Published in PLOS One on 2026-07-22, this study is presented as an attributed evidence briefing. The excerpts below are the original researchers’ words, reproduced under their Creative Commons Attribution licence. Health Signal has selected the abstract and, where needed, opening background paragraphs; the complete methods, results, limitations and references remain in the linked paper.
Original authors: Zewdie Birhanu, Beshea Gelana, Nimona Berhanu, Shabu Abdulbari, Bikiltu Abdissa, Jemal Abafita, Badassa Wolteji Chala, Morankar Sudhakar, Gudeta Abebe, Yamirot Andualem, Haimanot Hailu, Dinka Irena, Hasen Haji, Tigist Teferi, Natalia Cantet, Maria Laura Alzua
Source: PLOS One • DOI 10.1371/journal.pone.0353876
Read the complete primary study ↗ · Creative Commons Attribution licence
From the researchers
Abstract
Ethiopia’s Community-Based Health Insurance (CBHI) launched in 2011, has significantly improved access to healthcare. However, the program has faced several challenges, including concerns about equity, financial sustainability, and limited resource mobilization stemming from its flat-rate premium contribution system. To address these issues, a new sliding-scale premium scheme—based on households’ socio-economic status—has been piloted in 13 districts across Oromia and Sidama regions in Ethiopia. However, empirical evidence on community responses to sliding-scale CBHI models remains unexplored.
To generate early empirical evidence on community responses to Ethiopia’s new sliding-scale CBHI policy (socio-economic-based premium differentiation), focusing on acceptability, perceived concerns, and community perceptions of relevance, appropriateness, affordability, equity and fairness.
The study was conducted between March and May 2024 in 13 pilot districts across Oromia and Sidama regions where the sliding-scale CBHI pilot was implemented. Using a qualitative design, data were collected through 10 focus group discussions and 16 key informant interviews with community members, local leaders, and health officials, who were purposely selected to capture diverse perspectives. Discussions explored community acceptance, affordability, and experiences with the new scheme. Transcripts were translated and analyzed thematically using ATLAS.ti 7.5, following open coding and triangulation to identify key themes on barriers, facilitators, and overall community response.
The study found generally positive community reception of the sliding-scale CBHI scheme, which was widely perceived as acceptable, more equitable, inclusive, and better aligned with households’ economic capacity. However, this acceptance was conditional, as it depended on sustained improvements in service quality, consistent availability of medicines, and transparent management of scheme funds. Moreover, operational challenges were also reported, including household misclassification, perceived favoritism, inconsistent application of eligibility criteria, and inadequate communication of the scheme’s procedures and decisions. While stakeholders viewed the reform as a promising step toward a more equitable and inclusive system, sustaining support will require strengthened trust and consistent service delivery.
The early implementation of Ethiopia’s Sliding-scale CBHI premium system was generally well received by community members and implementers, who viewed it as fair, contextually appropriate, and aligned with households’ ability to pay. The participatory, asset-based classification process enhanced legitimacy, ownership, and trust. However, operational and ethical challenges such as misclassification, favoritism, inconsistent criteria, and limited communication were reported. Participants highlighted the need for improved transparency, grievance handling mechanisms, and consideration of broader livelihood factors to sustain trust and ensure long-term acceptance and equity in the scheme.
1. Background
Since the enactment of its national health policy in 1993, the Ethiopian government has emphasized the importance of health financing reforms as a central strategy to improve population health outcomes, reduce financial hardship, and enhance equitable access to healthcare services. Among the key milestones in this trajectory is the establishment of the Community-Based Health Insurance (CBHI) program in 2011 [1–3]. Initially piloted in 11 districts, CBHI aimed to expand financial protection for informal rural communities facing barriers such as out-of-pocket costs, geographic isolation, and limited awareness of health insurance. It was also designed to improve access to essential healthcare, mobilize domestic health resources, promote equity in financing, and strengthen community ownership and participation in health system management. By 2022, the CBHI had been scaled up to cover 921 of 993 targeted districts, reaching approximately 8.9 million households, or around 40 million individuals, corresponding to 56% of the eligible population [4]. This rapid expansion reflects both the government’s commitment to universal health coverage (UHC) and the perceived utility of CBHI in reducing financial barriers to care.
Reading this evidence
Use the full paper to check the study design, participant selection, comparator and outcome definitions before drawing a practical conclusion. An association does not by itself show cause and effect. A reported performance measure needs its denominator and uncertainty. A finding from a particular facility, sample or time period should retain that scope when it is discussed elsewhere.
This briefing makes the source accessible within the wider financing & policy desk. It does not assess an individual patient or certify a product. When considering relevance to another health system, examine the original authors’ account of context and limitations, then seek local implementation evidence. The related reporting below provides other studies to read alongside this one; it is a topic connection, rather than a claim that their results are directly comparable.
© 2026 Zewdie Birhanu, Beshea Gelana, Nimona Berhanu, Shabu Abdulbari, Bikiltu Abdissa, Jemal Abafita, Badassa Wolteji Chala, Morankar Sudhakar, Gudeta Abebe, Yamirot Andualem, Haimanot Hailu, Dinka Irena, Hasen Haji, Tigist Teferi, Natalia Cantet, Maria Laura Alzua. Excerpts reproduced under CC BY. Selection, formatting and contextual notes by Health Signal. The researchers are the authors of the source study, not members of Health Signal’s staff.
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