SAMARA UNIVERSITY

COLLEGE OF MEDICAL AND HEALTH SCIENCE

DEPARTMENT OF PUBLIC HEALTH

DETERMINANTS OF COMMUNITY BASED HEALH INSURANCE MEMBER

ENROLLMENT IN ASITA RURAL AND AFAMBO WOREDA

By:-Allo Mohammed [B.sc in Nursing

Main Advisor: Mr. Etsay woldu (MPH, Assistant professor)

Co Advisor Mr. Belay Ali (MPH, Lecturer)

A research proposal to be submitted to Samara University, College of medical and Health

Sciences Department of public health, in partial fulfillment of the requirements for masters of
Public Health [MPH] Degree in General Public Health

January , 2023

Samara, Afar, Ethiopia

i
 SAMARA UNIVERSITY

COLLEGE OF MEDICAL AND HEALTH SCIENCE

DEPARTMENT OF PUBLIC HEALTH

Master’s Research Proposal Submission Form

Name of Principal Investigator [B.SC in Nursing]

Name of Main Advisor Dr. Etsay woldu(MPH, Assistant professor)

Email: etsaywold@gmail.com

Name of Co-Advisor Mr. Belay Ali(MPH, Lecturer)

Email: belayebrahim@gmail.com
Full title of Research Proposal Determinants of community based health insurance
enrollment in Asaita rural and Afambo Woreda, Afar,
Ethiopia, 2023
Duration of Research project
Data will be conducted from May 07 to 23, 2023

Study Area Asaita and Afambo district, Afar, Ethiopia

Address of Principal Investigator

Asaita, Afar, Ethiopia
Email:-
Phone

Summary
ii
Background: Health security is increasingly being recognized as an integral part of poverty
reduction effort. CBHI is a pledge agreement requiring the health insurer to cover basic health
service costs in exchange for premium payments into a collective fund which is designed,
owned, and administered by members.

Objective: the objective of the study is to identify the determinants of community based health
insurance member enrollment in Asaita rural and Afambo District

Methods: A case-control study is designed to help determine if an exposure is associated with an

outcome (i.e., disease or condition of interest). For this purpose the study will be conducted
based on case control study. And the study period will be from February 2023 to June 2023

iii
 Contents
Research Proposal Submission Form…………………………….………………………………ii

Summary

1.Chapter One: Introduction............................................................................................................1

1.1 Background of the study........................................................................................................1
1.2 Statement of the study...........................................................................................................2
1.3 Significance of the study.......................................................................................................4
2.Chapter Two: Review of Related Literatures...............................................................................5
2.1. Magnitude of Community based health insurance utilization..............................................5
2.2. Determinant factors associated with enrollment of CBHI....................................................7
2.2.1. Socio-demographic Factors...........................................................................................7
2.2.2. Health and health related factors.................................................................................11
2.2.3. Socio-economic and client factors...............................................................................13
2.2.4. Conceptual framework on CBHI enrollment...............................................................15
3.Chapter Three: Objective of the study........................................................................................16
3.1. General objective................................................................................................................16
3.2. Specific Objectives.............................................................................................................16
4.Chapter Four: Methodology.......................................................................................................17
4.1. Description of the study area..............................................................................................17
4.1.1. Demographics..............................................................................................................17
4.1.2. Location of Asaita........................................................................................................17
4.2. Study design and period......................................................................................................18
4.3. Source population...............................................................................................................18
4.3.1. Study population..........................................................................................................18
4.4. Inclusion and exclusion criteria..........................................................................................19
4.4.1. Inclusion criteria..........................................................................................................19
4.4.2. Exclusion criteria.........................................................................................................19
4.5 sample size determination and sampling procedure............................................................19
4.5.1. Sample size determination...........................................................................................19

iv
 4.5.2. Sampling procedure.....................................................................................................19
4.5.3. Data collection instruments.........................................................................................20
4.5.4. Data collection methods..............................................................................................20
4.6. Study variables....................................................................................................................20
4.6.1. Dependent variable: Community-based health insurance enrollment.........................20
4.6.2. Independent variables..................................................................................................20
4.6.3. Operational definitions................................................................................................20
4.7. Ethical consideration..........................................................................................................22
4.8. Data processing and analysis..............................................................................................22
5. Work plan..............................................................................................................................23
6. Budget....................................................................................................................................24
7. References ................................................................................................................................24

v
 1. Chapter One: Introduction

1.1 Background of the study

According to (1) the development of a country’s economy is closely interrelated with the health
status of its population. An efficient and equitable health care system is an important instrument
to break up the vicious circle of poverty and ill health (2). Scarce economic resources, low or
modest economic growth, constraints on the public sector and low organizational capacity
explain why the design of adequate health financing systems in developing countries, especially
the low income ones (3). Earlier on, cost-recovery for health care via user fees was established in
many developing countries usually as a response to severe constraints on government finance.
However, most studies alert decision- makers to the negative effects of user fees on the demand
for care, especially that of the poorest households (2) and (3).

Alternative health financing systems exist, de-linking utilization from direct payment, and
thereby protecting the population, especially the most vulnerable groups, from having to resort to
various coping mechanisms (4). That is why community based health insurance (CBHI) has been
considered as an intermediate stage ensuring moving away from households direct payment for
healthcare services to the forms of prepayment, in change to universal health coverage. It is a
pledge agreement requiring the health insurer to cover basic health service costs in exchange for
premium payments into a collective fund which is designed, owned, and administered by
members (5). No country in the world is able to fully provide health cover to citizens effectively
due to a lack of spending money for health care services. The World Health Organization
(WHO) stated the pressing situation as 150 million people worldwide suffer a financial
calamitous shock each year, and more than 100 million are nudged into poverty due to direct
payments for health care-related services (5). Among the advanced countries, reports showed
that even the USA cannot offer health service cover to all citizens, and 46 million Americans
have insufficient health services coverage (6).

Health insurance implemented in developed countries benefits people through available prompt
medical care, improving their health status, providing better health outcomes, reducing the
physical burden for the insured and the demand for free-cost care from the provider CBHI as a
system of health insurance is designed to ameliorate health care service encounters of destitute
and informal sector employees (7) Implementation of CBHI in Asia and central Africa is
accredited with providing benefits such as protecting the destitute against extraordinary health
care services costs, providing financial safety for the poor, minimizing the equity gap, reducing
out-of-pocket spending, building members’ self-belief through community control procedures
with its design and implementation challenges (8). Enormous initiatives were used to expand the
CBHI in developing countries, and initiatives employed to help people went on further than the
experimental stage because of many impediments, mainly a challenge of enrollment and poor
adherence to scheme requirements as a consequence of the variable training and attitudes of the

1
volunteers (9). Implementation studies carried out in Asia and Africa on CBHI schemes
indicated that the performance, as planned in the design phase, was not adequate, wasted
resources resulted in the loss of trust among the members (10). The method being implemented
in Nepal is not promising as the scope and impact are very limited (11). In Cameroon there are
difficulties such as a sustainable existence and in Burkina Faso the high drop-out rate of the
members has been documented (12). Sub-Saharan Africa is well-known to have a high burden of
disease and low government expenditure on health. The accessibility of CBHI schemes largely
exhibited weak presentation (13).

