The interaction of healthcare service quality and community-based health insurance in Ethiopia.

Community-based health insurance (CBHI) as a demand-side intervention is presumed to drive improvements in health services quality, and the quality of health services is an important supple-side factor in motivating CBHI enrollment and retention. There is, however, limited evidence on this interaction. This study examined the interaction between quality of health services and CBHI enrollment and renewal. A mixed-method comparative study was conducted in four agrarian regions of Ethiopia. The study followed the Donabedian model to compare quality of health services in health centers located in woredas/districts that implemented CBHI with those that did not. Data was collected through facility assessments, client-exit interviews, and key informant interviews. In addition to manual thematic analysis of qualitative data, quantitative descriptive and inferential analyses were done using SPSS vs 25. The process related (composite index including provider-client interpersonal communication) and outcome related (client satisfaction) measures of service quality in CBHI woreda/districts differed significantly from non-CBHI woredas/districts, but there were no significant differences in overall measures of structural quality between the two. The study found better diagnostic test capacity, availability of tracer drugs, provider interpersonal communication, and service quality standards in CBHI woredas. A higher proportion of clients at CBHI health centers gave high ratings of overall satisfaction with services. Individual and household factors including family size, age, household health care-related expenditures, and educational status, played a more significant role in CBHI enrollment and renewal decisions than health service quality. Key-informants reported in interviews that participation in the scheme increased accountability of health facilities in CBHI woredas/districts, because they promised to provide quality services using the CBHI premium collected at the beginning of the year from all enrolled households. This study indicates a need for follow-up research to understand the nuanced linkages between quality of care and CBHI enrollment.

Introduction

Timely access to health care can minimize the impact of ill health. Health insurance can reduce the cost of accessing health services and lessen the impact of ill health on the household’s ability to earn income [1,2]. Many low-income countries have introduced revenue-supported health insurance for urban informal workers and rural residents. With a mix of government co-funding, premiums, and registration fees, households can ameliorate the impact of illness by sharing risk and spreading out the costs of health care over time. Community-based health insurance (CBHI), often administered by communities or local governments, elicits voluntary enrollment for a fee for a period of one year [3,4]. In return, enrollees receive a specified set of services with no out-of-pocket co-payment at the point of care. CBHI has been promoted widely in low- and middle-income countries [5]. However, enrollment into CBHI or other types of insurance has historically been low in sub-Saharan Africa [6].

With the aim of ensuring access to quality health care services by all citizens without financial burden, the Ethiopian government established the Health Insurance Agency [7]. In 2011, the agency began piloting a CBHI scheme in 13 woredas in four of its largest agrarian regions (Amhara; Oromia; the Southern Nations, Nationalities, and Peoples’ Region [SNNPR]; and Tigray) [8]. Prompted by the pilot’s success and viability, the government of Ethiopia scaled CBHI up to 512 woredas in six regions, expanding to Benishangul-Gumuz, Harari, and two city administrations (Addis Ababa and Dire Dawa) [8,9]. As of 2019/20, CBHI schemes are functional as part of a phased national rollout plan, in 700 woredas and cities—covering some 32.2 million people or almost a third of Ethiopia’s population [10]. The voluntary CBHI scheme is available to households in rural, semi-urban, and urban areas who are not employed within the formal sectors of the economy. The scheme charges member households a nominal one-time registration fee along with a yearly enrollment/renewal premium. The annual premium is between USD 7 and 8 per rural household and USD 10 and 14 per urban household. A general subsidy from the federal government matches 10% of the CBHI enrollment proceeds. Also, local governments at the woreda and regional level allocate a certain amount of budget as targeted subsidy each year to cover the free enrollment of select poor and indigent households unable to pay for CBHI membership [11]. CBHI covers basic costs for inpatient and outpatient services at public health facilities within a member’s catchment area.

Enrollment in CBHI reflects a financial investment in the health system by individual citizens. At the same time, increased demand for quality services has the potential to lower average quality if limited resources are strained. Since 1998, the Ethiopia Ministry of Health has invested and given health facilities autonomy to use the revenue they collect from user fees and other sources to improve access to and quality of healthcare service. Studies in different countries, including Ethiopia, focus on factors that affect CBHI enrollment and renewal and the role of CBHI on service quality [1,12-18]. Findings showed that long waiting times, poor patient-provider interactions, unavailability of diagnostics and essential drugs, unfavorable client perception of health care quality, and low client-service satisfaction were associated with high CBHI scheme dropout rates. This indicates that quality of healthcare affects decisions about whether to reenroll in CBHI [19-22]. However, service quality was not shown to be the reason for CBHI drop-out rates in pilot areas [12]. Enrollment rates were also affected by timing, the payment modality involved in enrolling into the insurance, trust in scheme management, and distance to health facilities. Acceptance of modern medicine or attitude toward planning for future illnesses might also affect enrollment [19,20,23,24]. Quality of health services is critical for member satisfaction and sustainability of the CBHI scheme. As CBHI is scaled up and more time passes, the role of quality of health services in CBHI enrollment in Ethiopia might become more evident.

The Ethiopian Hospital and Primary Health Care Alliance for Quality guidelines steer efforts to enhance the health care delivery structure and process and improve the client experience of care. By aiming to increase the availability of supplies, use new tools, apply innovations, strengthen providers skills, and improve work environments, implementation of CBHI in a woreda has the potential to ensure a threshold level of quality of healthcare service. CBHI provides financial protection to its members and increases health care seeking behavior and health service utilization [25,26]. This, in turn, creates pressure on health facilities and providers, and may affect the quality of healthcare service at the health centers, but there is limited evidence on the interaction between CBHI and quality of health services. This study examined the interaction between quality of healthcare service and CBHI uptake. The following research questions were explored: (i) Has the introduction and implementation of CBHI improved quality of healthcare services? and (ii) Does quality of healthcare affect enrollment in and renewal of CBHI?. The study presents quality of healthcare services through the Donabedian model, which posits that the presence of structural quality facilitates process quality, which leads to outcome quality based on client experience and satisfaction [27]. This model was adopted because it explores all the three elements of quality and postulates that the CBHI implementation mechanism itself and the related enhanced revenue generation would improve quality of health care service; enhanced quality of health care service or perceived quality itself would generate greater enrollment into CBHI.

