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Research Article
Revised

Effects of community-based health insurance on modern family planning utilization in Ethiopia

[version 2; peer review: 1 approved with reservations, 1 not approved]
PUBLISHED 19 Sep 2019
Author details Author details

This article is included in the International Conference on Family Planning gateway.

Abstract

Background: Community-based health insurance (CBHI) has been established in a number of developing countries to expand access to modern health care service. However, few studies have focused on health care utilization of CBHI members in Ethiopia. Accordingly, the aim of this study was to assess the effect of CBHI on modern family planning (FP) utilization as part of its routine outcome monitoring activities.
Methods: The USAID Transform: Primary Health Care project, conducted a continuous monitoring follow up visit using a multistage sampling technique in its four major targeted regions. A total of 3433 households were selected and 3313 women of reproductive age (15-49 years) were interviewed. The questionnaire captured the CBHI status of each household and FP use data from randomly selected women. Microsoft Access database was used to enter the data, which was then transferred to SPSS Version 20 for further analysis. 
Results: 49% of women (aged 15-49 years) were found to be enrolled in CBHI scheme.  Half of the women (50.2%) use any family planning method, of which 49% of them used modern family planning method in project-supported areas. Over half of women (57%) who are exposed to CBHI schemes utilized family planning method which is statistically significant 
Conclusions: Modern FP utilization among insured women was higher compared with uninsured women. While FP methods are provided for free, CBHI enrollment improves FP use among women of child-bearing age. Women who have access to CBHI may frequently visit health facilities seeking services for themselves and their families, during which they may be introduced to FP services. This in turn may improve their awareness and attitude towards FP. The results will increase awareness for program implementer's of the benefits of CBHI schemes in FP programming, particularly in rural settings, and provide an opportunity to increase lifelong returns in Ethiopia.

Keywords

Family planning, utilization, CBHI, Ethiopia

Revised Amendments from Version 1

Based on the reviewers comment and suggestion the manuscript revised and all revised sentence highlighted in red color.
Abstract section: The reviewers provide important comment in the abstract section: The authors of this article revised the abstract specifically result section.
Introduction section:  the reviewer heighted some points in the introduction section related to FP status in Ethiopia.  We tried to address the issues in the introduction section related to FP status in Ethiopia.
Method section: The reviewer highlighted issues related to analysis method. The revised manuscript contain detailed about the statistical analysis using regression method.
Result section: based on the reviewer comment all result section including tables and result interpretation revised.
Discussion section:  The reviewers address some issue related to brief discussion of the section because of the few factors.  The authors of this manuscript briefly described based on the revised result and add detailed additional information. The limitation of the study described separately.
The reference section: the revised manuscript adds some new reference list, because the result and discussion section revised accordingly to the reviewer comment.

See the authors' detailed response to the review by Joseph Obure and Carl Mhina

Introduction

In 2011, the Government of Ethiopia introduced a community-based health insurance (CBHI) program and implemented it using a phased-in approach. The program was first piloted in 2011–2013, within 13 woredas (districts) of the four most populous regions: Oromia, Amhara, SNNP and Tigray. Prompted by its success, lessons learned, and viability of implementing the scheme as concluded in the evaluation carried out of the 13 pilot CBHI schemes in 2014/15, the Government decided to scale-up the CBHI program to other woredas. Currently, CBHI is being implemented in a total of 512 woredas in six regions and two city administrations1. CBHI is a health insurance scheme that pools resources from citizens (members) in the informal sector in the form of contributions into a collective fund, which is managed by a scheme management body, generally functioning under the woreda health bureau, and governed by board members drawn from CBHI scheme members and other key stakeholders as appropriate2,3. USAID has been supporting the Government of Ethiopia in health sector financing reforms in Ethiopia, including CBHI implementation since their inception through its consecutive previous projects. In continuation of this assistance, USAID recently launched a new 5-year activity, the Health Financing Improvement Program, 2018–2023 to support health sector financing. Additionally, the USAID Transform: Primary Health Care project provides technical support in its focus woredas towards the initiation, launching and operationalization of CBHI schemes4.