According to (14) Ethiopia is the second largest county, next to Nigeria in terms of population
size in Africa. However the country ranks low in access to modern healthcare services compared
to African countries. Even though Ethiopia has been implementing the primary health-care
approach since mid-1970s, the country was quietly continued with a basic challenge comprised:
insufficient coverage of services, disproportion of access, inadequate quality of care, and high
out-of- pocket expenditure (15). In Ethiopia, CBHI scheme have been introduced in 2011 to
reduce the financial shock due to unexpected and irregular out-of-pocket payments and to
increase the resource pooling for health-care that would improve access and utilizations of health
services (16). The government of Ethiopia depends greatly on outdoor supporters (50%) and out-
of-pocket payments (34%) to fund health services for its population (17).

Given the significant importance of community based health insurance in improving access to
and utilization of healthcare service, in 2016 only 5% of Ethiopian was enrolled for CBHI
schemes membership (18). Having information on the determinants of enrollment into the CBHI
scheme would help in devising strategies that promote communities’ enrollment into the CBHI
scheme. Hence, this study is aimed at identifying determinants of enrollment into CBHI scheme
membership in Asaita and Afambo Woreda, Afar regional state, Ethiopia

1.2 Statement of the study

Large numbers of people in low and middle income countries are facing increasing difficulties in
supporting sufficient funding for health care (19). Globally, about 44 million households face
catastrophic healthcare spending, while approximately 25 million households are impoverished
as a result of these direct healthcare expense (19). Since many governments have failed to
establish formal financial protection mechanisms and insurance schemes, the majority of the
world’s poor must rely on their resources to pay for medical expenses (20). Low and middle-
income countries (LMICs) account for about 90% of these cases (21). This direct healthcare
expenditure accounted for 37% in Ethiopia, and out-of-pocket (OOP) expenditure has risen over
time and remains one of the country’s major hurdles to healthcare access (22).

United Nations formulated a list of 17 Sustainable Development Goals (SDGs) in 2014, with the
third goal being to "ensure healthy lives and promote well-being for all at all ages" (23). The
attainment of Universal Health Coverage (UHC) is a key element of this target 3.8 (23). UHC is
a system in which "all individuals and communities have access to the health care they need

2
without incurring financial hardship" (24). Any UHC strategy must deal with the issues of
healthcare financing, access to safe, effective, high-quality basic healthcare services, resource
distribution, and financial hardship protection (25). Reforms like community-based health
insurance (CBHI), are vital to ensuring that health systems contribute to health equity, and social
justice, primarily by advancing toward universal access and social health protection (26).

Ethiopia is striving to achieve UHC through state-managed schemes such as CBHI. CBHI is a
risk-pooling approach that aims to disperse health expenditures across families with varying
health profiles to provide greater access to healthcare services by allowing cross- subsidies from
wealthy to poor populations (27). It is an autonomous, not-for-profit, voluntary, and member-
based scheme in which the community is actively involved in driving its setup and management
It is a non-profit health-financing mechanism based on the principles of solidarity and risk-
sharing (27).

The CBHI scheme in Ethiopia was formed to improve access to health care and lower out-of-
care quality (26). However, health-seeking behavior and access to modern health care are low.
Ethiopia has made rapid economic progress in recent decades, but it remains a developing
country with a high disease burden. Ethiopia’s health system is challenged by a lack of funding
and relies heavily on international aid. Due to a lack of resources in the healthcare system,
healthcare services are underutilized. Compared to other low-income African countries, the
Ethiopian government’s health spending is quite low (27).To alleviate the low level of health
care service utilization and improve access to quality health services in an equitable, efficient,
and sustainable way, the government of Ethiopia launched CBHI schemes for the agriculture and
informal sector in 2011 (28). For the first time, the program was implemented in 13 rural
districts across the country’s four main regions (Tigray, Amhara, Oromia, and SNNPR) (6). It
was implemented to decrease financial stress resulting from unexpected OOP payments. In
Ethiopia, OOP spending accounts for a significant proportion of health sector spending. In 2013,
90.6% of private health expenditure in Ethiopia was from OOP. Despite the government’s
efforts, the CBHI healthcare services utilization rate still failed to achieve the expected goal (7)

The prevalence of community-based health insurance enrollment in Ethiopia was 20.2%. The
enrollment rate of households in the scheme was high in both Amhara (57.9), and Tigray
(57.9%) regions and low (3.0%) in the Afar region (2). There were several local empirical
studies previously like (2), (3), (4), (5), (6), (7), (8), (9), (10), (11), (13), and (14) on
determinants for enrollment in CBHI scheme using cross sectional study which is difficult for
dynamic population like pastoralist and it is difficult to establish causal relationship in cross
sectional study. Since the data are collected at one single occasion in the case of cross sectional
study it is difficult to get data in the pastoralist and population who move from one place to other
may out of the target in the study. On the other hand there were few studies that were conducted
on the determinants for drop out from CBHI like (13),(26), (35), (36), and (37). Even though
these studies were conducted by case control study, they focused on the determinant factors that
influencing on dropout from CBHI. Since what factors make the individual to enroll in to the

3
CBHI and what factors make them drop out are different. Therefore, such previous studies were
also failed to answer for the study what the researcher has rising in the aim of the study for this
particular area Afar.

Additionally, there was no previous study in this particular area with any of study design and
also if the issue was left without investigating it, the advantages that will get from risk sharing
aim of CBHI may miss from the vulnerable group of the Afar people. Therefore, a further study
on CBHI enrollment is needed by using more efficient study design for the dynamic population
and that is why the researcher has initiated to assess the determinant factors for enrollment in
CBHI by using case control study design in Asaita and Afambo woreda Afar regional state,
Ethiopia.

1.3 Significance of the study

Understanding the factors that determining the enrollment in community based health insurance
in the study area may give factual insight to the successful in the implementation of CBHI in the
study area by stakeholder in different positions. The study also may contributes to the scientific
development of public health profession on the knowledge of community based health insurance
and produces input information that might help policy makers on CBHI and furthermore, it may
helps as baseline for other researchers who want to study more on the topic area.

