Willingness to join community-based health insurance and associated factors among households in Ethiopian: a systematic review and meta-analysis.

Background: In Ethiopia, out-of-pocket medical expenses make up one-third of all medical expenses, which makes it difficult for households to obtain and utilize healthcare. One of the prepayment mechanisms that shield low-income households from unaffordable medical bills is the community-based health insurance (CBHI) program. This systematic review and meta-analysis aimed to estimate the pooled willingness to join Community-based Health Insurance schemes and its associated factors among households in Ethiopia.

Methods: Articles were searched from PubMed, Google Scholar, Web of Science, Scopus, Science Direct, and Ethiopian Universities' repositories for grey literature. The study used the modified PRISMA guidelines for rewriting and reviewing the literature. The quality of studies was assessed using Joanna Briggs Institute Critical Appraisal tools. Data was extracted using Microsoft Excel and exported to STATA version 16 software for analysis. Cochran's Q statistic and I² tests were utilized to determine the heterogeneity between studies. Studies publication bias was determined using a funnel plot and Egger's test. Subgroup analysis was conducted to demonstrate variations of the effect sizes across study regions. Finally, we utilized a random-effect model to compute the overall willingness to join the CBHI scheme and its determinants among households in Ethiopia.

Result: We included thirty studies to determine the pooled prevalence of willingness to join the CBHI scheme and its determinants. The pooled magnitude of households' willingness to join the CBHI scheme was 60.42% (95% CI: 51.45%, 69.38%). Old aged (AOR = 2.17, [95% CI: 1.37, 3.44], I2 = 82.33%), formal educational status(AOR = 2.74, [95% CI: 2.10, 3.56], I² = 59.85%), Rich wealth index (AOR = 2.51, [95% CI: 1.99, 3.18], I² = 48.25%), good knowledge/awareness of CBHI scheme(AOR = 4.21, [95% CI: 3.01, 5.88], I² = 66.0%), experienced illness in the last three months (AOR = 3.42, [95% CI: 2.19, 5.35], I² = 71.15%), and large family size (AOR = 2.36, [95% CI: 1.95, 2.87], I² = 50.81%) were determinants of willingness to join the CBHI scheme. In addition, affordability of CBHI premium (AOR = 3.12, [95% CI: 2.34, 4.14], I² = 10.35%), poor health status (AOR = 3.23, [95% CI: 2.57, 4.06], I² = 35.97%), trust in scheme (AOR = 4.38, [95% CI: 1.91, 10.06], I² = 88.35%), chronic diseases (AOR = 3.24, [95% CI: 2.40, 4.37], I2 = 67.15%) and good quality of healthcare services (AOR = 2.91, [95%CI:2.08, 4.09], I² = 65.40%) were also predictors of willingness to join the CBHI program.

Conclusion: The pooled prevalence of willingness to join the CBHI scheme was low and below the national target of 80%. Age, family size, educational status, wealth status, illnesses in last three months, presence of chronic illnesses, affordability of the premium for the CBHI scheme, self-reported health status, Knowledge/awareness of the scheme, trust in the scheme and perceived quality of healthcare service were significantly determine the willingness to join the CBHI scheme. Health providers should provide detailed awareness creation through health education on the concepts and principles of the CBHI scheme.