PLOS ONE

RESEARCH ARTICLE

Enrollment in community based health

insurance program and the associated factors
among households in Boricha district, Sidama
Zone, Southern Ethiopia; a cross-sectional
study
Dawit Nageso ID1*, Kebede Tefera2, Keneni Gutema2
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a1111111111 1 Boricha District Health Office, Balela, Sidama, Ethiopia, 2 School of Public Health, College of Medicine and
Health Sciences, Hawassa University, Hawassa, Ethiopia
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a1111111111 * dawitmisge3@[Link]
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Abstract
OPEN ACCESS
Background
Citation: Nageso D, Tefera K, Gutema K (2020)
Enrollment in community based health insurance In absence of any form of health insurance, out-of-pocket payments for health care lead to
program and the associated factors among decreased use of health services and catastrophic health expenditures. Community-based
households in Boricha district, Sidama Zone,
health insurances has been promised financial model for informal sectors to reduce these
Southern Ethiopia; a cross-sectional study. PLoS
ONE 15(6): e0234028. [Link] problems in many countries. When this comes down to Ethiopia, in the South Nation Nation-
[Link].0234028 ality People’s Region of the country established 52 schemes including Boricha district, the
Editor: Khin Thet Wai, Ministry of Health and study area However, there has been little evidence about the enrollment status and the
Sports, MYANMAR associated factors in the study area in particular elsewhere in general.
Received: August 26, 2019
Objective
Accepted: May 18, 2020
The study aims to assess the current enrollment status of households in community based
Published: June 2, 2020
health insurance and the associated factors in Boricha district of Sidama Zone, Southern
Copyright: © 2020 Nageso et al. This is an open
Ethiopia.
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and Methods and materials
reproduction in any medium, provided the original
A community based cross-sectional study design was employed from February 01, 2019 to
author and source are credited.
March 31, 2019, using a sample of 632 households. Data were collected using interviewer-
Data Availability Statement: All relevant data are
administered pre-tested questionnaire and entered into EPI-Info 7and transported to
within the manuscript and its Supporting
Information files. SPSSversion20 for analysis. Multi-variable logistic regression analysis along with odds ratio
and the corresponding 95% CI was conducted and significance was declared at P-value
Funding: The author(s) received no specific
funding for this work. <0.05.

Competing interests: The authors have declared

that no competing interests exist. Results
Abbreviations: AOR, Adjusted Odds Ratios; CBHIS, Current enrollment status of households in community based health insurance was found to
Community Based Health Insurance Scheme; be 81 (12.8%). According to this study, educational status; secondary school& above[AOR

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PLOS ONE Enrollment in community based health insurance program and the associated factors; a cross-sectional study

CBHI, Community Based Health Insurance; CI, = 2.749, 95%CI(1.142, 6.618)], timing of collecting premium [AOR = 0.433; 95% CI (0.196,
Confidence Interval; COR, Crude Odds Ratios; 0.958)], family size �5, [AOR = 4.16;95%CI (1.337, 12.944)], no trust on scheme manage-
FMOH, Federal Ministry of Health; FGDs, Focused
Group Discussions; HHH, Households Head; IRB,
ment[AOR = 0.272; 95%CI (0.140, 0.528)], lack of information [AOR = 0.086; 95%CI (0.026,
Institutional Review Board; MPHEP, Masters-Of 0.288)], dissatisfaction with health care service received[AOR = 0.303; 95%CI (0.171,
Public Health in Epidemiology; NGO, Non- 0.537)], no chronic illness in the family[AOR = 0.259; 95%C.I.(0.137, 0.488)] were factors
Governmental Organization; OOPs, Out-Of-
significantly associated with current enrollment status in CBHI.
Pockets; ORs, Odds Ratios; PCA, Principal
Component Analysis; PPS, Proportional to the Size;
PCU, Primary Care Unit; SNNPR, South Nation Conclusions
Nationalities People Region; SPSS, Statistical
Package for Social Science; WHO, World Health Households head’s education status, timing of premium collection, family size, no trust on
Organization. scheme management, lack of information, services dissatisfaction and chronic illness in the
family member were the identified factors associated with enrollment in CBHI in the study
area. Therefore, to enhance the enrollment and sustainability of CBHI in the study area
awareness creation, improving timing of premium collection, strengthening scheme man-
agement, improving quality of service are the areas that decision makers needs to
intervene.