CBHI is believed to considerably increase the demand for health care services because the financial burden on households and/or individual beneficiaries at the time of seeking health care will be removed as CBHI schemes cover these costs. The design of Ethiopian CBHI learned from the experience of other countries, and has recorded notable progress in several community health outcomes over the past 10 years5. Family planning (FP) is a proven strategy to reduce maternal and child mortality and morbidity among women of reproductive age6. In low income countries, including Ethiopia, use of modern family planning method is low but is showing an increase in recent years. In 2019, 41 percent of currently married Ethiopian women were using a modern method of contraception, a significant improvement from 6 percent in 20007. These achievements occurred as a result of the Ethiopian government’s and development partners work in expanding family planning through various strategies. The low increase in the rate of contraceptive use over the decade suggests sluggish progress in the family planning program. This suggests that the challenge for Ethiopian family planning program is to promote family planning by providing better information and services about family planning as well as reproductive health, especially in rural areas.

CBHI contributes to the improvement of health seeking behaviour, health care utilization and service quality8. Different evidence suggests that CBHI membership has positive effects on health care utilization810. Despite this positive pattern, the overall health risk profile of those who have enrolled in the scheme does not seem to be very different from those who have not yet enrolled11. There is no specific evidence of the role of CBHI in improving modern FP utilization. The main aim of this study was to evaluate the effect of CBHI on modern FP utilization.

Methods

Study background

The USAID Transform: Primary Health Care project conduct continuous monitoring follow up visits using a multistage sampling technique in its four major targeted regions. The project had been supporting 360 woredas in its four major target regions and established 29 clusters-level offices (CLOs) and considers all CLOs. The sample technique was a combination of simple random and random-walk technique. A sampling frame was prepared by listing the woreda health offices (WorHOs) under each CLO, health centers (HCs) under each WorHOs and Health Posts (HPs) under each HC. A total of 164 WorHOs, 328 HCs and 694 HPs were selected randomly in proportion to the size of the region. A HP is found in a kebele (village), which is the lowest administrative area in Ethiopia. If the HP was randomly selected for the project continuous household survey, then the kebele associated with the selected HP was chosen for the next stage of sampling.

After getting the associated list of kebeles, prepared the list of gotts from the HP associated kebeles in consultation with the health extension worker (HEW) and selected one gott randomly from each associated kebeles. A gott is a geographic area under the kebele covering on average 250 households. The survey team utilized a list of households under the selected gotts from the health post registry book. The list of the households served as a sampling frame for the selection of the households. The survey team selected five households from each got using a random-walk technique in person at their household. If there was more than one eligible respondent found in a household, simple random sampling was used to select one eligible respondent. Of the total planned 3433 households, data were collected and analyzed from 3313 women of reproductive age in the households.

The sample size requirements were based on estimates for the proportion of modern methods of FP utilization on the day of the monitoring follow-up visit at 95% confidence. The sample size determines used in double population proportion formula12. For the purpose of this analysis, our definition of modern FP included oral contraceptives, emergency contraceptives, injectable contraceptives, contraceptive implants, and IUDs.

Data collection was conducted from October 1 to December 31, 2017 and 3313 women of reproductive age (15–49) were interviewed. A household questionnaire13 was developed in consultation with program technical advisors. Regional and CLO staff members received training to use the survey questionnaire and were responsible for data collection in their respective catchment.

Data processing and analysis

The data management process was managed by the monitoring, evaluation and learning teams at regional and country office levels. Microsoft Access database was used to enter the data, which was then transferred to SPSS Version 20 for analysis. A total of 10% of the questionnaire was selected and re-entered and cross-checked for data consistency and completeness. It was observed that about 99% of the questionnaires were entered accurately. Data cleaning was performed to check for frequencies, accuracy, consistencies and missing values. Frequencies, proportion, and summary statistics were used to describe the study population in relation to the study variables. Significance tests performed using the cut-off values set is p<0.05 with 95% confidence interval (CI). Further, logistic regression analysis was employed to predict the effect of CBHI on contraceptive use. Significance tests performed using the cut-off values set is p<0.05 with 95% confidence interval (CI).

Ethical consideration

This report used project data that has been collected as part of the annual random follow-up monitoring visit to households in project areas and the result was not linked to individual identifiers. The results of the study did not distinguish respondents’ race, age, health information, religion, sex and sexual orientation or any other social groups. Therefore, the study did not require ethical clearance by a human research ethics committee. However, the project obtained permission to implement and assess progress from the regional health bureaus of Amhara, Oromia, SNNPR and Tigray.

