Ethiopia Social Health Insurance
Country of Operation
Target income level
- Bottom 20%
- Lower-middle income (20-40%)
- Middle-income (40-60%)
- Higher middle-income (60-80%)
- High-income (80-100%)
SummaryEthiopia's Social Health Scheme will include all family health services and curative care that are part of the Essential Health Package in Ethiopia.
The current level of Ethiopia’s health expenditure per capita is US$7.10. The goal of the program is to ensure that, at a minimum, all formal sector workers and their dependents have health coverage.
Key program components
Curative services will include in-patient and out-patient services delivered through accredited public and private health facilities. Coverage is mandatory for everyone working in the formal sector.
The social health insurance is to be financed through payroll/pension contributions made by employers and employees. Contribution will be based on member’s level of income and will be a fixed rate of their salary. Employee contributions will be matched by an employer contribution of an equal amount. The premium will be determined based on the findings of a study on the unit costs of medical services in the benefits package. The government will contribute to start-up costs.
The scheme will use a fee for service payment mechanism. The Departmental Based Grouping (DBG) – a form of case-based payment mechanisms- was chosen as the payment mechanism to be used by the Health Insurance Agency to reimburse providers for inpatient services. 16 DBG has been identified. There will be different rates for the different DGB and for public and private health facilities.
An autonomous health insurance agency/institution will be established at the federal level to manage the health insurance fund, provide overall guidance, and undertake monitoring and evaluation & capacity building activities. The agency will establish local offices in all regions. The regional offices will have a large set of responsibilities that will range from promoting the quality of services, to paying providers and enforcing provider compliance with contractual arrangements. The board of directors will supervise the autonomous health insurance agency. It is also proposed that the National Bank of Ethiopia, which regulates financial institutions, will also oversee the financial performance of the agency.