Barriers and enablers of community-based health insurance enrollment in the Sidama national regional state, Southern Ethiopia, 2024: A qualitative study

The universal health coverage (UHC) efforts in low- and middle-income countries such as Ethiopia encounter significant challenges in the implementation of community-based health insurance (CBHI) programs. This study investigated barriers and enablers influencing CBHI enrollment in Sidama National Regional State. Using purposive sampling, 48 participants were recruited, including four focus groups (12 participants each) and 20 key informant interviews. Participants comprised CBHI members (n = 5), non-members (n = 5), community leaders (n = 4), policymakers (n = 3), and healthcare providers (n = 3). Data collection occurred over three weeks in May 2024, with thematic analysis employed following phenomenological principles. Ethical considerations such as informed consent, confidentiality, and data protection were strictly observed. Findings indicate that awareness of CBHI has improved across Sidama; however, persistent misconceptions remain, including beliefs that CBHI is exclusively for the poor or is synonymous with preparing for illness. Several structural barriers were identified, notably ambiguous governance frameworks, a lack of accountability, and inadequate human resources. Issues in service delivery further undermine program effectiveness, characterized by discrimination against CBHI members, frequent shortages of essential medications and laboratory services, and delays in payment processes. Financial management challenges, lack of transparency, and the absence of grievance mechanisms were also found to erode community trust in the CBHI system. Despite these challenges, CBHI is recognized as valuable for reducing healthcare costs and enhancing access, particularly among women and low-income households, empowering women’s autonomy in health decisions. Community-based health insurance (CBHI) in the Sidama Region has improved awareness and access to healthcare. However, sustainability is challenged by misconceptions, governance challenges, and service delivery issues, which undermine trust and reduce enrollment and retention. Addressing governance, transparency, equity, and community involvement is crucial to strengthening CBHI and ensuring equitable healthcare access.