The assessment questionnaires of CBHI effect on modern family planning directly related to their program monitoring and meant to inform the program. The interviews were not intended to develop or contribute to generalizable ‘knowledge. Participants were informed about the purpose of the survey, project approaches to enabling the responsive, iterative implementation that has taken place project life cycle. After discussion and understanding of the purpose the project obtained oral consent from each participant, since participants were fearful of being identified.

Results

Family planning usage

A total of 3313 reproductive age women found in 3433 households were included in this analysis. The mean age of the women was 29 years ±8.3 standard deviations (SDs). Approximately 40% of women were in the 25–30 years age bracket, while 15% of the respondents were above 36 years. Almost all of the respondents (96%) were currently married. Among the study participants, 64% of reproductive age women were found under CBHI woredas, of which 49% of the women were enrolled in CBHI. Most of the respondents (87%) believed CBHI is important, of which 67% of them enrolled CBHI scheme. From the total respondent, 45% of them reported exposure to family planning information through different media (Table 1). (Table 1). De-identified raw data are available on Open Science Framework13.

Table 1. Respondents characteristics and enrolment in community-based health insurance (CBHI), USAID Transform: Primary Health Care project Follow up visits, 2017.

VariablesFrequency (%
age in Years                                                      <25902 (27.2)
25–301337 (40.4)
31–36580 (17.5)
>36494 (14.9)
Mean age29.5 ±8.34
Marital status (Married/not married)3250 (95.5)
HHs found under CBHI in a woreda2009 (63.9)
CBHI Enrollment status1011 (48.8)
Believe CBHI is important1308 (86.7)
Believe CBHI is important and enrolled979 (76.6)
Believe CBHI is not important but enrolled22 (11.9)
Exposed/Received FP related information
(at least three FP method (Y/N)
1280 (45.1)

HH; Households

Table 2 depicts the prevalence rate of modern contraceptives method mix among reproductive age women. The table shows that 50.2% of the respondents utilized any method of FP, 49% used modern methods and 0.5% of the respondents utilized permanent methods. The table shows that 53.5% of young women are currently using any FP method and 16.4% of respondents are using long-acting reversible contraceptives

Table 2. Contraceptive method mix among reproductive age women (15–49 years), USAID Transform: Primary Health Care project Follow up visits, 2017.

Method MixPrevalence rate of women with
age group (95% CI)
15–49 years15–24 years
Any method50.2(48.4-51.9)53.5 (50.1-56.8)
Modern method49.0(47.2-50.7)51.9 (48.6-55.3)
Long-acting reversible contraceptive15.1(13.9-16.4)16.4 (13.9-18.9)
Short acting contraceptive33.3 (31.7-35)35.6(32.3-38.8)
Permanent methods0.5(0.2-0.7)

CI; confidence interval.

Effect of CBHI on FP usage

Table 3. The result of logistic regression revealed that women who were 36 years and above, who are enrolled CBHI scheme and received FP information (at least three methods) were significantly associated with use of FP methods. Women who fall between the age of 36 and 49 years were 2.3 times more likely to use contraceptive method than who age 15–24 years. Exposure/received to FP information showed that women exposed family planning (at least three FP methods) information through different media were 1.65 times more likely to use contraceptive than those exposed less than three FP method related information. Over half of the women (57%) who are enrolled in CBHI scheme utilized modern family planning methods. Women enrolled CBHI scheme, the results show that women who are exposed to CBHI scheme (enrolled CBHI) 1.43 times more likely to use contraceptive method than those that never enrolled CBHI. The effect of CBHI on family planning utilization is statistically significantly (p=0.002). While family planning methods are provided for free, CBHI enrolment improves family planning use among women of child bearing age. Women who have access to CBHI may frequently visit health facilities seeking services for themselves and their families, during which they may be introduced to family planning services. This in turn may improve their awareness and attitude towards family planning. As a result, women who are part of CBHI may have better FP utilization rate compared to women who are not.

Table 3. logistic regression model with crude and adjusted odds ratio using the 2017 USAID Transform: Primary Health Care project Follow up visits.