Introduction
In countries where limited health insurance are practiced, direct out-of-pocket (OOP) pay-
ments dominate health care financing system, this is mainly the case of many low-and middle
income countries [1]. Thus, many households in these countries lack adequate financial pro-
tection; households face financial catastrophe and its impoverishing effects of paying for health
services in the form of out-of-pocket [2]. Globally, about 44 million households faced cata-
strophic health expenditure while about 25 million households are impoverished because of
direct health care payments. Over 90% of healthcare financial difficulties and their conse-
quences have been occurring in Sub-Saharan African countries, where resources are limited
[2]. Thus, implementation of community-based health insurance (CBHI) has emerged as a
possible health financing mechanism in reducing out of pocket payment, particularly in areas
where many people engage in informal workers and rural residence of these countries [3].
CBHI is known for facilitating resource mobilization to promote health service uptake and
provide financial risk protection to insured members by reducing their OOP payments [4]. In
the absence of any form of risk-pooling mechanism, high OOP payments can lead to a high
level of poverty and catastrophic financial stress in vulnerable households. In such situations
they are forced to borrow money, sell assets, or change resources from other necessity to cover
healthcare expenditures [5–7]. Historically, CBHI has been implemented in many countries of
the worlds’ health financing system, but it is particularly prevalent in Sub-Saharan Africa
(SSA). Especially, it is part of an overall health financing strategy in a number of countries
where the high OOP financing of care, the doubtful financial flows from donors, the large
rural and informal sector populations, and the weak capacity of governments to raise taxes [8].
In Ethiopia, CBHIS first launched in June 2011 as pilot in 13 districts found in four main
regions namely, Tigray, Amahara, Oromiya and South Nations and Nationalities people’s
Region (SNNPR) [9]. It was set up as a community-based health project that gathers payments
made by members into a fund that covers basic health care costs at local health care centers
whenever any member of the group is sick [10]. High proportion of enrolled households in
CBHI is an indicator of the general attractiveness of scheme and also it measures the extent to

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PLOS ONE Enrollment in community based health insurance program and the associated factors; a cross-sectional study

which the scheme sustained. The higher the enrollment in health insurance, the more house-
holds can avoid the financial implications of treatments costs and secure access to care when it
is needed. In practice, however, CBHI often fails to achieve its potential, primarily because it
fails to high levels of participation [11].
Previous study focused on the already enrolled households’ level of satisfaction with CBHI
scheme and the associated factors and such study provide significant contribution for the
implementation and further expansion of the program [12]. However, less is known of the
enrollment status and factors associated with it. Consequently, the available report shows low
coverage in which the current study wants to address. For instance, one national report in
Ethiopia shows only 48% enrollment of households in the pilot schemes with large variation
within and between districts. It ranges from as low as 25% in Deder and as high as 100%(Uni-
versal enrollment) in Yirgalem town [13].
Regardless of the promising government’s health financing strategy in that the scheme can
be expanded and that CBHI can provide an important basis for reducing out-of-pocket pay-
ments, researches on the households enrollment in CBHI program and the associated factors
are still very limited in Ethiopia in general and in the Boricha district of south Ethiopia in par-
ticular. Thus, the current study aims to examine enrollment status and the associated factors in
the study area to fill the aforementioned gaps.

Methods and materials

Study area and period
The study was conducted in Boricha district, Sidama Zone, Southern Ethiopia from February
to March, 2019. Boricha district is one of the 19 rural districts and 6 town administrations in
the Zone; it is located 32 km from Hawassa town, the capital of SNNPR. It was among the five
districts of Sidama Zone where the CBHI scheme was introduced as the expansion of pilot pro-
gram next to Yirgalem town in Sidama zone. The total estimated population of the district was
332,791 as of mid-2018. The district has a total of 42 Kebeles, of which municipal town Kebeles
were 03 and rural Kebeles were 39. The total estimated households of the district were 67,916.
CBHI was implemented in all Kebeles of the district in 2012/13. Regarding health care facili-
ties, there were one public district Hospital, 10 public health centers, one None Governmental
Organization (NGO) clinic, 39 health posts and eight private clinics in the district [14].

