Browsing by Author "Berhan Tassew"

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    Assessment of Catastrophic Health Expenditure and Coping Strategies of Multi Drug Resistant Tuberculosis (MDR-TB Patients in Addis Ababa, Ethiopia.
    (Addis Ababa University, 2023-06) Hiwot Asmerom ; Alemayehu Worku ; Berhan Tassew
    Introduction: The World Health Assembly (WHA) in 2014 adopted the World Health Organization’s (WHO) END TB strategy containing three pillars among which TB affected families’ catastrophic costs to be zero percent by 2030. Tuberculosis (TB), which mostly affects the poorest of the poor, is an example of a disease that can substantially contribute to the disease poverty trap. Even though most countries have aimed to provide the diagnosis and treatment of TB free of charge, a number of studies have found out that patients are still subject to direct and indirect cost due to TB illness and care-seeking, hampering access and putting people at risk of financial ruin or further impoverishment. A number of health care financing schemes have been designed and implemented in Ethiopia. However, the status of catastrophic cost for TB in general and MDR- TB have not been established for the country. Objective: The objective of this study is to assess catastrophic health expenditure and coping strategies of MDR-TB patients in Addis Ababa. Methods: Facility based cross-sectional survey to assess catastrophic health expeditures and coping strategies of patients with MDR-TB was employed at two hospitals in Addis Ababa, the leading of which are known TB care and research. All MDR-TB patients being cared for the disease at the time of the survey were identified from the national TB registry for inclusion. For accurate estimation of costs and other associated factors such as coping strategies all MDR-TB patients being treated in two hospitals known for initiating treatment and follow-up for MDR-TB fulfilling the inclusion criteria were part of the survey. Result: In this survey about 54.3 % of households experienced catastrophic health expenditure more than 20% of their annual household income. To cope with the costs associated with TB care, patients underwent variety of coping mechanisms including about 61 (33%) patients borrowing an estimated average of 5739 birr (108 USD); about 26 (14%) patients selling house properties (mainly household items, land and livestokcs) with the estimated mean market value of the property sold being 21375 birr (403 USD); and about 21 (11.4%) patients undergoing dissavings including withdrawal of money from banks the amoung standing at an average of 55000 ETB (1037 USD). Conclusion: The catastrophic cost of MDR-TB service Addis Ababa cannot be overlooked, despite the free policy. This study has revealed the incidence of catastrophic health expenditure among households affected by MDR-TB is about 54.3%..
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    Assessment of Cost and Investment Return Including Health Gains of Malaria Control and Elimination Program In A Malaria Hot Spot Area, Abobo District, Western Ethiopia
    (Addis Ababa Universtity, 2025) Dagim Tefera; Berhan Tassew; Werissaw Haileselassie
    Background: Malaria remains a major public health concern that places a substantial burden on health system resources. In 2024 WHO report, Ethiopia ranked among the top five countries with the highest malaria burden. Given competing health priorities, evaluating the costs and returns of continued malaria control investments is essential to sustain political and financial commitment. To achieve global malaria eradication targets by 2030, micro-level analyses are crucial to guide evidence-based policy decisions and ensure the efficient allocation of limited resources. Method: A retrospective five-year program cost and return analysis was conducted on the cost and investment return of malaria intervention in Abobo district, western Ethiopia. Review of five year intervention record was carried out to quantify cost and investment return associated with malaria intervention using community health planning and pricing techniques. Intervention costing was done based on micro-costing model approach using a standardized tool that categorized costs by pillars of malaria control and elimination program. Return on investment was measured by applying Return on Investment (ROI) model using Live Saved Tool (LiST) method. To assess the effects of program variation on cost and benefit, sensitivity analysis was performed. Data were analyzed using Excel and SPSS software packages. Result: Out of the 191,829 suspected cases that were tested by RDT or microscopy, 45.5% of them were positive over a five-year period. Falciparum was predominant in an incidence of 45.74%. The expenses incurred for passive case management, vector control, and Risk Communication and Community Engagements are $1.4 to $5.5 million, $0.82 to $0.09 million, and $0.95 to $1.44 thousand, respectively. Inflation and depreciation increased uniformly across all program cost components by 26% to 27% over the study period. Correspondingly, the return on investment declined by approximately 21% to 71.7%. Conclusion: The economic benefits derived from reduced disease burden not only enhance community health but also contribute to broader socio-economic development. Continued investment in malaria control not only saves lives but also yields considerable economic returns that can support broader health system-strengthening. The declining ROI trend observed over five years signals a need to improve program efficiency and targeting.
