Perceived quality of care among households ever enrolled in a community-based health insurance scheme in two districts of northeast Ethiopia: a community-based, cross-sectional study.

OBJECTIVES: To examine how clients perceived the quality of healthcare they received and identify associated factors both at the individual and facility levels. DESIGN: A community-based, cross-sectional study. SETTING: Two rural districts of northeast Ethiopia, Tehulederie and Kallu. PARTICIPANTS: 1081 rural households who had ever been enrolled in community-based health insurance and visited a health centre at least once in the previous 12 months. Furthermore, 194 healthcare providers participated in the study to provide cluster-level data. OUTCOME MEASURES: The outcome variable of interest was the perceived quality of care, which was measured using a 17-item scale. Respondents were asked to rate the degree to which they agreed on 5-point response items relating to their experiences with healthcare in the outpatient departments of nearby health centres. A multilevel linear regression analysis was used to identify predictors of perceived quality of care. RESULTS: The mean perceived quality of care was 70.28 (SD=8.39). Five dimensions of perceived quality of care were extracted from the factor analysis, with the patient-provider communication dimension having the highest mean score (M=77.84, SD=10.12), and information provision having the lowest (M=64.67, SD=13.87). Wealth status, current insurance status, perceived health status, presence of chronic illness and time to a recent health centre visit were individual-level variables that showed a significant association with the outcome variable. At the cluster level, the work experience of healthcare providers, patient volume and an interaction term between patient volume and staff job satisfaction also showed a significant association. CONCLUSIONS: Much work remains to improve the quality of care, especially on information provision and access to care quality dimensions. A range of individual-level and cluster-level characteristics influence the perceived quality of care. For a better quality of care, it is vital to optimise the patient-provider ratio and enhance staff job satisfaction.

A mixed methods study of community-based health insurance enrollment trends and underlying challenges in two districts of northeast Ethiopia: A proxy for its sustainability.

BACKGROUND: The term "community-based health insurance" refers to a broad range of nonprofit, prepaid health financing models designed to meet the health financing needs of disadvantaged populations, particularly those in the rural and informal sectors. Due to their voluntary nature, such initiatives suffer from persistently low coverage in low- and middle-income countries. In Ethiopia, the schemes' membership growth has not been well investigated so far. This study sought to examine the scheme's enrollment trend over a five-year period, and to explore the various challenges that underpin membership growth from the perspectives of various key stakeholders. METHODS: The study employed a mixed methods case study in two purposively selected districts of northeast Ethiopia: Tehulederie and Kallu. By reviewing the databases of health insurance schemes, quantitative data were collected retrospectively from 2017 to 2021 to examine enrollment trends. Trends for each performance indicator were analyzed descriptively for the period under study. Face-to-face interviews were conducted with nine community members and 19 key informants. Study participants were purposely selected using the maximum variation technique. Interviews were audio recorded, transcribed verbatim, and translated into English. Thematic analysis was employed with both deductive and inductive coding approaches. RESULTS: Over the course of the study period, enrollment in the scheme at both districts exhibited non-linear trends with both positive and negative growth rates being identified. Overall, the scheme in Tehulederie has a relatively higher population coverage and better membership retention, which could be due to the strong foundation laid by a rigorous public awareness campaign and technical support during the pilot phase. The challenges contributing to the observed level of performance have been summarized under four main themes that include quality of health care, claims reimbursement for insurance holders, governance practices, and community awareness and acceptability. CONCLUSIONS: The scheme experienced negative growth ratios in both districts, indicating that it is not functionally viable. It will fail to meet its mission unless relevant stakeholders at all levels of government demonstrate political will and commitment to its implementation, as well as advocate for the community. Interventions should target on the highlighted challenges in order to boost membership growth and ensure the scheme's viability.

Financial viability of a community-based health insurance scheme in two districts of northeast Ethiopia: a mixed methods study.