Methods

Study area and period

Since 2017, USAID Transform: Primary Health Care project, in collaboration with the Ministry of Health, has supported continuous improvement of quality of healthcare services in Ethiopia. Benefiting nearly 53 million people, Transform strengthens the management and performance of Ethiopia’s national health system by improving quality of service delivery across the continuum of primary health care, improving household and community health practices and health care-seeking behaviors, and strengthening program learning to impact policy and activities related to the prevention of child and maternal deaths. The study was conducted in selected health centers located within, USAID Transform: Primary Health Care implementation regions and focused on interaction between CBHI enrollment and healthcare service quality. Data was collected from August to September 2019.

Study design

An embedded mixed-method comparative study was conducted in four agrarian regions of Ethiopia (Amhara, Oromia, SNNPR, and Tigray) to provide information on quality of healthcare services in woredas that implemented CBHI and those that did not. The study was guided by the Donabedian model.

Sampling and sample size determination

As there is no pre-determined estimate of level of differences to base our assumptions for estimating sample size, standard sample size formula could not be used to calculate sample. Woredas were selected from the four regions where USAID Transform: Primary Health Care is implemented. The sampling frame included woredas that have implemented CBHI for at least 24 months and non-CBHI woredas that are in USAID Transform: Primary Health Care areas. Within the CBHI and non-CBHI groups, woredas with health centers that initiated a quality improvement (QI) intervention with the project’s support and woredas with health centers that have not yet initiated a QI intervention were included. Two woredas from each category were randomly selected from Amhara, Oromia, and SNNP, and a single woreda was randomly selected from Tigray for each of the four categories. A total of 28 woredas were selected from the four regions.

Two health centers were randomly selected from each of the 28 woredas for a total of 56 health centers. Exit interviews were conducted among participants who used in the selected health center for any health services. Participant selection was completed through consecutive sampling method until an adequate sample from each health center was obtained. The plan for exit interviews was to include one participant from a health center in non-CBHI woreda for every three-participants interviewed from a health center located in CBHI woreda. For each health center in a woreda that was not implementing CBHI (non-CBHI woreda), five participants were interviewed while 15 were interviewed from health centers located in CBHI woredas. This provided a total of 140 interviews from participants in non-CBHI woredas and 420 interviews with participants in CBHI woredas (which included 224 currently CBHI enrolled, 112 who dropped out of CBHI and 84 who never enrolled participants) for a total of 560 study participates.

The qualitative key informant interviews were conducted with people who had experience with the interaction between CBHI and quality of health services. With the same sampling techniques used in quantitative data collection, 28 key informant interviews were conducted: four with regional officials, four with zonal officials, four with woreda CBHI officials or CBHI management team members (in CBHI woredas), eight with woreda office heads (four from CBHI woredas and four from non-CBHI woredas), and eight with health center heads in each of the study’s regions.

Data-collection process and instruments

The assessment used three data collection methods (Fig 1). Structural-quality measures were investigated through a facility survey with a standard tool. Process-quality measures were investigated based on exit interviews with participants about their perception of provider adherence to quality standards and procedures, as well as key informant interviews at health facilities, woreda, zonal, and regional health bureaus. Outcome-quality measures were explored based on client satisfaction as they exited the health facility.

Fig 1

Quality of care measurement domains and data sources.

Participants exit interview

Exit interviews were conducted using a structured questionnaire translated into local languages with 560 participants who visited health centers selected for the study on the day of data collection. Along with participant demographic information, the exit interviews elicited participants’ views on health care services received during the visit preceding the interview, previous experience in the same health center, and attitudes toward CBHI in general. In addition to individual characteristics (such as age, sex, marital status, education) and out-of-pocket expenditure during the facility visit on the day of the interview, eight indicators were used to measure client service satisfaction, comparing clients from CBHI woredas with their counterparts. These indicators were: overall quality of service, availability of medicines and supplies, availability of diagnostic services, cleanliness of facility, wait time between arrival and service, wait time between services, friendliness of staff, and availability of private counseling services. In addition to client service satisfaction, the exit interview included tracer indicators that were used to develop composite measures of interpersonal relations (4 indicators) and client perception about provider adherence to proper procedure (10 Likert scale indicators). The exit interview instrument was adapted from the evaluation tool used for the CBHI pilot in Ethiopia [28].

Facility survey

Structure quality was assessed in 56 health facilities using a standard facility assessment tool focused on an inventory of availability and readiness of basic health facility infrastructure: basic amenities (6 tracer items), basic equipment (6 tracer items), diagnostic capacity (7 tracer items), essential medicines (25 tracer items), and standard precautions for infection prevention (9 tracer items). In addition to facility surveys, interviews were conducted with facility heads and supplemented with observation of facility adherence to service quality standards. Observation of service quality standards included 18 tracer indicators on the facility’s QI structure, capacity to implement QI, providers’ ability to provide patient-centered care, patient-safety practices, availability of quality monitoring and sharing processes, and practices for QI learning. The facility survey instrument and analysis methodology were adopted from WHO’s SARA tool [29]. The facility service quality standard assessment tool was adopted from the national standards used for facility quality inventory [30].

Key informant interviews

A qualitative assessment to understand the design, operation, and implementation of CBHI at different levels of the health system was conducted with 28 key informants who were heads of regional health bureaus, zonal offices, woreda health offices, health centers, as well as woreda level CBHI focal persons. The questionnaires were prepared in English, translated into the local languages (Tigrigna, Amharic, and Oromifa), and translated back into English to check consistency. Twenty data collectors who were fluent in the local language (five for each region) were selected for data collection and four supervisors with experience in CBHI, and service quality integration were selected for supervision. Training, consisting of mock interviews and practical exercises for both data collectors and supervisors, was conducted over five days in July 2019. The questionnaires were pretested and refined to ensure they were clear and could be understood by both the data collectors and respondents.

Data management and analysis

The research team assessed the quality, accuracy, and completeness of the collected data using range plausibility and cross-validation checks. The data was collected using local languages and back translated in English before analysis. The quantitative data was entered into EPI-Data vs 3.02 for Windows and exported into SPSS vs 25 for further analysis. Data analysis consisted of descriptive statistics and comparisons across woredas as defined by CBHI status. Composite indicators (summary measures) were analyzed and compared. A two-level hierarchical linear model was performed to study the relative strength of structure, process, and individual characteristics in predicting client satisfaction with quality of services. Similarly, logistic regression was used to determine the predictors of CBHI enrollment. A 95% level of significance was considered for variables found to have significant association (p-value ≤0.05) with the outcome variable.

