Willingness to Join and Pay for Community-Based Health Insurance Among Urban Households of Mettu Town, Oromia, South West Ethiopia in 2022

Background: Community-based health insurance (CBHI) is a non-profit health risk-pooling system for informal sectors. Its primary goal is to improve access to healthcare and provide financial protection against catastrophic medical expenses. In Ethiopia, 34% of healthcare funding comes from households’ out-of-pocket spending. This can lead to dire consequences, including financial ruin, debt, and the need to sell assets or forgo education. Avoiding care can result in long-term illness, disability, or death. Despite the urgent need for a solution, there has been a lack of empirical evidence on the willingness of urban populations in Ethiopia to participate in CBHI schemes, which is why this study was conducted. Methods: A mixed-methods, community-based, cross-sectional study was conducted in Mettu town from March 1 to 15, 2022. Quantitative data was collected using a pre-tested, structured questionnaire administered to 406 randomly selected households. For the qualitative portion, 18 participants were chosen via purposive sampling for three focused group discussions (FGDs). The quantitative data was analyzed using EPI Data 3.1 and SPSS ver. 20. Binary logistic regression was used to assess associations; variables with a P-value of ≤ 0.25 in the bivariate analysis were included in a multivariable logistic regression model. Variables with a P-value of < 0.05 in the final model were considered statistically significant predictors. The findings from the FGDs were triangulated with the quantitative results. Results: The study achieved a high response rate of 94.6%, with 384 of 406 participants completing the survey. The findings revealed a strong inclination towards CBHI, with 88.5% of participants willing to join the scheme. Among those willing to join, 87.6% were also willing to pay, representing 77.6% of the total study population. The statistical analysis identified several significant factors. Daily laborers were more than four times more likely to join than merchants (AOR: 4.15; 95% CI: 1.27-13.52). Households in the high-income quintile were also more than four times more likely to join compared to the middle-income group (AOR: 4.06; 95% CI: 1.18-14.00). Conversely, households in the lower-income quintile and those with a neutral perception of the quality of healthcare services had a statistically negative association with willingness to pay. The qualitative findings supported the quantitative data, with most participants finding the proposed scheme attractive but emphasizing the need to improve healthcare quality before implementation. Conclusion and Recommendations: The study concludes there is a high and promising willingness among urban households in Mettu town to join and pay for a CBHI scheme. The willingness to pay is, however, negatively influenced by perceptions of healthcare quality and income level. Despite these challenges, the study identifies a clear potential demand for such a program. Researchers suggest that for the successful execution and sustainability of the scheme, it is paramount to improve healthcare quality and to consider the financial capacity of lower-income families.