Drivers of community-based health insurance enrolment in post-war Tigray, Ethiopia

Community-based health insurance (CBHI) is crucial for strengthening primary healthcare (PHC) and progressing towards universal health coverage (UHC), especially in resource-constrained, war-affected settings. While previous studies have explored CBHI in various contexts, this study uniquely investigates household willingness to join (WTJ) CBHI and its determinants in post-war Tigray, Ethiopia, offering valuable insights into the specific challenges and opportunities in this under-researched setting.

We conducted a multistage community-based survey across 15 districts within 6 accessible administrative zones, 1 year after the cessation of hostilities, sampling 2289 households in 30 clusters. The primary outcome variable-household WTJ CBHI-was analysed in relation to sociodemographic factors, a wealth index, type of frequently accessed healthcare facility, knowledge on CBHI benefits and prior experience with CBHI. Weighted logistic regression identified significant predictors of WTJ with p<0.05.

2270 households participated (99.17% response rate). Respondents were 60.31% female, and median age 42.50 years (IQR 33-55). Pre-war CBHI enrolment of households was approximately 62.40% (95% CI 60.11% to 64.63%), while post-war WTJ reached about 87.57% (95% CI 85.99% to 88.99%) of households. Key WTJ predictors included younger age, marital status, host community status, farming occupation, belonging to the 'less poor' wealth quintile, hospital access, knowledge of CBHI benefits and previous CBHI membership.

This study reveals substantial interest in CBHI among households in post-war Tigray, highlighting its potential to strengthen the healthcare system. To ensure equitable access and achieve UHC-particularly in rural and war affected areas-revitalising CBHI and rebuilding PHC are essential. While longitudinal research is warranted to understand how war-driven contextual changes affect CBHI demand over time, policies should prioritise affordability, enhance awareness and strengthen hospital linkages. This supports the prioritisation of CBHI investment as a crucial strategy in this context and potentially in similar under-resourced and war-torn settings.