Qualitative data analysis

The key informant responses were audio-recorded, transcribed verbatim in local languages (Amharic, Oromifa and Tigrigna) and translated into English. Thematic analysis was used to analyze the data in three phases: preparation, team organization and reporting the summary result in each team. The first phase of the analysis started with careful reading of the data multiple times to become immersed in and familiar with the data. In the organization phase, each transcript was read carefully by the first author who highlighted the theme text (words or phrases) that appeared to describe the phenomenon under the study (use of CBHI, quality service, interaction). The highlighted theme text was openly and manually coded with descriptors. The third author read the data to confirm the descriptive codes. These codes were revised, and the codes that emerged from the revision were jointly reviewed before they were integrated into the analysis. The other authors collaborated with the first and third author to review, discuss and agree on the final code categories. The final analysis was summarized manually based on agreed emerging themes.

Ethical considerations

Ethical approval was obtained from Amhara, Oromia, SNNPR and Tigray Regional public health research institute institutional review board (IRB) committees, and permission letters were secured from the sampled health facility head. Each respondent gave informed verbal/oral consent after being told the purpose, risks, benefit, confidentiality, voluntary nature of participation, whom and how to contact principal investigators and procedures of the study in the presence of head of the facility. All respondent identifiers were kept confidential, and data were anonymized.

Results

Table 1 describes basic data by woreda insurance and personal insurance status within the woredas where CBHI was introduced. Woredas with insurance show higher age; it is likely that an older population is less educated and may also have a larger family. The differences in health expenditure across the woredas indicate that insurance has reduced health expenditure in the past year at point of care.

Table 1

Sample characteristics by woreda insurance status.

Categories	CBHI N = 415	Non-CBHI N = 141	All N = 556
Age	38.3	33	37
Some education (Proportion)	0.51	0.64	0.54
Income yearly, Birr2	16600	16600	16600
Family size	5.21	4.8	5.11
Health Exp Last year, Birr2	820	1204	925
Health Care Exp, this visit2	65	39	46
Distance to HF, minutes2	42	42	42

1Reporting at p-value < 0.05 unless otherwise stated.

2Some figures are rounded off and there is consistent reporting rounding off for some of these figures.

Tendencies to report to nearest 5 and 0 are common in many surveys.

Has the introduction and implementation of CBHI improved quality of health services?

Structural quality for health centers located in CBHI woredas showed general service-readiness index mean score (a composite summary measure combining information from observation of five general service-readiness domains: basic amenities, standard precautions, basic equipment, diagnostics, and essential medicines) of 0.62. This implies facilities’ readiness to provide 62% of general health services (Table 2). There was no statistically significant difference between overall structural quality in CBHI and non-CBHI health centers based on the general service-readiness index (mean difference = -0.002, p<0.9). However, the average diagnostic test capacity and availability of tracer drugs was better in CBHI woredas and availability of basic equipment was better in non-CBHI woredas.`

Table 2

Descriptive statistics for service-readiness and general-process-score index.

Aggregated index	CBHI		Non-CBHI		Mean difference	Sign (2-tailed)
	Mean	SD	Mean	SD
Service-readiness
Basic equipment	0.78	0.17	0.81	0.16	-0.03	<0.048**
Diagnostic test capacity	0.46	0.34	0.43	0.34	0.03	<0.510
Basic amenities	0.62	0.16	0.63	0.17	-0.01	<0.457
Tracer drug	0.47	0.35	0.43	0.31	0.04	<0.220
Standard precautions for infection prevention	0.77	0.19	0.79	0.19	-0.02	<0.210
Process-quality
Perceived provider followed proper procedure	0.50	0.25	0.50	0.27	0.00	<0.888
Perceived interpersonal relations	4.67	0.58	4.55	0.67	0.11	<0.077*
Observed availability of quality standard	0.61	0.23	0.54	0.26	0.06	<0.011**
Overall service readiness index	0.62	0.17	0.62	0.17	-0.002	<0.904
Overall process index	1.92	0.23	1.87	0.31	0.05	<0.065*

N = 556 Individual within 56 health facilities.

Significance levels for P values

*** p<0.01,

** p<0.05,

* p<0.1.

The general process score is a composite index of observed availability of service-quality standards, clients’ perception of providers adherence to proper procedures, and clients’ perception of interpersonal relations. This score showed differences between CBHI and non-CBHI woredas. Availability of service quality standards was better in CBHI woredas with a statistically significant difference between health centers located in CBHI and non-CBHI woredas (mean difference = 0.06, p<0.01). Client perception about interpersonal relationships between clients and service providers was also slightly better in CBHI woredas, but the difference was not statistically significant (mean difference = 0.11, P<0.08). The mean value of the general service process index for health centers located in CBHI woredas was perceived to follow proper service processes 92% of the time, while health centers in non-CBHI woredas were perceived to follow proper service processes 87% of the time. However, this difference was not a statistically significant (mean difference = 0.05, p<0.06).

Clients were asked to rate their level of satisfaction from very satisfied, to neutral and to very dissatisfied, based on their experience of service received (Table 3). More than 92% of respondents from health centers located in CBHI woredas were either satisfied or very satisfied with overall service quality. A higher proportion of clients of health centers in CBHI woredas gave high ratings of overall satisfaction (very satisfied/satisfied) than those in non-CBHI woredas (mean difference = 0.36, P <0.001).

Table 3

Patient satisfaction with service received (%).

Quality measures	CBHI woreda respondents			Non-CBHI woreda respondents
	Very satisfied/satisfied	Neutral	Dissatisfied/very dissatisfied	Very satisfied/satisfied	Neutral	Dissatisfied/very dissatisfied
Satisfaction indicator
Overall quality of service	92.4	5.1	2.6	84.8	7.2	7.9
Availability of drugs/medical supplies	89.2	3.9	6.8	79.3	9.3	11.4
Availability of diagnostic service	92.3	3.6	4.1	82.1	7.5	10.4
Cleanliness of facility	92.2	5.1	2.7	89.9	5	5
Short wait time (from the time of arrival in the health facility to seeing the health professional)	89.1	2.9	8	82.1	5	12.8
Short wait time between services (between consultation and diagnostics)	87.7	2.4	9.9	84.3	2.9	12.8
Friendliness of staff	92.7	4.1	3.1	87.1	5.7	7.1
Availability of private counseling service	94.7	1.9	3.4	87.1	5.7	7.1
Overall satisfaction of clients (mean score values)	4.25			3.89
	Mean difference = 0.35; P<0.000***

N = 556 Individual within 56 health facilities.

Significance levels for P values

*** p<0.01,

** p<0.05,

* p<0.1.

