Willingness to Join Community-Based Health Insurance and Its Associated Factors among Households in West Gojjam Zone, North Mecha Woreda ,Amhara region,

Community-based health insurance schemes are becoming increasingly recognized as a potential strategy to achieve universal health coverage in developing countries. Ethiopia is a low income country with more of health spending out of pocket payment by households. Health insurance is also expected to provide nancial protection because it reduces the nancial risk associated with falling ill. Therefore; nancial risk in the absence of health insurance is equal to the out-of-pocket expenditures because of illness. Cross-sectional community based study design was conducted by using a pretested structured questionnaire. Multi-stage cluster, simple random and systematic sampling techniques was used to select 296 households as study units which were allocated to the kebeles proportionately. The sampled households were selected using simple random sampling technique. Bivariate and multivariate logistic regression was used for analysis of variables and 95% condence level and P value <0.05 was used to measure strength of association. Factors Associated With Willingness To Join Cbhi Bivariate and multivariate analysis of logistic regression model were carried out to identify factors associated with willingness to join CBHI scheme. Variables with p-value of less than 0.2 in bivariate analysis were entered to multivariate analysis. The study revealed that household heads whose residence in urban area ,occupation working as merchant compared to farmer, occupation employed in merchant compared government employee, willingness to pay, join in CBHI scheme have advantage ,CBHI packages full the needs of HH treatment and CBHI health facilities provided good services, were signicantly associated with join in CBHI at p-value<0.05 .

health insurance and community involvement in user-fee management' [1].Community-Based Health Insurance is a type of insurance means informal sectors through contributing some amount of money, and the schemes are not-for-pro t type of health insurance that has been used by poor people to protect themselves against the high costs of seeking medical care and treatment for illness [2]. It covers a wide variety of health insurance arrangements with vast gradients in terms of ownership, management, membership, and service as well as nancial coverage in distinctive settings and designed for different population groups [1].
Community-based social dynamics and collective risk sharing, solidarity, participatory decision-making and administration, non-pro tability and voluntary membership are characteristics of community-based health insurance schemes. The schemes provide free health care services, included bene t packages, for individual or household members who enroll by paying premium required [3].
Globally, about 44 million households faced catastrophic health expenditure while about 25 million households are impoverished because of direct health care payments. Over 90% of healthcare nancial di culties and their consequences have been occurring in Sub-Saharan African countries, where resources are limited [4].In the majority of African countries including Ethiopia, more than 40% of their total health expenses were constituted by out-of-pocket payment and this resulted in scarcity of nances for health [5].
Universal health coverage monitoring report in 2017 showed that many people lack essential health service and people are pushed into poverty spending too much budget. It showed that in the entire worlds, more than 7.3 billion people do not receive all essential health service they needs. Over 800 million people spend at least 10% of their household budget to pay for health care and 100 million people are pushed to extreme poverty due to their health care expenditure [6].Low enrollment in CBHI remains a challenge in many African countries. Out of the total 900 million catchment population, only 2 million people are participating in the CBHI scheme, which accounts for only 0.2% of the catchment population [5].
CBHI schemes have been operating in sub-Saharan African since the 1990s [9].However, enrollment and retention have been a problem [7,8]. In 2006, only 2 million out of an estimated 900 million people were enrolled in a CBHI scheme in Africa [9]. A recent systematic review of the literature on CBHI coverage in low-and middle-income countries shows that supply and demand side factors impact enrollment [10].
Mebratie et al., in their study of drop-out rates in Ethiopia, highlighted three additional factors that contributed to CBHI renewal: the cost of premiums, health status and understanding of health insurance The government of Ethiopia is working to narrow the existing wide gap between community demand for health care and nancial constraints in the health sector by implementing the CBHI scheme in rural areas [11].Currently, CBHI scheme is being implemented over 161 districts and recent evaluation shows improvements in health service utilization among districts implementing CBHI scheme [12]. Health-care nancing in Ethiopia has been characterized by low government spending, strong reliance on out-of-pocket expenditure, ine cient and inequitable utilization of resources, and poorly harmonized and unpredictable donor funding over the years [13].
The bene ts packages of CBHI in Ethiopia include all family health services and curative care that are part of the essential health package in Ethiopia when the scheme is scaled up to full implementation. Curative services include inpatient, outpatient services and acute illnesses [14]. Therefore, the objectives of this study was assessment of willingness to join community based health insurance and factors associated with households in North Mecha Woreda, West Gojjam Zone, Amhara region, Ethiopia.

Study setting, design and methods
The study was conducted in North Mecha Woreda, West Gojjam Zone, and Amhara region. Amhara region is the second most populous region in Ethiopia next to Oromia region. From the total population of Amhara [49.9%] were male and 51.1% of them female population. The majority of the population were rural residence (80.6%).The community based cross-sectional study design was conducted. The study was used quantitative research methods as a tool for data collection. Structured questionnaire was employed to collect data from the study households heads.

