Introduction

Globally, the costs of health care are increasing which causes many people to fall into poverty. The out-of-pocket health care expenditures resulted in massive financial barriers to health care utilization among the lower socioeconomic society [1,2]. Every year, nearly 150 million people globally experience financial catastrophe due to out-of pocket health care expenditures. Evidence had suggested that households spend more than 40% of their income on health care services. The catastrophic nature of health care expenditure is disproportionately very high among the rural households in low-income countries where 80% of the health care service is dependent upon out-of-pocket charges. These high health care expenditures cause short-term health shock and can lead to debt and asset sales which intern brings people into deep poverty [3–6].

The world health organization (WHO) recommends different health care financing strategies to reduce the catastrophic nature of out-of-pocket health care expenditures. Subsequently, countries are designing and implementing different health insurance programs. These include community-based health insurance (CBHI), social health insurance (SHI), and private insurance schemes. These health insurance schemes were aimed to provide financial protection against the cost of illness and increase health service utilization. Studies suggested that insured people were more likely to visit health care institutions than uninsured people when they get sick. This suggested that health insurance programs could help in expanding health service utilization and thereby it could help in achieving universal health coverage [7–10].

Universal health coverage (UHC) is a situation in which all individuals and communities receive health services they need without suffering financial hardship [11,12]. High and middle-income countries have achieved UHC through the implementation of health insurance programs [13]. Similarly, developing countries like Ghana, Rwanda, and Nigeria have achieved rapid utilization of UHC through the national health insurance program [14–16]. However, the UHC strategy confronts the challenges of health care financing in developing countries [13–17]. More than half of the African countries are still relying on out-of-pocket health care services. This out of pocket health care expenditure affect health service utilization among the poor rural communities in low income countries which in turn affects the plan of achieving universal health coverage [18–20].

Ethiopia has planned to achieve universal health coverage by 2035 [21]. However, the health service utilization in the country remained low (34.3%) compared to most of the African countries [12]. Studies showed that poor health care financing is a major contributor for the low health service utilization in the country. Consequently, Ethiopia has designed two policy options; community-based health insurance and social health insurance schemes to improve the health care financing system. Community-based health insurance is a voluntary health insurance program designed to improve financial access to health care services for the informal sectors of rural communities. Whereas, social health insurance is a form of mandatory health insurance to the formal sector employees [22,23].

Although the social health insurance proclamation was ratified in 2010, it is not yet implemented in Ethiopia. However, the country has been implementing community-based health insurance programs since 2011. The objectives of launching CBHI were to improve financial access to health care services; increase resource mobilization; and improve the quality of health care services [22,24]. A national pilot study on the effectiveness of CBHI schemes in Ethiopia showed that CBHI members were using health services 26% more than non-members. Additionally, there was a significant difference in the rate of healthcare utilization between insured (50.5%) and uninsured (29.3%) households [10]. This suggested that scaling up community-based health insurance program in the country could help in expanding health service utilization [25].

The health care system in Ethiopia is guided by a 20-year health sector development strategy which is implemented through a series of five-year health sector development programs. Currently, the country is implementing the fourth health sector development plan which has introduced a three-tier health care delivery system. The primary level consists of health posts (1/5,000), health centers (1/25,000), and primary hospitals (1/100,000). Secondary level services are provided by general hospitals (1/1million) and tertiary services by specialized hospitals (1/5million). These three levels of health care systems are integrated through the referral system and provide service for CBHI members. The communities could get their CBHI membership through the health development army and health extension workers at the nearest health center or hospital [26–28].

The community-based health insurance program is organized at the kebele, woreda, regional, and national levels. The woreda administrator is responsible for `Signing agreements with health care provider’s/health facilities; `Reimbursing health care providers; Administering the fund (keeping financial records; preparing financial statements); Managing the database (which contains data on members, contributions, and utilization). A General Assembly and Board of Directors oversee the governance of CBHI schemes at the woreda level. At the kebele level, the executive body is responsible for registering members, collecting premiums, and channeling funds to each woreda scheme. The communities are directly linked to the program via the leaders of the health development army and the health extension workers [28,29].

The community-based health insurance benefit package includes outpatient and inpatient services, laboratory services, imaging services, supply of drugs, and related services with the exception of eyeglasses, dental implant, dialysis, higher specialized procedures, and aesthetic procedures. All governmental health centers that are situated in the woreda and fulfill the minimum standard of service delivery are contracted to provide services to the members. All pilot woreda has also signed service contracts with their region’s respective referral hospitals. Three regions (Amhara, Oromia, and Tigray) entered contracts to ensure the possibility of interregional referrals [28].

