Linking poverty-targeted social protection and Community Based Health Insurance in Ethiopia: Enrolment, linkages, and gaps.

Background: Community-Based Health Insurance (CBHI) has received increasing attention in low and middle-income countries as a pathway toward universal health coverage. In 2011, the government of Ethiopia piloted CBHI and subsequently integrated CBHI with its flagship social protection programme, the Productive Safety Net Program (PSNP) which was established in 2005. We examined enrolment decisions by PSNP households, including, understanding of the programme, reasons for non-coverage, and factors associated with enrolment decisions.

Methods: Cross-sectional data for this study come from an Integrated Safety Net Program (ISNP) baseline survey implemented in four rural woredas in Amhara region, Ethiopia between December 2018 and February 2019. We collected data from 5398 PSNP beneficiary households, categorized as either Public Work (PW) or Permanent Direct Support (PDS) types. We used descriptive methods to characterize sample households and fitted binary logistic regression to identify factors associated with households' CBHI enrolment decisions.

Results: Current CBHI enrolment is higher among PW households (70.1 %) than PDS clients (50.3 %). The most common reason for not enrolling in both PW and PDS households is cost. Results further show that the following characteristics are positively associated with CBHI enrolment: the number of children and working-age adults in the household, older household head, female household head, married household head, having been food insecure in the previous 12 months, heads having experienced illness in the past month, and increasing household wealth status.

Conclusion: While demographic factors are important in households' decisions to enrol in CBHI, various mechanisms could be used to increase enrolment among vulnerable households such as PDS clients. In this regard, while better communication about CBHI could increase enrolment for some households, other poor and vulnerable households will need fee waivers to induce enrolment.