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    Assessment of Diabetes Self-Care Practice and Its Associated Factors among Patient on Follow Up at Public and Private Primary Level Health Care in Addis Ababa, Ethiopia.
    (Addis Abeba Universty, 2015-06) Berhan Tassew; Demeke Assefa
    Background: Diabetes mellitus is as one of the rapidly increasing non communicable diseases requiring continuous medical care and mainly life time patient self-care practice to prevent acute and chronic complications. Various factors influence one’s ability to perform diabetes self-care and these factors are not typically stable for all patients. Despite the importance of identifying these factors for health care providers to individualize clinical approaches, as to the current knowledge of the investigator there is no comprehensive assessment and documentation in Ethiopia particularly at primary health care level where these are closer to the people and first line contact point to the patients. Objective: To assess the magnitude of self-care practice and associated factors among diabetic patients who are on follow up at primary level health care (health centers and private clinics) in Addis Ababa, Ethiopia Methods: Facility based, cross-sectional study design was conducted from February to March 2015.A total of 595diabetic patients were selected by systematic random sampling method from both public health centers and private clinics in Addis Ababa. Data was collected based on interview administered method using pre tested structured questioner. Descriptive analysis was done and level of diabetic self- care practice was determined based on the mean value among the self -care practice questions asked. Bivariate and multivariate logistic regression was done to identify factors that were associated with diabetic self -care practice. The odds ratio with 95% CI was used to determine the association. A statistical significance was declared at p value <0.05. Result: Among 595 respondents about 311(52.3%) had good diabetic self-care practice. The mean (SD) age of the respondents was 53.5(14) and 343(57.6%) were male. The presence of co-morbidities (AOR=1.68, 95%CI; 1.07-2.65), having glucometer at home (AOR=2.01, 95%CI; 1.19-3.38), diabetic association membership (AOR = 3.02, 95%CI; 1.30-7.04), follow up in private clinics (AOR=3.05, 95%CI; 1.55-5.97), treatment satisfaction (AOR =1.69, 95%CI; 1.08-2.59) were significantly associated with good self-care practice. Conclusion: The study demonstrated almost half of the patients 52.3% had good diabetic self-care practice but still substantial number 47.7% of respondent had poor self-care. Good self-care was associated with having glucometer at home, diabetic association membership, attending follow-up in private clinics, treatment satisfaction. Advocating and empowering patients regarding the importance of diabetic self-care practice is highly recommended.
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    Assessment of Dropout Rate and Associated Factors from Community Based Health Insurance among Informal Workers in Gumbichu Woreda,Oromia Region, Ethiopia.
    (Addis Abeba University, 2020-12) Negash Kebite; Damen HaileMariam; Berhan Tassew
    Background: Ethiopia has introduced community-based health insurance (CBHI) scheme to enhance healthcare services utilization and protect the poor from catastrophic health expenditure in 2011. Previous studies indicate that CBHI support the efforts being made to create access to primary healthcare services, a number of schemes are mostly constrained by low membership uptake, high dropout rate and exclusion of the poor. Objective: - To assess of dropout rate and associated factors from Community-based health insurance (CBHI) among informal workers in Gumbichu Woreda, East Shoa Zone, Oromia Region. Methods: Community-based cross-sectional study design was employed. Using interviewer administered questioners to assess factors affecting dropout of CBHI in Gumbichu Woreda. The study participants were selected by using systematic random sampling technique. The sample size required for the study is 624. Results: The study found that educational statuses of respondents were found to be an associated factor for dropout of CBHI. Households who are illiterate were 2.174 times more likely to drop out from CBHI than those who were secondary education and above, AOR = 2.174, 95% CI (0.906, 4.422). Socio-economic status of households also affect dropout. Household with wealth status of low income were 3.44 times more likely to drop out from the CBHI than those high wealth statuses, AOR = 3.44; 95% CI (1.344, 8.805). Households with middle income group were 1.238 times more likely to drop out than those high-income groups, AOR = 1.238; 95% CI (0.693, 2.213). Perceiving service quality is also reason and positively correlated with members to dropout from their membership (r=0.297 at p=0.00). Limited scope of illness covered by the scheme and distance from health facility are also reasons and positively correlated with members to dropout from their membership (r =0.272 at p = 0.00) and (r = 0.117 at p = 0.0015). Conclusion: This study brings reasons and factors for dropout of CBHI membership. It is found that education, socio-economic status, limited scope of illness, distance from health facility and quality of healthcare services were correlated with dropout of CBHI.
