Willingness of Urban Formal Sector Workers to Support a Community-Based Health Insurance Scheme in Ethiopia.

Abstract

Introduction: The Ethiopian health system is largely financed through household out-of-pocket payments and external donor support, increasing the risk of catastrophic health expenditures. To address these challenges, the government introduced two health insurance schemes: Community-Based Health Insurance (CBHI) targeting the informal sector and a still to be implemented Social Health Insurance (SHI) scheme for the formal sector. Although designed to operate separately, the long-term goal is to integrate them into a unified national risk pool. Achieving this integration requires cross-group solidarity, especially as formal sector employees may subsidize CBHI. This study investigates the willingness of formal sector workers to support CBHI, which is critical for long-term financial sustainability in the Ethiopian health insurance landscape.

Methods: The paper is based on a survey of 1,919 formal sector workers and pensioners in major administrative regions of Ethiopia. A survey-based experiment was used to elicit support for CBHI. Respondents were randomly assigned to one of five cases that varied by the information provided on CBHI subsidies and benefits. Descriptive statistics and logit models were used to analyze willingness to support CBHI.

Results: There is strong support from urban formal sector employees for the CBHI. Regardless of the scenario presented, after adjusting for non-response, at least 66% of participants supported the scheme. Regional variations were observed, and knowledge of health insurance was positively associated with support. Existing access to formal insurance was linked with lower support.

Discussion: Strong evidence of solidarity among formal sector workers bodes well for further expansion of the CBHI. Despite supporting CBHI, formal sector employees are resisting SHI due to cost concerns and skepticism about its benefits, unlike CBHI's known outcomes. SHI resistance signals the need for targeted communication and trust-building as the country moves toward achieving universal health coverage.