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Abstract

Background:

Community-based health insurance services (CBHI) are important for supporting families in accessing affordable health services in government health institutions in Ethiopia. However, beneficiaries and health professionals have been challenged with accessing and delivering these services, respectively. Therefore, this study aimed to assess the community-based health insurance-related satisfaction of beneficiaries and the experiences of both beneficiaries and health professionals.

Design and methods:

A convergent parallel mixed-method study design was employed, combining a quantitative cross-sectional study with an exploratory qualitative case study. Descriptive statistics and bivariate and multivariate logistic regression analyses were used. SPSS version 26 was used for quantitative data analysis. We analyzed the qualitative data manually after verbatim transcription and translation. Variables with p-values of less than 0.25 in the bivariate analysis were candidates for multivariate logistic regression analysis, and variables with p-values of less than 0.05 were considered as significant.

Results:

We collected data on 414 community-based health insurance beneficiaries, with a 98.1% response rate. Five beneficiaries and three health professionals were also included in the qualitative inquiry. The magnitude of beneficiaries’ community-based health insurance service satisfaction was 65.7%. The length of enrollment, availability of prescribed drugs, availability of adequate medical equipment, participation in CBHI-related meetings, and CBHI-related knowledge of respondents were factors associated with satisfaction with CBHI services.

Conclusion:

The degree of community-based health insurance service satisfaction is still low. There are multiple experiences faced by both beneficiaries and health professionals related to community-based health insurance that urge the need for large community awareness programs for sustainability.

Keywords

health insurance satisfaction beneficiary health professional Ethiopia

Introduction

Health insurance in developing countries provides immense opportunities for people, especially poor people, to access healthcare anytime the need arises. It therefore serves as a means of promoting universal health coverage (UHC) and achieving sustainable development goal 3, which seeks to ensure healthy lives and promote well-being for everyone at all ages.^1,2

Community-based health insurance (CBHI) is a new way of supporting healthcare financing, and it applies all the principles of the insurance system, such as risk pooling, risk sharing, and financial protection, except that it is not meant for profit. Community-based health insurance is important for supporting families in accessing affordable health services in most government hospitals.^3,4

To provide an alternative to paying for healthcare, the Ethiopian government implemented CBHI in 2011 in an attempt to alleviate the financial catastrophe caused by out-of-pocket expenses. The CBHI was first introduced in Addis Ababa in 2016 and scales up to four main regions: Amhara, Oromia, southern nations and nationalities, and Tigray.^5–7 As per the July 2025 Ethiopian health insurance service report, CBHI has been expanded nationwide, providing access to 1195 districts, covering 13.67 million households and 63 million beneficiaries.⁸

Evidence supporting policy and decision-making can be provided by the satisfaction levels of CBHI enrollees and the factors that influence their satisfaction. Member satisfaction is crucial for maintaining CBHI member enrollment in a program and ensuring its sustainability. The CBHI program’s key strategic weapon is client satisfaction, which can increase beneficiary renewal rates by retaining current members and attracting new ones. It also indicates the growing need to meet clients’ expectations during service delivery and improves program sustainability. Membership renewals and future enrollment are affected by the scheme’s viability. As a result, the scheme becomes financially unstable, which may jeopardize its capacity to pay for its members’ expenses and ultimately cause it to cease operations. Since CBHI membership is voluntary, member satisfaction with the services they receive is crucial since they may decide not to join and may also persuade others not to enroll in.^9–12

According to some studies, client satisfaction levels with CBHI services range widely from 45% to 90%. Numerous studies have demonstrated that enrollees’ satisfaction with health insurance is influenced by sociodemographic factors, including sex, age, marital status, occupation, family size, educational status, and household financial status. Enrollees’ satisfaction with the CBHI is affected not only by sociodemographic factors but also by characteristics related to the health services themselves. Enrollee satisfaction with the CBHI is positively correlated with waiting time, availability of medications, friendliness of healthcare professionals, and proper laboratory service provision. Additionally, research conducted in developing nations has demonstrated that enrollees’ awareness of health insurance benefit packages has an impact on their level of satisfaction with the program. Client satisfaction with the program is also influenced by factors related to the experience of community-based health insurance.^16–18