Following the comparative analysis, a two-level hierarchical linear model was used to analyze predictors of overall satisfaction of respondents living in CBHI and non-CBHI woredas. There was a significant heterogeneity among health centers regarding satisfaction with perceived service quality (Table 4). The intraclass correlation coefficient (ICC) in the null model for overall client satisfaction was 37.9%. This means that 38% of the variation in overall client satisfaction between the health centers is due to the difference between the health centers (cluster variation). The fixed estimate, that is estimated overall average satisfaction score across all health centers and client (individual), is 4.1 and is statistically significant. The fixed-effect model indicates that among the individual-level characteristics, client perception of interpersonal relations, perception of provider adherence to proper procedures, and client’s spending on non-medical costs were significantly associated with overall average client satisfaction (p<0.05). No facility-level variables significantly contributed to overall average client satisfaction with service quality. Therefore, predictors of client satisfaction were related to their perception of service received.

Table 4

Predictors of overall client satisfaction with quality of health service received.

Characteristics	Coefficient	95%CI	P-values
Individual level
Age	-0.001	(-.003,.002)	<0.730
Sex	0.01	(-.067,.086)	<0.802
Marital status	-0.07	(-.156,.0148)	<0.105
CBHI enrollment status	0.06	(-.028,.145)	<0.191
Spent non-medical expenses during facility visit	-0.001	(-.001, -.000)	<0.021**
Educational status
Illiterate (R)
Primary (1–6)	-0.01	(-.097,.082)	<0.86
Secondary (7+)	-0.1	(-.17,.023)	<0.14
Perception of interpersonal relations	0.46	(.392,.545)	<0.000***
Perception of proper procedures followed by providers	0.47	(.314,.627)	<0.000***
Facility level
Observed availability of service quality standard	0.36	(-.764,.036)	<0.075*
Basic equipment	0.03	(-.655,.705)	<0.942
Basic amenities	-0.20	(-.794,.396)	<0.512
Tracer drug	0.21	(-.403,.824)	<0.501
Diagnostic test	-0.19	(-.734,.357)	<0.499
Standard precautions infection prevention	0.05	(-.446,.548)	<0.841

N = 556 Individual within 56 health facilities.

Significance levels for P values

*** p<0.01,

** p<0.05,

* p<0.1.

Does quality of care affect enrollment in and renewal of CBHI?

Of the total respondents in the CBHI woredas, 81% were ever enrolled as a CBHI member. Of these, 69% were currently enrolled, and 31% did not renew. More than 79% of respondents in both groups said they enrolled to protect themselves from financial shortfalls when seeking care, and 46% of respondents said they enrolled because the premium was lower than the out-of-pocket payments for user-fees and other associated costs they and their household members incurred every time they sought health care (Table 5). Of the participants currently enrolled in CBHI scheme, 36% named frequent illness as their reason for enrollment. The decision to join a CBHI scheme is made on voluntary basis by each household, nearly 6% of respondents reported pressure to enroll by kebele administration (CBHI officials) during the enrollment process.

Table 5

Reasons for enrolling, discontinuing or not enrolling in CBHI scheme (%) (multiple responses).

Reasons for Enrolling or not Enrolling	Currently Enrolled (N = 223), n (%)	Previously Enrolled (N = 99), n (%)	Never Enrolled (N = 77), n (%)
Reasons for Enrolling in CBHI
Frequent illness	80 (36)	10 (10)
Financial protection	180 (81)	77 (78)
Fee waived	12 (5)	4 (4)
Low premium fee	106 (48)	42 (42)
Pressure from officials	14(6)	13 (13)
Reasons for not Enrolling or Discontinuing
Infrequent illness		12 (12)	4 (5)
Affordability		21 (21)	17 (22)
Lack of knowledge about either how to enroll or renew		23 (23)	33 (43)
Limited-service availability		7 (7)	14 (18)
Low service quality		11 (11)	4 (5)
CBHI staff not trusted		3 (3)	2 (3)
Long waiting time		4 (4)	4 (5)
Wanted to wait to confirm the benefit from other members		18 (18)	13 (17)17 (22)
Others

Financial protection and low premiums were the main reasons for CBHI enrollment and renewal. Among those never enrolled (n = 77), lack of understanding of the enrollment process (43%) and affordability (22%) played a prominent role, and some stated they wanted to confirm the benefits of the scheme with others (17%). Similarly, among members who did not renew (n = 99), 23% stated they did not have adequate knowledge about membership renewal, and 21% said that the enrollment fee was not affordable at the time of the renewal period and 11% declined to renew due to low service quality of available health care.

The logistic regression results showed that participant age, household family size, and high health care spending played an important role in CBHI enrollment and renewal. The findings determined a 5% increase in the odds of CBHI enrollment for a one unit increase in respondent age (AOR = 1.05, 95% CI: 1.03–1.07) indicating an increase in CBHI enrollment as the age of the client increases. Household family size was positively associated with enrollment: households with more than one member were 1.3 times as likely to enroll as single-member households (AOR = 1.27, 95% CI: 1.09–1.46). Educational status was significantly associated with renewal: respondents with a secondary level of education and above were less likely to drop out of the CBHI scheme (AOR = 0.89, 95% CI: 0.81–0.98). From a statistical point of view, our regression analysis failed to establish a significant association of service quality indicators (structural, process, and outcome quality) with CBHI enrollment and renewal (Table 6).

Table 6

Determinants of CBHI enrollment and renewal.

Indicators	Enrollment		Renewal
	AOR	95% C. I	AOR	95% C. I
Age	1.05	(1.03–1.07) ***	0.96	(0.93–0.98) ***
Sex (female/male)	1.18	(0.66–2.10)	0.60	(0.29–1.22)
Marital status (unmarried/married)	0.61	(0.31–1.19)	1.28	(0.55–2.99)
Educational level	1.06	(0.98–1.14)	0.89	(0.81–0.98) **
Spent of non-medical cost during facility visits 1	0.97	(0.96–0.97) ***	1.04	(1.02–1.05) ***
Family size	1.27	(1.09–1.46) **	0.83	(0.69–0.99) **
Service satisfaction	1.15	(0.62–2.16)	0.85	(0.38–1.86)
Structural-quality index	0.77	(0.07–8.61)	1.38	(0.07–25.66)
Process-quality index	0.62	(0.23–1.63)	1.79	(0.51–6.27)
Constant	0.52		1.01

Significance levels for P values

*** p<0.01,

** p<0.05,

*p<0.1.

1Non-medical cost is a composite cost that includes transport, lodging & food.