Study design
A community based cross-sectional study design was employed.

Source and study populations

The source populations for the study were all households reside in Boricha district. House-
holds’ heads older than 18 years who are not involved in the formal sector employment and
reside for 6 months in the selected Kebeles of the district were included in the study.

Sample size determination

The sample size was calculated using single population proportion formula by considering the
following assumptions: n = Z2α/2PQ/d2, Zα/2 = Reliability Coefficient with 95% confidence
interval, d = standard error allowed (0.05) and p = proportion of household enrolment in
CBHI = 43.2% from previous study [15]. Considering design effect (DE) of 1.5, and non-
response rate of 10%, the calculated total sample size was 622 households assuming this sample
for determining the level of enrollment status. However, it is necessary to calculate sample size

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PLOS ONE Enrollment in community based health insurance program and the associated factors; a cross-sectional study

for factors associated with enrollment status of households. Hence, we calculated based on pre-
vious studies; such as members low confidence on CBHI management, information about
CBHI and family size using EpiInfo statCalc; with the assumptions percentage outcome in
unexposed group, power of 80%, Ratio (Unexposed: Exposed) one (1), 95%CI, Odds ratio,
non-respondent rate (10%) and design effect (1.5). Finally, we have taken lack of trust on
CBHI management as a main associate factors with enrollment status of households in CBHI
26.1% of outcome in unexposed group, Odds ratio of 1.88 which yielded the largest sample
size, 392 [15]. Considering 10% non-response rate, the final total sample in this case was size
was 646. Hence 646 was larger, we considered it as our final sample size for the study.

Sampling procedures
First the Kebles were stratified in to Urban and rural. Then, a two stage sampling procedure
was employed. Using simple random sampling technique, one (01) Kebele from urban and ten
Kebeles from rural residence were taken. Then, the sampled 646 households were selected
using stratified systematic random sampling technique after assigning proportionate amount
of households to each sampled Kebeles.

Data collection tools and procedure

Data were collected using interviewer-administered pre-tested questionnaire. The questionnaire
was adapted from national Health Insurance Agency’s CBHI evaluation survey of Ethiopia [16]
and adjusted in to local context. The English version of the adapted questionnaire was further
translated in to local language (Sidama) for data collection. The tool was pre-tested on 5% of the
actual sample size in two Kebeles different from target area but have similar socio-demographic
status and other related variables with the study population. Based on the pre-test findings,
some items were revised, edited and some ambiguous items were clarified. Consequently, infor-
mation drawn from the pretest was discussed among data collectors and supervisors in order to
ensure better understanding of data collection process. Five diploma nurses who are native
speakers of Sidama language and two professional supervisors with BSc. in health were partici-
pated. Data were collected by face to face interview after introducing the study objectives to the
study participants and coming to consensus on the importance of the study.

Data quality assurance techniques

To assure the data quality, training was given for data collectors and supervisors for 02 days.
Each item of data collection tool was seen thoroughly and clarified during the training.
Besides, pre-testing of the questionnaire was done to improve the validity and reliability of the
instrument. Further, appropriate information and instruction on the objective and relevance
of the study were given for the respondents. Proper categorization and coding of responses
and skip patterns were also maintained. Questionnaires filled by data collectors were reviewed
and checked daily for completeness, consistency and relevance by the supervisors and then by
principal investigator. All the necessary feedback was offered to data collectors in the next
morning before the routine data collection was conducted.