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    The Financial Burden of Out of Pocket Expenditure for Treatment of Diabetic Mellitus in Addis Ababa
    (Addis Ababa Universty, 2018-10) Aster Emiyou; Berhan Tassew
    Background: Diabetes Mellitus is a chronic disease. Worldwide it exerts a huge toll on suffer financially and emotionally. The chronicity and complexity of the disease leads to diverse financial and psychological stress especially at the household level that exposes household for catastrophic expenditure. Objective: The objective of this study was to assess the financial burden of out of pocket expenditure for treatment of diabetic mellitus in Addis Ababa. Methods: A total of 434 Diabetic Mellitus patients who were living in Addis Ababa and getting health care service in public hospitals were selected using systematic random sampling technique. Data was collected using structured questionnaire and processed using STATA software. Results: The study found that the average out-of-pocket expenditure for treatment of diabetic mellitus patients to be Birr 662 per month. As far as the overshoot catastrophic expenditure is concerned, amongst the very low-income respondents, 54% of them spent 40% or more their total expenditure on DM management. Also, on the other hand, amongst the very high income respondents, 24% of them spent 40% or more their total expenditure on DM management. Thus, the extent of catastrophic diabetic payment at low income households was 94%. The regression results also indicate that as level of education increase, respondents are less likely to encounter a catastrophic DM expenditure compare to Basic and Elementary education. From the results, it became clear that household with large households family size are less likely to encounter catastrophic DM expenditure compared to their small family size counterparts. As the patient/household member become educated, the possibility of being engaged in high income generating occupation will increase and thus, the family members tend to support each other financially. This shows that both the descriptive statistics and regression analysis produced similar results. Conclusion: It would appear that the OOP for DM management negatively affected the financial burden of the respondents. This will however be improved when the patients and/or the housed hold member become educated, engaged in high income generating occupation and the family members are supported each other financially.
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    Health Care Services Utilization and its Determinant Factors among Health Professionals, Addis Ababa, Ethiopia, 2018 G.C: Health Facility Based Mixed Study.
    (Addis Ababa University, 2018-10) Miraj Cheru; Damen HaileMariam; Berhan Tassew
    Background: The main function of health system is ensuring the availability and accessibility of health service. Service provision is an immediate output of the health system, but health service utilization in sub Saharan Africa is very low. Similar to that the health service utilization in Ethiopia also is low. Dimensions that are barrier for health service utilization are geographic accessibility; availability of health workers, drugs and equipment; affordability and acceptability. Objective: To explore pattern of health service utilization and its determinant factors among health professionals in Addis Ababa, Ethiopia, 2018 G.C. Methods: Institutional-based cross-sectional study supplemented with a qualitative study was conducted to explore patterns of health service utilization and its determinant factors among health professionals by using stratified sampling technique. The total sample size for the study was 634 using single population sampling technique methods with 10% non-response rate. Data was collected using structured questionnaire for quantitative data and in depth interview was conducted on 12 respondents for qualitative data. To increase the quality of data training was provided to the data collectors to familiarize with the questionnaire, at the time of data collection data was checked for completeness and consistency by principal investigator and data was transcribed in full text and response in all interview sessions was reviewed and combined. EPI- info version 7 and SPSS version 20 for quantitative and open code version 3.6.2.0 for qualitative data was employed for analysis. Logistic regression was used and odds ratio was calculated to ascertain association between dependent and independent variable at p values of less than 0.05. The result had presented in tables, graphs, words and charts. Result: The final multivariate logistic regression model has shown that satisfaction on skill and competency of health care provider, having unhealthy perceived health status and having known chronic illness were found to have a statistically significant association with utilization of health care service. While participants who were satisfied with skill and competency of health care provider were 2.265 more likely utilize health service than not satisfied (AOR=2.265, 95% CI: 1.112, 5.627). Also respondents who perceived that their health status was healthy were 0.035 times less likely utilized health service than unhealthy (AOR=0.035, 95% CI: 0.009, 0.132). the final multinomial regression shows that respondent that perceived that high cost of health care service are 7.902 more likely preferred health center than private clinics(AOR=7.902, 95% CI:2.301,27.141) ) The qualitative part of this study shown that majority of the respondents first they had observed within their health facility. But, they preferred advanced health facility in order to get advanced health care service. And also shown that there is free health care service for health care providers within government health facility but there is specific of amount of money planned annually to get health care service for staffs that are worked within non-governmental for non-profit health facility. Conclusion: In conclusion the level of health services utilization rate was found to be low. There is no uniform payment trend to utilize health care service employees among private, governmental and NGOs. Efforts have to be made to increase utilization of modern health services through establishing uniform payment trend among health facilities for health work forces.