Although the CBHI scheme has been implemented for more than a decade in Ethiopia, beneficiaries’ level of satisfaction and the contributing factors in the area have not been well explored. Although few studies related to CBHI client satisfaction have been conducted in Ethiopia, the magnitude of client satisfaction with CBHI has not yet been studied in North Gondar. Additionally, our study focused particularly on qualitative inquiries of both beneficiaries and healthcare professionals, which have not been explored generally in Ethiopia. Therefore, this study aims to determine the magnitude of satisfaction with CBHI services and its associated factors among clients who visit public hospitals in the North Gondar Zone and to explore the challenges faced by beneficiaries and health professionals. The results can be used to improve CBHI service satisfaction. Furthermore, health managers and policymakers may use it for program adjustment.

Methods and materials

Reporting

We reported this manuscript based on the Reporting of Observational Studies in Epidemiology (STROBE) statement.¹³

Study area

This study was conducted at public hospitals in the North Gondar Zone. Debark city is the capital of the Zone and is located 830 km from Addis Ababa. According to the census conducted in 2021 by the Central Statistical Agency of Ethiopia, the total population of this Zone is 1,138,097. This zone has one general hospital and three primary hospitals that provide health care services for the population. The hospitals included Mytsebry Primary Hospital, Dabat Primary Hospital, Janamora Primary Hospital, and Debark General Hospital. Debark General Hospital is located in Debark town and serves 85,298 people. It is also the only referral hospital for the population found in the North Gondar Zone. Dabat, Janamora, and Mytsebry primary hospitals are located in Debat, Janamora, and Mytsebri towns and serve for more than 19,000, 21,000, and 21,000 people, respectively (North Gondar Zone Health Bureau, 2021).

Study design and period

A convergent parallel mixed-methods study was employed, combining a quantitative cross-sectional study with an exploratory qualitative case study. The quantitative strand assessed the magnitude and determinants of satisfaction with CBHI services, while the qualitative strand explored the lived experiences (both positive and negative) of beneficiaries and health professionals. Both strands were conducted from June 1 to 30, 2024, and findings were triangulated to provide a comprehensive understanding of CBHI service delivery.

Source population

All CBHI users and health service providing professionals in the public hospitals of the North Gondar Zone were source populations.

Study population

All the randomly selected CBHI members utilized services and health professionals working in the public hospitals of the North Gondar Zone during the data collection period.

Eligibility criteria

A client or client guardian who was a member of the CBHI was included in the study, and a member of the CBHI client who was unable to respond for different reasons was excluded. Health professionals working in public hospitals in North Gondar Zone for at least 1 year were also included in the qualitative exploration.

Sample size determination

A single population proportion formula was used on the basis of a cross-sectional study performed at Addis Ababa, Ethiopia, on satisfaction with community-based health insurance and associated factors with 46.3% satisfaction.⁵

\begin{array}{l} n = \frac{{(z @ / 2)}^{2} . p (1 - p)}{w 2} \\ \frac{{(1.96)}^{2} \times 0.463 (0.537)}{0.05 \times 0.05} = 383 \end{array}

where, n = the sample size, α = the precision level or level of significance, p = the population proportion, w = the marginal error, Za/2 = the value under the standard normal table.

Adding a 10% nonresponse rate = 422.

Sample size for the qualitative data

For the qualitative component, eight in-depth interviews were conducted purposively: five with CBHI beneficiaries and three with health professionals (one nurse, one physician, and one pharmacist).

Variables of the study

Dependent variable

Satisfaction with CBHI services.

Independent variables

Sociodemographic variables

Age, sex, religion, educational status, and marital status.

Client experience with CBHI

Length of enrollment, Office opening, Cost of CBHI, Membership length, Knowledge of CBHI benefit packages, Trusting government bodies, CBHI-related meeting.

Health facility-related factors

Availability of drugs, availability of laboratory services, waiting time, HP respectfulness, HP friendliness, previous illness within 3 months, frequency of visits, and health service utilization.