Data processing and analysis

Data entry and processing were done by EPI INFO version 7 computer packages and exported
to Statistical Package for Social Sciences (SPSS) version 20 for analysis. Descriptive statistics
including frequency, percent, table and graph were used to describe the results. The Hosmer-
Lemeshow statistics and deviance coefficient was used to check the goodness of fit of the model

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PLOS ONE Enrollment in community based health insurance program and the associated factors; a cross-sectional study

and the model was good fit (P = 0.863), and also multi-collinearity was checked for variables
that were statically significant on bivariate analysis; accordingly variables with high correlation
coefficient were not found in the model. Similarly, missing values were also checked. Factors
associated with current enrollment status of households in CBHI were first assessed using
binary logistic regression. Based on this assumption, we considered variables with P �0.25 cut-
off point as a candidate for our multivariable analysis. Wealth status of the households was com-
puted by Principal Component Analysis (PCA). Finally, a P-value of �0.05 was considered to
declare the significant factors along with Odds ratio and the correspondent 95%CI.

Ethical consideration
Ethical clearance for the study was obtained from Hawassa University institutional Review
Board (IRB). Also, permission letters were taken from Hawassa university school of public
health, Sidama Zone Health Department and Boricha District Health Office. To maintain con-
fidentiality, individual identifiers were not included. Moreover, a well explained informed con-
sent was obtained from each respondent. Participants were also given right to participate or
not, answer all questions or stop any were before completing all questions.

Operational definition
Community based health insurance: is an insurance scheme arranged for informal sector,
managed and operated by governmental structure that provides risk pooling to cover all or
part of the costs of health care services [15].
Catastrophic health expenditures: is an expenditure related to medical treatment that can
pose as treat towards a households financial ability to maintain it subsistence needs (minimal
resources that are necessary for survival [17].
Enrollment status in CBHIS: is acceptance of CBHI to use and, pay premium for a com-
plete year and possess updated service card [15].
Health insurance: is insurance against the risk of incurring medical expenses among indi-
viduals and families [15].
Kebele: is smallest administrative structure in Ethiopia.
Out-of-pocket payment: is type of health service cost that covered by service users to the
service providers at a time and place of service provision [8].
Revenue collection: is process by which health system obtains financial contributions from
different bodies [8].
Pooling: is spreading the risk of health expenditures among all members through accumu-
lated and managed contributions from individuals [8].
Purchasing: is process by which pooled contributions are used to pay providers to deliver a
set of health interventions [8].
Household satisfaction: -the satisfaction of households with the service provided in the
health facility by health professionals were measured with 8 questions. They were organized to
be responded in the Likert scale, ranging from 1(Poor) to 5(Excellent). The, the mean value
was calculated and those who score above the mean were considered to be satisfied and those
who score below the mean were considered to be dissatisfied [18].
Time taken to reach nearby facility: it is time taken when an individual uses on foot to go
to a nearby health facility.

Results
Out of the 646 respondents who were identified for the study, 632 were responded to the inter-
view, yielding 97.8% response rate.

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PLOS ONE Enrollment in community based health insurance program and the associated factors; a cross-sectional study

According to this finding, only 81 (12.8%) of households were currently enrolled in the
community based health insurance. The study also revealed factors such as educational status
of households’ head, inconvenience of time of premium collection, family size, trust on scheme
management, having information about CBHI, satisfaction with the service provided by
nearby facilities and chronic illness in the family member were associated with current enroll-
ment status in CBHI.

Socio-economic and demographic characteristics of the respondents

From the total study participants, 375 (59.3%) were males and 257(40.7%) were females. Con-
sidering the age of participants, 336 (53.2%) were between 18 and 38 years, 260 (41.1%) were
between 39 and 58 and the rest 36 (5.7%) were 59 years and above. Three hundred sixteen
(50%) of the respondents were illiterate, 141 (22.3%) of the study participants didn’t attend for-
mal education, but because of adult education they can read and write, and the primary, and
secondary and above account for 120 (19%) and 55 (8.7%) respectively (Table 1).
Regarding occupation of household head, the majority were farmers 569 (90%) and the rest
63 (10%) were merchants. In considering residence of respondents, about 602(95.3%) were
from rural and only 30 (4.75) were Urban. Concerning marital status of study subjects, 529
(83.7%) were ever married, 85 (13.4%) single and 18 (2.8%) others. Five hundred forty nine
(86.9%) of respondents had five or more family members and the rest 83 (13.1%) had less than
five family members (Table 1).

