The level and determinants of enrollment in the Community-Based Health Insurance (CBHI) scheme in Ethiopia: A systematic review and meta-analysis

Abstract

Background: Community-based health insurance (CBHI) is a risk-pooling approach that tries to disperse health expenditures across families with varying health profiles to provide greater access to healthcare services by allowing cross-subsidies from wealthy to poor populations. It is crucial to assess the level of CBHI enrolment and its determinants in Ethiopia, where government health spending is limited to less than 5% of GDP, far below the Alma Ata Declaration's benchmark of 15%. Although various epidemiological studies on CBHI enrolment status and its determinants have been undertaken in Ethiopia, the results have been inconsistent, with significant variability. However, no nationwide study assessing the pooled estimates exists today. Furthermore, the estimated strength of association at the country level varied and was inconsistent across studies. Hence, this systematic review and meta-analysis aimed at estimating the pooled prevalence of CBHI enrolment and its determinants in Ethiopia.

Methods: A comprehensive search of studies was done by using PubMed, EMBASE, Science Direct, HINARI, Scopus, Web of Science, and the Cochrane Library. The database search was complemented by google scholar and some repositories for grey literature. The search was carried out from February 11 to March 12, 2022. The relevant data were extracted using a Microsoft Excel 2013 spreadsheet and analyzed using STATATM Version 16. Studies reporting the level and determinants of CBHI enrolment in Ethiopia were considered. A weighted DerSimonian Laired random effect model was applied to estimate the pooled national prevalence of CBHI enrolment. The Cochrane Q test statistics and I2 tests were used to assess the heterogeneity of the included studies. A funnel plot, Begg's and Egger's tests, were used to check for the presence of publication bias.

Results: Fifteen studies were eligible for this systematic review and meta-analysis with a total of 8418 study participants. The overall pooled prevalence of CBHI enrolment in Ethiopia was 45.5% (95% CI: 32.19, 58.50). Affordability of premium for the scheme[OR = 2.58, 95% CI 1.68, 3.47], knowledge of respondents on the CBHI scheme[OR = 4.35, 95% CI 2.69, 6.01], perceived quality of service[OR = 3.21, 95% CI 2.04, 4.38], trust in the scheme[OR = 2.32, 95% CI 1.57, 3.07], and the presence of a person with a chronic disease in the household [OR = 3.58, 95% CI 2.37, 4.78] were all found to influence CBHI enrolment.

Conclusion: Community health workers (CHWs) need to make a high effort to improve knowledge of CBHI in rural communities by providing health education. To deal with the issue of affordability, due emphasis should be placed on building local solidarity groups and strengthening local initiatives to aid poor members. Stakeholders in the health service delivery points need to focus on the dimensions of high service quality. The financial gap created by the adverse selection of households with chronically ill members should be rectified by implementing targeted subsidies with robust plans.

Fig 1. PRISMA flow diagram describing the selection of studies for systematic review and meta-analysis.

Fig 2. Forest plot showing the pooled prevalence of CBHI enrolment in Ethiopia, 2017–2022.

Fig 3. Forest plot showing subgroup analysis of CBHI enrolment by geographical regions of Ethiopia, 2017–2022.

Fig 4. Subgroup analysis of CBHI enrolment in Ethiopia by study years, 2017–2022.

Fig 5. Funnel plot displaying publication bias of studies reporting the level of CBHI enrolment in Ethiopia, 2017–2022.

Fig 6. Sensitivity analysis for pooled estimates of CBHI enrollment in Ethiopia, 2017–2022.

Fig 7. Forest plot showing an association between perceived affordability of premium payment and CBHI enrolment in Ethiopia, 2017–2022.

Fig 8. Forest plot showing the association between knowledge of CBHI scheme in CBHI enrolment in Ethiopia, 2017–2022.

Fig 9. Forest plot showing the association between perceived service quality and enrolment in the CBHI scheme in Ethiopia, 2017–2022.

Fig 10. A forest plot showing the association between having a person in the household with a chronic disease and enrollment in the CBHI scheme in Ethiopia, 2017–2022.

Fig 11. A forest plot showing the association between having trust in the scheme and CBHI enrolment in Ethiopia, 2017–2022.