Data types and sources
Both primary and secondary data type was used in this study. The primary data source was obtained from structured questionnaire. While, the secondary data source also obtained through published and unpublished documents, like books, journal articles and annual research reports of various institutions that are relevant to this study included to obtain secondary data.

Source and study population
All households in Wets Gojjam administrative Zone were considered as source population and all household heads in the randomly selected Kebels from Woreda were the study populations.

Sampling techniques
You know that various researchers use different sampling techniques and procedures based on, the interest of the investigator, the nature of study and the number of study subjects. For this study, probability sampling technique was used to select the study area and study subjects. The researcher was used a multi-stage cluster sampling techniques to select the study area ,subjects, and the proportionate allocation would be used to determine the sample of each selected kebeles from study the site. In the rst stage, from the total of thirty six kebeles of the Woreda, ten kebeles were selected using simple random sampling techniques. In the second stage, by using systematic sampling, the list of household heads were obtained from family folder or community health information system at health center. Finally, the study participants were selected using simple random sampling.

Sample size determination
The sample size was determined using single population proportion formula, with the assumptions of 5% margin of error and 95% CI; Ζα/2 = Critical value =1.96, taking P= 77.8% =0.778 was done in Bugna district, Northeast, Ethiopia and 10% non-response rate .

Data collection
Data were collected using a structured questionnaire and the questionnaire was developed based on available information obtained from various literature. The questionnaire was prepared rst in English and next translated into Amharic local language for data collection process. Six trained data collectors and two supervisors were involved in the data collection process. Supervisors followed the data collectors and provided any necessary correction on the spot.

Data quality control
To control data quality accurately, the intensive training was provided one day about the aims of the study, procedures and data collection techniques. Prior to the study 5% pretest structured questionnaire was carried out on household heads outside the study area to check the reliability of the questionnaire. Some questionnaire was adjusted based on pretest ndings. Next to this, the data collectors goes to normal data collection process. The collected data was reviewed, checked for completeness by supervisor's manually each day before enter to SPSS software. After this, data entering, editing, cleaning and analysis was done by using SPSS software version 22.

Data analysis
The collected data was analyzed using binary and multivariate logistic regressions to determine the effect of various factors on the outcome variable. The results were presented in the form of tables and text using frequencies and summary statistics such as standard deviation, mean, and percentage to describe the study population in relation to relevant variables. The degree of association between dependent and independent variables was assessed using odds ratio with 95% con dence interval and pvalue < 0.05 declared statistical signi cance.

Results
Demographic and socio-economic characteristics of respondents A total of 285 study participants responded for the interviews, making the response rate 96.3%. All in all, (90.9%) of the study participant households were willing to join the community-based health insurance scheme. Among study participants, (88.4%) and (11.6%) were male and female respectively. The age of the respondents has been classi ed with 4 age categories. The results show that, (10.9 % )of the respondents were in age category of 18-28, While(16.8%) them were from 50 and above 50 years and (34.1%)were from 40-49.The signi cant number of the respondent's (38.2%%) was in the age category of 29-39. This implies that, the majority of the respondents were concentrated in the age category of adult and productive age. Regarding to place of the residence, majority of the respondents (81.1%) were rural and the rest (18.9%) were urban dweller. Concerning to religious a liation of the study participants, (86.3%) and (13.7%) they were Orthodox and others.
It can be understood that, the majority study participants from marital status category was married (89%). Concerning the educational level (44.2%) of the respondents were illiterate, (29.8%) them were read and write educational status, while (26.8%) of them were primary school and above. As shows in Table 1, the occupational status of the respondents (60.7%) were engaged farming and (7.7%) were house wife. The 5.3 % of the respondents were government employee, while (12.3%) were working as a daily laborer and (14%) of them were merchants. The study result shows that (74.4%), (18.9%) and (6.7%) of the respondents have an average monthly income from 300-2000, 2001-4000 and 4001-9000 ETB within households respectively. Among participants who had WTJ, (89.8%) were also willing to pay for this proposed health insurance scheme. With regard to CBHI premium, (70.2%) of respondents reported that paying the proposed health insurance cost was affordable. Majority of the respondents (89.2%) were renew family member ID timely and paid the renewal ID cost, (100%) were covered by self-sponsor. Among those respondents the amount of expenditure cost to register and renewed ID, (70.2%), (15.4%), and (14.4%) were found the interval from, 240-350, 351-450, and 451-1000 ETB with decreasing order respectively.
As Table 2, indicated (80%) of respondents family members had encountered an illness in the past one year. Of which, (80%) got a medical treatment from different health facility. From those respondents, (17.5%), (46.5%) and (36%) of them were from public health center, private health center and government hospital respectively. And (86.4%), respondents that it took >60 minutes to reach the health facility. Among 285 sampled respondents, (43.2%) were CBHI package ful l the needs of household treatment and majority of the respondents (72.6%) said that CBHI facility provided good services. It can be understood that, (45.6%) of the respondents rated their perceived quality of health care service in the district as low, while the overall CBHI service level was poor(66.7). The main challenges utilization of health services in government health institution, (34.2%), (32.7%), (26.3%),(4.2%) and (2.6%) were absence of available medicine, poor service delivery, lack of enough laboratory equipment, health professionals not have good behavior and shortage of ambulance services respectively.