Operational definitions

Satisfaction with the CBHI: Study participants who scored above or equal to the mean score of the satisfaction questions were classified as satisfied, and those whose score was less than the mean score were classified as dissatisfied.^14–16

Data collection tool and procedure

We collected data with an interviewer-administered questionnaire adapted from different studies.^5,10,17,18 We used pretested structured questionnaires for interviews in separate rooms prepared for this purpose only. For the quantitative part, the interview was administered by four BSc nurses. For the qualitative part, four MSc holders were used to conduct the in-depth interviews.

Sampling procedure

To select the study participants, the calculated sample size was proportionally allocated to each hospital based on their average monthly client flow from the most recent report prior to data collection. According to this report, a total of 8411 CBHI beneficiaries visited the hospitals in 1 month: Debark General Hospital (2597), Dabat Primary Hospital (2110), Janamora Primary Hospital (1904), and Mytsebry Primary Hospital (1800). Using proportional allocation, 131 participants were selected from Debark General Hospital, 106 from Dabat Primary Hospital, 95 from Janamora Primary Hospital, and 90 from Mytsebry Primary Hospital.

Finally, individual participants were selected using systematic random sampling technique. The sampling frame was established using triage order at the patient entry point. Based on the total number of clients (N = 8411) and the required sample size (n = 422), the sampling interval was calculated as K = N/n ≈ 20. The first participant was identified using simple random sampling, and then every 20th client at the service delivery exit was enrolled until the required sample size was achieved.

Data processing and analysis

After data collection, the data were coded and entered into Epi-Info version 7.2 and then exported to SPSS version 26 for analysis. Descriptive statistics such as the mean and standard deviation (SD) were used to present the results. Bivariate logistic regression was used to determine the independent effect of predictors on the dependent variable, and multivariate logistic regression analysis was conducted to identify the final predictors after controlling for other independent variables. Variables with p-values less than 0.25 in bivariate logistic regression were candidates for multivariate logistic regression. AORs with 95% CIs were estimated to determine the relationships between the independent variables and the dependent variable after controlling for the effects of confounders with 95% CIs. Variables with a p-value <0.05 were considered to have a statistically significant association with the outcome variable.

Qualitatively, a semi-structured interview guide was used, focusing on participants’ and healthcare professionals’ experiences, challenges, and perceptions related to CBHI service utilization and delivery. All interviews were audio-recorded, transcribed verbatim, and translated into English. Then, thematic analysis was conducted manually.

Data quality assurance mechanisms

To ensure the consistency and content of the questionnaire, the data collection tool was first prepared in English, translated into Amharic, the local language, and then translated back into English. The interviewers were under supervision during the entire data collection process. Five percent of the sample size was used for the pretest. Supervisors and data collectors received 2 days of training on the study’s purpose, data gathering methods, and data collection tools. Additionally, the principal investigator and supervisors later reviewed the gathered data. Qualitatively, we ensured Trustworthiness through triangulation of sources, member checking with selected participants, and peer debriefing.

Results

Socio-demographic characteristics of the participants

A total of 414 clients participated in the quantitative analysis of this study, with a response rate of 98.1%. Among them, the majority (70.85%) of the participants were married and male (66.35%). The mean age of the participants was 28.62 years (±6.43 years). More than three fourths of the participants were rural residents or farmers (Table 1).

Table 1.

Sociodemographic characteristics of the CBHI beneficiaries at public hospitals in North Gondar Zone, Ethiopia, 2024.

Variable	Category	Frequency (N)	Percent (%)
Age	18–28	111	26.81
	29–39	171	41.30
	40–50	88	21.26
	>50	44	10.63
Sex	Male	277	66.90
Sex	Female	137	33.10
Marital status	Married	293	70.77
Marital status	Unmarried	121	29.23
Number of households	≤3	272	66.70
Number of households	>3	142	33.30
Educational status	Illiterate	111	26.57
	Able to read and write	181	43.72
	Primary	76	18.36
	Secondary and above	46	11.12
Place of residence	Rural	298	71.98
Place of residence	Urban	116	28.02
Occupation	Farmer	266	62.25
	Housewife	86	20.77
	Merchant	47	11.35
	No job	15	3.62

Magnitude of CBHI service satisfaction

The mean score was used to determine the cutoff point of satisfaction. Hence, 272 (65.70%) of the respondents scored above the mean and the remaining 142 (34.30%) scored below the mean score of the satisfaction questions (Figure 1).

