Household’s Head Satisfaction and Associated Factors Towards Community-Based Health Insurance (CBHI) Schemes Among Enrollees in Northwest Ethiopia
Abstract
Background: Community-based health insurance (CBHI) is an emerging form of microhealth insurance that relies on the principle of solidarity, with community members pooling money to help with medical expenses. The level of household heads’ satisfaction with CBHI schemes is more likely to affect their decision to remain enrolled and the entrance of new members. However, studies regarding household heads’ satisfaction with the CBHI schemes are scarce in Ethiopia. Therefore, this study aimed to determine the level of satisfaction with CBHI schemes and associated factors among heads of households in Northwest Ethiopia.
Methods: A community-based cross-sectional study was conducted from March 1–30, 2022. A stratified random sampling technique with multistage sampling was used to select 604 study participants. A face-to-face interview was conducted using a pretested structured questionnaire. Both bivariable and multivariable logistic regression analyses were conducted. An adjusted odds ratio (AOR) with 95% confidence intervals (CIs) was computed to evaluate the strength of the association, and variables with a p value < 0.05 at a 95% CI were considered statistically significant.
Results: This study found that about 56.1% of household heads were satisfied with the CBHI schemes. Being older age (AOR = 1.85; 95% CI: 1.17, 2.94), rural residence (AOR = 4.13; 95% CI: 2.24, 7.62), visited only health center (AOR = 0.34; 95% CI: 0.20, 0.55), distance from a health facility (AOR = 3.18; 95% CI: 1.82, 5.55), agreement with prescribed drugs (AOR = 2.31; 95% CI: 1.36, 3.92), friendliness with healthcare provider (AOR = 3.65; 95% CI: 2.18, 6.10), and had a good knowledge of benefit packages (AOR = 3.00; 95% CI: 1.93, 4.67) were significantly associated with household head satisfaction.
Conclusion: The overall satisfaction of household heads with the CBHI schemes was good. The type of health facility visited, residence, age, distance from health facilities, relationship with healthcare providers, agreement with prescribed medications, and knowledge of community based health insurance were significantly associated with participants’ satisfaction. Thus, these findings suggest that improving access to healthcare services, fostering better relationships between healthcare providers and beneficiaries, and enhancing awareness of CBHI benefits could further increase satisfaction levels among households.
1. Introduction
According to the World Health Organization (WHO), 12% of the population in the world spend at least 10% of their household income on healthcare, and half of the people do not have access to the health services [1]. In low- and middle-income countries (LMICs), healthcare services are unaffordable and inaccessible to the majority of underprivileged people [2].
Community-based health insurance (CBHI) is a new form of microhealth insurance that relies on the principle of solidarity, with community members pooling money to help with medical expenses [3]. Furthermore, CBHI has its foundation on the reduction of adverse selection possibility, connections with healthcare providers, and an underlying ethic of enrollment, solidarity, and mutual aid [4, 5].
The Ethiopian government has launched CBHI, which aspires to cover 85% of the population who are engaged in the informal sector [6]. However, the CBHI enrollment coverage in Ethiopia was 55% [7], but the renewal rate shows an increment from 54% to 82%, and a significant number of dropouts were observed in each year [8].
Entrance of new enrollees and renewal of enrollment are more likely to be affected by enrollees’ satisfaction with the insurance schemes [9–11]. To identify the gaps on the quality of healthcare service delivery and providing insight on the accessibility and responsiveness of healthcare services, evaluating the enrollees’ satisfaction play a crucial role [12]. It can also be used as a guidance tool for nongovernmental organizations (NGOs), healthcare facilities, and the Ethiopian Health Insurance Agency (EHIA). Only a few institutional-level studies are conducted in Ethiopia, which reported that the satisfaction of household heads was ranged from 56.2% to 61.1% [13–15]. Nonetheless, to the best of researchers’ knowledge, no study has been conducted on the satisfaction of CBHI users at the community level in the study area. Furthermore, evidence showed that there is a significant differences in community enrollment with the CBHI scheme across different areas of the country due to the variations in administrative and healthcare service provider facilities [16, 17]. Thus, this study aimed to assess the household heads’ level of satisfaction and associated factors towards CBHI schemes in Northwest Ethiopia.
2. Methods
2.1. Study Design
A community-based cross-sectional study was conducted to assess the level of satisfaction and associated factors with the CBHI schemes.
