Social Health Insurance in Ethiopia: A Synthesis of Evidence on Willingness to Enroll, Institutional Preparedness, Fiscal Space, and Service Readiness as a Platform for Policy Action
Abstract:
Ethiopia enacted Proclamation No. 690/2010 establishing a Social Health Insurance (SHI) scheme for formal sector employees, yet the program has remained non-operational for over fourteen years. With the government renewing its resolve to launch SHI and the National Health Compact (2025) projecting a doubling of the government health financing share by 2030, a consolidated review of current evidence is urgently needed. This narrative review synthesizes published evidence on four dimensions critical to SHI implementation: willingness to join and pay (WTJ/WTP), institutional preparedness, fiscal space, and health service availability and readiness. Searches were conducted across PubMed/MEDLINE, Google Scholar, Scopus, and Hinari, supplemented by grey literature from the World Bank, WHO, ILO, UNICEF, and the Ethiopian Ministry of Health, covering January 2010 to April 2025. Pooled WTP for SHI among the formal sector workforce was 42.25% for the broader formal sector in a 2023 meta-analysis (19 studies) and 49.62% for public civil servants in a 2024 meta-analysis, the divergence reflecting the populations pooled; average WTP stood at 1.6% of gross monthly income, well below the proposed 3% premium. Willingness to join ranged from 47.5% to 74% across settings, moderated by income, knowledge, quality perceptions, and provider network scope. Institutional readiness is constrained by gaps in EHIS claims management, ICT infrastructure, and strategic purchasing capacity. Fiscal space is restricted by a tax-to-GDP ratio of only 6.8% and persistent high inflation, although the National Health Compact signals new financing ambition. Service readiness in public facilities is critically low, with basic amenities available in only 39% and diagnostics in 40% of facilities. The four domains are deeply interconnected, and a launch that addresses WTP concerns without resolving service quality deficits will reproduce the same impasse that has persisted since 2010. Coordinated, evidence-informed reform across all four domains is a prerequisite for a viable and equitable SHI program in Ethiopia.References:
[1]. Mebratie AD, Shamebo D, Alemu G, Shigute Z, Bedi AS.
Willingness of urban formal sector workers to support a community-based health
insurance scheme in Ethiopia. Clinicoecon Outcomes Res. 2025;17. Available
from: https://doi.org/10.2147/CEOR.S533996
[2]. Federal Democratic Republic of Ethiopia. Social Health
Insurance Proclamation No. 690/2010. Addis Ababa: Federal Negarit Gazeta; 2010.
[3]. Zarepour Z, Mebratie A, Shamebo D, Shigute Z, Alemu G,
Bedi AS. Social health insurance and healthcare seeking behavior in urban
Ethiopia. Ann Glob Health. 2023;89(1). Available from: https://doi.org/10.5334/aogh.4240
[4]. World Bank, Government of Ethiopia. National Health
Compact: Ethiopia [Internet]. World Bank; 2025. Available from: https://thedocs.worldbank.org/en/doc/0273f33ab6ee48c5d842108b9b55c789-0140022025/original/National-Health-Compact-Ethiopia.pdf
[5]. Baethge C, Goldbeck-Wood S, Mertens S. SANRA-a scale
for the quality assessment of narrative review articles. Res Integr Peer Rev.
2019;4:5. Available from: https://doi.org/10.1186/s41073-019-0064-8
[6]. Setegn A, Andargie G, Amare G, Debie A. Willingness to
pay for social health insurance among teachers at governmental schools in
Gondar Town, Northwest Ethiopia. Risk Manag Healthc Policy. 2021;14:861-868.
Available from: https://doi.org/10.2147/RMHP.S299119
[7]. Girma S, Abebe G, Tamire A, Fekredin H, Taye B.
Teachers' willingness to pay for social health insurance and its determinant
factors at Harar Region, Ethiopia, 2021. Clinicoecon Outcomes Res.
2023;15:181-193. Available from: https://doi.org/10.2147/CEOR.S397766
[8]. Regassa Z, Negera E, Silashi T, Kaba Z, Mosisa G.