Figure 1.

Magnitude of satisfaction among CBHI service beneficiaries at hospitals in North Gondar, Ethiopia, 2024.

Factors associated with client satisfaction

From the bivariate logistic regression analysis, nine variables with p-values of less than 0.25 were entered into the multivariate logistic regression analysis. In the multivariate logistic regression analysis, the length of enrollment, availability of prescribed drugs, availability of adequate medical equipment, participation in CBHI-related meetings and CBHI-related knowledge of respondents were factors associated with satisfaction with CBHI services (Table 2).

Table 2.

Multivariate logistic regression analysis of factors associated with CBHI service satisfaction among beneficiaries who visited public hospitals in North Gondar, Ethiopia, 2024.

Variable	Category	Satisfied		COR (95% CI)	AOR (95% CI)	p-Value
Variable	Category	Yes	No	COR (95% CI)	AOR (95% CI)	p-Value
Number of households	≤3	121	151	1	1
Number of households	>3	76	66	0.22 (0.08, 0.63)	0.84 (0.55, 1.42)	0.105
Place of residence	Rural	212	86	2.16 (2.13, 6.65)	1.30 (0.77, 2.65)	0.19
Place of residence	Urban	57	59	1	1
Occupation	Farmer	155	111	2.24 (1.11, 2.62)	1.23 (0.022, 2.04)	0.24
Occupation	No job	6	8	1	1
Length of enrollment (years)	≤3	87	32	1	1
Length of enrollment (years)	>3	178	117	2.27 (1.84, 3.01)	1.97 (1.21, 2.46)	0.032*
Received the correct prescribed drug	Yes	98	71	2.92 (1.83, 4.02)	2.11 (1.55, 2.99)	0.016*
Received the correct prescribed drug	No	66	179	1	1
Received requested laboratory service	Yes	93	114	0.07 (−1.33, 1.42)	0.12 (−0.97, 2.88)	0.28
Received requested laboratory service	No	74	133	1	1
Participated CBHI related meeting	Yes	190	61	6.14 (3.34, 8.96)	4.50 (3.37, 6.32)*	0.003*
Participated CBHI related meeting	No	77	86	1	1
Knowledge on CBHI package	Good	189	121	5.17 (3.20, 7.92)	4.55 (2.38, 6.12)	0.001*
Knowledge on CBHI package	Poor	31	73	1	1
Adequate medical equipment	Yes	149	115	5.14 (4.32, 6.11)	2.54 (1.47, 4.23)	0.039*
Adequate medical equipment	No	123	27	1	1

Significant.

Experiences of beneficiaries in CBHI services

To explore the experiences of beneficiaries, we conducted five in-depth interviews related to CBHI services. Among them, three were males, and two were females. Two were farmers, two were merchants, and one was jobless. Hence, the main statements of the participants are as follows.

Participant 1 “The healthcare service was good, but we cannot get some of the drugs prescribed and laboratory services ordered in the hospital.”

Participant 2 stated “One who pays for the drugs and laboratory services was given priority during health care rather than CBHI service beneficiaries.”

Participant 3 stated “Last time, I couldn’t buy the drugs ordered outside the health center and I went to traditional healers after I returned home since I was not afforded the cost of the medicine written for me.”

Participant 4 “I think they sell the drugs the government was given them to provide us.” “They don’t like people who have health insurance books; if you ask for sales, they will provide you with the drug.”

Participant 5 “The cost of healthcare and drugs is too high, I find the CBHI service very useful even I could not be cured without it, but the government should fulfill unavailable drugs and other supplies to be covered by CBHI service.”

Experiences of health professionals related to CBHI services

Among the health professionals, we conducted three in-depth interviews with one nurse, one physician, and one pharmacist.

