Dr. Alebel B. Weldesilassie, together with Dr. Jemal Adem and Dr. Shibiru Melesse, presented a study examining strategies to improve Community-Based Health Insurance (CBHI) enrollment and health service utilization among the urban poor in Ethiopia. The presentation was delivered during the Policymakers Workshop jointly organized by CEGA, the Policy Studies Institute (PSI), and the Policy Innovation Research Center (PIRC) on 22 July 2026.

Dr. Alebel began by providing the context and policy problem that motivated the study. He explained that access to essential health services remains limited across many African countries despite substantial efforts to achieve Universal Health Coverage (UHC). Referring to the 2023 Universal Health Coverage Service Coverage Index, he noted that although Ethiopia has made considerable progress, access to health services remains below the level required to achieve Sustainable Development Goal (SDG) 3. He further observed that Community-Based Health Insurance (CBHI), which is intended to reduce financial barriers to healthcare, had achieved relatively low coverage among the urban poor. According to him, low enrollment among ultra-poor households continues to undermine progress toward universal health coverage.

Dr. Alebel identified several barriers that discourage households from enrolling in Community-Based Health Insurance. These included the unaffordability of insurance premiums, limited public awareness about the scheme, lack of trust in insurance providers, poor quality of healthcare services, and cultural beliefs that influence healthcare-seeking behavior. He noted that previous research had produced mixed and inconclusive evidence regarding the effectiveness of affordability and awareness interventions, suggesting that their impacts are highly context-specific.

Against this background, Dr. Alebel explained that the primary objective of the study was to examine whether targeted premium subsidies, information provision, or a combination of the two could increase Community-Based Health Insurance enrollment and improve healthcare utilization among poor urban households. He further stated that the research sought to identify the most cost-effective strategy for expanding insurance coverage among vulnerable populations.

Describing the study design, Dr. Alebel reported that the research employed a randomized controlled trial (RCT) involving 1,400 poor households selected from 39 of Addis Ababa’s poorest districts. The study population was identified using the Urban Productive Safety Net Programme (UPSNP) registry, and the intervention was implemented in collaboration with the Addis Ababa City Administration Health Bureau. Baseline data were collected between August and September 2024, while endline data were gathered between November and December 2025. He also noted that the study achieved a relatively low attrition rate of 7.4 percent.

Dr. Alebel explained that participating households were randomly assigned to four experimental groups. The control group, consisting of 350 households, received no intervention. The first treatment group (T1), also comprising 350 households, received a 50 percent premium subsidy equivalent to ETB 750. The second treatment group (T2) received an information intervention consisting of training sessions and brochure distribution. The third treatment group (T3) received both the premium subsidy and the information intervention. According to him, this experimental design enabled the researchers to isolate the independent and combined effects of financial incentives and information provision.

Presenting the initial findings, Dr. Alebel reported that Community-Based Health Insurance enrollment remained generally low across all study groups. Nevertheless, enrollment rates were consistently higher among households that received interventions than among those in the control group. He explained that 44.1 percent of households receiving both financial subsidies and information enrolled in the insurance scheme by the end of the study, compared with 32.6 percent among households receiving only financial subsidies, 30.7 percent among those receiving only information, and 21.6 percent in the control group. These findings suggested that financial support substantially increased enrollment, particularly when combined with information provision.

Dr. Alebel then discussed the effects of the interventions on healthcare utilization. He reported that households receiving either the financial subsidy alone (T1) or the combined subsidy and information package (T3) demonstrated significantly higher utilization of health services than households in the control group. Specifically, these households were more likely to visit health centers and seek medical care when ill. However, he emphasized that the information-only intervention (T2) did not produce statistically significant improvements in healthcare utilization.

He further demonstrated that Community-Based Health Insurance enrollment itself was strongly associated with improved healthcare utilization. Households enrolled in the insurance scheme were substantially more likely to visit health facilities and seek healthcare when they reported illness than households that remained uninsured. According to Dr. Alebel, these differences were highly statistically significant, providing strong evidence that insurance enrollment improves access to healthcare services.

Turning to the estimated impacts of the interventions, Dr. Alebel explained that the financial subsidy alone increased Community-Based Health Insurance enrollment by approximately 9.1 percentage points under the intention-to-treat (ITT) analysis and by 58 to 61 percentage points under the local average treatment effect (LATE) estimates. The combined intervention of financial subsidy and information provision produced an even larger effect, increasing enrollment by approximately 21 percentage points under the ITT analysis and 98.7 percentage points under the LATE estimates. By contrast, the information-only intervention generated negligible effects on insurance enrollment.

Dr. Alebel also presented the study’s cost-effectiveness analysis. He explained that the financial subsidy alone proved to be the most cost-effective intervention, generating enrollment gains ranging from 6.5 to 44.4 percent per US$1 invested. The combined intervention ranked second in terms of cost-effectiveness, producing returns of between 5.7 and 26.7 percent per US$1 invested. In contrast, information provision alone produced very limited returns, generating only 0.2 to 0.3 percent per US$1 invested, making it the least cost-effective intervention evaluated in the study.

Summarizing the key findings, Dr. Alebel emphasized that both financial subsidies and the combined subsidy-and-information package significantly increased Community-Based Health Insurance enrollment, whereas information provision by itself had virtually no impact. He also observed that although the interventions substantially improved enrollment, they did not produce statistically significant overall improvements in healthcare utilization beyond the effects attributable to insurance enrollment itself. According to him, these findings highlight the central role of financial affordability in determining participation in Community-Based Health Insurance.

Reflecting on the broader implications of the study, Dr. Alebel concluded that the existing flat-rate premium structure effectively excluded many ultra-poor households from participating in the insurance scheme. He noted that although approximately 83 percent of surveyed households expressed willingness to enroll in Community-Based Health Insurance, only 19 percent ultimately accepted the financial subsidy and completed enrollment. He attributed this low uptake primarily to affordability constraints, explaining that the 66 percent subsidy level was still insufficient for many of the poorest households. Consequently, he concluded that a one-size-fits-all subsidy approach was ineffective for expanding insurance coverage among the ultra-poor.

Based on these findings, Dr. Alebel presented several policy recommendations. First, he argued that targeted premium subsidies should become the principal strategy for expanding Community-Based Health Insurance among poor urban households. In particular, he recommended providing full premium subsidies for the ultra-poor to accelerate progress toward Universal Health Coverage. Second, he emphasized the importance of developing effective targeting mechanisms to accurately identify eligible beneficiaries. He suggested utilizing the existing poverty-targeting system under the Urban Productive Safety Net Programme together with trusted community elders to improve the identification of the ultra-poor. Finally, recognizing the fiscal constraints facing the government, he recommended redirecting resources currently devoted to standalone information campaigns toward targeted financial subsidies and exploring cross-subsidy mechanisms to improve the long-term financial sustainability of the insurance programme.

In closing, Dr. Alebel acknowledged the contributions of the Network of Impact Evaluation Researchers in Africa (NIERA) and its funders, including SAS-P and NIERA, as well as the Addis Ababa City Administration Health Bureau, the Ethiopian Health Insurance Service, the field data collection teams, and the participating households whose cooperation made the research possible.