A mixed methods study of community-based health insurance enrollment trends and underlying challenges in two districts of northeast Ethiopia: A proxy for its sustainability

Background Community-based health insurance initiatives in low- and middle-income countries are plagued by persistently low coverage due to their voluntary orientation. In Ethiopia, the schemes membership growth has not been well investigated so far. This study sought to examine the scheme's enrollment trend over a five-year period, and to explore the various challenges that underpin membership growth from the perspectives of various key stakeholders. Methods The study employed a mixed methods case study in two districts of northeast Ethiopia: Tehulederie and Kallu. Quantitative data was collected by reviewing the databases of schemes. Key informant interviews and in-depth interviews were conducted face-to-face with 19 key stakeholders and nine community members, respectively. Study participants were purposely selected using the maximum variation technique. Interviews were audio recorded, transcribed verbatim, and translated into English. Thematic analysis was employed with both deductive and inductive coding approaches. Results Enrollment in the two districts has shown an inconsistent trend over the study period (2017 to 2021). The scheme in Tehulederie has a relatively better enrollment trend, particularly in terms of membership retention, which could be due to the strong foundation laid by a rigorous public awareness campaign and technical support during the pilot phase. The challenges contributing to the observed level of performance have been summarized under four main themes that include quality of health care, claims reimbursement for insurance holders, governance practices, and community awareness and acceptability. Conclusions The scheme experienced negative growth ratios in both districts with inconsistent trends, showing that the scheme is not functionally viable. It will regress unless relevant stakeholders at all levels of government demonstrate political will and commitment to its implementation, as well as advocate for the community. Interventions should target on the highlighted challenges in order to boost membership growth and ensure the viability of the community-based health insurance.