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Background Ethiopia piloted community-based health insurance in 2011, and as of 2019, the programme was operating in 770 districts nationwide, covering approximately 7 million households. Enrolment in participating districts reached 50%, holding promise to achieve the goal of Universal Health Coverage in the country. Despite the government’s efforts to expand community-based health insurance to all districts, evidence is lacking on how enrolment in the programme nudges health seeking behaviour among the most vulnerable rural households. This study aims to examine the effect of community-based health insurance enrolment among the most vulnerable and extremely poor households participating in Ethiopia’s Productive Safety Net Programme on the utilisation of healthcare services in the Amhara region. Methods Data for this study came from Amhara pilot integrated safety net programme baseline survey in Ethiopia and were collected between December 2018 and February 2019 from 5,398 households. We used propensity score matching method to estimate the impacts of enrolment in community-based health insurance on outpatient, maternal, and child preventive and curative healthcare services utilisation. Results Results show that membership in community-based health insurance increases the probabilities of visiting health facilities for curative care in the past month by 8.2 percentage points (95% CI 5.3 to 11.1), seeking care from a health professional by 8.4 percentage points (95% CI 5.5 to 11.3), and visiting a health facility to seek any medical assistance for illness and check-ups in the past 12 months by 13.9 percentage points (95% CI 10.5 to 17.4). Insurance also increases the annual household per capita health facility visits by 0.84 (95% CI 0.64 to 1.04). However, we find no significant effects of community-based health insurance membership on utilisation of maternal and child healthcare services. Conclusions Findings that community-based health insurance increased outpatient services utilisation implies that it could also contribute towards universal health coverage and health equity in rural and informal sectors. The absence of significant effects on maternal and child healthcare services may be due to the free availability of such services for everyone at the public health facilities, regardless of insurance membership. Outpatient services use among insured households is still not universal, and understanding of the barriers to use, including supply-side constraints, will help improve universal health coverage. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-023-09024-3.

Additional file 1: Appendix 1. Impact evaluation design details. Appendix 2. Methods: Details on Matching Algorithm and Sensitivity Analysis . Appendix 3. Predictors of enrolment into CBHI. Appendix 4. Propensity Score Matching (PSM) Results. Appendix 5. Sensitivity analysis and robustness check. Appendix 6. Variable types and measurements [71–79].

Additional file 3: Supplementary Table 2. Robustness check results

Additional file 2: Supplementary Table 1. Study design and sampling information

The study discusses the aspirations and preferences of youth in rural sub-Saharan Africa using a large-scale SMS-based survey data and complements it with an investigation on the causal effects of adolescent aspirations on migration decisions when youth in southwestern Ethiopia. The cross-country youth study shows that most rural youth in Africa prefer working in nonfarm economic sectors. It also finds that above half of the rural youth are undecided about their migration aspirations, providing an opportunity for governments to influence the rural out migration of youth. However, policymakers should also be equally aware that anti-poverty policy measures that simply improve the incomes of rural youth might have unpredictable and unintended consequences on their migration decisions. As a result, policy measures may have to also influence the perceptions of youth toward farming and rural life, and to make rural areas more attractive to the youth. Taking southwestern Ethiopia as a case in point, it was found that above half the adolescents have negative perceptions about farming (both farming life and the pre-requisites to become a farmer). The results also show that educational and occupational aspirations during adolescence exert differing effects on migration decisions after four years. That is, while those who aspired to attain more years of schooling are unlikely to out-migrate within this time period, their counterparts who aspired to have high socio-economic status occupations tend to out-migrate from the respective areas. The study concludes that the out-migration of youth from rural areas and small towns may not be only due to push factors such as lack of farmland, but it could also be due to their aspirations to work in high socio-economic status occupations which are not often found in the rural areas. Thus, African countries should work to make rural areas and farming more attractive to the aspiring youth such as through improving access to technology, developing infrastructure, and providing support to rural non-farm sectors expansion.

While community-based health insurance (CBHI) becomes increasingly integrated into health systems in developing countries, there is still limited research and evidence on its probable health impacts beyond its functions for health financing or for facilitating access to services. Using a cross-sectional data from rural south-west Uganda, we apply a two-stage residual inclusion instrumental variables method to study the impact of community health insurance on stunting in children under five years. Results indicate that each year a household was enrolled in insurance was causally associated with a reduction in the probability of stunting of 5.7 percentage points. Predictive marginal effects show that children in households which have had insurance for at least 5 years had a probability of stunting of only 0.353 compared to 0.531 for children in households with no insurance. Households in CBHI were more likely to attend more free antenatal and postnatal care visits and report fewer illnesses and reported less health expenditures. Moreover, CBHI enrolment was also associated with reduced health costs. We recommend that developing countries should facilitate the expansion of community health insurance scheme not only for their contribution to health financing but even more for mortality and morbidity aversion.