Ethiopia has planned to enroll eighty percent of the households under the CHBI program by the end of 2020. However, only 48% of households are utilizing the program with a higher rate of dropout. As a result, the community-based health insurance utilization in the country had remained one of the lowest in Sub-Sahara African countries. Several factors were responsible for the low achievements of community-based health insurance programs in the country. These factors include educational status, residence, family size of the household, membership in other social supporting systems like Idir, and quality of health service in the catchment area [30,31].

Household willingness is an important determinant for the successful implementation of the CBHI program in the country. However, only a small number (12.8%) of the households were willing to join the program in Ethiopia [32]. Additionally, 36% of the participants who were a member of CBHI are not willing to renew their membership for the next period [29]. This low level of willingness could result in low CBHI utilization and a high dropout rate and which in turn affect the 2035 country plan of achieving universal health coverage [21]. Besides, there was regional variation among studies regarding willingness to join the program and associated factors [33–41]. This study was intended to examine willingness towards the community-based health insurance and associated factors in south wollo zone northeast Ethiopia.

Methods and materials

Study area, design, and period

The Community-Based cross-sectional study was conducted in rural households of WerebBabu district, South Wollo Zone, Northeast Ethiopia from June to July 2020. South Wollo is one of the 12 zones in the Amhara region with 22 districts which is located 401 km northeast of Addis Ababa, the capital city of Ethiopia, and 480 km to the East of Bahirdar, the capital city of the Amhara region. Based on the population projection of the 2007 national census conducted by the Central Statistical Agency of Ethiopia (CSA), South Wollo has a total population of more than 3 million with an area of 17,067.45 square kilometers. South Wollo has a total of 598,447 households resulting in an average of 4.2 persons to a household [42]. In this study, household heads in 8 kebeles were included, however, household heads residing less than six months in the kebele, critically ill or mentally incapable household heads with no other household members greater than 18 years were excluded (Fig 1).

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Fig 1. Map of WerebBabu District, South Wollo Zone, Northeast Ethiopia, July 2020 taken from the Woreda administrative office.

https://doi.org/10.1371/journal.pone.0261642.g001

Sample size determination

The sample size was determined using a single population proportion formula by considering the 95% confidence interval, margin of error 5% (d = 0.05), proportion (P) = 79% taken from the previous study [31], and 1.5 design effect. The maximum sample size was considered after checking various parameters of measurements from the prevalence and associated factors. Then, the researcher added 10% to compensate for the non-responses and the final sample size for the study was 421.

Where: n = required sample size, Zα/2 = critical value for normal distribution at 95% confidence level (1.96), p = proportion of CBHI among households, d = 0.05 (5% margin of error), and DEFF = design effect to compensate loss of efficient of sample power.

Results

Socio-demographic profile of the study participants

A total of 398 households were included with a response rate of 94.5 percent. The mean age of the participants was 41.85(±3.47 SD) years whereas the minimum and the maximum age of the participants were 25 and 63 years respectively. The majority of the participants (83.4%) were male household heads. Regarding their marital and educational status, 87.4% were married and 50% were illiterates (Table 1).

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Table 1. Sociodemographic characteristic of the respondents in WerebBabu district, Northeast Ethiopia, July, 2020.

https://doi.org/10.1371/journal.pone.0261642.t001

Factors associated with willingness to join CBHI program

Male-headed households were 80% [AOR: 0.2, 95%CI:0.07, 0.58] less likely to join community-based health insurance programs. Similarly, participants with a positive attitude towards the CBHI scheme were 4.1 [AOR: 4.1, 95%CI:2.32, 7.22] times more likely to join the insurance program and respondents with good knowledge of the scheme were 2.6 [AOR: 2.62, 95%CI:1.43, 4.8] times more likely to join the program. Household heads with a family size of less than 4 were 82% [AOR: 0.18, 95%CI:0.08, 0.41] less likely to join the community-based health insurance scheme and respondents who are members of Idir were 54% [AOR: 0.46, 95%CI:0.25, 0.84] less likely to participate in the program. Households who have no chronic illness in their families were 69%(OR:0.31, 95%CI:0.13,0.77) less likely to join the program. Rural households were almost 2 times (OR:1.9, 95%CI:1.09–3.32) more likely to join CBHI program compared to the urban households (Table 2).

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Table 2. Factors associated with willingness to join community-based health insurance program among households in WerebBabu district, Northeast Ethiopia July, 2020.

https://doi.org/10.1371/journal.pone.0261642.t002

Discussion

Community-based health insurance program was designed as a means of financial protection against the cost of health care utilization chiefly among the lower socioeconomic societies. However, studies have suggested that small segments of the population are utilizing the program particularly in developing countries like Ethiopia. Additionally, the community’s willingness towards the program is low in Ethiopia compared to most of the African countries and there have been dissimilarity among studies in the country regarding willingness toward the program and associated factors.

