“I [had] never visited a physician in my life,” explains Kassa Tadesse, a 55 year old farmer from the Ade’a woreda (district) of Ethiopia. The father of four admits that neither he nor his wife or children had ever seen a doctor.

“No needle ever touched us,” he said.

Tadesse first went to a doctor four years ago, when he was diagnosed with diabetes. Around the same time of his diagnosis, the Ade’a woreda launched a community-based health insurance (CBHI) program. Through the program, Tadesse and his family could receive medical services free of charge after paying an annual fee, and his household became one of the first to enroll. Where once he would have had to spend a sizeable portion of his monthly earnings from farming each month to cover his diabetes medication, his care became fully covered by insurance.

Ade’a is one of about 350 woredas in Ethiopia in which beneficiar­ies have started using CBHI to access health care services. Prior to the availability of CBHI, many households in Ethiopia lacked access to health insurance and large out-of-pocket expenses made health care services either prohibitive or impoverishing.

To address the issue, and advance the global move toward universal coverage, Abt Associates provided technical support to the Ethiopian government to pilot a federally subsidized model of CBHI in 13 woredas through the Health Sector Financing Reform / Health Finance and Governance (HSFR/HFG) project, funded by USAID.

HSFR/HFG evaluated the pilot program and found that on average, more than 50 percent of eligible households enrolled in the CBHI schemes. CBHI members are utilizing health care services more than twice as much as non-CBHI members.  Each year, approximately 75 percent of CBHI members re-enroll in the program.

In Ade’a, 42 percent of the woreda’s roughly 26,000 households have become CBHI members, and more than 14,000 visits to health facilities were made by member beneficiaries in one year.

HSFR/HFG supported the Ethiopian government to design and implement a national CBHI program scale-up strategy targeting over 80% of the Ethiopian population that is engaged in the informal sector. Today, CBHI is providing coverage to over 19 million people.

“Much of our work focuses on partnering with national governments to address financial barriers that block access to priority healthcare services,” said Dr. Bob Fryatt, director of the HSFR/HFG project.  “In Ethiopia, they were trying to address three critical challenges: a seriously under-financed health sector, high donor dependence and a high out of pocket spending burden on households. All these factors created barriers to UHC.”

Numerous factors have played a role in Ethiopia’s efforts to successfully expand CBHI.  Political support and government funding were critical, as was having the right institutional arrangements and organizational capacity to operate public health insurance.  Each woreda is staffed with three government employees:  a CBHI coordinator, health officer and an accountant/data management officer, who are overseen by a CBHI board of woreda officials and community representatives.

Ethiopia’s government made CBHI coverage one of the government’s development targets and allocated subsidies in order to ensure that those who live in poor households could participate.  Before introducing CBHI, it enacted supply-side reforms to improve the quality of care necessary to implement CBHI successfully.  One such reform allowed facilities to retain revenue from user fees and use it for quality improvements such as purchasing needed drugs and medical supplies, instead of sending it to the federal treasury.

Ethiopia is one of eight other countries – Botswana, Ghana, India, Indonesia, Namibia, Nigeria, South Africa and Vietnam – where the Abt-led HFG project is supporting local leaders with innovations to expand access to healthcare.

Lessons Learned

• Expanding health insurance is a political and a technical process.
• Coverage of the poor can’t happen without government involvement.
• Remember the supply side, so that increased health insurance coverage and demand for health care connects to accessible, quality services.
• Institutional arrangements and organizational capacity are essential to expand coverage.
• Expansion of insurance requires intentional, iterative learning and adaptation.

For more information:

https://www.hfgproject.org/where-we-work/africa/ethiopia/

https://www.hfgproject.org/members-community-based-health-insurance-ethiopia-share-experiences/ (video)

https://www.hfgproject.org/what-we-do/health-financing/