VariablesCOR (95%)AOR (95%)
Age in Years                                                              <2511
25–301.08 (0.90-1.3)1.23(0.91-1.68)
31–361.19(0.96-1.49)1.39(0.97-1.99)
>361.94(1.53-2.46)2.3(1.56-3.41)
HHs found under CBHI in a woreda (Y/N)0.87(0.74-1.01)1.46 (0.66-3.24)
HHs enrolled in CBHI scheme (Y/N)1.34 (1.12-1.62)1.43 (1.08-1.90)
Believe CBHI is important (Y/N)1.75(1.27-2.41)1.42(0.94-2.14)
Exposed/Received FP related information
(at least three FP method (Y/N)
1.56(1.36-1.83)1.65(1.31-2.08)

HH; Households, AOR; adjusted odds ratio, COR; crude odds ratio

Discussion

This study revealed that CBHI impacted modern family planning utilization among insured and uninsured women. Modern family planning utilization among insured women was higher compared with uninsured women. The positive results of the CBHI schemes in encouraging health care utilization suggests that CBHI can be effective instrument for achieving universal health coverage, together with other policy tools14. According to the findings of Shimelis, CBHI membership has a potential to increase healthcare utilization15. Similarly, Giedion et al.16 reviewed 23 studies and found differences in how CBHI affected service access and utilization among different population groups. Nevertheless, the evidence indicates that, overall, the CBHI universal health coverage scheme improves access and utilization of services16. Similar evidence showed that the trend of outpatient service care increased for insured households, while it declined for the uninsured8,9. The finding of this study showed that women with CBHI improved modern family planning utilization among uninsured women of child-bearing age. The government of Ethiopia is rolling out CBHI to improve community financial protection when receiving health facility service and utilization as well as of health care service improvements10,11,17,18. Although FP methods are provided for free, women who have access to CBHI may frequently visit health facilities seeking services for themselves and their families, during which health care provider might be introduced to FP services and their importance. Studies show that the number of outpatient visits per insured household member increased, while for uninsured households in the CBHI districts the corresponding members are reduced their visits9,11. This in turn may improve their awareness and attitude towards family planning.

The finding of this study confirmed that, women who have exposure/received more than three family planning method information more likely utilized family planning methods. Providing family planning information and or service to women during their other health service visits may be an effective way to reach women with high unmet need for family planning. Pervious evidence also showed that integration of family planning information and or service with others health service significantly contributed to family planning utilization1921. Offer integrated family planning service and or information with maternal and childbirth services an ideal platform to reach women and their partners with family planning information and service22.

Limitation

This study report highlighted important findings to support the integration of family planning and CBHI program in Ethiopia, but not without limitations, which could affect conclusions based on some of the findings. During the analysis, the study not included important contributed variables to the change of family planning utilization due to lack of individual and social cultural variables in the follow up visit tool. The analysis not allowed the casual effect of individual factors that contribute their association, except characteristics such as perception about CBHI and age; this study did not allow a link with other potential causes that may affect utilization of modern FP methods. An important limitation of this study is that strong conclusions could not be drawn with respect to the casual effect of changes of family planning use. This is due to the cross-sectional design of the survey; hence causality could not be established.

Conclusion and recommendation

The present study showed that more than half of the respondents are currently using modern FP methods. CBHI enrolment was significantly associated with use of family planning method. Child-bearing women who were not exposed to the CBHI scheme should be the target audience. Moreover, it needs communication strategy that will provide information about the contribution of CBHI on FP utilization. The results of this study will help program implementers be aware of the benefits of the CBHI scheme in FP programming particularly in rural settings, and the opportunity to achieve family planning program.

Data availability

Underlying data

Open Science Framework: Effects of community-based health insurance on modern family planning utilization in Ethiopia. https://doi.org/10.17605/OSF.IO/ZS2T312.

This project contains the raw responses to the survey for each participant in file HH 2017.sav.

Extended data

Open Science Framework: Effects of community-based health insurance on modern family planning utilization in Ethiopia. https://doi.org/10.17605/OSF.IO/ZS2T312.

This project contains the survey questionnaire in file HH FUV Checklist.pdf.

Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication).

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Version 2
VERSION 2 PUBLISHED 09 May 2019
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Kassie G and Tefera B. Effects of community-based health insurance on modern family planning utilization in Ethiopia [version 2; peer review: 1 approved with reservations, 1 not approved]. Gates Open Res 2019, 3:1461 (https://doi.org/10.12688/gatesopenres.12960.2)
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Comments on this article Comments (0)

Version 2
VERSION 2 PUBLISHED 09 May 2019
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Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

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