Qualitative findings

Factors influencing CBHI enrollment and delivering quality service are categorized by three themes (service availability and quality, right to access service). All key informant interview respondents said health service quality generally has improved in both CBHI and non-CBHI woredas recently. Clients in CBHI woredas are more likely to demand quality service than those in non-CBHI woredas who are paying out-of-pocket for health care services. This is because CBHI woredas promise to provide quality services using the CBHI premium that is collected at the beginning of the year from all enrolled households regardless of pre-existing health conditions. Their demands include the right to be served on time, the right to access basic drugs and laboratory services within a single facility, and the right to be treated respectfully by providers.

When we ask patients to buy drugs from a private pharmacy, CBHI members started to ask a question like, “who is going to pay us?”, and “who will reimburse our expenses?”. They say it is their right to get full service from here [health facility] as they were promised. They demand all services to be available at the facility.

–CBHI health center head

Key informants reported that these client expectations drove CBHI health facilities to work towards fulfilling the minimum quality requirement promised during CBHI enrollment.

One zonal CBHI focal person shared:

We had a challenge of renewing memberships and enrolling potential new members. This was because of the weakness in the service provision. Lack of adequate drug supply and poor service delivery had contributed.

According to the key informant interviews (with zonal and woreda CBHI focal persons), drug- and diagnostic-supply shortages in CBHI health facilities have forced providers to refer patients to private facilities for certain services. While alternatives are limited in Ethiopia, drug purchases, for example, can be made in the private sector. The clients were offered reimbursement for the costs they incurred in the private facilities, but because clients did not expect these referrals, these incidents have led to misunderstandings and client dissatisfaction. The study findings showed a shortage of drugs and supplies received from Ethiopian pharmaceuticals supply agency (EPSA) in both CBHI and non-CBHI facilities. However, facilities in CBHI woredas have the advantage of accessing financing from the CBHI scheme to procure drugs and supplies. As another interview participant (woreda CBHI focal person) mentioned, “In addition to the drugs supplied through EPSA, the facilities’ boards have recommended to buy additional drugs from private suppliers and make it available for patients. We are trying our best to do that.”

In summary, comparing quality of health services across health centers in CBHI and non-CBHI woredas, our findings revealed no significant differences at the structural level—for example, in facility-level preparedness to treat illness. But upon examination of specific indicator domains—for example, availability of diagnostics test and tracer drugs, we found minor differences. This and the fact that our exit interviews indicated that clients visiting health centers in both CBHI and non-CBHI woredas reported no structural issues related to quality of health service implies that the health centers are comparable in their overall preparedness to treat illness, but availability of replenishable items such as drugs and diagnostic tests was slightly better in CBHI woredas.

Discussion

There were differences in process- and outcome-quality indicators across health centers in CBHI and non-CBHI woredas. Provider-client interactions and perceived adherence to service quality standards appeared to influence client satisfaction more than any other factor. Respondents who were already engaged with the health centers might view facility care more positively than the general population. This type of finding has been noted elsewhere [23]. Subjective measures like the Likert scale might yield more optimistic values than those respondents report if probed. A study conducted in Burkina Faso found that, when probed, households gave less favorable answers to questions regarding satisfaction with health insurance than they did initially [31]. It is also possible that those who chose not to renew their CBHI enrollment or who never enrolled participated in the exit interviews to a lesser extent, as they might live further away from health centers. We should expect lower values than those reported for the current study, but we have no reason to think that values in one set of regions were more or less inflated than any other set of regions. Although nearly all respondents reported high satisfaction, clients of health centers in CBHI woredas ranked their satisfaction with services higher than clients of health centers in non-CBHI woredas. Clients in non-CBHI woredas reported lower availability of essential drugs, and when drug supply at the health center was low, more people reported purchasing drugs from private facilities. This phenomenon was not observed in the CBHI areas, indicating that it might be easier for clients in health centers in CBHI woredas to acquire drugs through non-payment.

Individual and household factors played a role in CBHI enrollment and renewal decisions than did quality of health service. Educational status, family size, and age were associated with insurance uptake. These individual factors raise a concern for equity in access to quality health services. Lower levels of education among those who did not renew might indicate the difficulty of reaching these clients with tailored information and education campaigns. The non-CBHI members in CBHI woredas demonstrated lesser understanding of insurance, signaling the need for more effective insurance education activities in the CBHI woredas. Household family size was positively associated with enrollment indicating those with more than one family member are motivated to enroll. The analysis indicated that older people are likely to be ill more frequently and therefore more inclined to enroll in insurance. The insured reported more illness, although this question did not elicit consistent answers from the uninsured. An ever-present problem with voluntary enrollment into insurance is adverse selection: those with higher risk of illness and more in need of health care are the first to enroll. The requirement to launch CBHI in woredas where half of the households in the woreda are willing to enroll can facilitate risk spread among the woreda population at large, strengthening the viability of health insurance and preventing strain on the quality of health service.

Among the primary purposes of health insurance is financing health care at the population level to alleviate the burden of expensive care incurred in a short period of time by individual households. A few insured patients had borrowed large sums of money in previous year before joining the scheme to finance health care costs. This suggests some degree of adverse selection, indicating incomplete risk sharing, as those who enrolled might have higher risk. Adverse selection can be hard to avoid when insurance enrollment is voluntary. Insured participants in this study borrowed less in general and paid much lower prices for drugs to buy from private pharmacies, a common health-care expense. Although there is some payment for care among the insured, it is relatively small. This finding is consistent with Mebratie and colleagues’ research findings, which showed a relationship between non-medical-related costs and enrollment status [12]. Respondents who spent more on these costs were less likely to enroll in or renew CBHI, because the insurance covers only medical treatment and not non-medical expenses such as transport, lodging, or food. Choosing to enroll in insurance is a complicated decision, and quality of health service is only one factor that influences this choice [12,23]. The descriptive and qualitative analysis revealed that quality of health care which includes availability of essential drugs is critical for enrollment and renewal of in the CBHI scheme. However, statistical analysis of the quantitative data showed that structural and process quality indices, and outcome proxy indicators showed no significant influence on CBHI enrollment or renewal decisions. Therefore, quality has not been the deciding factor in uptake of insurance. These results are consistent with other study findings [23]. However, more clients in CBHI facilities expressed satisfaction with the quality of services they received compared to their counterparts. The government has a universal responsibility to deliver an acceptable level of quality health care services in all facilities, whether CBHI or non-CBHI.