4
 2. Chapter Two: Review of Related Literatures

.
2.1. Magnitude of Community based health insurance utilization
A study conducted by (15) using longitudinal survey of households supported by qualitative
method in CBHI pilot regions, in Ethiopia during the time of 2011/12 indicated that overall the
uptake of CBHI was 45.5% during December 2012. But since April 2020 in piloted four regions
the uptake was 44%, 35%, 49%, 34% in Oromia, SNNPR, Amhara and Tigray respectively. The
Case study conducted in the same regions by USAID 2011-14 reviewing the secondary
documents in the piloted districts revealed that the average CBHI enrolment rate was 52.4% of
eligible households, six woredas had enrolment rate higher than 60%, with 100% coverage in
Yirgalem woreda (SNNPR) and 91% in Tehuledere (Amhara). Deder (Oromia) had the lowest
CBHI enrolment 35% (12). As Ethiopian Health Insurance Agency Evaluation of Community-
Based Health Insurance Pilot Schemes in Ethiopia, 2015 the enrolment rate in the pilot area were
found to be 67% in Dimbitchu and Damboya, 62% in South Achefere, and 38% in Fogera (13).
But According to the study conducted in Thehuledere district South Wollo zone by Samuel et al,
during 2015 the CBHI enrolment rate was 94% (14).

A study done by (16) on pooled coverage of community based health insurance scheme
enrolment in Ethiopia systematic review and meta-analysis, 2016–2020 indicated that among 269
identified, 17 studies were included and the overall coverage of CBHI scheme was 45% (95% CI
35%, 55%) in Ethiopia. The sub-group analysis shows higher enrolment rate 55.97 (95%CI:
41.68, 69.77) in earlier (2016–2017) studies than recent 37.33 (95%CI: 24.82, 50.77) studies
(2018–2020). The study also concludes that the pooled coverage of CBHI enrolment is low in
Ethiopia compared the national target of 80% set for 2020. It is also concentrated in only major
regions of the country.

Based on regional difference in the magnitude of CBHI implementation there were several
studies. According to (12) a community-based cross sectional study done in Ethiopia in Maro
District SNNPR and the result indicated that the prevalence of community-based health
insurance enrolment was 20.3% [(95%CI:[ 23.8, 31.2)].

In Sidama (13) 20.2% of the respondents were enrolled in the scheme, in Addis Ababa 67.3%
(3), in Akaki the magnitude of community-based health insurance (CBHI) utilization was
(66.3%) (17). In West Gojam Zone 58% (8), in North Shoa Zone 58.6% of the respondents were
members of community-based health insurance (9), in Ebinat District the performance of the
district in the membership into the health scheme have been found to be 65% and 71% in terms
of renewal (11).Based on evidence from the 2019 Ethiopia Mini Demography and Health Survey
5
the prevalence of CBHIS enrollment in Ethiopia was 33.13% (17). Generally the range of CBHI
magnitude in Ethiopia is from 20.2% up to 91%.

2.2. Determinant factors associated with enrollment of CBHI

2.2.1. Socio-demographic Factors

A community based cross sectional study conducted in South Gonder Zone about determinants
of CBHI enrollment indicated that residence, marital status, education level, occupation status,
family size, presence of under-five children in the household, presence of elders in the
households (19). A cross sectional study was done in Addis Ababa on determinants for CBHI
enrollment by (12) a d identified that relatively older ages [(AOR:3.7; 95% CI:[ 0.07,10 )],
formal education [(AOR:1.3; 95% CI:[ 3.6,34 )], non farmers [(AOR : 3 ; 95% CI: [0.9, 80)]. and
agree on affordability of premium [(AOR: 0.6 95% CI:[ 0.02, 1.842)], good knowledge on CBHI
[(AOR: 2.7 ; 95% CI : [0,0.192)], had statistically significant association with community-based
health insurance enrolment.

Another case control study conducted North west Ethiopia (9) was identified that educational
status, awareness about CBHI, perception of CBHI scheme and illness experience of family
influence CBHI utilization and (20) also were identified that family size between 4 and 6 (AOR
= 2.26; 95% CI: 1.04, 4.89), history of illness by household (AOR =3.24; 95% CI: 1.68, 6.24),
perceived amount of membership contribution was medium (AOR = 2.3; 95% CI: 1.23, 4.26),
being married (AOR= 6; 95% CI:1.43, 10.18) and trust on program (AOR =4.79; 95% CI: 2.40,
9.55) were independent determinants for increased enrollment decision in the community-based
health insurance. A systematic study conducted by (4) on factors determining community based
health insurance utilization in Ethiopia were found to be associated with supply side, health
facility, demographic and socioeconomic predictors. Among demographic and socio-economic
factors, the report of the studies regarding to gender and age was not consistent. However
income, education, community participation, marriage, occupation and family size were found to
be significant predictors and were positively related with the scheme’s utilization. According to
(21) a case control study was done in Western Ethiopia and identified that who had college and
above education level were 3.90 times more likely to be enrolled into CBHI scheme compared to
those with no education (AOR = 3.90, 95%CI; 1.19, 12.75). Similarly, in this study respondents
with good awareness level on CBHI scheme membership were 4.74 times more likely to be
enrolled for CBHI compared to those with poor awareness level (AOR = 4.74, 95% CI; 2.50,
8.99). Respondents who perceived premium of payment for CBHI as cheap were found to be
5.82 times more likely to be enrolled CBHI scheme membership compared to those who
perceived premium of payment for CBHI as expensive (AOR = 5.82, 95% CI; 2.49, 13.60).

A community based cross-sectional study was conducted in Sidama Region, 2020 (13) identified
that ages 31-59 years(AOR :2.62, 95% CI :1.48-4.66)and >=60 years(AOR : 2.87, 95% CI :1.23
6.74), households who had no formal education(AOR:1.66, 95% CI:1.02-2.72),affordability of
premium (AOR:0.28, 95% CI: 0.15-0.54), knowledge on CBHI(AOR: 3.53; 95% CI: 1.21,

6
10.27) and perceived quality(AOR: 0.52, 95% CI: 0.25-0.87) had statistically significant
association with community based health insurance enrollment. Similarly unmatched Case-
Control Study was done in East Wollega for determinants of enrollment in CBHI program (21)
and identified that educational level, knowledge, time of membership payment, laboratory test
availability, perception on respectful care and wealth status were significant determinants of
CBHI enrolment status. In addition, a case control study was done in Jimma (35) and identified
that household heads from middle wealth quintile [1.23(1.08-2.97)], poor health status
[10.32(3.8-27.7)], family size>5members [3.0(1.3-6.7)], being model household [4(1.5- 11.6)],
<60min travel time on foot [3.7(1.9-7.0)].

Similarly, a study conducted on households of Bench Maji Zone, SNNPR using cross sectional
study design, older ages were 94 % less likely to enroll in CBHI and to join the scheme (22) and
being female is 70% more likely chance of being participant in Kenyans public health insurance
program. But in the study done on determinants of health insurance in the rural population of
south India, the male gender was significantly associated with health insurance (23). However in
the study done on determinants for participation in public health insurance among urban slum
residents of Kenya in 2012, on determinants of health insurance owner ship among women in
Kenya, using cross sectional study on households, age was not significantly associated with
participation in the scheme (23). But in the study done on determinants of health insurance in
the rural population of south India, the male gender was significantly associated with health
insurance (16). Regarding the marital status and the association between willingness to join the
scheme, singles were 87.7% less likely to join CBHI scheme (22), likewise, marital status was
preventive determinant factor in study conducted by Kimani et.al household heads who are not in
union were 43% less likely to participate in the public health insurance program than those who
are currently in union (23).

