Comparison of Health Service Utilization and Determinants between Insured Women and Uninsured Women in the Sidama Region, Southern Ethiopia: A Multilevel Analysis

  

    
Types of the models
    
Model    selection criteria
  
  

    
LL 
    
AIC
    
BIC
  
  

    
Null    model (Model0)
    
-735.57
    
1487.13
    
1522.82
  
  

    
Individual    variables (Model1)
    
-538.58
    
1111.17
    
1187.01
  
  

    
Community    variables (Model2)
    
-697.86 
    
1409.72
    
1440.95
  
  

    
Individuals    and community variables (Model3)
    
-513.40  
    
1084.16
    
1177.86
  

Table 6: Model Comparison and selection criteria among women of non-CBHI
members in the central zone of Sidama region, Ethiopia, 2024 (n=640).

The null model (Model 0) served as a baseline without any predictor variables. Consequently, the model indicated the worst fit with the highest (least negative) log-likelihood (LL) of -735.57 and the highest Akaike Information Criterion (AIC) and Bayesian Information Criterion (BIC) values of 1487.13 and 1522.82, respectively. In contrast, the individual variable model (Model 1) fits substantially better than the null model, with a lower LL (-538.5831), AIC (1111.17), and BIC (1187.01). This improvement implied that individual factors significantly influence healthcare utilization among women who are non-CBHI members.

Similarly, the community variables model (Model 2) outperformed the null model. However, this model has worse metrics than Model 1, suggesting that community factors alone do not explain as much variation as individual variables. Furthermore, the combined model (Model 3) demonstrated the best fit, with the lowest LL (-513.40), AIC (1084.16), and BIC (1177.86). Therefore, a multi-level approach including individual and community determinants provided the most comprehensive perspective on healthcare utilization patterns. In conclusion, the superior performance of Model 3 supported adopting an integrated framework considering individual, community, and health system influences. This application of a multi-level approach provided a more nuanced understanding of healthcare utilization patterns and their associated factors among non-CBHI members.

Discussion

The study conducted in central Sidama Zone, Ethiopia, among 1,280 women (640 CBHI members and 640 nonmembers) indicated that the frequency of healthcare utilization revealed relatively higher healthcare utilization among CBHI members (368 (57.5%) compared to non-members (253 (39.5%). Accordingly, CBHI membership was associated with a 77.34% higher frequency of health facility visits compared to non-members.

This trend aligned with other studies observed across Ethiopia, where CBHI membership was consistently associated with increased healthcare use. For example, a study in Woreta town, south Gondar zone, found that health service utilization rates were 50.5% for CBHI scheme members and 29.3% for non-members [53]. Similarly, another study in north-west Ethiopia reported healthcare utilization rates of 35% for CBHI members and 22% for non-members [53].

Another study in the Berek district, Oromia region, found that the CBHI utilization rate was 49.8% among informal workers, with the majority having acquired knowledge about CBHI from medical experts. This suggests that CBHI membership is associated with increased healthcare utilization, particularly among vulnerable groups as this eases the financial burden of acquiring healthcare [54].

There were similar trends beyond Ethiopia. For example, in Burkina Faso, healthcare utilization was 40% higher as compared to non-members, while the differential effect on utilization of inpatient care between insured and non-insured groups was insignificant [33]. Likewise, in Senegal, insured individuals use health care more frequently than non-insured ones [55].

Similarly, in Bangladesh, a study found that healthcare utilization was higher among CBHI members (50.7%) compared to nonmembers (39.4%) [56]. A study from India also revealed that there were significant differences in the average number of healthcare visits between insured and uninsured members [57].

Additionally, in Rwanda, where CBHI coverage was nearly universal, insured households were twice as likely to use health services when compared to uninsured households [58,59]. Moreover, a study from Kenya depicted that insured members utilized higher hospitalization care compared to non-insured individuals [60].

The higher frequency of health facility visits among CBHI members underscored the importance of expanding affordable financial risk protection mechanisms [61,62]. This is because community-based health insurance schemes could provide financial protection to members, reduce out-of-pocket expenses, and increase access to healthcare services [63].

The study conducted in the central Sidama zone of Ethiopia further highlighted various individual and community-level factors that influenced healthcare utilization among women. According to this study, age was positively associated with healthcare utilization, indicating a 1.2% increase in healthcare visits for each additional year of age. Similarly, research in Sri Lanka demonstrated that older adults exhibited higher healthcare utilization rates, particularly for chronic conditions, due to increased health awareness and the necessity for regular medical attention [64]. In Nigeria, a study indicated that older adults sought more healthcare services, reflecting a similar trend [65,66]. Additionally, research in India showed that older women were more inclined to utilize maternal health services due to greater health awareness [67].