Table 1. Demographic and socio-economic characteristics of respondents in Boricha district, Southern Ethiopia, 2019 (n = 632).
Variables Category Frequency Percent
Gender of household head Male 375 59.3
Female 257 40.7
Age of respondents Age 18–38 336 53.2
Age 39–58 260 41.1
Age above 59 36 5.7
Marital status of respondent Married 529 83.7
Single 85 13.4
Others 18 2.8
Educational status Illiterates 316 50.0
Can read & write 141 22.3
Primary 120 19.0
Secondary & above 55 8.7
Family size of household <5 member 83 13.1
> = 5 member 549 86.9
Occupation of household head Farmer 569 90.0
Merchant 63 10.0
Residence of households Rural 602 95.3
Urban 30 4.7
Wealth quintile of households poor 252 39.9
medium 127 20.1
rich 253 40.0
Time to reach nearby facility <30 min. near to reach 160 25.3
30–60 min. medium 255 40.3
>60 min. far to reach 216 34.2
Money shortage No 463 73.3
Yes 169 26.7

[Link]

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PLOS ONE Enrollment in community based health insurance program and the associated factors; a cross-sectional study

Fig 1. Enrollment status of households in CBHI in Boricha district, Southern Ethiopia, 2019.
[Link]

With reference to accessibility to health facilities in terms of time it takes to reach it, about
160(25.3%) of the study participants traveled for <30minutes, 255(40.3%) respondents travel
for 30–60 minutes and 216 (34.2%) travel more than 60 minutes to get health care services
when required. Concerning Wealth index of individual household, 252 (39.9%), 127 (20.1%)
and253 (40%) of the households were of poor, medium and rich respectively (Table 1).

Current enrollment status of household in community based health

insurance in Boricha district South Ethiopia, 2019 (n = 632)
Out of the total 632 study participants, 551 (87.2%) were currently not enrolled in community
based health insurance (CBHI) and only 81 (12.8%) were enrolled in CBHI currently (Fig 1).

Scheme related factors

In this study, out of the total respondents, 88 (13.9%) said that they waited long time to get the
service card after paying, 485 (76.7%) ever heard about CBHI scheme,130 (20.6%) yearly based
payment regardless of getting service,182 (28.8%) said they received poor service as compared

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PLOS ONE Enrollment in community based health insurance program and the associated factors; a cross-sectional study

Table 2. Participants’ response about features related with community based health insurance in Boricha district, 2019(n = 632).
Variables Categories Frequency Percent
Having information about CBHI No 147 23.3
Yes 485 76.7
Long time waiting service card after paying No 544 86.1
Yes 88 13.9
Year based payment without served No 502 79.4
Yes 130 20.6
poor service as compared to payers No 450 71.2
Yes 182 28.8
High payment as compared to OOP No 534 84.5
Yes 98 15.5
Inconvenience of premium collecting time No 467 73.9
Yes 165 26.1
Accidental change of rule No 534 84.5
Yes 98 15.5
no trust on scheme management No 397 62.8
Yes 235 37.2
In appropriate use of service card No 538 85.1
Yes 94 14.9

Health related factors affecting current enrollment status in CBHI in Boricha district, 2019

[Link]

to payers, 98 (15.5%) said payment is high compared to payers, 165(26.1%) complained incon-
venience of premium collecting time, 98 (15.5%) accidental change of rule/regulations by the
scheme management, 235 (37.2%) said they have no trust on scheme management and 94
(14.9%) reported inappropriate use of service card (Table 2).
All study participants interviewed on potential health related factors. Accordingly, five hun-
dred seventeen (81.8%) said that they wait 60–360 minutes& above, 115 (18.2%) noted that
they wait for �60 minutes. Seventy three (11.6%) of the respondents claimed that they received
poor service in governmental health care facilities as compared to private ones. Ninety four
(14.9%) of the respondents said they experienced chronic illness in their family members, 455
(72%) were not satisfied in the service they received from the nearby facility and 486 (76.9%)
reported shortage of drugs in the health care facilities they visited (Table 3).

