Good practices for the implementation of CBHI
Six themes emerged related to good practices in implementing CBHI.
Political commitment to UHC and preparedness for future donor transitions
Two thirds of interviewees said that the global call for action around UHC had become the top health priority for the Ethiopian government, and had helped to catalyze the adoption of CBHI in Ethiopia. To achieve UHC for both the informal and formal sectors, said the KIs, there was increasing demand for new approaches to health financing and resource mobilization. After reviewing practices from other countries (especially African countries), the informants argued that these factors accelerated the push for health insurance to become the first policy tool choice to achieve UHC in Ethiopia.
“As part of SDGs [the Sustainable Development Goals], the government wants to meet universal health coverage by 2030 and one of the means is through health insurance. So, this is among the reasons behind designing the health financing and health insurance strategy.” KI 07
Half of the KIs said that another key factor driving the adoption of health insurance was the country’s impending transition away from development assistance for health and the growing realization among country stakeholders that alternate health financing sources would need to be identified. Half of the interviewees expressed concerns that donor financing would start decreasing over time, especially given Ethiopia’s rapid economic growth in recent years. Financing through health insurance, they argued, has provided additional resources to support the pathway towards self-sufficiency in Ethiopia and has become a key policy agenda item in the health sector.
“government health financing in the health sector remains usually donor dependent; if you look at the most recent national health accounts it is still about 35% of the health sector [that] is financed by external donors. Of course, this is down from about 50%, three to four years’ back … so then the government sees health insurance as one of the mechanisms of a way out from donor dependency of the health sector”-KI 08
Strong leadership and accountability, and wide engagement of stakeholders
Most interviewees (15 out of 18) agreed that CBHI was driven and implemented by strong political will and support, and said that commitment and leadership at the federal level helped to mobilize resources and improve accountability of different government agencies. At the top level, explained the KIs, it also provides clear directions to enhance the engagement of the private sector and of NGOs.
“I think, first of all, that the Ethiopian government is very strong in terms of political leadership which is in my humble opinion, one of the most important things if not the most important thing to have a successful health financing reform … generally, they can be quite directive in how they want to have NGOs and donors work within the country.”- KI 05
KIs described how the strong political commitment at the top levels of the Ministry of Finance, Ministry of Health and Ethiopian Health Insurance Agency (EHIA) also contributed to the development of CBHI. Additionally, other related stakeholders, including regional governments, development partners, the private sector, international and local NGOs, civil society organizations (CSOs), medical associations and academic institutions widely participated in the development of CBHI at different stages and in different ways. For example, development partners and NGOs provided technical assistance, while regional governments played an important role in adapting the framework issued by the federal government and mobilizing the community.
“The federal ministry of health provided leadership support for the health insurance initiative. Donors and then the developing partners were also involved in the design and implementation process in the form of providing technical assistance and financial support for the implementation of the program. Of course, we have other local actors like the regional governments, zonal administrations, woreda administrations, health service providers. They have their own roles and responsibilities, particularly if you see the regional governments in the area of the community health insurance [that] involved the community. The role of the regional governments & woreda administrations were very high [important] like in community mobilization and developing and adapting the legal frameworks that is provided from the federal government. Yes, there are a number of non-governmental organizations that are supporting the government in implementing health insurance, mainly the international NGOs, for example WHO is providing support, UNICEF is providing support, the World Bank is providing capacity building support, Clinton Health Access Initiative is also providing technical & financial support, the Korean International Health by the Korean government they are also involved. The degree of involvement could vary but [they are] providing support for the government in addition to our project.” —KI 14
Promoting resource mobilization and community participation
About half of respondents believed that by putting health care financing and health insurance at the top of its policy agenda, this in turn helped the government to mobilize resources for the health sector. On the demand side, government subsidies can be provided through insurance. Additionally, premiums collected by CBHI from individuals also join the overall funding pool, and CBHI re-allocates the funds to those who need health care. Compared with paying out-of-pocket payments at the point of care, KIs argued that the pooling and financial risk protection provided by CBHI should improve access to and affordability of health care.
