Equity in healthcare: Stakeholder perceptions on the implementation of the Community-Based Health Insurance scheme in Ethiopia
The last four decades have seen universal health coverage (UHC) become a central part of the global agenda. Despite this centrality, a large proportion of academics still focus solely on health schemes in the Global North, and the remaining few that have evaluated interventions in developing countries have rarely considered the inequities and power dynamics that exist within health systems in a comprehensive and interrelated way. This study adopted a qualitative approach, primarily based on 223 semi-structured interviews, to explore stakeholder perceptions on the implementation of the Community-Based Health Insurance Scheme (CBHIS) in Ethiopia. In doing so, this research offers a bold contribution to understanding the extent to which efforts to achieve UHC in the regions of Tigray and Oromia can be considered equitable, particularly when gender and ethnicity are examined. It explores how implementation can diverge from programme design by investigating the role of health workers, as street level bureaucrats, in the day-to-day delivery of the scheme. It also contextualises findings through the theoretical lenses of patient-centredness, the five dimensions of access, and the notions of gender-based power dynamics. This study shows that although the CBHIS has contributed to increasing access to healthcare services for many, particularly those residing in rural areas, such progress has been partially hindered by complex implementation challenges. Low awareness levels and high health worker workloads, combined with a shortage of medication and diagnostic equipment in public health facilities, amongst other issues, have resulted in a scheme that is not always able to meet the expectations of its members. Furthermore, CBHIS decision-makers were confronted with the challenge of striking a balance between equity and financial sustainability. This study contributes to understandings about how individuals navigate health insurance programmes, how front-line stakeholders interpret policy directives, and how authorities respond to emerging and shifting implementation challenges.