2.2. Study Area and Period
This study was carried out in the Bibugn district in Northwest Ethiopia between March 1 and March 30, 2022. The district has 4 urban and 15 rural kebeles, with an estimated total population of 97,626. One primary hospital, four health centers, and 18 health posts were found in the district [18]. Since March 2017 G.C., the district has been implementing the CBHI scheme program. In the district, 81% of households are currently enrolled in CBHI schemes [19].
2.3. Population
All households’ heads who enrolled to the CBHI scheme in Bibugn district were the source population, whereas the study population were households’ heads who enrolled to CBHI scheme in selected kebeles of Bibugn district.
2.4. Eligibility Criteria
Households that were members of the CBHI schemes and had at least one family member who visited public health facilities at least once starting from their enrolment were included. However, those who were seriously sick and unable to give a response were excluded from this study.
2.5. Sample Size Determination
Additionally, sample size adequacy was checked by using factors associated with households’ heads satisfaction with CBHI schemes (Table 1).
| Variable | Proportion | Sample size |
|---|---|---|
| Having adequate knowledge of the CBHI benefit packages | 45.7% | 630 |
| Households who visited only hospitals | 14.8% | 320 |
| Households who agreed with the laboratory services received | 87.9% | 270 |
| Households with enrollment length ≥ 12 months | 69.1% | 542 |
Therefore, after adding the 10% nonresponse rate, the maximum sample size was 630.
2.6. Sampling Technique and Procedure
A stratified multistage sampling technique was employed to select the study participants. After kebeles were stratified into urban and rural kebeles, a simple random sampling method was applied to select 30% of kebeles from each stratum. Finally, the study participants were selected using a systematic random sampling method (Figure 1).
2.7. Data Collection Tools and Procedures
A structured questionnaire developed by reviewing various literatures [16, 17, 20, 21]. Then, 10 items related to satisfaction on a 5-point Likert scale were used. Data were collected through face-to-face interviews with the heads of households. Data collection was conducted by four BSc nurses, supervised by one senior public health officer.
2.8. Data Quality Assurance
The questionnaire was prepared in English and translated to Amharic and back to English to ensure consistency. A pretest was conducted among 32 study participants who live in Dega Damot district. A two-day training was given to data collectors on the objectives of the study, methods of data collection, data collection tools, and ethical principles. Spot checks on the quality of data collection were made in the field, and the completeness of questionnaires was checked. The internal consistency of the scales was checked using Cronbach’s alpha test.
2.9. Data Processing and Analysis
The data were entered into Epi Data version 4.6 and then exported into SPSS version 23.0 for analysis. Descriptive statistics such as frequencies, means, medians, and percentages were calculated. Bivariable and multivariable logistic regression analyses were carried out to assess the association between independent variables and the outcome variable. Variables with a p value of less than 0.2 at CI 95% in the bivariable analysis were included in the multivariable logistic regression, analysis and a p value < 0.05 at 95% CI was used to declare the statistical significance. The Hosmer and Lemeshow goodness-of-fit test was checked to ensure that the model was adequate (p = 0.12). Multicolinearity was checked using the variance inflation factor (VIF = 1.72) and the internal consistency of the 10 items was checked using Cronbach’s alpha (0.84).
2.10. Operational Definitions
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Households’ heads overall satisfaction: Households’ heads were labelled as satisfied if they scored median or above median on satisfaction questions [17, 20].
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Knowledge of the CBHI benefit package: Households were labelled as having adequate knowledge if they scored greater than or equal to the median of the CBHI benefit package knowledge questions [17].
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Wealth Index: It is the score which show the households economic status. It was assessed by using respondents’ reported assets: farmland, crops production, livestock, infrastructure (refrigerator, TV, radio, bed, phone, bicycle, motorcycle, etc.), sanitary condition, housing conditions, dwelling construction, water source, and other vital items in the household. Household wealth index was computed using principal component analysis (PCA). Variables with no outlier frequency (< 5% and > 95%) were used for PCA and variables with communality values greater than 0.5 were used to create factor scores. Households were categorized as poor, medium, and rich by taking previous similar study as a reference (20).