Table 3. Health related factors affecting current enrollment in community based health insurance in Boricha district, 2019.
Variables Categories Frequency Percent
Waiting time < = 60 minutes 115 18.2
60–360 minutes & above 517 81.8
Poor serve in governmental institutions No 559 88.4
Yes 73 11.6
Chronic illness in the family No 538 85.1
Yes 94 14.9
Satisfaction of service in the nearby facility Satisfied 177 28.0
Dissatisfied 455 72.0
Drug availability Insufficiently available 486 76.9
Sufficiently available 146 23.1
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PLOS ONE Enrollment in community based health insurance program and the associated factors; a cross-sectional study

Table 4. Multivariable analysis result on factors associated with enrollment in community based health insurance in Boricha district, 2019 (n = 632).
Variables Enrollment status COR(95%CI) AOR(95% CI)
Yes No
Educational status
Can read and write 13(16%) 128(23.2%) 0.842(0.430,1.650) 0.983(0.452,2.139)
Primary 22(27.2%) 98(17.8%) 1.862(1.0339,3.337) 1.882(0.920,3.851)
Secondary and above 12(14.8%) 43(7.8%) 2.315(1.113,4.813)� 2.749(1.142,6.618)�
Illiterates 34(42%) 282(51.2%) 1 1
Family size of household
�5 members 77(95.1%) 472(85.7%) 3.222(1.147,9.052)� 4.16(1.337,12.944)�
>5 members 4(4.9%) 79(14.3%) 1 1
Time to reach nearby health facility
30–60 minutes 18(22.2%) 237(43.1%) 0.343(0.184,0.641)� 0.480(0.229,1.005)
�60 minutes 34(42%) 182(33.2%) 0.844(0.490,1.434) 0.995(0.521,1.899)
<30 minutes 29(35%) 131(23.8) 1 1
Having information about CBHI
No 3(3.7%) 144(26.1%) 0.109(0.034,0.350)� 0.086(0.026,0.288)�
Yes 78(96.3%) 407(73.9%) 1 1
Shortage of money
Yes 12(14.8%) 157(28.5%) 0.436(0.230,0.828)� 0.769(0.344,1.721)
No 69(85.2%) 394(71.5%) 1 1
Inconvenience of premium collecting time
Yes 9(11.1%) 156(28.3%) 0.317(0.154,0.648)� 0.433(0.196,0.958)�
No 72(88.9%) 395(71.7%) 1 1
No trust on scheme management
Yes 14(17.3%) 221(40.1%) 0.312(0.171,0.569)�� 0.272(0.140,0.528)��
No 67(82.7%) 330(59.9%) 1 1
Waiting service card for long time
Yes 3(3.7%) 85(15.4%) 0.211(0.065,0.684)� 0.350>(0.100,1.21)
No 78(96.3) 466(84.6%) 1 1
Drug availability in facility
Insufficient available 53 (65.4%) 433 (78.6%) 0.516 ([Link])� 0.717 (0.376, 1.366)
sufficient available 35 (43.2%) 118 (21.4%) 1 1
Satisfaction on services
Dissatisfied 43(53.1%) 412(74.8%) 0.382(0.237,0.615)�� 0.303(0.171,0.537)��
Satisfied 38(46.9%) 139(25.2%) 1 1
Chronic illness in the family
No 14 (17.3%) 221 (40.1%) 0.298 (0.175,0.507)�� 0.259 (0.137, 0.488)��
Yes 67 (82.7%) 330 (59.9%) 1 1
[Link]

Determinants of enrollment status of household in community based

health insurance program
In multivariable analysis, the significant factors associated with CBHI enrollment (P<0.05)
were; educational status, family size, having information about CBHI scheme, timing of col-
lecting premium, lack of trust on scheme management, dissatisfaction in the service provided
by nearby health facilities and chronic illness experiences in the family (Table 4).
Accordingly, participants with educational status of secondary& above were almost 3 times
more likely to be enrolled than those who were illiterates, AOR = 2.749; 95%CI (1.142,6.618).

