Willingness to Join and Pay for Community-Based Health Insurance among Urban Households of Mettu Town, Oromia, south west Ethiopia in 2022
Authors: Dagne Dagim 
Published: February 2025

Background: Community-Based Health Insurance (CBHI) is a non-profit scheme aimed at informal institutions, facilitating collective pooling of health risks. It is managed by its members with the objective of improving healthcare access and protecting households from catastrophic out-of-pocket medical expenses. In Ethiopia, approximately half of healthcare sector funding relies on donor contributions, while 34% comes from household out-of-pocket expenditures. Such costs can deplete family resources, impair future income generation, and have intergenerational consequences, forcing families into debt, asset sales, or educational sacrifices for children. Conversely, delaying or rejecting medical care can lead to chronic illness, disability, or death. There is currently limited empirical evidence on urban households’ willingness to join and pay for CBHI in Ethiopia, underscoring the necessity of this study.
Objective: To assess the willingness to join and pay for CBHI and identify associated factors among urban households in Mettu Town, Southwest Ethiopia.
Methods & Materials: A mixed-method, cross-sectional community-based study was conducted from March 1–15, 2022. Quantitative data were collected using a pre-tested, structured, interviewer-administered questionnaire, while qualitative data were gathered through focus group discussions (FGDs). A simple random sampling technique selected 406 households, and purposive sampling was employed to choose 18 FGD participants across three groups. Quantitative data were analyzed using EPI Data 3.1 and SPSS version 20. Binary logistic regression was applied to assess associations, with variables showing p ≤ 0.25 in bivariate analysis subjected to multivariable logistic regression. Statistically significant predictors were determined at p < 0.05. Qualitative findings were triangulated with quantitative results.
Results: Out of 406 sampled households, 384 participated (94.6% response rate). Of these, 340 participants (88.5%) were willing to join the scheme, and 298 (77.6%) expressed willingness to pay. Daily laborers (AOR: 4.15; 95% CI: 1.27–13.52) and households in the highest income quintile (AOR: 4.06; 95% CI: 1.18–14.00) were positively associated with willingness to join. Conversely, households in the lower income quintile (AOR: 0.14; 95% CI: 0.03–0.73) and those with neutral perceptions of healthcare quality (AOR: 0.32; 95% CI: 0.11–0.96) showed negative associations with willingness to pay. The FGDs revealed that participants found the proposed scheme attractive, particularly if improvements in healthcare quality were prioritized.
Conclusion and Recommendations: The study revealed high willingness among urban households to join (88.5%) and pay (87.6%) for CBHI. However, perceptions of healthcare quality and household income levels negatively affected willingness to pay. To ensure successful implementation, it is recommended to enhance healthcare service quality and consider subsidizing contributions for lower-income families.