Furthermore, a study in Kenya found that older adults utilized more healthcare services, particularly for chronic diseases [68]. The positive relationship that was found between older age and an increased frequency of healthcare visits aligned with evidence that health often deteriorates with age [69,70].

This pointed out that health problems become worse as the age of the woman increases, calling for the importance of providing accessible healthcare for aging women to meet their growing health needs [71]. For example, older women may require frequent health facility visits due to chronic health conditions, which can be managed through primary care services [72].

Similarly, the study discovered that older women may have had a higher perceived need for healthcare services due to their increased vulnerability to health issues, leading to frequent and more regular health facility visits [73]. Consequently, the positive association between age and healthcare utilization in Ethiopia aligned with findings from Sri Lanka, Nigeria, India, and Kenya, suggesting that older individuals are more likely to seek medical attention due to health concerns.

The study also revealed that women residing in rural areas had a 26.3% lower frequency of health facility visits compared to their urban counterparts. The urban-rural dichotomy is a common issue in many countries. For instance, in Nigeria, rural women faced significant barriers to healthcare access, such as transportation challenges and fewer available services, which resulted in lower healthcare utilization [74,75]. Similarly, a study in Bangladesh identified that rural populations had limited access to healthcare facilities, exacerbating health disparities [76]. Similar findings from China highlighted that rural residents had lower healthcare utilization compared to their urban counterparts, primarily due to socioeconomic factors and healthcare infrastructure disparities [77].

Additionally, a study from Ghana also found that rural residents utilized fewer healthcare services due to distance and a lack of transportation [78]. In Ethiopia, another study identified that rural households were less likely to seek modern healthcare compared to urban households [79]. Thus, findings from Ethiopia and other countries reflect a broader trend where rural residents encounter challenges that hinder their access to healthcare use [80]. The evidence from Nigeria, Bangladesh, China, and Ghana supports the notion that urban-rural disparities significantly influence healthcare utilization, highlighting the need for targeted interventions in rural areas.

Moreover, the study found that literate women had a 30% higher frequency of health facility visits compared to those without formal education. This association is consistent with a study from Bangladesh, which indicated that educated women sought maternal healthcare due to enhanced health literacy [81]. In South Africa, a study revealed that higher educational attainment was associated with increased healthcare utilization, as educated individuals were more likely to understand and navigate the healthcare system [82]. In Finland, high healthcare utilization across educational levels was attributed to universal healthcare access and public health campaigns targeting all demographics [83].

In Ethiopia, a study indicated that maternal education influenced healthcare utilization for childhood illnesses, with educated mothers being more likely to seek care for their children [84]. Additionally, a study in Indonesia showed that education was a significant predictor of healthcare utilization among women, with higher education levels associated with increased healthcare utilization [85]. Therefore, the positive association between education and healthcare utilization in Ethiopia is consistent with findings from Bangladesh, South Africa, Indonesia, and other developing nations, suggesting that education enhances health literacy and encourages proactive health-seeking behavior.

This is because literacy could empower women to better understand their health needs and seek healthcare use Likewise, literacy may have also improved women's ability to communicate with healthcare providers, which could lead to better healthcare outcomes [86]. Conversely, a study in India found that despite higher education levels, cultural barriers still impacted women's healthcare-seeking behavior which could be due to different socio-cultural context [87].

Additionally, the study also indicated that extended waiting time at healthcare facilities was associated with a 32% reduction in health facility visits. Longer waiting times are a recognized barrier to healthcare access worldwide [88]. For example, a study in the United States revealed that patients often delayed or avoided necessary care due to long wait times, particularly in emergency departments [89].

Another study from Taiwan revealed that waiting times significantly impacted healthcare utilization, with longer waits resulting in decreased outpatient and inpatient utilization [90]. Additionally, a study in Ghana highlighted that long waiting times deterred patients from seeking healthcare, particularly in rural areas [91].

In Ethiopia, another study depicted that longer waiting times contributed to low healthcare utilization, especially among rural populations [92]. Therefore, long waiting times could lead to frustration and dissatisfaction among patients, reducing their likelihood of seeking healthcare [93]. This could be particularly problematic for women, who may have had limited time due to their responsibilities at home and in the community [94].

Consequently, the negative impact of longer waiting times on healthcare utilization in Ethiopia mirrors findings from the United States, Taiwan, Ghana, and other developing nations, underscoring the importance of establishing efficient healthcare delivery systems. Conversely, research in India found that efficient scheduling systems in hospitals reduced waiting times, leading to higher patient satisfaction and utilization rates. This suggests that system improvements can enhance patient satisfaction and encourage higher healthcare utilization rates [95].