“The objective of the health insurance is to generate additional finance for the health sector because we have already identified insufficiency of financing as one of the major problems of the quality compromised in Ethiopia. So it was assumed that the health insurance will bring additional resource to the health care system which is one of the objectives.”-KI 09
Beyond financial contributions, said the KIs, communities were involved in decision-making and governance of the health system, which was a unique opportunity to promote community engagement. The fact that communities started to make health service providers accountable was an important driver for quality improvement in service provision. So far, explained the KIs, exempted health services of CBHI are provided for free, which motivated the community to use the public facilities more often instead of paying out of pocket for services in private facilities. The increased service use by CBHI beneficiaries provided additional incentive to the providers to be responsive to the community’s increasing health demands and to improve quality of health services.
“Before CBHI programs, health facilities were not functional during weekends especially on Saturday... After the launching of CBHI, some facilities made Saturday a regular working day so that people from the rural community would access health care services to insured CBHI program members. This shows that the health facilities have become responsive for the need of the community.”- KI 15
Improved access and service use and positive impact on women’s empowerment
KIs argued that increased enrolment in CBHI has contributed to changes in health seeking behaviors. Most KIs stressed that CBHI increased access to and use of both inpatient and outpatient services.
“In those places [woredas/districts] where the health insurance scheme is properly implemented with broad community awareness and participation, service utilization has increased. In general, as health-seeking behavior improved the health service utilization has improved in CBHI woredas.” -KI 02
In addition to changes in health service use, most KIs said that the scheme promoted women’s empowerment by reducing their financial burden in accessing health care. The scheme provided additional support for women to seek health care when it is was needed, and also helped to raise women’s voices and concerns in demanding better services through community mobilization in decision-making.
“Women [are] also empowered and able to use the services since they were not forced to pay during the service provision. In Ethiopia women are mostly depending on their husbands. They are raising some issues if there is a gap. It also enables them to ask the facilities for their rights, collectively and individually.”- KI 08
Financial protection helping to address equity and poverty reduction
More than half of the KIs agreed that CBHI provided financial protection through risk sharing, prepayment, and subsidies to address equity and poverty reduction in the resource-poor settings. In particular, there has been a “fee waiver” for those who could not afford health services; the government has paid on behalf of the poor population. Health service expenditures exceeding 3000 birr to 4000 birr have been covered through CBHI, which meant that out-of-pocket payments and catastrophic health expenditures of CBHI beneficiaries were reduced. One-third of respondents held the opinion that CBHI had helped the government’s efforts on poverty reduction in the community.
“While the scheme helped the government as an alternative domestic resource mobilization platform, it helps the members of the insurance scheme to access and utilize health care services without too much worrying about financial expenses … So far, the scheme managed to reduce the out of pocket spending of the members though it is marginal.”- KI 12
“[On] equity, in areas where the woredas are committed to pay for the poor, it [CBHI] really had protected the poor. In woredas where there is almost universal health coverage, it [CBHI] is really bringing equity [in] utilization of services.” -KI 03
Learning process from the pilot and from other countries
Many stakeholders (7 out of 18) believed that CBHI benefitted from the adoption of lessons learnt from the pilot program and from other country experiences. Before the introduction of CBHI, the Ethiopian government learned from CBHI schemes in other countries, including Rwanda and Ghana. CBHI pilots, which were only initiated in 13 districts, were manageable, and the assessment and feedback on the pilot helped to scale up CBHI to more woredas.
“Implementation of the pilot first of course, CBHI scheme was really good, was very manageable because we started very small, we started with 12 districts, and then added more, so it was really manageable and it was I think a wise approach to start with [a] few districts and because it worked. There was a strong commitment from those selected districts. The government, regions, and district were happy to scale it up.” -KI 04
Major challenges for scaling up CBHI
Despite the good practices and successes of CBHI identified by interview respondents, KIs also identified a number of challenges that will need the attention of relevant bodies if CBHI is to provide UHC in Ethiopia.
Limited risk pooling and financial sustainability
More than two thirds of KIs were concerned that financial sustainability would be the most challenging issue for the further development of CBHI in Ethiopia. CBHI, by its nature, is implemented at the woreda level and beneficiaries join the scheme voluntarily. The voluntary nature of enrolment leads to a fragmented financing mechanism with limited risk pooling and reduced financial sustainability.