BACKGROUND: Community-based health insurance initiatives in low- and middle-income countries encountered a number of sustainability challenges due to their voluntary nature, small risk pools, and low revenue. In Ethiopia, the schemes' financial viability has not been well investigated so far. This study examined the scheme's financial viability and explored underlying challenges from the perspectives of various key stakeholders. METHODS: This study employed a mixed methods case study in two purposively selected districts of northeast Ethiopia. By reviewing financial reports of health insurance schemes, quantitative data were collected over a seven years period from 2014 to 2020 to examine trends in financial status. Trends for each financial indicator were analyzed descriptively for the period under review. Interviews were conducted face-to-face with nine community members and 19 key informants. We used the maximum variation technique to select the study participants. Interviews were audio recorded, transcribed verbatim, and translated into English. Thematic analysis was applied with both inductive and deductive coding methods. RESULTS: Both schemes experienced excess claims costs and negative net income in almost all the study period. Even after government subsidies, the scheme's net income remained negative for some reporting periods. The challenges contributing to the observed level of financial performance have been summarized under five main themes, which include adverse selection, moral hazard behaviors, stockout of medicines, delays in claims settlement for service providers, and low insurance premiums. CONCLUSIONS: The health insurance scheme in both districts spent more than it received for claims settlement in almost all the period under the study, and experienced heavy losses in these periods, implying that it is not financially viable for the period in question. The scheme is also unable to fulfill its purpose of protecting members against out-of-pocket expenses at the point of health care. Interventions should target on the highlighted challenges to restore financial balance and enhance the scheme's viability.

Continued adherence to community-based health insurance scheme in two districts of northeast Ethiopia: application of accelerated failure time shared frailty models.

BACKGROUND: The sustainability of a voluntary community-based health insurance scheme depends to a greater extent on its ability to retain members. In low- and middle-income countries, high rate of member dropout has been a great concern for such schemes. Although several studies have investigated the factors influencing dropout decisions, none of these looked into how long and why members adhere to the scheme. The purpose of this study was to determine the factors affecting time to drop out while accounting for the influence of cluster-level variables. METHODS: A community-based cross-sectional study was conducted among 1232 rural households who have ever been enrolled in two community-based health insurance schemes. Data were collected using an interviewer-administered questionnaire via a mobile data collection platform. The Kaplan-Meier estimates were used to compare the time to drop out among subgroups. To identify predictors of time to drop out, a multivariable analysis was done using the accelerated failure time shared frailty models. The degree of association was assessed using the acceleration factor (δ) and statistical significance was determined at 95% confidence interval. RESULTS: Results of the multivariable analysis revealed that marital status of the respondents (δ = 1.610; 95% CI: 1.216, 2.130), household size (δ = 1.168; 95% CI: 1.013, 1.346), presence of chronic illness (δ = 1.424; 95% CI: 1.165, 1.740), hospitalization history (δ = 1.306; 95% CI: 1.118, 1.527), higher perceived quality of care (δ = 1.322; 95% CI: 1.100, 1.587), perceived risk protection (δ = 1.218; 95% CI: 1.027, 1.444), and higher trust in the scheme (δ = 1.731; 95% CI: 1.428, 2.098) were significant predictors of time to drop out. Contrary to the literature, wealth status did not show a significant correlation with the time to drop out. CONCLUSIONS: The fact that larger households and those with chronic illness remained longer in the scheme is suggestive of adverse selection. It is needed to reconsider the premium level in line with household size to attract small size households. Resolving problems related to the quality of health care can be a cross-cutting area of ​​intervention to retain members by building trust in the scheme and enhancing the risk protection ability of the schemes.

Utilization of Routine Health Information from Health Management Information System and Associated Factors Among Health Workers at Health Centers in Oromia Special Zone, Ethiopia: A Multilevel Analysis.

INTRODUCTION: Health management information system is a building block for the health system. Even if using health facility data at all levels is critical, it is poorly practiced in developing countries. There is limited evidence about the utilization of routine health information from the health management information system in the study area. This study aimed to assess the utilization of routine health information from health management information system and associated factors among health professionals at health centers in Oromia special zone, Amhara region, Ethiopia. METHODS: A facility-based cross-sectional study was conducted from February to March 2019. A total of 369 health professionals who were the focal person for each service delivery point were taken from the selected health centers. The data analysis was done using STATA version 14. A multilevel mixed-effect logistic regression model was carried out to identify factors associated with utilization of routine health information from the health management information system. Adjusted odds ratio with 95% CI was reported to show the strength of association. A P-value of <0.05 was used to declare statistical significance. RESULTS: The magnitude of good routine health information utilization among health care professionals was 52.8%. Training (AOR=2.40, 95% CI=1.35, 4.26), availability of standard indicator definition (AOR=2.01, 95% CI=1.13, 3.57), data analysis skills (AOR=2.59, 95% CI=1.45, 4.62), regular feedback (AOR=2.29, 95% CI=1.29, 4.05), performance evaluation (AOR=2.60, 95% CI=1.19, 5.68) and timely reporting (AOR=2.89, 95% CI=1.54, 5.42) were significantly associated with routine health information utilization. CONCLUSION: The overall utilization of routine health information from the health management information system was low. Therefore, the Zone health department and woreda health offices need to give training on HMIS data use, and avail standard indicator definition for all health care workers at all service delivery points.