Willingness to join and pay social health insurance and associated factors
among public sector workers in Didu Woreda, South West Ethiopia, 2018. SAGE
Open Med. 2022;10. Available from: https://doi.org/10.1177/22799036221123957
[9]. Kaso AW, Obsie GW, Debela BG, Tololu AK, Mohammed E,
Hareru HE, et al. Willingness to pay for social health insurance and associated
factors among public civil servants in Ethiopia: A systematic review and
meta-analysis. PLoS One. 2024;19(2). Available from: https://doi.org/10.1371/journal.pone.0293513
[10].
Bayked EM, Toleha
HN, Chekole BB, Workneh BD, Kahissay MH. Willingness to pay for social health
insurance in Ethiopia: A systematic review and meta-analysis. Front Public
Health. 2023;11. Available from: https://doi.org/10.3389/fpubh.2023.1089019
[11].
Federal Ministry
of Health, Ethiopia. Health Sector Transformation Plan II (HSTP II):
2020/21-2024/25. Addis Ababa: FMoH; 2020.
[12].
International
Labour Organization (ILO). ILO trains social health protection actors in
Ethiopia [Internet]. ILO PROSPECTS Programme; 2024. Available from: https://www.ilo.org/resource/news/ilo-trains-social-health-protection-actors-ethiopia
[13]. P4H Network. Strengthening health financing and HTA
institutionalization: WHO mission to Ethiopia [Internet]. P4H Network; 2024.
Available from: https://p4h.world/en/news/strengthening-health-financing-and-hta-institutionalization/
[14]. m4health AG. Digitalising Ethiopia's health insurance
systems [Internet]. m4health AG; 2024. Available from: https://m4health.pro/project/digitalisation-of-health-insurance-services-in-ethiopia/
[15]. London School of Hygiene and Tropical Medicine,
Results for Development. Financing primary healthcare in Ethiopia: Overview of
briefs. London: LSHTM; 2022.
[16]. Results for Development (R4D). Three challenges
affecting community-based health insurance in Ethiopia [Internet]. R4D; 2024.
Available from: https://r4d.org/blog/3-challenges-affecting-community-based-health-insurance-in-ethiopia/
[17]. Heller PS. The prospects of creating fiscal space for
the health sector. Health Policy Plan. 2006;21(2). Available from: https://doi.org/10.1093/heapol/czj013
[18]. African Development Bank. Ethiopia economic outlook
2023/24 [Internet]. African Development Bank Group; 2024. Available from: https://www.afdb.org/en/countries/east-africa/ethiopia/ethiopia-economic-outlook
[19]. Reuters. Ethiopia becomes Africa's latest sovereign
default after missing bond payment. London: Reuters; 26 December 2023.
[20]. UNICEF Ethiopia. National health budget brief 2023/24.
Addis Ababa: UNICEF; 2024.
[21]. UNICEF Ethiopia. National health budget brief 2024/25.
Addis Ababa: UNICEF; 2025.
[22]. Federal Ministry of Health, Ethiopia. Ethiopia
National Health Accounts VII. Addis Ababa: FMoH; 2017.
[23]. Aschalew AY, Kelkay JM, Teshale G, Demissie KA,
Baykemagn ND, Tadele A, et al. Availability and readiness of health facilities
for non-communicable disease services in Ethiopia: Evidence from the nationally
representative health facility survey 2022. PLoS One. 2025;20(12). Available
from: https://doi.org/10.1371/journal.pone.0336675
[24]. Ethiopian Health Insurance Service (EHIS). Annual
Performance Report 2017/18. Addis Ababa: EHIS; 2018.
[25]. Republic of Kenya. Social Health Insurance Act, No. 16
of 2023. Nairobi: Government Printer; 2023.
[26]. Ethiopian Health Insurance Service (EHIS). Health
insurance ten years strategic plan (2020/21-2029/30). Addis Ababa: EHIS; 2022.
[27]. USAID Health Financing Improvement Program (HFIP). HFIP newsletter: Highlights from Ethiopia's health insurance program [Internet]. Abt Associates; 2023. Available from: https://www.hfip-newsletter.com/