“I think most of the challenges will be … .ensuring that everybody is enrolled, to ensure that the risk pools are actually able to be sustainable, that at some point, there is, maybe consolidation of the various woreda level schemes to ensure that they are more viable and financially strong. And I think these are some of the things that will be ironed out as times goes, there is more people enrolled in this scheme, they will see the benefit of enrolling in the scheme.”-KI 07
Both KI 03 and KI 04 pointed out that some woredas have experienced “financial bankruptcy,” given the relatively small size of the funding pool. The factors that interviewees mentioned as being associated with financial unsustainability of CBHI included low coverage rates; coverage of mostly poor populations who cannot afford the fee and premium; and coverage with high numbers of people who use health services intensively. To improve the financial sustainability of CBHI, five KIs suggested that Ethiopia should consider increasing the level of risk pooling to improve cross-subsidization, while another four KIs argued that mandatory participation in CBHI should be considered. These options were also being discussed within the government.
“We need to establish a pooling system to influence cross subsidization between woredas and also between regions”-KI 02
“From the very beginning, CBHI was actually designed to be voluntary, but now I think there is a discussion that from our own experience and from other countries experience as well, the experience shows that CBHI is voluntary and the capacity of the scheme is challenging and there is also adverse effect of selection which actually compromises the capacity of the scheme and the objective of the scheme. That is actually being discussed currently, because there is no legal framework for CBHI and now I think the government or health insurance agency is developing a draft proclamation to make it compulsory, but still there is a debate and discussion that it should not be compulsory.”-KI 16
KIs also mentioned government subsidies as another challenge for the financial sustainability of CBHI. The CBHI pilots received subsidies from the government in a variety of formats, including human resources, administrative support and premium support for poor populations. After scaling up, it is not clear who will cover the cost of subsidies and provide administrative personnel to all the regions implementing CBHI.
“The costs, the government has to subsidize since CBHI scheme has been implemented. Not only for CBHI, but also even for the SHI as well as because currently the public health centers are highly subsidized [at] about 20%. So in CBHI, the salary and all other costs actually the government decided that. When they decided to implement health insurance in Ethiopia, in the government of Ethiopia the higher-level officials or ministry of cabinet decided that the contribution of the beneficiaries will only be used for the services that they have got, so all the other costs will covered by the government.”- KI 11
Finally, KIs argued that the operational plans for the benefit package, coverage and even premium had not been considered properly. Different elements of the CBHI scheme were not mapped out and connected with each other. For example, the scheme has not mapped actuarial projections to current premium levels and future claims pay outs, which may impact the scheme’s financial sustainability. While the premium was supposed to be affordable for most of the population, several stakeholders were concerned that the benefit package was “too generous” and cannot be afforded under current coverage rates and premium levels. Additionally, the moral hazard problem occurred whereby CBHI beneficiaries intended to use more services than the uninsured. Two stakeholders also mentioned this as another factor that could endanger the sustainability of CBHI.
“CBHI was a very good model of bringing all [different levels of government and beneficiaries] together but what I found is operationally it has not [been] designed well yet. It is [at] a very initial stage managing the operation part of the scheme because how we are going to reach out to people, how the premium is going to be collected, how providers are to be paid … how the Ethiopian health insurance agency will treat between the public and private sector … I think that is something where I see a gap in EHI [Ethiopian Health Insurance] agency.”-KI 01
“We have made a promise of a very extensive and elaborate package of services, which might not be feasible in real term [s] so, therefore, a lot of empirical analysis needs to be done.” KI-10
Lack of legal framework and poor institutional accountability
Most KIs stated that the lack of a proclamation (legal framework) presents institutional and structural barriers to implementation of CBHI and it makes accountability challenging. A legal framework would clarify the institutional and structural arrangements for CBHI, which would help implementation; KIs argued that such a framework is urgently needed.