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PLOS ONE Enrollment in community based health insurance program and the associated factors; a cross-sectional study

Enrollment status of households in CBHI among participants who had family size �5 was
about 4 times higher than those who had family size <5, AOR = 4.16;95%CI (1.337, 12.944).
Consequently, Household heads who did not trust scheme management were enrolled less
likely than who did and this was significant, AOR = 0.272; 95%CI (0.140, 0.528). Similarly,
CBHI enrollment among respondents who were not informed about it were less likely than
those who were informed, AOR = 0.086; 95%CI (0.026, 0.288) (Table 4).
Subsequently, enrollment status in CBHI among respondents who complained timing of
collecting premium were significantly less likely than those who did not, AOR = 0.433; 95%CI
(0.196, 0.958). Household’s enrollment in CBHI among respondents who were dissatisfied by
services in nearby facility were also significantly less likely than those who were satisfied,
AOR = 0.303; 95%CI (0.171, 0.537).
Similarly, enrollment status of households in CBHI among study participants who didn’t
experienced chronic illness in their family member were significantly less likely than families
who experienced chronic illness in their family, AOR = 0.259; 95%C.I. (0.137, 0.488) (Table 4).

Discussion
As compared to previous studies (18–20), CBHI enrollment status in the current study was
very low. For instance, the study done in Southwest Ethiopia revealed 77.85% enrollment rate
[19]. Similarly, study conducted in Aleltu district of Oromia region in Ethiopia and another in
Nigeria showed 75% [20] and 62.8% [21] respectively.
The possible reason for this discrepancy might be that the enrollment status measured in
the current study considered acceptance of CBHI to use, and pay premium for a complete year
and possess updated service card. For example, members who ever enrolled but drop out were
not included in this study. Besides, variations in commitment of local decision makers might
also have resulted in the low coverage of CBHI scheme reported in our study area.
According to the findings of the current study, educational status of the households’ head
was among a statistically significant factors associated with the current enrollment in CBHI.
Households whose heads were secondary & above were almost three times higher to be
enrolled in CBHI than the households’ heads that were illiterate. This is in line with previous
studies [21, 22]. As is expected, education influence people’s knowledge, attitude and practice
for certain rewarding programs like that of being CBHI voluntary membership.
In support of previous studies [23, 24], in our study, household heads who had never
experienced chronic illness in their family were less likely to be enrolled in CBHI than house-
holds whose family members experienced chronic illness. This positive association between
the two might have occurred due to the fact that high-risk individuals usually prefers to be
insured than the low risk or healthy individuals to avoid financial risk of out of pocket
payment for health care services. This might be an indication of the likely risk of adverse
selection.
In this study households with larger family sizes were more likely to be enrolled in CBHI
than household with smaller family size. This finding is similar with the finding of national
evaluative study conducted in Ethiopia [25], and also in line with the study done in rural com-
munity of Fogera District, North West Ethiopia [26]. Obviously, households with large family
size faces higher risk of being sick and expected to suffer from financial risks, particularly in
low income communities. So, they might have chooses to be enrolled to avoid the risk of out of
pocket payment during the time of illness.
In our study participants who have do not trust scheme management were less likely to be
enrolled in CBHI than those who trusted scheme management similar to previous studies [21,
27].The scheme administrators might have not been responsive to control and support the

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PLOS ONE Enrollment in community based health insurance program and the associated factors; a cross-sectional study