Additionally, the study conducted in rural Kenya on the perception and uptake of health
insurance for maternal care: a cross sectional study, marital status was significantly associated
with health insurance uptake, married pregnant women are 6.4 times more likely to uptake health
insurance than unmarried ones (25). Similar study in Kenya among reproductive age of women
married women are 80% more likely to be associated with having health insurance compared to
never married women (26), however marital status had no significant association as of the study
conducted on community health fund membership in Tanzania (27).

According to the study conducted on determinants of enrollment in of informal sector workers in

cooperative based health scheme in Bench district house wives were 76% more likely to join
CBHI scheme than farmers (15). But in the study with Tehuledere district of Amhara regional
state, merchants were 18% more likely to comply with CBHI scheme requirements than farmers
(28), even though, occupational status had no bearing effect on health insurance status in the
study conducted in rural population of India (23). According to the study conducted in Tanzanian
on community health fund membership households’ family size was positively associated with
willingness to join CBHI, with each additional house hold member the chance of being member

7
in the scheme increases by 4.3 percentage points (27). The same thing holds true in study
conducted in Bench Maji zone, as number of family size increases the probability of willingness
to join CBHI increases with 69 percentage points (15).

In the same way larger households (5-6 members) were more likely to be enrolled in the
cooperative based health schemes (29). The study done on Determinants of Rural Household’s
Willingness to Participate in Community Based Health Insurance Scheme in Edo State,
Nigeria,2012,revealed that, household size was positively signed implying that respondents with
larger families are more likely to be willing to participate in community based health insurance
scheme than respondents with smaller households odd ratio of 1.7 that respondents with large
household size were 1.7 times or 70% more likely to participate in CBHI scheme compared to
those with smaller households (30). Similarly in the study conducted on Determinants of
Willingness to Join Community- Based Health Insurance Scheme in a Rural Community of
North-Western Nigeria,2016, household who comprised of > 5 members had about 3 times more
likely to join CBHI than members who constitutes five or less (31). However family size had no
determining role in the study conducted on determinants of enrolment in health insurance, in the
rural population of India (23).

2.2.2. Health and health related factors

With respect to health status and health service related factors; a study (4) identified that illness
experience, benefit package, awareness level, previous out of pocket expenditure for health care
service and health service status (quality, adequacy, efficiency and coverage) were significantly
and positively related but premium amount, self-rated health status and bureaucratic complexity
were found to be negative predictors. Similarly concerning health related factors, unmatched
case control study was conducted (21) and identified that availability of laboratory services,
focus on respectful care provision of health care work force and convince the medium and above
wealth status classes that the objective of CBHI is to have solidarity of helping each other.

According to (21) a case study was done in western Ethiopia and identified that respondents who
perceived their own health status as good during data collection were found to be 5.58 times
more likely enrolled for CBHI scheme membership compared to those perceived as poor their
own health status (AOR: 5.58, 95%CI: 2.87, 10.87) and in this study also respondents who
perceived high quality of care were found to be 8.37 times more likely enrolled in CBHI scheme
membership compared to those perceived low quality of care (AOR = 8.37; 95% CI; 3.62,
19.38). Households whose treatment choice modern healthcare were 2.94 times more likely to be
enrolled compared to those who treatment choice was traditional/home healing (AOR = 2.94,
95%CI; 1.47, 5.87). similarly a case control study was done in Jimma Zone, Ethiopia and
identified that being exposed to health facilities [2.4(1.6- 4.5)], being exposed to indigenous
community insurances [2.9(1.5-5.7)], those who trust on CBHI committee [23.2(9.2-46.8)],
having favorable attitude towards CBHI [6.8(3.4-13.8)] and having awareness on CBHI [8.3(3.4-
13.8)] were more likely to be enrolled in to CBHIS.

8
A systematic review and meta-analysis study was conducted on towards universal coverage, the
level and determinants of enrollment in CBHI (6)and the study identified that the presence of a
person with a chronic disease in the household [OR = 3.58, 95% CI 2.37, 4.78] were all found to
influence CBHI enrolment. A case control study (20) identified that history of illness by
household (AOR =3.24; 95% CI: 1.68, 6.24).

A study conducted by (16) accessibility of health care facilities was positively associated with
CBHI membership and one standard deviation increase in travel time to health centers (45 min)
increases enrolment by 3.6 percentage points. While the study conducted in Bench Maji zone on
willingness to join community-based health related factors revealed that distance of households
from the nearest health facility measured by time unit was negatively associated with WTJ
CBHI, in this study one minute increase to reach the nearest health facility is associated with
1.6% chance of being not willing to join CBHI (22). Previously a study conducted on the piloted
regions of Ethiopia (15), identified that there is no evidence that household’s self-assessment of
health status has bearing effect on community based health insurance enrolment. But in the study
conducted in Debub bench district households self-reported health status has negative association
with WTJ the scheme (17), likewise there is negative linkage between presence of chronic
disease and enrolment as study done by Mebrtie et al,2015 (5), coming to households perceived
quality of health care, there is a clear and discernible link between the quality care on offer and
CBHI uptake (21).

A case control study on factors associated with enrollment for community-based health insurance
scheme in Western Ethiopia (23) identified that perceived health status (AOR = 5.536; 95% CI;
1.403–21.845), perceived quality of care (AOR: 21.014 95%CI; 4.178, 105.686) and treatment
choice (AOR = 2.94, 95%CI; 1.47, 5.87) were factors significantly associated with enrollment to
CBHI. A community-based cross-sectional study on magnitude of community-based health
insurance utilization and associated factors in Northern Showa (9) and identified that awareness
about CBHI, perception of CBHI scheme and illness experience of family influence CBHI
utilization. For instance, availability of blood testing equipment in the closest health facility
increases the probability of CBHI enrolment by 30 percentage points (20). Average waiting time
to see a health care professional, a measure of quality in its own right and a proxy for facility
staffing levels, exerts a negative effect on enrolment. A one standard deviation reduction in
waiting time (28 min) is associated with a 14 percentage point increase in enrolment (22).