“Okay, the first one is the legal framework. We need to have legal framework, we need have the proclamation approved before we scale it up because that legal framework will correct and will address some of the challenges like the pooling, the voluntarily vs compulsory kind of issues of debate and that will address actually through that proclamation and there is also discussion to build the pooling at regional level and that needs to be addressed through the legal framework.”–KI 16
KIs argued that implementation of CBHI is hindered by the separation of regulatory bodies and implementers. The Ethiopian Health Insurance Agency (EHIA) was established at national level to lead the overall development of CBHI, with branch offices at regional level. However, the woreda administrators or woreda health offices are accountable for the establishment, operation and management of the CBHI. There is no effective coordination between EHIA and woreda, and KIs expressed their concern that this lack of coordination would be even worse after the scaling up of CBHI. Moreover, district-level management structures are costly to replicate across the country and potentially not effective. CBHI is managed at the woreda level, with three dedicated staff members, computers and other equipment installed in woreda health or administrative offices.
“Currently we have a critical challenge: when the agency (the Ethiopian health insurance agency) was established to manage and to lead health insurance throughout the country, but if you see Community-Based Health Insurance scheme, the scheme was established at woreda level and in some woredas, they are accountable for woreda administrators and in some regions, they are accountable for woreda health offices. So, there is no direct accountability line between the woreda and the branch office of the agency (the Ethiopian health insurance agency and its branches).” -KI 02
Weak health service delivery system and limited engagement with private sector
Most KIs (15 out of 18) worried that the health service delivery system is not ready to provide proper care for CBHI beneficiaries. The current management, said the KIs, is unable to hold providers accountable for providing cost-effective, quality care and services are reimbursed on a fee for service basis without checks in place to control costs or quality. Many facilities provide low quality services and providers differ in their readiness to deliver quality care due to problems in staffing, medicines, laboratory facilities, reception, and outpatient services.
“In terms of providers of services, the major area of concern is readiness of facilities, which is beyond the capacity of the providers. When we say readiness, it is infrastructure. Some of them do not have power, some of them do not have electricity, so the ability of the facilities to provide respectful care, responsive care, sometimes is limited.”-KI 03
Most respondents raised weak supply chain management as one of the root causes of poor quality of services. The supply side constraints, they argued, in the areas of pharmaceutical and medical supplies procurement, transportation and distribution need much attention. Additionally, the implementation of CBHI has raised the expectations of the population in terms of better availability of services, especially access to pharmaceuticals.
“The other [problem] is the availability of medicines. Medicines availability has highly improved in Ethiopia but still there is inequitability in Addis Ababa: you can find a lot of medicines and public facilities having majority of pre-essential drugs that are expected to be availed in the facilities based on the regulatory agencies standard guideline, but you can rarely find [these medicines] when you go to the health facilities. The availability of medicines is scarcely available.” -KI 09
Eight KIs explained that while engagement with the private sector was encouraged and implemented at the federal level, this practice was not reflected at the regional level. CBHI is often affiliated with woredas and/or regional health bureaus at the regional level, making the public sector the dominant service provider for CBHI beneficiaries. Due to a lack of policies supporting public and private sector collaboration, private providers considered CBHI as a “threat” because CBHI has promoted service use at public sector facilities. Private providers were also excluded from the decision-making process of CBHI. The limited engagement from the private sector at the regional level further reduced the competition between public and private provision.
“ … there is not enough competition in the health sector as I said before, so they [CBHI] have mentioned that the public facilities are included in the system and the scheme has not even included the private sector. So, essentially, they [providers of CBHI, i.e., the public sector] are characterized by poor services for the customers”-KI 12
Three KIs reported that health workers also complained about an increased workload after the implementation of CBHI and a lack of incentives for taking on additional responsibilities. Despite the increase in health service use due to the increase in enrolment and coverage of the health services under CBHI, health providers were still receiving the same payment without compensation for the increased workload.
“One of the major unintended effects on CBHI probably is overload for health workers... I think work overloads were not expected, particularly in good facilities. Although the health providers think that they are overloaded and hence should get incentives, the government insisted that this is the health provider’s normal duty … “KI 03
All these factors, said the KIs, led to poor quality of health services or limited availability of medicines or medical supplies. Two interviewees pointed out that if these issues are not handled properly, CBHI beneficiaries would abandon the scheme.