scheme in relation to community’s preference, people’s overall satisfaction and trust with the
CBHI is likely to decrease, In turn, this affects enrollment in CBHI even more highly.
Participants who complained inconvenience of premium collecting time were less likely to
be enrolled in CBHI than those who did not. This is in line with previous reports in one study
on [20, 27], and also in one study on CBHI in developing countries [21]. Possible explanation
for this might be; informal sectors usually rural communities are characterized by low saving
practice that make them only capable to pay at specific point in time, for instance during har-
vesting time(seasonal based income). As a result, they may not have the cash in pocket to pay
as scheduled by premium administrators.
The current study showed that being informed about scheme is significantly associated
with enrollment in CBHI. This is in support of a study done in Nigeria [28]. As is expected,
individuals with better information may ask details of the services and get more understand-
ings of its advantage that drives them to be enrolled in CBHI.
Consumers’ satisfaction with service provided at the nearby health care facility was found
to have a significant, positive association. This is comparable with previous finding [3, 12].
Obviously, satisfaction level of the client reflects the existing gap in the CBHI program imple-
mentation and client’s expectation, implying that clients with lower satisfaction were less likely
to be enrolled in the CBHI scheme.
Age, gender, marital status, religion, area of residence and household income were shown
to have significant association with enrollment in CBHI in previous studies [3, 29–31]. How-
ever, in this study they were not significantly associated with enrollment in CBHI. This could
be due to socio- economic and cultural background difference of the study populations.
In this study, household wealth index is not significantly associated with direct enrollment
in CBHI. Possible explanation for this may include; response bias due to respondent’s expecta-
tion of aid from both government and NGOs as Boricha district is known by dry weather and
exclusively natural rain dependent. Thus, large numbers of dwellers in the district are sup-
ported by various NGOs. This indicates respondent’s expectation might make them to tell
either under or overestimate assets they do have; on other hands, almost all households in the
study area had cultivated lands and owned common domestic animals. This tells that there
might not as such economic difference between the households. Thus, these reasons might
have affected the association of household wealth index with enrollment in CBHI.
Our study is not without limitation however. Possibility of social desirability biases is one,
though we attempted to provide clear information about the aim of the study, for example, a
response to monthly income. As one would expect, possibility of adverse selection bias by
scheme members is another limitation of this study. Third, we converted some original level
information in to categorical information to present the results in a more unified format, for
example the variables “time taken to reach nearby facility” beside its advantage, this might
have limited the information we received from respondents.

Conclusions and recommendations

This study revealed that the current enrollment status of households in CBHI is low in the
study area. Consequently, the study identified family size, educational status of households’
head, having information about CBHI, timing of premium collection, satisfaction in the ser-
vices, and lack of trust on scheme management and presence of chronic illness in the family as
the associated factors with the low enrollment of CBHI in the study area. Therefore, more
awareness creation, revising timing of premium collection in consideration with local context,
improving scheme management system in increasing members’ trust should be emphasized to
improve CBHI enrollment.

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PLOS ONE Enrollment in community based health insurance program and the associated factors; a cross-sectional study

Declaration
Ethical approval
Ethical clearance and supportive letter were obtained from Hawassa University College of
Medicine and Health Sciences Institutional Review Board (IRB). Also permission letter were
taken from Hawassa University School of Public Health, Sidama Zone Health Department and
Boricha District Health Office. To maintain confidentiality individual identifiers was excluded.
Verbal informed consent was taken from each respondent after approval of IRB. Since the
majority of the study population was from rural informal sectors, we anticipated literacy status
of the study participants by verbal informed consent. This is also permissible by the IRB of
Hawassa University College of Medicine and Health Sciences. However, participants were
given full right to participate or not to participate fully or partially.

Supporting information
S1 Data.
(SAV)

Acknowledgments
We would like to thank Hawassa University Medicine and Health Science College for giving
opportunity to carry out this thesis work. Our pleasure typically goes to study participants and
data collector for their valuable time, commitment and more of their support in all. We would
like to show our appreciation for the Boricha district health office and Sidama Zone health
department. We are grateful to Mr. Tsedeke Abaynhe, Hawassa University Department of
English for editing the English language of the manuscript.

Author Contributions
Conceptualization: Dawit Nageso.
Formal analysis: Dawit Nageso, Kebede Tefera, Keneni Gutema.
Investigation: Dawit Nageso, Keneni Gutema.
Methodology: Dawit Nageso, Kebede Tefera.
Resources: Dawit Nageso.
Software: Kebede Tefera, Keneni Gutema.
Supervision: Dawit Nageso, Kebede Tefera.
Writing – original draft: Dawit Nageso.
Writing – review & editing: Dawit Nageso, Kebede Tefera, Keneni Gutema.

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