Fairer by design: testing sliding-scale premiums policy in community based health insurance as a pathway to inclusive social protection in Ethiopia: a cluster randomized controlled trial
1
Health Policy and Management, Jimma University, Jimma, Ethiopia
2
Health Behavior and Society, JIMMA UNIVETSITY, Jimma, Ethiopia
3
Pharmacy, JIMMA UNIVETSITY, Jimma, Ethiopia
4
Economics, Universidad de La Plata - Conicet, Argentina, Argentina
Popul. Med. 2026;8(Supplement Supplement 1):A1570
ABSTRACT
INTRODUCTION:
Ethiopia’s Community-Based Health Insurance (CBHI), launched in 2011 with a flat-rate premium model, expanded healthcare access but raised concerns about equity and sustainability. The uniform premium burden may deter low-income households due to affordability and reduce participation from wealthier households due to perceived low service quality.
OBJECTIVE:
This study assesses the impact of a socio-economic-based premium model on healthcare utilization, financial protection, and community acceptance to inform equitable CBHI reform.
METHODS:
A cluster randomized controlled trial was conducted across 26 Ethiopian districts (13 interventions, 13 control ). In intervention districts, premiums were adjusted by socio-economic status: higher-income households paid more, while lower-income and indigent households paid less or were exempted. The control group retained the flat-rate premium. Baseline data were collected from 5,214 households (Jan–Mar 2024), with follow-up conducted from Jan–Mar 2025. The difference in difference analysis compared effects in terms of short-term financial protection and acceptance.
RESULTS:
Midline results show the socio-economic model improved financial protection and community support. Compared to the control group, out-of-pocket health expenditure declined significantly among households in the treatment group, with the largest reductions observed among poorer households. Catastrophic health expenditures fell in the treatment group (22.1% to 17.4%) but rose in the control group (18.5% to 20.3%). Health-related impoverishment increased less in the treatment group (+0.17 vs. +0.89 points). Willingness to re-enroll reached 83.8%, with sharper declines in refusal among wealthier treatment households. Perceived affordability and fairness improved under the new model. Overall acceptance of the new model was high (70.2%), despite wealthier households' limited engagement.
CONCLUSIONS:
The socio-economic-based premium model provides a pathway toward a more equitable and inclusive CBHI system in Ethiopia, strengthening social protection and ensuring that vulnerable populations can access essential health services without financial hardship.
Ethiopia’s Community-Based Health Insurance (CBHI), launched in 2011 with a flat-rate premium model, expanded healthcare access but raised concerns about equity and sustainability. The uniform premium burden may deter low-income households due to affordability and reduce participation from wealthier households due to perceived low service quality.
OBJECTIVE:
This study assesses the impact of a socio-economic-based premium model on healthcare utilization, financial protection, and community acceptance to inform equitable CBHI reform.
METHODS:
A cluster randomized controlled trial was conducted across 26 Ethiopian districts (13 interventions, 13 control ). In intervention districts, premiums were adjusted by socio-economic status: higher-income households paid more, while lower-income and indigent households paid less or were exempted. The control group retained the flat-rate premium. Baseline data were collected from 5,214 households (Jan–Mar 2024), with follow-up conducted from Jan–Mar 2025. The difference in difference analysis compared effects in terms of short-term financial protection and acceptance.
RESULTS:
Midline results show the socio-economic model improved financial protection and community support. Compared to the control group, out-of-pocket health expenditure declined significantly among households in the treatment group, with the largest reductions observed among poorer households. Catastrophic health expenditures fell in the treatment group (22.1% to 17.4%) but rose in the control group (18.5% to 20.3%). Health-related impoverishment increased less in the treatment group (+0.17 vs. +0.89 points). Willingness to re-enroll reached 83.8%, with sharper declines in refusal among wealthier treatment households. Perceived affordability and fairness improved under the new model. Overall acceptance of the new model was high (70.2%), despite wealthier households' limited engagement.
CONCLUSIONS:
The socio-economic-based premium model provides a pathway toward a more equitable and inclusive CBHI system in Ethiopia, strengthening social protection and ensuring that vulnerable populations can access essential health services without financial hardship.
| eISSN: | 2654-1459 |
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