Factors Associated With Willingness To Join Cbhi
Bivariate and multivariate analysis of logistic regression model were carried out to identify factors associated with willingness to join CBHI scheme. Variables with p-value of less than 0.2 in bivariate analysis were entered to multivariate analysis. The study revealed that household heads whose residence in urban area ,occupation working as merchant compared to farmer, occupation employed in merchant compared government employee, willingness to pay, join in CBHI scheme have advantage ,CBHI packages ful l the needs of HH treatment and CBHI health facilities provided good services, were signi cantly associated with join in CBHI at p-value<0.05 . [16] and north of Nigeria (90%) [17]. the result of this study exceeds those study done in Debub Bench (77.8%), [18] and, Fogera districts (80%) [19]. this might be due to variation in the sample size, study period, knowledge, and perception of participants towards the CBHI scheme.
In this study, the place of residence of the study subjects affects join in CBHI scheme. Urban residence of household heads were 1.484 times less likely to join the scheme compared to rural residences (AOR=1.484; 95% CI; 2.343-6.427). This might be in rural area households have large number family size, limited resource and low nancial potential, due to this the probability of WTJ the CBHI scheme in rural higher than compared to urban.
This study also showed the occupational status of CBHI members had a signi cant association with join CBHI. Merchants were 0.098 times less likely to join CBHI than compared to farmers (AOR=0.098; 95% CI; 0.027-0.363).The study results which is supported by the study conducted in the Edo state of Nigeria [20].This might due to the fact that households heads by merchants were more likely to have the nancial ability to cover their health care costs compared to farmer. Farther more, merchants were 0.050 times less likely join in the scheme compared to government employee(AOR= 0.050;955 CI;004-0.639). This night be, due to the fact that household's heads by merchants were more obtained daily income or revenue and easily cover nancial cost of health care services than government employee. Because the government employee only have monthly salary and the salary might not enough to cover the health costs.
Household heads willingness to pay CBHI had signi cantly associated with willingness to join in the scheme. The respondents were not willingness to pay community based health insurance schemes 0.097 times less likely to join in CBHI than compared to those who pay(AOR=0.097;95% CI=0.035-0.267).This might be availability of services in health facility good. Moreover, after joining the scheme is to get high quality health service at affordable costs, quality of health care at public facilities such as patient reception may high. Due to this, pay to CBHI signi cantly affect join in CBHI The study indicated that households join in CBHI scheme were not have advantage 0.080 times less likely to join in the scheme than compared to (Yes) those who have advantages (AOR,0.080; 95% CI, 0.027-0.236).In the study, community based health insurance package ful l the needs of HH treatment indicated a strong positive effect in join the scheme. Household heads who were not CBHI packages ful l the needs of HH treatment 0.322 times less likely to join CBHI than compared to (Yes) the packages ful l the needs of HH treatment (AOR, =0.322; 95%CI; 0.111-0.936).
The study participants shows that CBHI health facilities provided a good services were signi cantly associated with willingness to join in CBHI scheme. Furthermore, the study subjects reported that CBHI health facilities not provided a good services were 0.269 times less likely to join CBHI than compared to (Yes) CBHI health facility provided a good services (AOR=0.269; 95%CI; 0.118-0.613).the study was similar with other studies results [8,21].This might be due to the direct bene ts gained from the quality of services delivered by health institutions.

Conclusions
According to this study, a high proportion of households were willing to join the CBHI scheme. A signi cant number of respondents were got high proportion of health care services from private health center than government health facilities. The main reasons low health care serves utilization in government health institutions were absence of available medicine, lack of enough laboratory equipment, shortage of ambulance services, poor services delivery and health professional's behaviors problems.

Abbreviations
Page 15/17 CBHI; Community based health insurance, AOR; adjusted odds ratio, COR; Crude odds ratio, OOP; out of pocket, ETB; Ethiopian birr, WTJ; willingness to join, HH; household, HF; health facility, SPSS; statistical package for social sciences, CI; con dence interval Declarations Ethics approval and consent to participate: Ethical clearance was obtained from University of Gondar, College of Social sciences and Humanities Research and Publication condition o ce (CHSHR&PCO).A formal letter of cooperation was written to North Mecha Woredas from University of Gondar and permission was obtained from respective kebeles administrators. The study participants were informed about the purpose and their right to refuse the study. After this Oral consent was obtained from all study participants before the interview.
Consent to Publication: Not applicable