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    Impact of Non-Communicable Disease Multi Morbidity on Health Care Utilization and Out-of-Pocket Health Expenditure at Tikur Anbessa Specialized Hospital Addis Ababa, Ethiopia, 2020.
    (Addis Abeba University, 2020-12) Mizan Habtemichael; Meseret Molla; Berhan Tassew
    Background:Out-of- pocket (OOP) health payment is the least efficient and most inequitable means of financing health care. In Ethiopia from the total health expenditure, OOP payment by household accounts 31 % which is more than the recommended 20%. Even though there are studies conducted on burden of OOP due to deferent NCDs like, cardiovascular disease, Cancer, diabetes mellitus and mental illness, there is no figure regarding the financial burden of OOP expenditure due to having more than one NCD (Multimorbidity). Objective: The study assessed the impact of NCD multimorbidity on health care utilization and OOP expenditure at Tikur Anbesa Specialized hospital, Addis Ababa in 2020. Method: Facility-based cross-sectional study was conducted at Tikur Anbesa Specialized Hospital from May 2020 to July 2020. Data was collected using pre-tested, structured interviewer administered questionnaire. Data were entered using epi data version 3.1 and analyzed using STATAV 14. Binary logistic regressions, multivariable logistic regressions and negative binomial regression was used to examine the association between variables. Result: A total of 392 respondents were participated in this study and prevalence of NCD multimorbidity was 67 % (95%CI 62.2-71.5). The frequency of OPD visits was associated with the number of NCD (IRR= 1.2, 95%CI; 1.15-1.25, P-value < 0.001) and an increased number of NCDs was also associated with a higher likelihood of having hospitalization (AOR= 1.5, 95%CI; 1.19- 2.00, P-value < 0.001). We found 30.7% and 12.9% of house holds incurred catastrophic health expenditure (CHE) at 25% and 40% threshold of total household expenditure respectively. At a threshold level of 25% and 40% of household non-food expenditure, the level of catastrophic payments was 61.2% and 38.7% respectively. Conclusion and Recommendation: Multimorbid patients came to health facilities more frequently and they were exposed to increase financial problems. CHE mostly affected those households with older member, unemployed member, family member who came from outside of Addis Ababa to get health care services. Respondents who were in the poorest wealth quintile, those who have increased number of NCD conditions, those house holds with a hospitalized member, household who was not a member of an insurance system, those who use both public and private health facilities, and patients who visit a health facility frequently were affected by CHE.NCD multimorbid patients should be prioritized in the implementation of financial risk protection mechanisms.
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    Increasing the Infection Prevention Coverage in Shoarobit Primary Hospital Northshoa, Ethiopia.
    (Addis Abeba University, 2019-01) Abebe Bizu; Berhan Tassew
    Introduction: Infection prevention and control is a central component of safe and high-quality service delivery at the facility level. With an inadequate practice of infection prevention, the risk of acquiring infections through exposure to blood, body fluids or contaminated materials in healthcare facilities is substantial .Lack of compliance with infection prevention and control measures has a number of consequences. Adherence to infection prevention and control practices is essential to providing safe and high quality patient care across all settings where healthcare is delivered. Objective : The overall objective of the project is to increase infection prevention and patient safety implementation from 50% to 80% at the end of June2011E.C in Shoarobit Primary Hospital ANRS, Ethiopia. Methods :Facility based pre-post interventional study design was applied in Shoarobit Primary Hospital. To understand the actual processes and problems faced on the ground, an actual state analysis was performed after measuring base line assessment. This allowed us to analyzed and understand the bottlenecks and problem areas within the hospital before implementing selected best interventions. Timeline and budget for capstone project completion:-from January 1st /30 to April /30/2019, with total project budget of 25465 ETB.