3. Results
3.1. Sociodemographic Characteristics of Study Participants
A total of 604 households’ heads participated in this study, which gives a response rate of 95.9%. Of these study participants, 91.2% were males, and the median age of participants was 39 (IQR: 25–88) years. About 80% of the participants were rural residents (Table 2).
| Variables | Categories | Frequencies | % |
|---|---|---|---|
| Age | ≤ 39 | 310 | 51.3 |
| > 39 | 294 | 48.7 | |
| Sex | Male | 551 | 91.2 |
| Female | 53 | 8.8 | |
| Marital status | Married | 528 | 87.4 |
| Unmarried | 76 | 12.6 | |
| Family size | ≤ 5 | 315 | 52.2 |
| > 5 | 289 | 47.8 | |
| Level of education | No formal education | 352 | 58.3 |
| 1–8 | 168 | 27.8 | |
| 9 and above | 84 | 13.9 | |
| Occupation | Farmer | 496 | 82.1 |
| Merchant | 80 | 13.2 | |
| Others | 28 | 4.6 | |
| Residence | Rural | 481 | 79.6 |
| Urban | 123 | 20.4 | |
| Wealth index | Poor | 197 | 32.6 |
| Medium | 186 | 30.8 | |
| Rich | 221 | 36.6 | |
3.2. Experience of Households in CBHI Schemes
Three-fifths of the households (60.1%) had a 4-year length of enrollment, more than half (54.6%) of the respondents had a history of visits at both health centers and hospitals, and more than three-fourths of the study participants (76%) visited health care facilities more than five times since enrolling in the CBHI schemes (Table 3).
| Variables | Categories | Frequencies | % |
|---|---|---|---|
| Length of household enrollment | 1 year | 49 | 8.1 |
| 2 years | 81 | 13.4 | |
| 3 years | 111 | 18.4 | |
| 4 and above years | 363 | 60.1 | |
| Health institution visited | Health center | 246 | 40.7 |
| Hospital | 27 | 4.5 | |
| Both | 331 | 54.8 | |
| Frequency of health facility visit | ≤ 5 times | 145 | 24.0 |
| > 5 times | 459 | 76.0 | |
| Participated in CBHI-related meetings | Yes | 543 | 89.9 |
| No | 61 | 10.1 | |
| Type of membership | Paying member | 547 | 90.6 |
| Indigent member | 57 | 9.4 | |
3.3. Household’s Head Knowledge on CBHI Benefit Packages
About half (49.3%) of the participants were labelled as having poor knowledge of the CBHI benefit packages (Table 4).
| Knowledge questions towards CBHI | Frequencies | % | |
|---|---|---|---|
| CBHI is good way of helping clients to relieve health expenditure | Yes | 508 | 84.1 |
| No | 96 | 15.9 | |
| Covers only care with in the country (Ethiopia) | Yes | 434 | 71.9 |
| No | 170 | 28.1 | |
| Covers only care from public health institutions | Yes | 419 | 69.4 |
| No | 185 | 30.6 | |
| Does not cover transportation fee | Yes | 559 | 92.5 |
| No | 45 | 7.5 | |
| Covers inpatient care | Yes | 496 | 82.1 |
| No | 108 | 17.9 | |
| Covers outpatient care | Yes | 582 | 96.4 |
| No | 22 | 3.6 | |
| Does not cover medical care for cosmetic values | Yes | 365 | 60.4 |
| No | 239 | 39.6 | |
| Does not cover kidney dialysis | Yes | 377 | 62.4 |
| No | 227 | 37.6 | |
3.4. Health Service Provision–Related Factors
One-fourths (25.7%) of the participants reside in > 5 km distance from healthcare facilities. About 72.7% of the participants reported that they got and agreed with the prescribed drugs. Three out of five of the participants (60.4%) reported that they did not get respect from the healthcare providers during their visit to healthcare facilities (Table 5).
| Variables | Categories | Frequencies | Percent |
|---|---|---|---|
| Distance from health facility | ≤ 5 km | 499 | 74.3 |
| > 5 km | 155 | 25.77 | |
| Agreement with laboratory services | Yes | 533 | 88.2 |
| No | 71 | 11.8 | |
| Agreement with prescribed drugs | Yes | 439 | 72.7 |
| No | 165 | 27.3 | |
| Got immediate care | Yes | 418 | 69.2 |
| No | 186 | 30.8 | |
| Friendliness/respect from healthcare providers | Yes | 239 | 39.6 |
| No | 365 | 60.4 |
3.5. Level of Households’ Heads Satisfaction With the CBHI Schemes
According to the current study, about 56.1% (95%CI = 52.2, 59.9) of household heads were satisfied with the CBHI schemes (Figure 2).