This study highlighted important findings to support the interaction between CBHI and quality of healthcare service. However, the data was not conclusive on factors that affect insurance uptake, exposing limitations of the study that also recognize the complexity of linking insurance with quality of health care. First, to show the linkages between facility- and individual-level quality scores and CBHI status, the facility-level was disaggregated into individual-level (client) data. There may be an atomistic fallacy. Second, poor quality of care might discourage people from using health centers altogether. This study explored health center users’ perceptions through exit interviews. The users had already made the choice to visit health centers, which indicates an inclination to value health center care already. Non-CBHI facility users may see a one-time payment as more affordable than the yearly CBHI fee. It is possible that quality of care is a small factor in the enrollment decisions of those already attending health centers and paying for services.

Conclusion

General structural quality of service was not statistically different between health centers in CBHI and non-CBHI woredas. However, availability of diagnostic test capacity and tracer drugs was slightly better in CBHI woredas than their non-CBHI counterparts. Process- and outcome-related measures of service quality based on clients experience in CBHI woredas scored better than and showed a statistically significant difference from non-CBHI woredas. The quantitative results were supported by key informant interview analysis: CBHI served to improve accountability of health facilities as well as critical aspects of service delivery (like drug availability), hence clients in CBHI facilities were satisfied. Regarding effects of service quality on CBHI enrollment or renewal, only within the woredas where insurance is being implemented and community members would have the choice of enrolling into insurance; showed individual and household (education, family size, age, and health care expenditure,) factors played a significant role in CBHI enrollment and renewal decisions.

The findings revealed that perceived quality of health care is essential for enrollment and renewal. However, health service quality was not shown to have a significant impact on CBHI enrollment or renewal in the statistical analysis of the quantitative data. An important point to note in this respect is ‘clients’ perception of quality, which is based on their experience of care and can differ from observed facility readiness and service availability or process of care provided according to standards and guidelines. Follow-up research is needed for a more nuanced look at the link between service quality and enrollment. Ease of enrollment is an important factor in increasing and retaining CBHI membership. Our findings indicate that households that did not renew CBHI lived further away from health centers, and some might have lacked information about the renewal process. Therefore, CBHI enrollment messages should address existing inequities and reach inaccessible households with tailored messages. Future education campaigns should consider emphasizing that future health risks are likely to be uniform across households and might not be related to the past incidences of ill health. Because age also seems to be a positive factor in enrollment, the program might want to consider offering young families a lower rate or making universal enrollment mandatory.

Study data.

(SAV)

Click here for additional data file.

Analysis.

(PDF)

Click here for additional data file.

Interview guide.

(PDF)

Click here for additional data file.

Survey tools.

(PDF)

Click here for additional data file.

7 May 2021

PONE-D-21-11751

The interaction of health service quality and community-based health insurance in Ethiopia

PLOS ONE

Dear Authors,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by 5 of July 2021. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Professor Hafiz T.A. Khan, Ph.D, CStat

Academic Editor

PLOS ONE

Additional Editor Comments:

Please revise the manuscript as per the comments of both reviewers. You need to check all your statistical results. Statistical p value cannot be 0000. In such case please indicate p<.001 which is highly significant.

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Please include your tables as part of your main manuscript and remove the individual files. Please note that supplementary tables should be uploaded as separate "supporting information" files.

3. Thank you for including your ethics statement:  "Each regional public health research institute’s ethical clearance committee reviewed and approved the study. Permission letters were obtained from the head of each selected health center for assessment in the center. All exit and key informant interview participants gave verbal informed consent.".

Please amend your current ethics statement to include the full name of the ethics committee/institutional review board(s) that approved your specific study.

Once you have amended this/these statement(s) in the Methods section of the manuscript, please add the same text to the “Ethics Statement” field of the submission form (via “Edit Submission”).

For additional information about PLOS ONE ethical requirements for human subjects research, please refer to http://journals.plos.org/plosone/s/submission-guidelines#loc-human-subjects-research.

4. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information. Moreover, please include more details on how the questionnaire was pre-tested, and whether it was validated.

5. When reporting the results of qualitative research, we suggest consulting the COREQ guidelines or other relevant checklists listed by the Equator Network, such as the SRQR, to ensure complete reporting (http://journals.plos.org/plosone/s/submission-guidelines#loc-qualitative-research). In this case, please consider including more information on the number of interviewers, their training and characteristics; and whether bias issues were considered. Moreover, please provide the interview guide used as a Supplementary file.

6. Please correct your reference to "p=0.000" to "p<0.001" or as similarly appropriate, as p values cannot equal zero.

7. Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified how verbal consent was documented and witnessed.

8. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

In your revised cover letter, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories.

We will update your Data Availability statement on your behalf to reflect the information you provide.

9. Thank you for stating the following in the Competing Interests section:

"The authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. The authors have declared that they have no competing interests exist."

We note that one or more of the authors are employed by a commercial company: JSI Research & Training Institute, Inc.

9.1. Please provide an amended Funding Statement declaring this commercial affiliation, as well as a statement regarding the Role of Funders in your study. If the funding organization did not play a role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript and only provided financial support in the form of authors' salaries and/or research materials, please review your statements relating to the author contributions, and ensure you have specifically and accurately indicated the role(s) that these authors had in your study. You can update author roles in the Author Contributions section of the online submission form.

Please also include the following statement within your amended Funding Statement.

“The funder provided support in the form of salaries for authors [insert relevant initials], but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The specific roles of these authors are articulated in the ‘author contributions’ section.”

If your commercial affiliation did play a role in your study, please state and explain this role within your updated Funding Statement.

9.2. Please also provide an updated Competing Interests Statement declaring this commercial affiliation along with any other relevant declarations relating to employment, consultancy, patents, products in development, or marketed products, etc.

Within your Competing Interests Statement, please confirm that this commercial affiliation does not alter your adherence to all PLOS ONE policies on sharing data and materials by including the following statement: "This does not alter our adherence to  PLOS ONE policies on sharing data and materials.” (as detailed online in our guide for authors http://journals.plos.org/plosone/s/competing-interests) . If this adherence statement is not accurate and  there are restrictions on sharing of data and/or materials, please state these. Please note that we cannot proceed with consideration of your article until this information has been declared.

Please include both an updated Funding Statement and Competing Interests Statement in your cover letter. We will change the online submission form on your behalf.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: I have attached the manuscript with tracked comments. Key issues include;

1. A table with biographic data of participants is essential.

2. You refer to 'quotas of participants' in your sampling. How was this decided.

3. It is unclear if qualitative data was collected using local languages? If this is the case, clarity is needed on how translation was undertaken.