The study also revealed that higher member satisfaction was associated with increased health facility visits, with a 4% increase in visits for each unit increase in healthcare satisfaction. Satisfaction with healthcare services influences utilization globally [96]. For instance, in Australia, higher patient satisfaction was linked to increased follow-up visits and preventive healthcare utilization [97]. A study conducted in China highlighted that patient satisfaction was a critical determinant of healthcare utilization [98]. Additionally, a study in South Africa found that high satisfaction levels among patients led to increased healthcare utilization, particularly in chronic disease management [99,100].

In Ethiopia, research indicated that satisfaction with healthcare services positively influenced the likelihood of seeking healthcare, particularly among women [101]. Thus, the positive relationship between member satisfaction and healthcare utilization in Ethiopia aligned with findings from Australia, China, and South Africa, suggesting that satisfied patients are more likely to seek care.

However, a study in the UK indicated that patient satisfaction varied significantly across different healthcare services, impacting overall healthcare utilization. The challenges faced in the UK highlight that, while satisfaction is crucial, systemic issues can affect overall healthcare utilization [102].

Moreover, the study found that women in communities with higher literacy levels exhibited a 76% higher frequency of healthcare visits. This was consistent with studies in India and Nigeria that demonstrated positive associations between community-level educational attainment and maternal healthcare utilization [103]. The impact of community literacy on healthcare utilization was also evident in South Africa, where higher literacy rates in communities are associated with increased health-seeking behaviors [104]. In Sri Lanka, community literacy significantly influenced healthcare utilization, with more educated communities demonstrating better health outcomes [105].

Community literacy rates were associated with better healthcare utilization among women's communities, demonstrating better health outcomes [106]. In Ethiopia, a study found that communities with higher literacy levels had significantly better healthcare utilization rates, particularly for maternal and child health services [107]. Therefore, the findings from Ethiopia reflect a broader trend where community literacy enhances individual healthcare-seeking behaviors.

The evidence from South Africa, Sri Lanka, Kenya, and other developing nations supports the notion that educated communities foster better health outcomes, while the situation in the United States indicates that systemic factors can overshadow the influence of literacy on healthcare utilization. In contrast, the United States has seen disparities in healthcare access and utilization that are less influenced by community literacy due to a more complex healthcare system where insurance status often plays a more significant role [108].

Finally, the study indicated that women in low-poverty communities had a 33% higher frequency of health facility visits compared to those in higher-poverty communities. This reveals that socioeconomic status significantly influences healthcare utilization worldwide [109]. For instance, in Brazil, a study showed that individuals in wealthier neighborhoods had better access to healthcare services [110]. In addition, findings from China indicated that higher per-capita household expenditure was positively associated with healthcare utilization, particularly among low-socioeconomic groups [111].

Furthermore, a study in Ghana revealed that economic status significantly influenced healthcare access, with poorer households facing substantial barriers to healthcare utilization [112]. In Ethiopia, a study found that households in the highest wealth quintile were three times more likely to seek healthcare in hospitals compared to those in the lowest quintile, highlighting the impact of economic status on healthcare utilization [113].

Consequently, the positive association between communitylevel socio-economic status and healthcare utilization in Ethiopia is consistent with findings from Brazil, China, Ghana, and other developing nations, suggesting that economic stability enhances access to healthcare services. Conversely, in Sweden, while socioeconomic status influenced healthcare access, the universal healthcare system mitigated many disparities, leading to more equitable healthcare utilization across different economic strata. The situation in Sweden illustrates that, while economic factors are important, systemic healthcare policies can reduce disparities and promote equitable access [114].

Limitations of the Study

This study has several notable limitations. Firstly, its crosssectional design restricts causal inferences [115] about the relationship between healthcare utilization determinants and community-based health insurance (CBHI) membership. The reliance on self-reported data may introduce response bias, thereby compromising the accuracy of reported healthcare utilization and associated factors.

Additionally, the study's focus is limited to the Sidama National Regional State, which may affect the generalizability of the findings to other contexts. Moreover, concentrating exclusively on women may overlook the influence of male decision-makers and broader family dynamics on healthcare utilization.

While various individual and community-level factors were examined, potential unmeasured socio-cultural influences may also play a role [116]in healthcare utilization The data collection was confined to a specific timeframe, possibly missing seasonal variations in health-seeking behaviors. Despite a high response rate, nonresponse bias is a concern, as individuals who declined to participate might differ systematically from those who did [117].

Finally, the study's quantitative approach may have overlooked qualitative insights [118] that could provide a more detailed understanding of participants' experiences with healthcare utilization. Acknowledging these limitations is essential for refining future research methodologies and deepening the understanding of factors contributing to healthcare utilization. Therefore, the extent of these limitations might have been undervalued or overvalued, and as such, the association of these determinants with healthcare utilization might have been underestimated or overestimated.

Conclusion

The Central Sidama Zone of Ethiopia conducted a study that revealed significant disparities in healthcare utilization between community-based health insurance (CBHI) members and nonmembers. Women of CBHI members showed substantially higher healthcare utilization rates (57.5%) compared to women of non- CBHI members (39.5%), a trend consistent with findings from other Ethiopian and other countries. This pattern revealed the relevance of CBHI schemes in improving healthcare access, particularly for vulnerable groups such as women.

