In January 2023, the Government of Ethiopia decided to pilot a sliding scale-based Community-Based Health Insurance (SS-CBHI) scheme, which is based on the household’s socio-economic status for premium contribution, across a total of 13 rural and urban districts to address inequity in universal health coverage. The research is supported by funding from the Fund for Innovations in Development (FID). Specifically, the new scheme aims to understand the impact of the proposed model on equitable healthcare utilization, given that poorer households faced significant financial challenges in accessing healthcare provided at a flat-rate contribution model. It will also evaluate the impact on out-of-pocket and catastrophic health expenditure, women’s empowerment and overall satisfaction and acceptance with the new policy initiative.
Conducted in rural and urban areas of two regions of Ethiopia (Oromia and Sidama), the randomized control trial is being led by Jimma University with support from the Ethiopian Health Insurance Service (EHIS), Oromia and Sidama health bureaus, and researchers of the Partnership for Economic Policy (PEP).
As part of the trial, while households in the control group continued to follow the flat-rate CBHI contribution scheme (fixed annual premium payment for all households regardless of their economic status), those in the treatment group were enrolled in the new policy initiative, which includes a tiered model of contribution instead. They were stratified into three categories—upper-income (ETB 1,710–1,930/year); middle-income (ETB 1,260–1,310/year) and Low-income/indigent (ETB 720/year). While the upper income households paid a higher premium followed by a lower premium for the middle-income ones, the government fully subsidized the low-income households.
This new pilot was introduced because the CBHI scheme—originally launched in 2011—charged all households the same premium amount regardless of income, which led to wealthier families paying relatively less while poorer households struggled to pay their premiums or were excluded due to inability to pay. At the end of a decade, in 2021, only 56% households were enrolled in the existing scheme.
The consequent 2023 pilot with the calibrated system of contribution has conducted two surveys so far—baseline and midline—to analyse the efficacy of the modified intervention with an endline survey to follow before the study concludes in December 2026. This blog dives into the early findings from these surveys, the lessons learnt, and the promise that the new policy initiative holds for building a stronger health ecosystem in Ethiopia.
Key findings from the surveys
As part of the study, quantitative and qualitative data was collected at baseline (March–May 2024) and midline (Dec 2024–Jan 2025) across a sample of 5,200 households (at each measurement point) in both treatment and control groups along with select primary healthcare units to track outcomes. Key findings are highlighted below.
Enrolment rates increase in low-income households – Enrolment rates in the sliding scale CBHI program increased significantly with 100% of low-income or indigent households (75,282) enrolled when the government waived their premium contributions and made enrollment free of charge. Among other income groups, 84% of middle-income households and 33% of high-income households participated in the pilot program at baseline. At midline, the enrollment was increased to 57% for the high-income households, while the middle and lower-income households sustained high levels of enrollment rates-nearly 100% for both groups
Satisfaction with the CBHI scheme at baseline – At baseline, satisfaction with the CBHI scheme was relatively low in both groups—55.1% in control areas and 44.4% in treatment areas. However, by midline, satisfaction in treatment areas rose dramatically to 74.9%, nearly matching the control group's 76.1%, indicating a major positive shift in perceptions and experience among those exposed to the intervention. Satisfaction increase in the control group might be likely due to broader health system improvements, greater familiarity with CBHI, and community learning. However, the sharper rise in treatment areas points to the strong influence of the new policy initiative.
With respect to satisfaction with health services reflected by overall user satisfaction at baseline, only 40.6% of treatment households were very satisfied with health services, compared to 50.5% in control areas. By midline, satisfaction in the treatment group rose significantly to 74.7%, surpassing the control group at 72.8%, indicating enhanced perceptions of healthcare quality and access. The midline survey that followed probed deeper into issues of satisfaction with healthcare services, equity, and more, when the pilot had been seeded for a longer period of time.
Greater perceptions of equity at midline – The perceptions of the community on the fairness and affordability of the scheme improved markedly in the treatment group, where 76% viewed the premium as just and acceptable at midline as compared to 58% at baseline. Moreover, the overall willingness to join the new scheme rose to 84% in both treatment and control groups by midline. There was also a greater reduction in the proportion of households reporting illness in the treatment group, which is suggestive of improved preventive care. Further, the outpatient service use declined in the treatment group as perceived status of health improved significantly from 55% (baseline) to 65% (midline).
Reduced Out of Pocket (OOP) and Catastrophic Health Expenditures (CHE) – The midline survey results showed that there was a decline in OOP expenditure in low-income households in the treatment group even as overall OOP expenditure increased in both groups. This indicates that the new policy initiative provided the intended protection to poorer households, where OOP costs declined from ETB 2,738 at baseline to ETB 1,958 at midline. Importantly, there was a significant drop in Catastrophic Health Expenditure (CHE) from 22.1% to 17.4% in the treatment group, while it rose in the control group. Lastly, the rise in impoverishment due to health spending was less sharp in the treatment group, once again establishing the shielding effect of the intervention.
Women report satisfaction with the scheme – Women reported having greater access and confidence when making health-related decisions in the treatment group as compared to the control group, although both groups agreed on the CBHI enhancing women’s roles in healthcare seeking. There could, thus, be a positive spillover effect on gender dynamics in healthcare utilization and decision-making.
The findings so far are promising. They demonstrate the effectiveness of the new policy initiative in improving equity, financial protection, and access to care, with participants finding it more affordable, acceptable and trustworthy. However, there are also emerging lessons that must shape the way forward.
The way forward—a promising path to equity and financial protection
The sliding-scale CBHI model demonstrates encouraging progress in advancing equity, enhancing financial protection, and improving user satisfaction and acceptance (perceived as a symbol of fairness and social justice)—indicating strong potential for broader adoption and institutionalization across settings. Despite its early success, the sliding scale CBHI model shows greater OOP spending, especially among middle-income treatment households—a trend that requires close observation and further investigations. On the other hand, even though the premium affordability is widely accepted, it hinges on service quality, inflation, and fair and transparent community stratifications. Communities are willing to pay more if care is reliable and respectful. Trust in the system depends on transparent implementation and the country's economic realities.
There is also a clear scope for broader reforms. Building on increased public trust in the health system in general and CBHI in particular, the government should invest in ensuring access to quality services, ensuring consistent medicine availability, and training health staff to deliver respectful care in well-equipped facilities. Overall, if the CBHI reforms are complemented by poverty reduction strategies and better health financing, it can lead to integrated social protection and systemic change to establish equitable and sustainable health insurance
Finally, a rigorous endline evaluation with increased communication, community engagement, and stronger monitoring and feedback loops will be critical to fully understanding greater impacts, user experience, scheme sustainability, and service delivery quality. The sliding scale CBHI scheme holds great promise, and if results continue to demonstrate positive impact on equity and financial protection, it could potentially pave the way for scaling up pro-poor universal health across other countries seeking similar pathways.