Nurse “Patients complain when shortages of supplies such as drugs, are available”; they said, “You are caring people who pay for services, but you do not care us.” “Even they don’t take the ordered drugs fully; they come within one or two days after taking the drug at home.” “Additionally, they come when they are not diseased. For example, one may come to take a drug for his wife by telling us her symptoms rather than bringing her.” “Awareness creation programs should be strengthened to the community about the benefit of CBHI, when to seek care, and the side effects of taking drugs inappropriately.”

A physician “Most people don’t have an understanding of the way and process of the referral system related to CBHI services.” “The only difference is payment; there is no bias related to CBHI membership.” “Drug related shortages may be due to delays in CBHI payments to the hospital.” “Health education should be given for each kebele about CBHI utilization.” “People are referring themselves to the hospital, and even they themselves order us to write X-ray requests and medications.” “CBHI services lead to high healthcare-seeking behavior in the community, and this leads to a high patient burden on the hospital.” “CBHI nonusers faced great challenges owning to the high cost of healthcare.” “Community awareness should be given with the right provider about the benefit of it.” “In addition, increasing the number of stamping offices, number of health professionals, and number of OPDs, wards, etc., may reduce the high burden of care and patient dissatisfaction.”

A pharmacist “Truly there are improper complaints, but we always try to aware the people who come to this hospital, but large community mobilization is required to solve the problem permanently.” “The other challenge is the inability of Woredas to pay their debts in a timely manner, which leads us not to fulfill drugs soon.” “Having CBHI service does not mean free healthcare service; the local governments are paying for their service. Therefore, nobody will bias them.”

Discussion

The aim of this study was to assess the magnitude of CBHI service satisfaction and associated factors among beneficiaries, and to explore the experiences of both beneficiaries and healthcare professionals using a convergent parallel mixed-methods design.

The magnitude of CBHI service satisfaction among beneficiaries was 65.7%. This finding is consistent with studies conducted in Arsi Negele (63.1%),¹⁹ but the patient satisfaction level in our study is higher than studies conducted in Addis Ababa (46.3%),⁵ Sheko district (54.7%),¹⁰ Leganbo district (58.6%),¹⁷ Jimma district (57.5),²⁰ Gondar Zuria (33.5%),²¹ Anilemo district (54.1%),¹⁸ and the Gurage Zone (54.2).²² Furthermore, it is lower than that reported in studies conducted in Boru Meda (80%)¹⁵ and Damotwoyde districts (91.38%).²³ These discrepancies could be due to differences in health institution patient loads, the availability of equipment and infrastructure, and CBHI beneficiary sizes. Additionally, there might be improvements in the current study because of lessons taken from previous experience and study recommendations. Furthermore, some of the studies were conducted during the pilot phase of CBHI implementation which resulted in varied satisfaction levels compared with the current full implementation phase.

Beneficiaries with adequate knowledge of CBHI packages were more likely to be satisfied than those with poor knowledge of CBHI packages. This was in line with some of studies conducted previously.^10,18,22,24 Additionally, beneficiaries who participated in CBHI related meetings were more satisfied than those who did not participate in CBHI meetings. The possible justification could be that having adequate knowledge and participating in meetings may result in client satisfaction due to appropriate utilization of the services. These findings were further confirmed and expanded by the qualitative interviews. Beneficiaries repeatedly emphasized the role of knowledge and awareness: “The cost of healthcare and drugs is too high; I find the CBHI service very useful, but the government should fulfill unavailable drugs and other supplies to be covered by CBHI service.” This statement reflects not only appreciation for CBHI but also an informed understanding of the package’s limitations, indicating that knowledgeable beneficiaries are more capable of identifying gaps and expressing expectations regarding service coverage. Health professionals echoed this view, highlighting the importance of awareness creation: “Awareness creation programs should be strengthened to the community about the benefit of CBHI, when to seek care, and the side effects of taking drugs inappropriately” (nurse). The physician also emphasized that health education should be provided at the kebele level regarding CBHI utilization.

