Women's Intention to Maintain Enrollment in Community-Based Health Insurance: A Multilevel Analysis in the Sidama Region, Southern Ethiopia, 2024.

Background: Community-based health insurance (CBHI) is essential for improving access to affordable healthcare and protecting vulnerable populations from catastrophic health expenditures in developing countries such as Ethiopia. Ensuring continued membership in CBHI is critical to maintaining these benefits and sustaining the financial viability of the scheme. Therefore, this study examined factors associated with women's intention to continue membership in CBHI in Sidama National Regional State, Ethiopia, in 2024. Methods: A community-based cross-sectional study was conducted among 640 women enrolled in CBHI. A pretested structured questionnaire was utilized to conduct face-to-face interviews using the Open Data Kit (ODK) mobile devices. Multilevel logistic regression analysis was employed to assess both individual and community-level factors of women's intention to maintain membership. The 95% confidence intervals (CIs) and p-values less than 0.05 were used to determine the association between the dependent and independent variables. Results: The analysis showed that women living in high-literacy communities had 3.27 times higher odds of intention to continue CBHI membership compared to those in low-literacy areas (AOR = 3.27, 95% CI: 1.02-10.51). Likewise, women perceiving CBHI as improving the quality of care were 4.22 times more likely to intend to continue membership (AOR = 4.22, 95% CI: 2.45-7.28). Additionally, perception of the premium as fair (AOR = 2.20, 95% CI: 1.10-4.43) and transparency in CBHI decisions (AOR = 1.87, 95% CI: 1.06-3.28) were positively associated with the odds of intention to remain in CBHI membership. Furthermore, each additional health facility visit was associated with increased odds of intention by 28% (AOR = 1.28, 95% CI: 1.03-1.59), and higher healthcare satisfaction was also associated with increased intention to continue CBHI membership (AOR = 1.17, 95% CI: 1.02-1.34). Conclusion: Both community-level literacy and individual-level factors, particularly perceptions of quality of care, fairness of premiums, transparency, frequency of health facility visits, and satisfaction, were associated with women's odds of intending to remain in CBHI membership. Policy efforts that strengthen service quality, promote transparent governance, and enhance community literacy may support sustained CBHI membership and contribute to more resilient health financing systems in Sidama, Ethiopia.