This study showed that 73.6% [95%CI:68.8%-77.9%] of the households were willing to join community-based health insurance schemes. The finding was similar to a study in Ethiopia (73%) [45], study in Saudi Arabia (69.6%) [46], and another study in Taiwan (69.5%) [47]. The possible reason might be due to the similarity in the study design or it might be due to similarity in the source populations where both of the studies involve rural households. These low level of community willingness could affect the 2030 plan of achieving universal health coverage.

However, the finding is higher than a study in Malaysia (63.1%) [48], another study in Malaysia (61.1%) [19], and a study in Nigeria (40%) [49]. The possible reason for the discrepancy could be due to the difference in the source populations. The low socioeconomic status of the population in Ethiopia might increase willingness to join community-based health insurance program compared to those higher socioeconomic populations in Malaysia and Nigeria. Besides, differences in sociocultural practice between countries may also explained the discrepancy of the findings.

On the other hand, the finding is lower than studies conducted in Southwest Ethiopia (78%) [44], Northern Ethiopia (79%) [50], northwest Ethiopia, east Gojjam (81.5%) [51], northwest Ethiopia, Fogera district (80%) [39], Nigeria (98%) [14], western Nigeria (82.45%) [52], and urban Bangladesh (86.7%) [53]. This could be due to the differences in program advocacy or community sensitization towards the community-based health insurance scheme among the study participants or the reason might be due to variation in socioeconomic or sociodemographic characteristics of the study participants.

This study revealed that respondents with good knowledge of CBHI were 2.6 times more likely to join the scheme compared to their counterparts. The finding is similar to a study in Siraro District, Ethiopia [45]. The reason could be knowledge on community-based health insurance gives an understanding about the services under community-based health insurance which enables people to join the insurance program. Similarly, participants having a good attitude on CBHI were 4 times more likely to join the program. This finding is similar to a study in Siraro District, Ethiopia [45]. This could be due to the fact that having a positive attitude toward the community-based health insurance program might increase their willingness to join the program.

Respondents who were a member of Idir were 54% less likely to join a community-based health insurance scheme compared to those who were not a member of Idir. This finding was supported by a study in Siraro District, Ethiopia [45]. The reason could be people having other means of social supporting systems like Idir might not need to join the community-based health insurance scheme due to the belief that they might get help from the social supporting systems during illness.

Male-headed households were 80% less likely to join CBHI compared to female-headed households. The finding is similar to the studies conducted in Ethiopia [51], Kenya [54], and Nepal [55]. This could be male household heads might not face financial constrains compared to the female headed households that could restrain from joining and utilizing the program. Respondents having a small family size (<4) were 82% less likely to join the program. The finding is similar to the studies conducted in Northwest Ethiopia [56] and Southern Ethiopia [32]. This might be justified by people with small family size might have financial potential to cover their health care services using out-of-pocket payments. In addition, households with small family size are less likely to pay health care expenditure compared to households with large family size. Thus, they are less likely to join community-based health insurance program.

In the current finding, rural households were 2 times more likely to join a community-based health insurance program compared to urban households. The finding was inconsistent with the study in Kenya where the urban communities were more likely to join the health insurance program compared to the rural communities [54]. This could be due to the wrong of the urban residencies in Ethiopia about health care services in the community-based health insurance programs. Furthermore, the urban community have been relied on private health facilities where CBHI does not refund their costs after they took the treatments.

Households with no chronic illness among family members were 69% less likely to join CBHI program compared to households with chronic illnesses. The finding is similar to studies conducted in Northwest Ethiopia [56], Southern Ethiopia [32], and Malaysia [48]. The possible reason could be people with no chronic illness in their household might not need frequent health care services and hence paying for the community-based health insurance program is considered as a wastage of resources and might not need to join the program.

Households who perceived good health care services in community-based health insurance were almost 3 times more likely to join community-based health insurance compared to their counterparts. The finding was similar to the studies conducted in Northeast Ethiopia [56] and Saudi Arabia [46]. This could be due to the fact that good quality health services satisfy the community and increase their willingness to participate in the community-based health insurance program.

Conclusion

Nearly three fourth of the participants were willing to join a community-based health insurance program. Several household and health service-related factors affected the community’s willingness toward the program. The government the regional and local health offices should improve the quality of health services, perform program advocacy (improve knowledge and attitude), and build trust among the community to scale up the program.

Supporting information

Acknowledgments