The participants who received the correct prescribed drug from the hospital pharmacy were more satisfied than those who did not receive the correct prescribed drug. This result was supported by studies conducted in different parts of Ethiopia.^15,18,21,22 This was also evident in the qualitative narratives: “The healthcare service was good, but we cannot get some of the drugs prescribed and laboratory services ordered in the hospital.” Another participant added, “Last time, I couldn’t buy the drugs ordered outside the health center, and I went to traditional healers after I returned home since I was not afforded the cost.” These perspectives highlight that drug shortages not only reduce satisfaction but also expose beneficiaries to unsafe alternatives, such as traditional healers.

Similarly, longer enrollment in CBHI (more than 3 years) was associated with higher satisfaction. This was in line with some of the studies conducted previously.^10,17,22 This may be explained by increased familiarity with the system and adjusted expectations. Qualitative accounts supported this, with some participants noting that despite service gaps, CBHI membership remained essential for affordability and access.

Participants who reported the availability of adequate medical equipment were more likely to be satisfied than their counterparts. This finding suggests that beyond drug supply, the presence of essential equipment and materials plays a critical role in shaping beneficiary satisfaction. The qualitative findings supported this result, as one patient explained, “The government should fulfill unavailable drugs and other supplies to be covered by CBHI service.” This highlights that satisfaction is closely linked not only to the affordability of services but also to the adequacy of medical infrastructure and resources. Ensuring the continuous availability of drugs, diagnostic tools, and equipment is therefore vital for maintaining trust in the CBHI program.

Strengths and limitations

The main strength of this study is that it assessed the experience of both health professionals and beneficiaries, which has not yet been explored in Ethiopia.

As a limitation, we were not able to assess the views of health officials in each hospital. Furthermore, the cross-sectional nature of the study design could be another limitation.

Conclusion and recommendation

The magnitude of community-based health insurance service satisfaction is still low. There are multiple experiences faced by both beneficiaries and health professionals related to community-based health insurance that urge the need for large community awareness programs for sustainability. Therefore, CBHI officials and health professionals need to mobilize larger communities to create awareness. Additionally, drugs and other medical equipment need to be available in each hospital with health insurance services.

Footnotes

Acknowledgements

We would like to acknowledge Debark University for funding this research project. Our gratitude also extends to Debark, Dabat, Janamora and Mytsebri hospitals for providing us with appropriate data and information. Finally, we gratefully thank the study participants, data collectors, administrations and health professionals.

ORCID iDs

Moges Tadesse Abebe

Dessie Alemnew Shiferaw

Ethical considerations

Ethical clearance was obtained from the ethical review committee of Debark University with reference number DKU/COHS/04/16. A permission letter was obtained from the University for each hospital. Written informed consent was also obtained from each participant after a thorough explanation of the purpose of the study. Responses of clients were unnamed and the confidentiality of the information was maintained. The data collectors were informed that the clients had the full right to discontinue or refused to participate in the study at any time.

Consent for publication

Not applicable.

Author contributions

MT and SB conceptualized, designed, collected and analyzed the data. YA and YA collected the data, drafted the initial manuscript and were involved in editing and revisions. DA and SB contributed to the initial manuscript drafting and editing. All the authors read and approved the final manuscript for submission.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by Debark University.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

The datasets used are available from the corresponding author upon reasonable request.

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Community-based health insurance service satisfaction and experiences of beneficiaries and health professionals in North Gondar Zone,Ethiopia

Abstract

Background:

Design and methods:

Results:

Conclusion:

Keywords

Introduction

Methods and materials

Reporting

Study area

Study design and period

Source population

Study population

Eligibility criteria

Sample size determination

Sample size for the qualitative data

Variables of the study

Dependent variable

Independent variables

Sociodemographic variables

Client experience with CBHI

Health facility-related factors

Operational definitions

Data collection tool and procedure

Sampling procedure

Data processing and analysis

Data quality assurance mechanisms

Results

Socio-demographic characteristics of the participants

Magnitude of CBHI service satisfaction

Factors associated with client satisfaction

Experiences of beneficiaries in CBHI services

Experiences of health professionals related to CBHI services

Discussion

Strengths and limitations

Conclusion and recommendation

Footnotes

Acknowledgements

ORCID iDs

Ethical considerations

Consent for publication

Author contributions

Funding

Declaration of conflicting interests

Data availability statement

References