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    Knowledge and Utilization of Modern Contraceptive Method and Determinant Factors among Women Beggars in Addis Ababa, Ethiopia
    (Addis Abeba University, 2019-11) Meaza Teguadie; Muluken Gizaw; Berhan Tassew
    Introduction: There was a gap between the rich and poor society in the use of contraception and it had persisted despite general global improvements in socioeconomic status and the expansion of family planning services. Modern contraceptive utilization was one of the services of reproductive health and its utilization had many challenges in poor societies in terms of desire and access of the service comparing from the higher class of the society. Women in the segment of low socio economic class of the population like female beggars were not well addressed in the reproductive health services. Objective: The objective of this study was to assess knowledge and utilization of modern contraceptive method and determinant factors among women beggars in Addis Ababa, Ethiopia. From March 28 up to April 2 /2019. Method: The study was conducted in Addis Ababaon women beggars by community based cross sectional study on selected three sub cities. A total of 326 women beggars were interviewed using a structured questionnaire. Data was transferred from epi info database to SPSS database using stat transfer for analysis. Logistic regression analysis was fitted and odds ratios with 95% Confidence intervals was computed to identify factors associated with utilization of modern contraceptive method. Result: A total of 326 women respondents enrolled at begging activity were included in the study. The participants were between 15-49 years with the mean age of 27and standard deviation of 6.2 years and 87.1% of them knew about contraceptive and 38.0% of them were recently using modern contraceptive. Primary education, read and write and perception of unwanted pregnancy was preventable were significantly associated with modern contraceptive knowledge (p<0.05). Women who were married [AOR=0.12 (0.05, 0.29)] was significantly associated with contraceptive utilization .Getting contraceptive at government health center [AOR=0.18 (0.08, 0.44)] was significantly associated with contraceptive utilization. Conclusion and Recommendation: This study showed that modern contraceptive utilization among women beggar was improving and their utilization of Injectable, Implant and IUCD were good but there was lack of understanding the different types and purpose of modern contraceptive method especially about emergency contraceptive and condom. There were different challenges in women beggars than the other women for utilization of modern contraceptive method.
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    The Magnitude of Chronic Renal Failure and Its Associated Factors among Patients at St. Paulo’s Hospital, Addis Ababa, Ethiopia.
    (Addis Abeba Universty, 2016-08) Meaza Zeleke; Berhan Tassew
    Background: Chronic renal failure is on the rise to cause of morbidity and mortality worldwide. According to the latest world health organization data, renal disease deaths in Ethiopia accounted for 1.47% of total deaths. However, limited study had previously been conducted to show the magnitude of CRF among medical outpatients at St. Paulo’s hospital. Therefore, this study was designed to determine the magnitude of CRF and associated factors on medical outpatient’s patients. Objective: To assess the magnitude & associated factors of chronic renal failure from Medical outpatient department in St. Paulo’s Hospital, Ethiopia Method: This study used an institutional based cross sectional study. A trained nurse using structured questionnaire to interviewed participants. The survey questionnaire was first written in English and then translated into Amharic. 320 patients were interviewed from using a structured questioner and their Medical record revised. Data entry and analysis was done using SPSS statistical package version 20. The descriptive statistics was done. Logistic regression used to check for the presence of association between variables at the 95% confidence level. Result: The overall magnitude of CRF among medical outpatient department patients was 12.2%. CRF all age group likely develop the disease at statistically significant P value < 0.05. CRF cases with kidney infection were 5% greater than without kidney infection (AOR = 0.05, 95% CI 0.02, 0.16, P<0.01). In addition CRF cases with hypertension were 40% greater than without hypertension (AOR =0.43; 95% CI 0.18, 0.97; P=0.04). Conclusion: It is demonstrated that chronic renal failure common in all age group and common among male than females. Chronic renal failure magnitude among patients with hypertension and kidney infection had statistical significance. Chronic renal failure is rising at an alarming rate therefore, we recommend that relevant prevention, diagnostics, and therapeutic measures must undertake in all health facilities
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    Magnitude of Turnover Intention and Associated Factors Among Health Care Professionals in Public Primary Hospitals in North Shewa, Amhara Region, Ethiopia, 2020.
