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Story and Perspective

Transforming the Lives of Ethiopian Women Through Community-Based Health Insurance

Dr. Mengistu Asnake Kibret


“We see cases that would have been difficult to handle at home, that tells me that we are saving a significant amount of maternal lives. Mothers needing blood transfusions and obstructed births are common and I shudder to think of these women’s fate if they had given birth at home,” said Yisak Kifle, Director of Adi Goshu Health Center in Ethiopia—a country where less than half of women give birth in a health facility.

Pathfinder and its partners are strengthening health systems across Ethiopia to prevent maternal, infant, and childhood deaths through the USAID Transform: Primary Health Care activity in 440 woredas (districts), serving nearly 56 million people. Photo credit: Sala Lewis

Although maternal and childhood mortality rates in Ethiopia have declined over time, making pregnancies safe and successful for both mothers and babies remains a challenge. Ending preventable maternal and child deaths requires building strong health systems and expanding access to health care to help save lives.

Pathfinder is strengthening health systems in Ethiopia through the USAID Transform: Primary Health Care Activity, in partnership with the Government of Ethiopia and a consortium of partners (Abt Associates, EnCompass LLC, Ethiopian Midwives Association, John Snow Research and Training Institute Inc., and Ethiopian Midwives Association). We are supporting the Ethiopian government to expand critical health services at the facility, community, and household levels so that mothers and newborns can access the care they need. As USAID Transform: Primary Health Care Activity’s Chief of Party, I have been proud to witness the changes our work has made in the lives of mothers and children by giving them more ready access to quality health care.

A health worker captures a child’s weight at the West Arsi Oromia Health Center in Ethiopia, where Pathfinder is improving health outcomes for mothers and their babies. Photo credit: Sala Lewis

Strong health systems must be people-centered. All Transform activities respond to the actual needs and situations of the people they serve. Transform engages individuals and communities as participants and beneficiaries—to identify and resolve problems that impact their health.

Through our community engagement activities, we have been able to motivate people to invest in and use primary health care services.  One aspect of this work has been expansion of community-based health insurance (CBHI) coverage.

What is CBHI?

CBHI is a form of health financing offered to households in low-resource rural and urban settings, giving vulnerable populations access to modern health care services. Participation is completely voluntary, and those that choose to participate make annual payments into a pool of community funds used to offset the cost of health care. Whoever is paying into the insurance can access health care, and so can any member of that person’s household. CBHI is partially subsidized and covers various essential health services (i.e. outpatient and inpatient services, surgeries, laboratory and imaging services, prescribed drugs dispensing for common illnesses, and care for childhood illness) that would otherwise be paid for by out-of-pocket spending.

Women are Empowered to Access Care

CBHI is not only important to the community, but also the overall health system. CBHI increases health service utilization, decreases financial hardship, improves maternal and child health outcomes, creates more predictable and sustainable financing for health facilities, and empowers women.

CBHI is a gamechanger for women because it gives them the freedom to make their own decisions about their health care needs without financial constraints. In Ethiopia, women and children often have no control over household finances; if they need to get health care privately, they must pay out-of-pocket. But through CBHI, women and children can access quality health care using an insurance card, without asking the male head of the household or other family members for permission and financial support.

CBHI is crucial to the communities it serves because it:

  • Encourages people to seek out health care since there is no need to worry about payment once you are enrolled.
  • Shields women and children from catastrophic out-of-pocket costs and guarantees that family members get services for a subsidized cost.
  • Strengthens community feedback to the health facilities and health care providers for improved quality of services, creating accountability on both sides.
  • Enriches quality of care and accountability of the health system overall.
Masreshah Abeba a health extension worker (HEW), conducts a prenatal checkup of an expectant mother at a health center in East Gojam Region in Ethiopia. Photo credit: Sala Lewis

Community Engagement is Essential

Community engagement activities have guided the setup of, management, and access to CBHI. To promote CBHI, community and religious leaders organize local meetings for the public to hear testimonials from current CBHI members who have benefited from the insurance, sensitizing others to the benefits of CBHI. Their voices and the testimonials of CBHI members are vital to successfully promoting CBHI enrollment, family planning and immunization services, and antenatal care for mothers.

Across villages, marketplaces, and community gatherings in Ethiopia, Transform uses mobile vans and audio-mounted vehicles to disseminate messages about CBHI, as well as malaria, maternal health, and other key health issues. This technique builds awareness about CBHI enrollment, healthy behaviors, and community events like pregnant women conferences (PWCs). PWCs educate women and expecting mothers about the importance of delivering their babies in a health center with a skilled attendant. These conferences are organized by local health centers and are led by midwives who inform women about life-saving maternal and newborn health services.

Additionally, through our partnership with the Ministry of Health, we’ve supported the development of family health cards in local languages that illustrate urgent maternal warning signs, the importance of child nutrition, breastfeeding, hygiene practices, and other topics. Health extension workers distribute family health cards during their regular visits to communities and households where they also encourage household members to enroll into CBHI.

Due to our combined efforts, CBHI enrollment has climbed. The enrollment rate in 2012 was 34% during the pilot phase, reaching 49% and 60% in 2018-19 and 2020-21 respectively. The total premium collected from members significantly increased from USD 361,777 in 2012 to USD 28.5 million in 2019. And it is now three times more likely that a CBHI member will visit a health facility than a non-member.

A group of women nurse their babies at a health center in Arsi Oromia Region in Ethiopia where Pathfinder and its partners are improving household and community health practices and behaviors. Photo credit: Sala Lewis

Since 2017, Transform has made remarkable progress in Ethiopia by using innovative techniques that empower local communities to improve household and community health practices. This would not have been possible without the integration of community engagement. We have deployed community engagement officers in the four regions where we work and introduced an innovative engagement strategy called “Health Post Open House” that helps community members understand the kind of services available and how these services can be improved with support from the local community. Through this strategy, people can use scorecards to provide feedback directly to health facilities. Interventions like these are transforming the lives of mothers and children and increasing access to life-saving care.

This is the first in a series of blog posts spotlighting the USAID Transform: Primary Health Care Activity’s work in strengthening health systems in Ethiopia. Learn more about our work here.  

*Disclaimer: All photos in this blog were taken before the COVID-19 pandemic.

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