A case control study was (13) done and identified that poor perceived quality of care (AOR =
3.66; 95%CI: 2.35, 5.69), low knowledge of community-based health insurance (AOR = 6.02;
95%CI: 2.97, 12.26), no active community communication (AOR = 5.41; 95%CI: 3.29, 8.90) no
chronic illness (AOR = 10.82; 95%CI: 5.52, 21.21) premium fee is not affordable (AOR = 2.35;
95%CI: 1.47, 3.77), and out of pocket money not reimbursed (AOR = 9.37; 95%CI: 4.44, 19.77)
were the determinants for the dropout from CBHI. Similarly, a case control study was done on
determinant factors for dropout from CBHI in rural districts of Gurage zone Southern Ethiopia,
and the result showed that the statistically significant influencing factors associated with dropout

9
from community-based health insurance were: highest wealth status (adjusted odds ratio [AOR]
= 2.36, 95% confidence interval [CI]:1.14–4.87), unfavorable attitude toward CBHI (AOR: 1.81,
95% CI: 1.87–3.37), no illness experienced in the last 3 months (AOR: 5.21, 95% CI: 2.90–
9.33). no frequent health facility visits (AOR:5.03, 95% CI:1.17–23.43), no exposure to
indigenous community insurance (AOR:0.10, 95% CI: 0.03–0.37), not graduated in the model
household (AOR: 3.20, 95% CI:1.75–5.83), being a member in the program for more than 3
years (AOR:0.55, 95% CI: 0.29–0.94), not trusting governing bodies (AOR:10.52, 95% CI:4.70–
23.53), the ordered drug was not available in the contractual facility (AOR:14.62, 95% CI:5.37–
39.83), waiting time was >3 h (AOR:4.26, 95% CI:1.70–10.66), and poor perception of service
quality (AOR:12.38, 95%CI:2.46–62.24).

2.2.3. Socio-economic and client factors

According to (33) case control study was done in Western Ethiopia and identify that households
from poor and middle wealth index were more likely to be enrolled into CBHI compared to those
from rich wealth index ((Poor, AOR = 2.59, 95%CI; 1.08, 6.20), (Middle, AOR = 4.13, 95%CI;
1.11, 15.32)). Similarly, a scoping review study was conducted in West Africa on factors
determining membership in community-based health insurance (10) and identified that low
education, low household income, poor quality of care, lack of trust in providers and remoteness,
rules considered too strict or inappropriate, low trust in administrators and inadequate
information campaign. But according to the study in Ethiopia Amhara regional state (11) and
identified that monthly income of the household (negatively), distance (negatively) and level of
awareness (very good category) are found statistically significantly affecting the variation of the
membership decision of household.

As the study conducted on willingness to pay for voluntary health insurance in Tanzania 2011
and determinants of enrolment in voluntary health insurance in India, 2013, Enrolment in
community-based health insurance schemes in rural Bihar and Uttar Pradesh, India, 2014.
Determinants of enrolment of informal sector workers in cooperative based health scheme in
Bangladesh, 2017 evidenced that house hold heads that had attained primary and above
educational statuses had more likely probabilities to join the scheme than who had no formal
education or no education at all (33), (34) and (35).

Estimated income of the household heads had both positive and negative association with CBHI
uptake. The study conducted on determinants of enrolment in voluntary health insurance of India
, 2013, higher estimated income households had higher (2times)probability of having voluntary
health insurance (34) ,but income level shown negative association ,that means households with
estimated higher income were less likely willing to participate in CBHI than those with higher
income (36). Evidences from literatures revealed that the households’ heads from highest wealth
index/ quintiles were more likely to be enrolled in CBHIs. For example the probability of having
health insurance increased as household wealth index increased, women from wealthier
households were 6 times more likely to have the scheme than poor households (24).

10
 Similarly in comparing each wealth group with the poorest, poorest group are about 90% less
likely to be enrolled in community health fund (20), likewise highest wealth quintiles were more
than 4 times more likely to join CBHI schemes than the second wealth quintiles (22). However,
the study conducted in the piloted regions of Ethiopia had revealed opposite result, in this study
poorest households contributed largest share of beneficiaries (15). In consideration of premium
affordability, study participants who agreed on CBHI premium fee affordability were 2.6 times
more likely to comply with CBHI requirements when compared with those respondents who
disagreed (28).In the study conducted in rural India, if we see the affordability of the premium to
the people, we can see that those people who can afford to pay were more likely to be insured
(34).

2.2.4. Conceptual framework on CBHI enrollment

The conceptual framework shows that socio-demographic factors, socio-economic factors, client
and health related factors, scheme related factors that affects CBHI enrollment adopted from
literature review.

Socio-demographic & Health related factors Scheme related & social

socioeconomic factors quality related
 Access of health
 Sex facility  Premium affordability
 Age  perceived quality of  Time of premium
 Family size health care collection
 Distance  Self reported health  Awareness
 Income status  Social capital
 Education  presence of chronic  Attitude about the
disease scheme
 Medicine availability

Enrollment to CBHI

Benefit related
Operation related
 Illness cases
 Trust on management of the
 family aged<5 and > 60
scheme
 Duration in the scheme
 Complain handling
 Hospitality 3. Chapter Three: Objective of the study
 Level of satisfaction
 Service use
 Quick service

11
3.1. General objective
The general objective of the study is to identify the determinants of community based health
insurance member enrollment in Asaita rural and Afambo District

3.2. Specific Objectives

Specifically the study will achieve the following objectives

To identify the magnitude of CBHI implementation in the study area

To assess determinant factors influencing the enrollment of community-based health insurance in

Afambo District

To examine the trends of enrollment and renewal rates over time in the study area.

4. Chapter Four: Methodology

12
4.1. Description of the study area
Afambo is a woreda in Afar Region, Ethiopia. It is named after Lake Afambo, located at the
border of this woreda with Asayita, near the international border with Djibouti. Part of the
Administrative Zone 1, Afambo is bordered on the south by the Somali Region, on the west by
Dubti, on the north by Asayita, and on the east by Djibouti. The largest town in this woreda is
Afambo.

The average elevation in this woreda is around 404 meters above sea level; the highest peak is
Mount Dama Ali (1069 meters). The only perennial river is the Awash, which passes through
Lake Afambo, and a chain of lakes south and east of it: Laitali, Gummare, Bario, and Lake Abbe.
As of 2008, Afambo has 79 kilometers of all-weather gravel road; around 22.33% of the total
population has access to drinking water.

4.1.1. Demographics
Based on the 2007 Census conducted by the Central Statistical Agency of Ethiopia (CSA), this
woreda has a total population of 24,153, of whom 13,312 are men and 10,841 women; with an
area of 1,258.97 square kilometers, Afambo has a population density of 19.18. While 822 or
3.40% are urban inhabitants, a further 6,529 or 27.03% are pastoralists. A total of 4,251
households were counted in this woreda, which results in an average of 5.7 persons to a
household, and 4,322 housing units. 99.96% of the population said they were Muslim.
According to (47) Afambo consisted of 7 kebeles (Administrative units) of which 3 kebeles
(Administrative units) were entirely dependent on livestock production and the remaining 4
kebeles (Administrative units) were agro-pastoralists practicing both farming and extensive
livestock rearing.