4. Interviews. Were these face to face interviews? Were they audio recorded? If so, were they recorded in different languages? If so, was data translated to English before analysis?

5. Clarity is needed on how many participants took part in; 1. exit interviews; 2. Survey; 3. Key informant interviews.

6. Data analysis - You state that thematic data analysis of qualitative data was undertaken, but no themes were presented. What framework was used for thematic analysis? Who undertook the thematic analysis?

7. The discussion need to be structured around the finds for each research question. The discussion reads like further reporting of results. This needs to focus on what the results mean for the participants and population under study.

8.The implications of the findings need a more rigorous critique. 1. What are the implications of people not renewing their insurance from a health point of view? 2. You report that there is no statistical difference between the quality of service in CBHI and non-CBHI areas. What are the implications of this on the USAID Transform: Primary Health Care project if the project is not making a measurable difference?

Reviewer #2: 1. The objectives are relevant to the study; however, they are broad and need to be revised to make them more specific. Try linking the objective to the overall aim and or the research title to avoid the possibility of answering yes or no.

2. Donabedian model used for the study seems appropriate but the reason for the model selection is not to justify. Make a little comment about other available potential models

3. The use of a mixed-method approach is critical for the study. The sampling technique for the 2 components of the study needs to be more refine and explicit.

4. The method used to recruit participants for the qualitative study should be clearly stated

5. The findings were very important and the conclusions were well written. However, the conclusion can be summary

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Professor K Mafuba, PhD

Reviewer #2: Yes: Abdulsalam Ahmed

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Submitted filename: PONE-D-21-11751_reviewer.pdf

Click here for additional data file.

2 Jul 2021

Additional Editor Comments:

Please revise the manuscript as per the comments of both reviewers. You need to check all your statistical results. Statistical p value cannot be 0000. In such case please indicate p<.001 which is highly significant.

Response: Thank you for your valuable feedback. We have revised the manuscript as per your suggestion.

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

Response: we have checked and attest that all formatting and style requirements have been met.

2. Please include your tables as part of your main manuscript and remove the individual files. Please note that supplementary tables should be uploaded as separate "supporting information" files.

Response: we have included the tables as part of the main body of the manuscript and uploaded our additional supplementary information (Supporting Information-Analysis) to provide a full information about data analysis output.

3. Thank you for including your ethics statement: "Each regional public health research institute’s ethical clearance committee reviewed and approved the study. Permission letters were obtained from the head of each selected health center for assessment in the center. All exit and key informant interview participants gave verbal informed consent."

Please amend your current ethics statement to include the full name of the ethics committee/institutional review board(s) that approved your specific study.

Once you have amended this/these statement(s) in the Methods section of the manuscript, please add the same text to the “Ethics Statement” field of the submission form (via “Edit Submission”).

For additional information about PLOS ONE ethical requirements for human subjects research, please refer to http://journals.plos.org/plosone/s/submission-guidelines#loc-human-subjects-research.

Response: We thank the reviewer for the kind words. We have revised the ethical statement in the method section and included the name of the institution which provided ethical approval. The same correction is also made in the submission form.

4. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information. Moreover, please include more details on how the questionnaire was pre-tested, and whether it was validated.

Response: Thank you for the suggestion. We included the procedure on questionnaire pretest in the revised manuscript. We also attached the English version of the study questionnaire as a supplement “Supporting Information-Exit interview & facility survey tools”.

5. When reporting the results of qualitative research, we suggest consulting the COREQ guidelines or other relevant checklists listed by the Equator Network, such as the SRQR, to ensure complete reporting (http://journals.plos.org/plosone/s/submission-guidelines#loc-qualitative-research). In this case, please consider including more information on the number of interviewers, their training and characteristics; and whether bias issues were considered. Moreover, please provide the interview guide used as a Supplementary file.

Response: We considered the suggested COREQ guideline while revising the qualitative analysis section, and we have uploaded our interview guideline as supplementary file to provide clear information about our qualitative data collection (Supplementary file-Interview guide).

6. Please correct your reference to "p=0.000" to "p<0.001" or as similarly appropriate, as p values cannot equal zero.

Response: we have revised the statistical values (p-values) in the revised manuscript based on the comments.

7. Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified how verbal consent was documented and witnessed.

Response: We have expanded the ‘ethical consideration’ section to reflect how consent was obtained and witnessed.

8. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

In your revised cover letter, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories.

We will update your Data Availability statement on your behalf to reflect the information you provide.

Response: Thank you, there are no restrictions about data sharing and all relevant data are within the manuscript and we have uploaded the full data set as a supporting file (Study data). we do provide a privilege to update the statement on our behalf.

9. Thank you for stating the following in the Competing Interests section:

"The authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. The authors have declared that they have no competing interests exist."

We note that one or more of the authors are employed by a commercial company: JSI Research & Training Institute, Inc.

9.1. Please provide an amended Funding Statement declaring this commercial affiliation, as well as a statement regarding the Role of Funders in your study. If the funding organization did not play a role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript and only provided financial support in the form of authors' salaries and/or research materials, please review your statements relating to the author contributions, and ensure you have specifically and accurately indicated the role(s) that these authors had in your study. You can update author roles in the Author Contributions section of the online submission form.

Please also include the following statement within your amended Funding Statement.

“The funder provided support in the form of salaries for authors [insert relevant initials], but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The specific roles of these authors are articulated in the ‘author contributions’ section.”

If your commercial affiliation did play a role in your study, please state and explain this role within your updated Funding Statement.

9.2. Please also provide an updated Competing Interests Statement declaring this commercial affiliation along with any other relevant declarations relating to employment, consultancy, patents, products in development, or marketed products, etc.

Within your Competing Interests Statement, please confirm that this commercial affiliation does not alter your adherence to all PLOS ONE policies on sharing data and materials by including the following statement: "This does not alter our adherence to PLOS ONE policies on sharing data and materials.” (as detailed online in our guide for authors http://journals.plos.org/plosone/s/competing-interests) . If this adherence statement is not accurate and there are restrictions on sharing of data and/or materials, please state these. Please note that we cannot proceed with consideration of your article until this information has been declared.

Please include both an updated Funding Statement and Competing Interests Statement in your cover letter. We will change the online submission form on your behalf.

Response: Thank you for your suggestion. We have taken all the funding statement and computing interest statement in our cover letter. To make clear we also included author’s contribution in the cover letter.

*****************************************

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

________________________________________

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

________________________________________

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

________________________________________

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

________________________________________

*****************************************

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: I have attached the manuscript with tracked comments. Key issues include.