    (Addis Abeba University, 2020-11) Sirak Teklemariam; Berhan Tassew
    Background: One of the most critical issues in public rural town primary hospital is the high turnover intention of skilled manpower. Good workforce retention is vital to ensuring well functioning health services capable of delivering improved health outcomes. Many factors such as salary, work environment and supervision influence the turnover intention. Objective: To assess the magnitude of turnover intention and associated factors among health care workers in public primary hospitals in North Shewa, Amhara region. Method: A health facility-based cross-sectional study was conducted in public primary hospitals in North Shewa, Amhara region from March 15 to June 15,2020, on 316 health professionals working in public primary hospitals using a simple random sampling technique. The data were collected using pre-tested self-administered structured questionnaires. The data was entered into Epidata version 3.1 and was analyzed using SPSS version 23 software. Descriptive statistics were conducted to summarize the sample characteristics and to calculate the mean score as a cutoff point so that those below the mean score(mean=2.9) were considered as having a turnover intention. Result: Out of 316 health professionals who responded to the questionnaires ,175(55.4%) of them reported to have intention to leave their current work place. The result showed that the socio-demographic factors were not significant, where as insufficient salary [AOR=3.03 (95%CI: 1.24,4.41)] ,insufficient incentives[AOR=2.19(95% CI:1.10,4.04)],insufficient supply of equipment and supplies[AOR=1.93(95%CI:1.04,3.49)],shortage of transportation access [AOR=1.89(95%CI:1.23,2.81)], workload [AOR= 1.76(95%CI:1.02,2.41)],insufficient development and inning [AOR=1.74 (95%CI:1.00,2.45)],unsatisfied with the management bodies [AOR=1.700 (95%CI:1.07,2.97)]and unavailability of clean water [AOR=1.67 (95%CI: 1.08,2.67)]and p<.001 for all factors were significantly associated with turnover intention of the health care professionals. Conclusions and recommendation :The magnitude of intention to leave among health care professionals working in public primary hospitals of North Shewa Zone Amhara Region was high. So it would be necessary to recommend that the hospital managers, the Zone health department and the region health bureau could be collaborated in order to reverse this intention and retain the health professionals based on these determinants found in this study.
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    The Relationship Between Demand for Health Insurance and Civil Conflict in Pastoralist Communities: a Case of Liben District in Oromia Regional State
    (Addis Abeba University, 2020-12) Dera Girma; Anagaw Derseh; Berhan Tassew
    Background: In sub-Saharan Africa, out-of-pocket expenditures constitute approximately 40% of total health expenditures, imposing financial burdens and limiting access to care in some of the poorest countries around the globe. Out of pocket (OOP) health care spending is one of the main sources for financing the Ethiopian health system. To reduce the catastrophic health expenditure the Community-Based Health Insurance (CBHI) scheme, implemented since 2011, is being progressively scaled up and targets informal sector workers and the poor in rural areas. There are a lot of impacts on health due to conflict it is possible to understand those drivers of health status that are direct measures such as mortality and indirect measures that is morbidity. Objective: This study aims to explore the relationship between demand for health insurance and civil conflict in pastoralist communities in Liben district of Oromia Regional State, 2020. Methods: a cross-sectional study was conducted by using Systematic random sampling technique among395 house holds those are the residents of Liben woreda. Each household was interviewed using structured questionnaire. Descriptive statistical methods were used to generate frequencies and the results were presented using table and graphs. Logit regression model were used for data analysis to explore if there is a link between demand for health insurance and the civil conflict. The study was conducted from May up to June, 2020 with 43,642.50 ETH. Birr budget. Result: Fifty eight percent of the study households were members of CBHI and 75.6% of the households also faced civil conflict. Household with family size of 9-11 were 3.82 times more enrolled to CBHI than those their house hold family size of with 3-5.The finding of this study indicate (AOR=6.17, CI=3.25, 13.84) those people who did not experience severe losses of income since the onset of the conflict had 6.17 times more enrolled to CBHI than those who experience severe losses of income. Conclusion: The findings in this study reveal the adverse effect of conflict on demand for health insurance. The enrollment rate of CBHI among non-affected by conflict was higher. The implication of the study finding is that the need to control civil conflicts in order to enhance utilization of health service and provide financial protection using health insurance schemes.