According to the Likert-scale questions, the respondents scored a minimum of 20 and a maximum of 50 points with a median score of 37 (Table 6).
| Variables | Strongly disagree | Disagree | Neutral | Agree | Strongly agree |
|---|---|---|---|---|---|
| Satisfied with the opening hours/working hours of the CBHI | 1 (0.2%) | 46 (7.6%) | 84 (13.9%) | 297 (49.2%) | 176 (29.1%) |
| Satisfied with collection process of insurance cards | 1 (0.2%) | 57 (9.4%) | 132 (21.9%) | 257 (42.5%) | 157 (26%) |
| Satisfied with the time to make use of the CBHI program after payment of registration fee | 31 (5.1%) | 160 (26.5%) | 169 (28%) | 159 (26.3%) | 85 (14.1%) |
| Satisfied with the schedule for paying of premium | 1 (0.2%) | 39 (6.5%) | 114 (18.9%) | 257 (42.5%) | 193 (32%) |
| Local CBHI management is trust worthy | 5 (0.8%) | 58 (9.6%) | 142 (23.5%) | 239 (39.6%) | 160 (26.5%) |
| Satisfied with permitted health institutions (satisfied with line of referral) | 75 (12.4%) | 184 (30.5%) | 143 (23.7%) | 108 (17.9%) | 94 (15.6%) |
| Satisfied with the information provided about CBHI | 1 (0.2%) | 66 (10.9%) | 109 (18%) | 255 (42.2%) | 173 (28.6%) |
| Satisfied with CBHI benefit packages | 2 (0.3%) | 56 (9.3%) | 133 (22%) | 240 (39.7%) | 173 (28.6%) |
| Want to stay enrolled in the CBHI schemes | 0 (0%) | 75 (12.4%) | 69 (11.4%) | 273 (45.2%) | 187 (31%) |
| Recommend others to be a member of CBHI | 3 (0.5%) | 63 (10.4%) | 175 (29%) | 203 (33.6%) | 160 (26.5%) |
3.6. Bivariable and Multivariable Logistic Regression Analyses
In multivariable regression analysis, age, residence, type of health institution visited, distance to health facility, getting prescribed drugs and agreement with it, friendliness of healthcare providers, and knowledge of CBHI benefit packages were found to be statistically significant independent predictors of satisfaction at p < 0.05, 95% CI.
The odds of satisfaction among enrollees greater than 39 years were 85% higher as compared to their counterparts (AOR = 1.85; 95% CI: 1.1, 2.94). Similarly, rural residents were 4.1 times more likely to be satisfied with the CBHI schemes than urban residents (AOR = 4.13; 95% CI: 2.2, 7.62). Furthermore, the likelihood of households’ head satisfaction among those households who visit health centers only with the CBHI schemes was lower by 66% as compared with those who visit both hospitals and health centers (AOR = 0.34; 95% CI: 0.2, 0.55). Households who lived 5 km or less from health facilities were 3.2 times more likely to be satisfied with the CBHI schemes as compared to their counterparts (AOR = 3.18, 95% CI: 1.82, 5.55).
Similarly, the odds of households’ head satisfaction were 2.3 and 3.6 times higher for those enrollees who got and agreed with healthcare service providers when compared to those enrollees who disagreed (AOR = 2.31; 95% CI: 1.36, 3.92; AOR = 3.65; 95% CI: 2.18, 6.10), respectively. Moreover, participants who had good knowledge of CBHI benefit packages were three times more likely to be satisfied with the CBHI schemes than those who had poor knowledge (AOR = 3.00, 95% CI: 1.9, 4.67) (Table 7).