Magnitude of disrespectful and abusive care among women during facility-based childbirth in Shambu town, Horro Guduru Wollega zone, Ethiopia.

BACKGROUND: Disrespectful care during childbirth causes suffering and discourages women from seeking facility-based care. It is one of the silent causes of maternal mortality and morbidity worldwide, but not yet well recorded especially in developing countries. The aim of this study was to measure the magnitude of disrespect and abusive behaviors of health professionals during childbirth and associated factors. METHOD: Community based cross-sectional study design was employed among 321 women who gave birth in public health facilities of Shambu town, Ethiopia, between January 01 and December 31, 2018. Simple random sampling was used to select the study participants. Data were collected using a semi-structured interviewer administered questionnaire. Prevalence of disrespect and abuse was measured by using seven categories of disrespect and abuse with their respective verification criteria. The data were entered into Epi-data 3.1 and then transported to SPSS version 23.0. Logistic regression models were fitted to determine the presence of statistically significant associations between the dependent and independent variables at p-value <0.05 and AOR values with 95% confidence interval. RESULTS: Out of 321 sampled respondents, 316 participated in this study with response rate of 98.4%. The overall prevalence of disrespect and abuse was 78.2% (95% CI: 73.5-83.2). The most common forms disrespect and abuse encountered by the mothers were: unconsented care (86.1%), non-dignified care (37.3%), lack of privacy (33.9%), physical abuse (21.5%) and neglectful care (13.3%). Mother's occupational status, increasing number of antenatal care visits and giving birth in a hospital setting were significantly associated with disrespect and abuse during facility-based childbirth. CONCLUSION: Though government interventions are in place, excessive levels of disrespect and abusive practices during facility-based childbirth persisted to be important problems in the study area. To address the unnecessary suffering, health policy makers and program designers should develop strategies to enhance respectful maternity care approaches. Health managers and health professionals should do their best to provide high quality, client-centered care in health facilities so that women are not discouraged from using them. We also recommend knowledge exchange with development partners to determine which practices will be adaptable and helpful to address the problem of mistreatment of women in health care facilities.

Utilization of clean and safe delivery service package of health services extension program and associated factors in rural kebeles of Kafa Zone, Southwest Ethiopia.

BACKGROUND: In Ethiopia, 94% of births take place at home unattended by trained persons. The government introduced an innovative strategy, Health Services Extension Program in 2003. Clean and safe delivery service is a component of maternal and child healthcare package of the program. However, little is known about the status of uptake of the service. This study thus aimed to assess utilization of clean and safe delivery service and associated factors in rural kebeles of Kafa Zone, Ethiopia. METHODS: A community based cross sectional survey was conducted in rural kebeles of Kefa Zone from January 21(st) to February 25(th), 2009 using a sample of 229 mothers. Kafa Zone is located 465 kilometres away from Addis Ababa to southwest of Ethiopia. Data were collected using a structured questionnaire and analyzed using SPSS for windows version 16. OR and 95% CI were calculated. P< 0.05 was considered statistically significant. RESULTS: Utilization of clean and safe delivery service was 43(19%). Women with formal schooling and those who knew at least two danger signs of pregnancy and labor were more likely to use the service than their counterparts; (AOR=5.8, 95% CI=2.1, 16) and (AOR=3.0, 95% CI=2.2, 10.6), respectively. Of 108(47.8%) mothers who had at least one antenatal care visit, 36(33.3%), were not advised about danger signs. Women who had at least one ANC visit and those who were advised about the danger signs of pregnancy and labor appeared to be more likely to use the service than their counterparts; (AOR=6.1, 95% CI=1.9, 21.3), and (AOR=5.4, 95%CI= 1.4, 21.7), respectively. CONCLUSION: Utilization of the service is low and was determined by women's educational status, history of abortion, knowledge of danger signs and antenatal care attendance. Educating women and improving their knowledge about danger signs of pregnancy and labor is recommended. Health extension workers should consider antenatal care visits as opportunities for this purpose.