Identifying Indigent Households for Subsidy and Exemption of Community Health Insurance Premium in Ethiopia: Considerations of Technical Approaches and Implementation Challenges

Abstract

In Ethiopia, a country grappling with the dual challenges of limited healthcare access and pervasive poverty, implementing community-based health insurance (CBHI) schemes has emerged as a pivotal public health intervention. In this doctoral project, I explore the complex processes and policy implications of identifying indigent households eligible for subsidy and exemption from CBHI premiums, a task that is crucial for the success of health insurance as a tool for social protection and healthcare access improvement. Employing a mixed-methods research design, the study combines quantitative analysis of national household survey data with qualitative insights gleaned from focus group discussions and interviews with key stakeholders, including policymakers, healthcare providers, and community members across the Oromia region. The quantitative findings reveal a CBHI scheme that, despite making progress, has yet to fully penetrate the Ethiopian population, with a notable discrepancy in enrollment rates between poor and non-poor households. This discrepancy underscores the scheme's potential to address the healthcare needs of economically vulnerable segments and highlights the substantial coverage gaps that persist. The household expenditure analysis further elucidates the population's economic disparities, emphasizing the importance of the CBHI scheme not only as a healthcare access mechanism but also as a potential buffer against the financial shocks associated with health crises. The qualitative component of the study uncovers the complexities of identifying indigent households for CBHI exemptions, a process fraught with challenges stemming from regional variability, decentralized execution, and the multifaceted nature of poverty. The research identifies the reliance on community-based decision-making as both a strength in its ability to incorporate local knowledge and needs and a potential weakness due to the risk of subjective biases and inconsistencies in application. Insights from the thematic analysis highlight several critical areas for policy action. First is the need for a harmonized yet adaptable policy framework that can ensure equity and transparency in indigent identification processes while allowing for adjustments to local contexts. Second, it is important to enhance financial sustainability through innovative funding strategies, governmental support, and integration of private healthcare providers into the CBHI network. And third is the imperative of improving awareness and perceived value of CBHI schemes through targeted informational campaigns and community engagement efforts. This thesis makes several contributions to the discourse on health insurance in low-resource settings. It provides empirical evidence on the challenges and successes of implementing CBHI schemes in Ethiopia, offers a nuanced understanding of the socio-economic factors influencing health insurance enrollment among indigent households, and highlights the critical role of policy formulation and community engagement in enhancing health insurance coverage. Furthermore, the study proposes actionable policy recommendations to improve the inclusivity, effectiveness, and sustainability of CBHI schemes.