Abstract
BACKGROUND: Community-based health insurance (CBHI) plays a crucial role in achieving universal health coverage. This study investigates the determinants, challenges, and opportunities related to CBHI in Tigray, Ethiopia. DESIGN AND METHODS: A mixed-methods approach was employed. In 2020, a cross-sectional survey was conducted involving 800 rural households in Tigray, combined with semi-structured key informant and in-depth interviews. Multistage random sampling and logistic regression analyses were also applied. RESULTS: Enrollment was strongly associated with having a chronic illness (AOR = 64.5, p ≤ 0.01), primarily due to a policy that permits indigents with chronic conditions to enroll without payment. Other factors included membership in a political party (AOR = 3.76, p ≤ 0.01), holding formal positions (AOR = 1.55, p = 0.03), receiving aid (AOR = 1.62, p ≤ 0.01), and membership in Edir (AOR = 1.66, p ≤ 0.01). Conversely, enrollment was negatively impacted by low trust (AOR = 0.66, p = 0.04), limited awareness (AOR = 0.4, p ≤ 0.01), poor healthcare quality (AOR = 0.51, p ≤ 0.01), bureaucracy (AOR = 0.02, p ≤ 0.01), being widowed (AOR = 0.34, p ≤ 0.01), and working as a daily laborer (AOR = 0.23, p ≤ 0.01). Key barriers included structural inefficiencies, substandard healthcare service quality, and inadequate awareness. CONCLUSION: To facilitate equitable expansion of CBHI, it is essential to address administrative obstacles, enhance trust and awareness, and provide support to vulnerable groups, in addition to leveraging traditional risk-pooling mechanisms.