The study also demonstrated a complex web of individual and community-level determinants influencing healthcare utilization, including age, educational level, place of residence, healthcare satisfaction, community-level poverty, community-level literacy, and waiting times. Despite the positive association with CBHI membership, overall healthcare utilization in Ethiopia is persistently below international standards, reminding us of the need for continued efforts to address both individual and community-level barriers to healthcare access.

These findings provided valuable evidence complementing the role of community-based health insurance in improving healthcare utilization. They also emphasized the importance of developing tailored interventions to tackle the specific challenges different communities face in accessing healthcare services, ultimately working towards more equitable and comprehensive healthcare coverage among women in Ethiopia.

Recommendations

Based on the findings of this study; while considering the limitations of the cross-sectional study design, the following recommendations were made to improve healthcare access and utilization among women in Ethiopia:

To address the barriers of rural-urban disparities, implement targeted interventions to improve healthcare access in rural areas. Additionally, develop community-wide education programs to enhance literacy rates, focusing on women, as higher community literacy is strongly associated with increased healthcare utilization. Furthermore, expand and improve community-based health insurance (CBHI) schemes to boost healthcare utilization among members.

However, consider local contexts when designing and implementing interventions, as CBHI effectiveness varies across regions in Ethiopia. Consequently, reduce waiting times at healthcare facilities through efficiency measures, as long waits discourage utilization, especially for women with limited time.

In addition, develop targeted healthcare services for older women, who demonstrate higher healthcare needs and utilization rates. Similarly, in collaboration with stakeholders, implement poverty reduction strategies at the community level, as lower poverty is correlated with higher healthcare utilization.

Finally, conduct longitudinal research to understand regional variations in CBHI effectiveness and healthcare utilization to inform policy decisions. Subsequently, develop comprehensive health education programs focusing on preventive care and early intervention, targeting women and their families. Therefore, these recommendations aim to improve healthcare access and utilization in Sidama, Ethiopia, while leveraging the positive impact of communitylevel education and insurance schemes.

Declaration

Ethics approval and consent to participate

This study was conducted following and in compliance with the Declaration of Helsinki and its later amendments, which provide ethical guidelines for medical research involving human study participants. Accordingly, ethical approval was received from the Institutional Review Board (IRB) of Hawassa University College of Medicine and Health Sciences, and informed consent was secured from each study participant.

Confidentiality and privacy were ensured, and a support letter from the regional health bureau was obtained to protect participant rights and well-being. To safeguard the confidentiality and privacy of study participants, the following approach was employed: Participants were thoroughly informed about the study's objective and assured that their responses would remain confidential and anonymous. Informed written consent was obtained using a consent form approved by the Institutional Review Board (IRB) committee.

The consent form detailed essential information, including the study title, the data collector's guide, the study's purpose, the approximate interview duration, and a guarantee of confidentiality and anonymity. This form was thoroughly documented by the interviewer, ensuring a comprehensive record of the consent process. Furthermore, a support letter was obtained to provide additional safeguards for the participants' rights and well-being. This letter added an extra layer of oversight and assurances regarding the study's confidentiality.

In summary, the combination of IRB approval, informed consent, and other measures rigorously ensured the protection of participants' privacy. This comprehensive approach ensured confidentiality and anonymity were prioritized throughout this research process.

Author contributions

Kare Chawicha Debessa: Conceptualization; Data curation; Formal analysis; Funding acquisition; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Writing-original draft; Writing-review & editing.

Keneni Gutema Negeri: Formal analysis; Investigation; Methodology; Project administration; Supervision; Validation; Writing-original draft; Writing-review & editing.

Mesay Hailu Dangisso: Formal analysis; Investigation; Methodology; Supervision; Software; Validation; Writing-original draft; Writing-review & editing.

Acknowledgment

The authors would like to sincerely thank the study participants, data collectors, supervisors, Hawassa University College of Medicine and Health Sciences, Sidama National Regional Health Bureau, and the health offices of Dale Woreda and Yirgalem City for their invaluable contributions to this research. Their support and collaboration were essential to its successful completion.

Funding

This study was supported by the Sidama National Regional Health Bureau. The funding organization had no role in the conceptualization, design, data analysis, manuscript preparation, and publication.

Availability of data and materials

The datasets utilized for this study are available within the manuscript as a supplemental file 3.

ORCID iDs

Kare Chawicha Debessa iD https://orcid.org/0009-0002-6118-9153

Keneni Gutema Negeri iD https://orcid.org/0000-0003-2697-7242

Mesay Hailu Dangisso iID https://orcid.org/0000-0003-2858-7248

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