4.1.2. Location of Asaita

Asaita is a town in northeastern Ethiopia, and before 2007 was the capital of the Afar Region of
Ethiopia. Administratively it is found in Zone One of the regional administration; and this Zone
comprises of eight woreda namely Asaita, Elidar, Afambo, Mille, Dubti, Kurri, Adaar and
Chifra, Asaita wereda shares boundary with the Republic of Djibouti internationally and with
Afambo, Dubti and Elidar weredas of Zone One in the region. As a zonal capital, the town has an
administrative linkage with all the weredas of its zone. With regard to linkages outside the
region, it has strong transport and economic interaction particularly with Dessie town of the
Amhara Region. The town has a latitude/longitude of 11°34′N/41°26′E and an elevation of 300
meter (980 ft) asc. Asaita is 655kms far from the capital city of Ethiopia, Addis Ababa and
65kms far from the capital city of Afar, Samara. Topographically, Asaita and its surrounding
area consist of basically flat landscape with some hills and small mountains that range in altitude
from 350 to 473 m.a.s.l (ATM, 2011). The total area of the study area is 5987 ha. (47).
According to Central Statistical Agency (CSA), Asaita is part of the administration of Awisi
zone. In this district there are 13 kebelles(It is the smallest administrative unit in Ethiopia) of
those 11 are rural and the remaining 2 are urban kebelles (48).

13
4.2. Study design and period
A case-control study is designed to help determine if an exposure is associated with an outcome
(i.e., disease or condition of interest). In theory, the case-control study can be described simply.
First, identify the cases (a group known to have the outcome) and the controls (a group known to
be free of the outcome). Then, look back in time to learn which subjects in each group had the
exposure(s), comparing the frequency of the exposure in the case group to the control group. For
this purpose the study will be conducted based on case control study. And the study period will
be from February 2023 to June 2023

4.3. Source population

Source population will be all rural households live in Asaita and Afambo district

4.3.1. Study population

All households that will be randomly selected kebeles will be the study populations

4.4. Inclusion and exclusion criteria

4.4.1. Inclusion criteria

All household heads/spouses live in rural selected Kebeles of Asaita and Afambo district.

4.4.2. Exclusion criteria

All household heads/spouses live in urban and government workers in the selected Kebeles of
Asaita and Afambo district.

4.5 sample size determination and sampling procedure

4.5.1. Sample size determination

The sample size is estimated by using Epi info version 7.2 from similar study (26)
conducted Western Ethiopia p1= 35% and p2 = 20% of CBHI non member and member
respectively, with assumption: 80% statistical power with level of significance at 95%
insured to uninsured ration 1:1 and 10 % rate is used. Therefore, the total sample size
becomes 302 from Epi info result and 10% non response rate 30.2 =332 total sample size
(166 members and 166 non members).

4.5.2. Sampling procedure

Afambo consisted of 7 kebeles (Administrative units) of which 3 kebeles (Administrative units)
were entirely dependent on livestock production and the remaining 4 kebeles (Administrative
units) were agro-pastoralists practicing both farming and extensive livestock rearing. Similarly
According to Central Statistical Agency (CSA) , Asaita is part of the administration of Awisi
zone. In this district there are 13 kebelles (It is the smallest administrative unit in Ethiopia) of
those 11 are rural and the remaining 2 are urban kebeles. Totally the numbers of kebeles in the
two woredas are 20 kebeles and the study participants will be drawn using multi-stage sampling
technique. In the first stage 5 kebeles will be selected randomly out of 20 kebeles considering the

14
representative kebeles making 3 kebeles from Asaita and 2 of them from Afambo. The second
stage will be involved the selection of households from these 5 kebeles. List of households for
the case (enrolled) and controls (non- enrolled) will obtain from each kebeles administration
household record list which will use as sampling frame. The sample size will be proportionally
allocated for selected kebeles based on each kebele’s number of households. Then simple
random sampling (lottery method) will be employed to select the cases and controls by taking
their list as a frame and labeling continuous numbering.

4.5.3. Data collection instruments

The study will use interview that will be adopted from Ethiopian Economic Association (EEA)
and EDHS. It will contain four parts, the first part contains socio-demographic characteristics,
the second part questions related to CBHI utilization, the third part contains health and health
related variables and fourth part addresses socioeconomic variables (wealth index).

4.5.4. Data collection methods

The data will be collected by interviewer administered pretested structured questionnaire. The
questionnaire initially prepared in English and then translated in to Amharic (local language of
the study area) and then back in to English by those proficient in the language and checked for
consistency. Training will be given for data collectors and supervisors for two days on how to
approach the study groups and fill the questionnaires. Data collection will be carried out by
house to house visit.

4.6. Study variables

4.6.1. Dependent variable:

Community-based health insurance enrollment

4.6.2. Independent variables

Socio-demographic factors: Age, household family size, education, occupation, marital status,
wealth index.

Health related factors: household members self-reported health status, accessibility of health care
facility, perceived quality of health care, presence of chronic disease in house hold members.

CBHI related factors: awareness of the CBHI, knowledge on CBHI, membership in social
capital, affordability of premium and trustworthiness in scheme management.

4.6.3. Operational definitions

Community-based health insurance utilization: households that are members of CBHI scheme as
verified by their renewed membership cards and currently new CBHI members are categorized
as (utilizes) otherwise, those that are not members and those that are dropped out are categorized
as (non-utilizes) of the CBHI (12).

15
Dependent variable of the model (CBHI participation):-The dependent variable for logit analysis
is binary choice dependent variable. This binary measurement includes the status of membership
or not of enrollment of the respondents which attains values 0 for one who is not a member of
the scheme or 1 if one is member of a scheme. A variable with such response will utilize binary
logistic model of the multivariate (more than one independent variable) type.

Independent variables:-Based on literature reviews the following factors are expected to

influence the effectiveness of CBHI scheme.

Age of household head (AGE):-It is a continuous variable defined as the household heads age at
the time of the study measured in years.

Sex (SEX): Sex is a dummy variable which explains whether the household leader is male or
female and coded in the model by “0” if the household head is female and “1” if household head
is male.

Household size (Famsize): It is a continuous variable representing the total number of family
members of the household and directly affects the household heads decision to participate in
community based health insurance.

Educational status of the household head (EDUSH):-It is a continuous variable defined as the
household heads educate in year by three Likert rate (no formal educate, primary educate and
secondary Scholl and above) of households.

Average Income(AvY): –It is households living status which is constructed using HH asset data
composed of different indicators adapted from modified to local and rural household context. It
has been measured by using the information of the ownership on the housing condition like;
amount of collected in the last one production year, number of household’s live stocks and
ownership of farm land.

Number of Illness Cases (Nillcases):-It is one of the proxies of health status and explains the
number of illness cases faced by households in the last year.

