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Community-Based Health Insurance in Ethiopia: Helping Millions Access Health Care


Boru Meda Hospital uses its retained revenue from community-based health insurance (CBHI) to buy medical equipment to improve its services. Here, Dr. Sarah Abebaw, its newest ophthalmologist, uses one of the hospital’s new slit lamps to examine a patient.

Abt Associates has supported the Ethiopian government’s piloting and expansion of CBHI across Ethiopia through the HSFR/HFG projects.

Photo credit: Ayenew Haileselassie, communications advisor, HSFR/HFG

The USAID-funded Health Sector Financing Reform/Health Finance and Governance project (HSFR/HFG) is working with the government of Ethiopia to improve financing and governance of health insurance and health services so that citizens can have access to quality health care and live healthier, more productive lives.

HSFR/HFG, led by Abt Associates, has been the lead partner supporting Ethiopia’s roll out and implementation of health care financing reforms at the national, regional, district – or woreda – and health facility levels. These include working with the Ethiopian Health Insurance Agency to implement and expand community-based health insurance (CBHI) and social health insurance schemes.

The project has achieved high levels of citizen engagement. As of March 2017, 14.5 million people have insurance through CBHI in Ethiopia. CBHI schemes have collected 601,543,647 birr – more than US$27 million – in member contributions. The government of Ethiopia has contributed an additional 186,469,026 birr ($8.1 million) in the form of general and targeted subsidies.

Successful Pilot CBHI Project Led to Expansion

Ethiopia initiated CBHI to benefit Ethiopian citizens engaged in the informal sector. Under the HSFR bilateral project, Abt provided technical support to the Government of Ethiopia in piloting CBHI in 13 woredas in Amhara, Oromia, Tigray, and the Southern Nations, Nationalities and Peoples regions from 2011-2013. Evaluation findings showed CBHI enrolled members used health services almost twice as much as the national average. Also, CBHI members were 26 percent more likely to seek care at time of sickness compared with non-members.

Informed by lessons learned during the pilot, the HSFR/HFG project team supported Ethiopia’s efforts to design and implement a national CBHI program scale-up strategy targeting 80 percent of Ethiopia’s population in the informal sector. HFG used a phased approach to expand CBHI from an initial 13 woredas to a total of 350. Of these 350 woredas, 227 have established CBHI schemes and the remaining 123 are undertaking preparatory activities and are expected to establish schemes.

Preparing Health Professionals, Administrators for CBHI

The HSFR/HFG project team prepared key people at all levels – federal, regional, woreda, health facility, and community – for successful implementation of the CBHI program. This included training 3,301 health facility staff on the CBHI directive, scheme contractual agreements, audits, reimbursement mechanisms, and provider payment mechanisms, and oriented 15,564 federal, regional, zonal, and woreda officials on the CBHI program.

HSFR/HFG monitored and supported CBHI implementation by visiting almost all CBHI schemes and health facilities – at least one health center and one hospital – that provide services to CBHI members once a year. Findings from these visits provided feedback at different levels of the health sector and were used by the Federal Ministry of Health, Ethiopian Health Insurance Agency, and regional and woreda authorities as data sources and to guide CBHI implementation in Ethiopia.

The HSFR/HFG project also participated in Federal Ministry of Health/Regional Health Bureau integrated supportive supervision visits in regions as part of a collaboration between Ministry of Health/Regional Health Bureaus and HSFR/HFG. The team visited zonal health departments, woreda health offices, CBHI schemes, hospitals, and health centers, and assessed the status of CBHI implementation, identified strengths and bottlenecks, and recommended feasible solutions. The team also assessed government budget allocation and utilization for targeted and general subsidies.

Getting the Message Out about CBHI

The HSFR/HFG project team held workshops on the concept and benefits of health insurance for journalists and other members of the media so that they had the knowledge and information needed to produce effective health insurance promotion programs.

HSFR/HFG worked with the Ethiopian Health Insurance Agency on media campaigns to raise community and stakeholder awareness about the health insurance programs, leading to the production and nationwide broadcasting of 13 TV and 227 radio PSAs with messages explaining CBHI and social health insurance initiatives, and encouraging CBHI enrollment and membership renewal.
Read more about Abt’s CBHI work:

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