| Variables | HH satisfaction | COR(95% CI) | AOR(95% CI) | |
|---|---|---|---|---|
| Satisfied | Not satisfied | |||
| Age of household head | ||||
| ≤ 39 | 129 | 181 | 1 | 1 |
| > 39 | 210 | 84 | 3.50 (2.49–4.92) | 1.85 (1.17–2.94)∗ |
| Residence | ||||
| Rural | 289 | 192 | 2.19 (1.46–3.29) | 4.13 (2.24–7.62)∗∗ |
| Urban | 50 | 73 | 1 | 1 |
| Length of enrolment | ||||
| 1 year | 14 | 35 | 1 | 1 |
| 2 years | 34 | 47 | 1.80 (0.84–3.87) | 2.23 (0.78–6.36) |
| 3 years | 56 | 55 | 2.54 (1.23–5.24) | 2.29 (0.84–6.20) |
| 4 and above years | 235 | 128 | 4.59 (2.38–8.84) | 2.49 (1.00–6.20) ∗ |
| Health facility visited | ||||
| Health center | 76 | 170 | 0.16 (0.11–0.23) | 0.34 (0.20–0.55)∗∗ |
| Hospital | 20 | 7 | 1.03 (0.42–2.53) | 1.15 (0.37–3.60) |
| Both | 243 | 88 | 1 | 1 |
| Distance from health facility | ||||
| ≤ 5 km | 289 | 160 | 3.79 (2.57–5.59) | 3.18 (1.82–5.55)∗∗ |
| > 5 km | 50 | 105 | 1 | 1 |
| Agreement with prescribed drug | ||||
| Yes | 292 | 147 | 4.98 (3.37–7.38) | 2.31 (1.36–3.92)∗ |
| No | 47 | 118 | 1 | 1 |
| Agreed with healthcare providers | ||||
| Yes | 191 | 48 | 5.83 (3.99-8.52) | 3.65 (2.18–6.10)∗∗ |
| No | 148 | 217 | 1 | 1 |
| Knowledge of CBHI benefit packages | ||||
| Poor | 117 | 181 | 1 | 1 |
| Good | 222 | 84 | 4.08 (2.90–5.75) | 3.00 (1.93–4.67)∗∗ |
- ∗p value < 0.05, ∗∗p value < 0.001.
4. Discussion
In this study, the level of satisfaction with the CBHI schemes among households’ heads in Bibugn district was found to be 56.1% (95%CI = 52.2, 59.9). This result is in line with studies conducted in Southern Ethiopia (54.1%) [20], Southwest Ethiopia (54.7%) [17], Nigeria (58.1%) [22], and Turkey (53.3%) [23]. However, the finding of this study is higher when compared to studies conducted in Bahir Dar, Ethiopia (50.2%) [24], Ghana (46.9%) [25], and Nigeria (42.1%) [26]. This difference may be due to the differences in study settings, since the former studies were facility-based, whereas the current study is community-based. In addition, differences in the sociodemographic characteristics of the respondents may also be the reason for the observed difference. For instance, only female participants were included in the study conducted in Bahir Dar, Ethiopia.
On the other hand, the finding of this study is lower than those of earlier studies conducted in the Wolaita zone, Ethiopia (91.38%) [16] and Bangladesh (83.4%) [27]. The differences in the operational definition of satisfaction may possibly be the reason for the difference in these results because the satisfaction score was calculated based on a percentage of the maximum scale in both of the former studies.
In this study, those households’ heads aged less or equal to 39 years were less likely to be satisfied with the CBHI schemes as compared to their counterparts. This finding is supported by previous studies conducted in Ethiopia [16, 20], Nigeria [26], and Turkey [23]. The possible reason could be that the frequency of getting sick increases as age increases, which in turn increases the frequency of health care service utilization. This is supported by evidence from a recent study in Ethiopia that stated that older age is associated with a decrease in dropout rates from the CBHI schemes [28].
According to the current study, being an urban resident was negatively associated with the CBHI scheme satisfaction. This is similar to a study conducted in Burkina Faso [12]. This might be due to the fact that urban residents may have higher expectations for healthcare service quality and may not get their expectations fulfilled during their visits to health care facilities, and they may prefer using private health facilities than rural residents. Contrary to this study, urban residency was associated with household satisfaction in insurance schemes in a study done in Turkey [23].
In this study, we found that there is a significant association between the type of health facility visited and satisfaction with CBHI schemes. Study participants who visited only health centers were less satisfied compared to households who visited either hospitals only or both hospitals and health centers. This is in harmony with previous studies done in Ethiopia [17] and Nigeria [26]. This may be attributed to the fact that hospitals are staffed with better providers (doctors and experienced professionals), equipped with advanced medical equipment, have a better drug and reagent supply, which may increase the quality of service and client satisfaction [29]. This evidence is supported by a study done in India, which reported that client satisfaction with health insurance was associated with the availability of doctors [30]. In addition, a recent report from Ethiopia revealed that the inaccessibility of hospitals is associated with dropouts from the CBHI schemes [28].