Awareness (INFOR):-It is a dummy variable which distinguishes between household heads those
informed about CBHI scheme and those not informed about the scheme and considered using
Likert scale of measurement from 0 for poor awareness to 3 for very good awareness.

Attitudes: is a dummy variable based on the response for positive or negative attitude/view
towards the scheme. Participants are asked two items with a yes or no response.

Distance from health institution (distahealthins):-Distance from health institution indicates that
the time taken to reach the nearest health center from the respondents’ home. Chronic disease
and disability are also additional concerns as independent variables.

16
 4.7. Ethical consideration
The data collection will be initiated after the ethical clearance will be obtained from Samara
University College of Health and medical science. An official letter of cooperation will be given
to Afar health bureau. The district health office and the 3 selected kebeles will be asked for an
official letter to get permission.

Data collectors will be trained on how to handle confidentiality and privacy using consent form
attached to each questionnaire. Confidentiality will be assured by excluding study participants
name during the period of data collection. The study purpose, procedure and duration, possible
risks and benefits of the study will be clearly explained for study participants. Data collectors
informed participants to enroll in the study if they are willing, written informed and signed
consent will be taken from the respondents before data collection. Any study participant willing
to engage in the study and those who want to stop interview at any time will be allowed to do so.

4.8. Data processing and analysis

Data will be cleaned and edited after entering into Epi data version 7.2 and then exported to
SPSS version 26 for analysis. Descriptive statistics will be computed and presented using
frequencies, proportions, summary statistics, graphs and tables. Variables that have P- value <
0.25 on bivariate analyses will be entered in the multivariate logistic regression model to identify
independent predictors of enrollment into CBHI. P<0.05 will be considered as statistically
significant. The strength of association and precision will be examined using adjusted odds ratio
at 95% confidence interval. The model fitness will be checked by Hosmer and Lemeshow
goodness of fit test.

5. Work plan
Tasks to be performed Time period
No 2022 2023
Respons Nov De Jan Fe Mar Apr Ma Jun 1ts 2nd
ibility b we wee
ek k
1 Title selection PI
2 Proposal writing and tool PI
development then submission to

17
 advisors
3 Incorporate all comments to proposal PI
4 Prepare and present proposal defense PI
5 Proposal defense PI
6 Ethical approval and clearance PI & ERC
7 Permission for data collection PI & CSA
8 Data cleaning &recoding PI
9 Data analysis PI

10 Thesis write up & first thesis draft PI

11 Second thesis draft& incorporate all PI

comments
12 Mock defense PI
13 Final defense PI
14 Finalizing the thesis PI
Footnote: PI- Principal investigator

6. Budget
Table1. Budgets break for determinants for enrollment in CBHI in Afambo district Afar
Regional state.

No Personnel cost Task they will do Qualification Quantity Day of Per Total
BSc work deim cost
1 Data clerk HIT/CS 2 5 192 1920
2 Principal investigator Observe PH 1 5 192 960
Total personal cost = 2880.00 birr

No Transport cost Task they will do Qualification Quantity Day of Per Total

18
 BSc work deim cost
1 Principal investigator Transport PH 1 10 300 3,000
2 Principal investigator Expenses (food, bed) PH 1 16 500 8,000
Total transport cost = 11,000.00 birr
No Item/supply cost Unit Unit price Quantity Total price
1 Pen Piece 100 1 100
2 Marker Piece 40 1 40
3 Print Piece 70 8 560
4 Telephone/mobile card Piece 100 40 4,000
5 Paper Piece 200 5 1,000
Total supply cost = 5700.00 birr
Sub-total = 20000 birr
Contingency = 10%= 2000 birr
Grand total = 22,000 birr

7. References
1. Doris Wiesmann, Johannes Jütting. The Emerging Movement of Community Based Health
Insurance in Sub Saharan Africa Experiences and Lessons Learned.. 2000.

2. Ahmed Tahir, Abdulahi Omer Abdilahi and Abdifatah Elmi Farah. Pooled coverage
of community based health insurance scheme enrolment in Ethiopia, systematic review
and meta-analysis, 2016–2020. 2020.

19
3. Aklilu Habte ID, Aiggan Tamene , Tekle Ejajo, Samuel Dessu , Fitsum Endale. Towards
universal health coverage: The level and determinants of enrollment in the Community-Based
Health Insurance (CBHI) scheme in Ethiopia: A systematic review and meta-analysis. 2022.

4. Azmeraw, Samuel. Determinants of Community Based Health Insurance Program

Implementation in Ebinat District, Amhara Regional State, Ethiopia. 2022.

5. Bekele, Teshome. Predictors of Community-Based Health Insurance in Ethiopia via Multilevel

Mixed-Effects Modelling: Evidence from the 2019 Ethiopia Mini Demography and Health
Survey. 2022.

6. Beriso, Zerihun.ASSESSMENT OF FACTORS INFLUENCING ENROLLMENT OF

COMMUNITY-BASED HEALTH INSURANCE SCHEME IN AMARO DISTRICT OF
SNNPR, ETHIOPIA,. 2020.

7. Dagmawe Menelek Asfaw, Sirage Mohammed Shifaw, Atinkugn Assefa Belete. The Impact
of community based health insurance on households walfare in Chilga District, Amhara regional
state, Ethiopia. 2022.

8. Racha Fadlallah, Fadi El-Jardali, Nour Hemadi , Rami Z. Barriers and facilitators to
implementation, uptake and sustainability of community-based health insurance schemes in low-
and middle-income countries: a systematic review. 2018.

9. Determinants of health insurance ownership among women in Kenya: evidence from the
2008–09 Kenya demographic and health survey. International Journal for equity in health,. 13:
27. 2014.

10. Desalegn, Mengistu. Determinants of Enrolment in Community Based Health Insurance

program among households in East Wollega Zone, west Ethiopia: Unmatched Case-Control
Study. 2022.

11. Mebratie, A. D, Sparrow, R., Alemu, G., Bedi, A. S,Yilma Z. Enrollment in Ethiopia’s
Community-Based Health Insurance Scheme, World Development,2015.74:5876.

12. Maina JM, KithukaP,Tororie S. Perceptions and uptake of health insurance for maternal care
in rural Kenya: a cross sectional study. Pan African medical journal,2016. 1:15.

13. Getasew Taddesse, Desta Debalkie Atnafu Asmamaw Ketemaw and Yibeltal Alemu.
Determinants of enrollment decision in the community-based health insurance, North West
Ethiopia: a case-control study. 2020.

14. WHO World health statistics 2019: monitoring health for the SDGs, sustainable develop-
ment goals. 2019.

20
15. Assefa Y., et al.,. Primary health care contributions to universal health coverage, Ethiopia.
Bulletin of the World Health Organization, 2020. 98(12): p. 894.
https://doi.org/10.2471/BLT.19.248328 PMID:. 1

6. FDRE, M.o.H. Ethiopia’s Fifth National Health Accounts Highlight of Major Findings
Briefing Notes.2014: Addis Ababa, Ethiopia. p. 28.