“If the people [CBHI beneficiaries] are paid for the services, they [beneficiaries] are serious about the premium and scheme. We have to be sure that the quality of services is available at the service delivery point.”-KI 15
“ … If you are a CBHI member and if services are not around, the insured community members started directly going to the districts administrators and say, “I am paying my money, where is the doctor? Where is the health provider? ”-KI 04
Absence of political commitment at the sub-national level
Over half of informants stated that although political support for CBHI was very high at the federal level, there were significant variations in political commitment between regions and woredas. Even though representatives from woredas were invited to the discussion on CBHI, in most cases the level of engagement was low. Additionally, collection of CBHI premiums was regarded as a “demanding” task by the woredas, and without delegated efforts from the woreda level administration, resources at community level could not be fully mobilized and posed a major bottleneck for the scaling up of CBHI.
“They [woreda representatives] are invited to discuss on sector strategies. I mean they don’t actively engage although there were many invitations so as to get all the partners to be engaged in the discussion, we have to invite them twice, maybe sometimes you have to invite them more. So, they are invited by the Ethiopian health ministry but actually honestly they are not engaged.”-KI 11
“Leadership commitments at all levels including the regional level, have been a challenge. There is a good commitment at federal level, but when you go to the woreda level, there is a difference, significant difference between woredas. Some of the woredas are able to achieve 100% [coverage], but there are woredas who only gained 20% coverage because of leadership commitment, so that they [woredas] are important.” -KI 02
Constrained implementation capacity, especially at the woreda level
Half of the KIs argued that lack of human and institutional capacity of the regional health and finance bureaus and woredas was a barrier to scaling up CBHI. The Ethiopian health insurance system needs further capacity in terms of its human resources, clear management structure and system building. Citing examples of how investments in other countries significantly contributed to health sector improvement, most respondents felt that capacity building and training were crucial to improving the implementation of CBHI in Ethiopia.
“ … The capacity challenge is not only in terms of skills but also quantity of the required staffing at the lower level. Supporting capacity building of the government at woreda level is particularly important. For example, there is only one person who is responsible for the kebele [neighborhood] working as a focal person for the scheme who is usually kebele manager who is only supported by the kebele’s community. He is in charge of all the activities in that particular kebele … ”-KI 13
Respondents mentioned that there is a lack of human resource capacity at lower levels, including limited ability at the woreda level to manage risks through clinical and financial auditing and through cash management. Providers also faced challenges in processing claims. In addition, variations in the commitment of the local management officials raised concerns about the sustainability of the schemes, as CBHI implementation depends heavily on the woreda administrative staff.
“Opening [CBHI] branch offices is not difficult, you can open branch offices, you can install the required infrastructure and so on, but if the country doesn’t have adequately trained officials who can manage, administer, and lead the process … .The health service will not be able to catch up all expectations of the community” -KI 04
To address the capacity issue, many stakeholders advocated for changes in the capacity building system such as the system of training and transferring skills from the federal to the lower levels. For example, professionals should have the chance to attend various trainings and learning opportunities to incorporate lessons and experiences of other countries in their health financing and health insurance practices.
“ … There needs to be an in-built system at all levels, especially from the federal level, to share the experiences they learnt from abroad and really ramping up its effort towards training all the way down to the regional and woreda levels. I think the big challenge is down at the woreda and kebele levels. So, the capacity building is usually very difficult to maintain and constantly sustain it. But it is important to cascade that information to the lower levels to bring comprehensive changes in the system.”- KI 06
Weak information systems to support daily operation and informed decision
Nearly half of all interviewees (7 out of 18) raised concerns about the health information system. The dependence on manual systems for the operations of CBHI led to reduced efficiency in core operations such as enrollment, claims management, and auditing. Digitalization and information technology (IT) systems will need to be adopted to manage the huge volumes of claims and to improve service provision if the scheme is to be scaled up to the national level. KIs argued that the lack of good information systems is a challenge at the central, regional and woreda levels for tracking progress and addressing problems in CBHI in a timely, transparent and reliable manner.
“ … The Government needs to work closely with the relevant stakeholders in order develop the information system so that they collect accurate and reliable data related to the premium collection, claims management and disbursements related to health insurance at all levels and analyse them for better decision-making.” -KI 05