Distance from health facilities is also found to be a significant predictor of households’ heads satisfaction with the CBHI schemes. The odds of satisfaction with the CBHI schemes among those participants who lived 5 km or less from health facilities were 3.2 times higher as compared to their counterparts. This result is supported by studies done in Ethiopia that reported travel time to the nearest health institution as a predictor of enrolment in the CBHI schemes [31, 32].
Friendliness or getting respect from health care providers also had a significant association with households’ satisfaction with the CBHI schemes. This finding is supported by previous studies conducted in Ethiopia [16] and Ghana [25, 33]. Evidence shows that implementation of the Compassionate, Respectful, and Caring (CRC) increases patient satisfaction [34].
This study also showed that getting prescribed drugs and agreeing with them was significant predictor of satisfaction in CBHI beneficiaries. Those who got it and agreed were more likely to be satisfied than those who did not. This finding is consistent with previous studies conducted in Ethiopia [20] and Bangladesh [27]. This might imply two things. The first one is the perception of CBHI users that the quality of health care providers may be poor. The second one is poor communication or counselling by health care providers to their patients, which again goes to the implication of poor practice in CRC or patient-centered care.
Moreover, our study also shows that knowledge about CBHI benefit packages is associated with households’ satisfaction with the CBHI schemes. Those participants who had a good knowledge about CBHI benefit packages were more likely to be satisfied than those with poor knowledge. This result is similar to the previous study findings in Ethiopia [17, 20] and Nigeria [26]. This may be linked to the fact that an enrollee’s satisfaction gets better only if they know the rules and regulations, or rights and obligations, including the benefits offered by the schemes, and when they act accordingly. This can be supported by previous studies conducted in Ethiopia, Sudan, and Senegal that showed enrollees poor knowledge of the health insurance benefit packages is often associated with dropout [21, 35–37]. In addition, knowledge and understanding of CBHI are also reported to be an enabler of enrolment [32].
5. Limitations of the Study
This study might have a recall bias since there is a time gap between receiving healthcare services and data collection period. Due to its nature of only quantitative study, some important variables that may affect households’ satisfaction may have been missed.
6. Conclusion
The overall satisfaction of household heads with the CBHI schemes was good. Factors such as age, residence, the type of health facility visited, distance to health facilities, relationships with healthcare providers, agreement with prescribed medications, and knowledge of CBHI benefit packages were identified as statistically significant predictors of satisfaction. These findings suggest that improving access to healthcare services, fostering better relationships between healthcare providers and beneficiaries, and enhancing awareness of CBHI benefits could further increase satisfaction levels among households. Furthermore, further study is needed by using other study designs, such as a mixed approach with qualitative and quantitative methods.
Nomenclature
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- CBHI
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- community-based health insurance
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- EHIA
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- Ethiopian Health Insurance Agency
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- FMOH
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- Federal Ministry of Health
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- HSTP
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- Health Sector Transformation Plan
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- LMIC
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- low-and middle-income countries
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- NGO
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- nongovernmental organization
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- NHIS
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- national health insurance schemes
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- VIF
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- variance inflation factor
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- WHO
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- World Health Organization
Ethics Statement
Ethical approval was obtained from the Institutional Review Board (IRB) of Bahir Dar University College of Medicine and Health Sciences with the reference number 0122/2021. A verbal informed consent was obtained from the household heads’ since written informed consent is not appropriate or feasible according to the educational level of the population being studied. However, all the purpose, benefit, confidentiality of the information, and the voluntary nature of participation in the study were informed to each study participant. All the processes of the research were performed and secured in accordance with the relevant guidelines and regulations.
Consent
The authors have nothing to report.
Disclosure
A preprint has previously been published [38].
Conflicts of Interest
The authors declare no conflicts of interest.
Author Contributions
Y.L. conceptualized the study, and G.T. and A.K. were involved in the design, analysis, interpretation, report, and manuscript writing. B.A.G., A.F.G., and M.A.M. made substantial contributions to the conception, analysis, and interpretation of data, drafting the manuscript, and critical revision of important intellectual content. All the authors read and approved the final manuscript.
Funding
The research did not receive funding from any sources.
Acknowledgments
We would like to express our sincere and deepest gratitude to Bahir Dar University, College of Medicine and Health Sciences, School of Public Health, Department of Health System Management and Health Economics for giving me the opportunity to undertake this research. We would also like to acknowledge Bibugn district CBHI office and health extension workers. Furthermore, we would also like to thank participants, data collectors, and supervisors.
Open Research
Data Availability Statement
Data will be available upon request from the corresponding author.