17. Berman P., Mann C., and Ricculli M.,. Financing Ethiopia’s Primary Care to 2035: A Model
Projecting Resource Mobilization and Costs. Boston, Massachusetts: Harvard TH Chan School
of Public Health,. 2015.

18. Central Statistical Agency, E. Ethiopia Demographic and Health Survey 2016. 2016, Addis
Ababa,Ethiopia, and Rockville, Maryland, USA: CSA and ICF. 551.

19. Kaba Kanko Conde, Aboubacar Mariama Camara , Manar Jallal , Mohamed Khalis. Factors
determining membership in community-based health insurance in West Africa: a scoping review.
2022.

20. Kimani JK, Ettarh R , Kyobuntungi C, Mberu B, Muindi K,. Determinants for participation
in health insurance program among residents of urban slum of Kenya , Nairobi ,results from
cross sectional survey, BMC Health service research,. 2012.

21. MachaJ, Kuwawenaruwa A, Makawia S, MtieG,Borghi J. community health fund

membership in Tanzania: a mixed methods analysis. BMC Health service research. 2014.

22. Sharo, Amenti Teka Geferso 1 and Sisay Begashaw. Community-Based Health Insurance
Utilization and Its Associated Factors among Rural Households in Akaki District, Oromia,
Ethiopia, 2021. 2022.

23. Meseret belete, Kedir Teji and Badasa Taye. Factors associated with enrollment for
community-based health insurance scheme in Western Ethiopia: Case-control study. 2021.

24. Ewunetie Mekashaw, Mes?n Haile Kahissay. Factors affecting community based health
insurance utilization in Ethiopia: A systematic review. 2019.

25. Panda P, Chakraborty A, DrorDM,Bedi AS. Enrolment in community-based health

insurance schemes in rural Bihar and Uttar Pradesh, India. Health policy and planning,2014.

26. Meseret Belete Fite Kedir Teji Roba, Bedasa Taye Merga , Belay Negash Tefera.Factors
associated with enrollment for community-based health insurance scheme in Western Ethiopia:
Case-control study. 2021.

27. Melaku H, ShimelesO,Berhane M. Willingness to join community-based health insurance

District, Bench Maji Zone, Southwest Ethiopia, BMC Public Health, . 2014.

21
28. Samuel GW, Gashaw AB,Solomon AW. Community based health insurance and
communities scheme requirement compliance Thehulederedistrict ,North east Ethiopia: cross
sectional community based study, ClinicoEconomics and Outcomes of research . 2017.

29. Yikeber Abebaw, Solomon Sisay, Amare Yilma. The effects of individual and community-
level factors on community-based health insurance enrollment of households in Ethiopia. 2022.

30. Walelign Mekonnen Gashaw, Kidanemariam G/Michael Beyene , Community-based Health

Insurance Membership Renewal and Associated Factors among Communities in Addis Ababa,
Ethiopia. 2022.

31. Mesafint Abeje Tiruneh. Spatial distribution and associated factors of community based
health insurance coverage in Ethiopia: further analysis of Ethiopian demography and health
surve, 2019. 2022.

32. Tsega Hagos Mirach, Getu Debalkie Demissie and Gashaw Andargie Biks. Determinants of
community-based health insurance implementation in west Gojjam zone, Northwest Ethiopia: a
community based cross sectional study design. 2019.

33. omas Getahun 1, Lakech Teklesilassie, Mizan Habtemichael , Yonas Abebe and Helen
Getahun. Magnitude of community-based health insurance utilization and associated factors
in Bassona Worena District, North Shoa Zone,Ethiopia: a community-based cross-sectional
study. 2022.

34. Berhanu Bifato, Amanuel Ayele. Community Based Health Insurance Enrollment and
Associated Factors in Sidama Region, Ethiopia. 2020.

35. Dojamo, Teshale.Determinants of enrollment to community-based health insurance among

rural households in Jimma zone, Southwest Ethiopia: Case control study. 2018.

36. Kebebush zapre, Fedila Yassin, Betelhem Tadesse, Omega Tolossa. Factors influencing
drop-out of households from community based health insurance membership in rural districts of
Gurage Zone, Southern Ethiopia: Community based case-control study. 2022.

37. GE, Chanie MG and Ewunetie. Determinants of enrollment in community based health
insurance among Households in Tach-Armachiho Woreda,North Gondar, Ethiopia, 2019. 2022.

38. Sharo, Amenti Teka Geferso and Sisay Begashaw. Community-Based Health Insurance
Utilization and Its Associated Factors among Rural Households in Akaki District, Oromia,
Ethiopia, . 2022.

39. Yikeber Abebaw et al. Factors Associated With Community Based Health Insurance
Healthcare Service Utilization of Households in South Gondar Zone, Amhara, Ethiopia. A
Community-Based Cross-Sectional Study. 2022.

22
40. Sudhir, ChaitraM,Deepa K.,. Determinants of Health Insurance in rural population of South
India. Indian Journal of forensic and community medicine, 2015.2 (3): p. 172-175.

41. Perceptions and uptake of health insurance for maternal care in rural Kenya: a cross sectional
study. Pan African medical journal,. 2016.

42. Sarker AR, Sultan M,Mahumud RA, Ahmed S,IslamZ,Morton A,. Determinants of
enrollment of informal sector workers in cooperative based health scheme in Bangladesh. PLoS
ONE, 2017.12(7): p.1-12.

43. Gobir AA, Adeyemi AO. Willingness to Join Community- Based Health Insurance Scheme
in a Rural Community of North- Western Nigeria. African Journal of health economics, 2016.

44. arker AR, Sultan M,Mahumud RA, Ahmed S,IslamZ,Morton A, Khan. Determinants of
enrollment of informal sector workers in cooperative based health scheme in Bangladesh. PLoS
ONE, 2017.12(7): p.1-12. S

45. Kuwawenaruwa A, MachaJ,Borghi J. Willingness to pay for voluntary health insurance in

Tanzania. East African Medical Journal,2011. 88(2): p.55-64.

46. Oriakhi HO, OnemoleaseEA. Determinants of Rural Household’s Willingness to Participate

in Community Based Health Insurance Scheme in Edo State Nigeria.Ethno Med, 2012.6(2): p.
95-102.

47. (CSA), Central Statistical Agency. POPULATION and HOUSING CENSUS OF

ETHIOPIA: Administrative Report. 2012: Addis Ababa, Ethiopia. 2007.

48. Aden Ali Mohammed,. GIS and Remote Sensing Based Suitable Site Selection for Solid
Waste Disposal: A Case Study of Asaita Town, Afar Regional state, Ethiopia. 2016.

23