1. A table with biographic data of participants is essential.

Response: Thank you for the suggestion. We have added a table to display the participants characteristics per individual CBHI enrollment status.

2. You refer to 'quotas of participants' in your sampling. How was this decided?.

Response: Thank you for your question. We followed a consecutive sampling until we get adequate sample from each sampled Health centers. We have revised statements to clearly present how many participants were included from health facilities in CBHI and non-CBHI implementing woredas.

3. It is unclear if qualitative data was collected using local languages? If this is the case, clarity is needed on how translation was undertaken.

Response: Qualitative data was collected using key informant interview guide. All interviews were done using local languages. The tools in English language were translated to local language and then back to English to make sure the concepts are not lost in the translation process. We have revised statements to clearly present how the data collected and analyzed

4. Interviews. Were these face to face interviews? Were they audio recorded? If so, were they recorded in different languages? If so, was data translated to English before analysis?

Response: Yes, both the qualitative and quantitative data was collected using local languages, and then back translated into English before analysis. The key informants’ responses were audio-recorded, transcribed verbatim in local languages (Amharic, Oromifa and Tigrigna) were back translated into English and thematic analysis was used to analyze the data. The data process statement was revised to clearly present qualitative data analysis in the revised version of the manuscript.

5. Clarity is needed on how many participants took part in; 1. exit interviews; 2. Survey; 3. Key informant interviews.

Response: Thank you for the issues raised, we were considered 560 exit interviews, 56 facility survey and 28 key informant interviews. We have revised statements to clearly present how many participants included, the data collected and analyzed.

6. Data analysis - You state that thematic data analysis of qualitative data was undertaken, but no themes were presented. What framework was used for thematic analysis? Who undertook the thematic analysis?

Response: Thank you, we have revised statements to clearly present how the qualitative data analysis was done and who undertook the analysis, the following statements are included in the main body of the manuscript under data analysis:

“The key informant participant responses were audio-recorded, transcribed verbatim in local languages (Amharic, Oromifa and Tigrigna) were back translated into English and thematic analysis was used to analyze the data. We had used three phases data analysis: preparation, team organization and reporting the summery result in each team. The first phase of the analysis started from careful reading of the data multiple times to become immersed in and familiar with the data. In the organization phase, each transcript was read carefully by the first author, highlighting the theme text (words or phrases) that appeared to describe the phenomenon under the study (use of CBHI, quality service, its interaction). The highlighted themes texts were openly and manually coded by giving each them text a descriptive code. The third author read the data to confirm the descriptive codes. These codes were revised, and the codes that emerged from the revision were jointly reviewed before integrating them into the analysis. The other authors reviewed with the collaboration of first and third author, discussed, and agreed on the final code categories. The final analysis was summarized manually based on agreed emerging themes”.

7. The discussion need to be structured around the finds for each research question. The discussion reads like further reporting of results. This needs to focus on what the results mean for the participants and population under study.

Response: Thank you for the suggestion. We have moved part of the discussion, that reads like a result, into the result section. Moreover, we have added a paragraph that introduces the discussion outline which presented interpretation of the findings by triangulating different components of the study as well comparing the findings with related studies, to facilitate understanding of observed nuances that influence CBHI and quality interactions and also identify gaps for future investigation.

8. The implications of the findings need a more rigorous critique. 1. What are the implications of people not renewing their insurance from a health point of view? 2. You report that there is no statistical difference between the quality of service in CBHI and non-CBHI areas. What are the implications of this on the USAID Transform: Primary Health Care project if the project is not making a measurable difference?

Response: Thank you for the suggestion, the study showed that perceived quality of health care is essential for enrollment and renewal, although we were not able to generate strong evidence that CBHI improved quality of service. This study was not designed to investigate the effect of CBHI enrollment on individuals’ health outcome (morbidity or mortality associated with insurance). However, we assume the collective risk and financial burden sharing due to enrolment will result in better health outcome in the long run. If the people not renewing their insurance, there is no specific harm from the health point of view. They may be required to pay from out-of-pocket next time when they seek health care and it may lead to catastrophic health expenditure. One thing to note here is that choosing to enroll in insurance is a complicated decision, and quality of health service is only one factor that influences this choice. The study recognizes the complexity of linking insurance with quality of health care and mentioned as a limitation of the study and recommends further follow-up research to look at the link between healthcare service quality and CBHI enrollment or renewal. The result does not have any implication on TRANSFORM project, but for ease of management, we conducted the study in transform intervention areas as a study site.

Reviewer #2:

1. The objectives are relevant to the study; however, they are broad and need to be revised to make them more specific. Try linking the objective to the overall aim and or the research title to avoid the possibility of answering yes or no.

Response: Thank you for kind words, addressed accordingly in the revised version

2. Donabedian model used for the study seems appropriate but the reason for the model selection is not to justify. Make a little comment about other available potential models

Response: We have added a statement explaining that Donabedian model was a good fit for purpose to this assessment because it explores all the three elements of quality (structure, process and outcome) which are interlinked. “This model was adopted because it explores all the three elements of quality and postulates that the CBHI implementation mechanism itself and the related enhanced revenue generation would improve quality of health care service; enhanced quality of health care service or perceived quality itself would generate greater enrollment into CBHI”.

3. The use of a mixed-method approach is critical for the study. The sampling technique for the 2 components of the study needs to be more refine and explicit.

Response: Thank you for your feedback. We have revised statements to clearly present how the sample and sampling technique used.

4. The method used to recruit participants for the qualitative study should be clearly stated

Response: Thank you, the revision was made in the manuscript

5. The findings were very important, and the conclusions were well written. However, the conclusion can be summary

Response: Thank you. We addressed it accordingly.

Submitted filename: point by point Response to Reviewers_f.docx

Click here for additional data file.

30 Jul 2021

The interaction of healthcare service quality and community-based health insurance in Ethiopia

PONE-D-21-11751R1

Dear Authors,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Professor Hafiz T.A. Khan, Ph.D, CStat

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for addressing my questions. I have no further comments. I enjoyed reading your paper and wish all the best with the publication.

Reviewer #2: All the raised concerned are appropriately addressed and the article has been considered for publication without further review.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: Yes: Professor Kay Mafuba

Reviewer #2: Yes: Abdulsalam Ahmed

11 Aug 2021

PONE-D-21-11751R1

The interaction of healthcare service quality and community-based health insurance in Ethiopia

Dear Dr. Tefera:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Professor Hafiz T.A. Khan

Academic Editor

PLOS ONE