A comparison of the reliability of the take-it-or-leave-it and the bidding game approaches to estimating willingness-to-pay in a rural population in West Africa

Estimating willingness to pay for public health insurance while accounting for protest responses: A further step towards universal health coverage in Tunisia?

Introduction

Developing countries face major challenges in implementing universal health coverage (UHC): a widespread informal sector, general discontent with rising economic insecurity and inequality and the rollback of state and public welfare. Under such conditions, estimating the demand for a health insurance scheme (HIS) on voluntary basis can be of interest to accelerate the progress of UHC‐oriented reforms. However, a major challenge that needs to be addressed in such context is related to protest attitudes that may reflect, inter alia, a null valuation of the expected utility or unexpressed demand.

Methods

We propose to tackle this by applying a contingent valuation survey to a non‐healthcare‐covered Tunisian sample vis‐à‐vis joining and paying for a formal HIS. Our design pays particular attention to identifying the nature of the willingness‐to‐pay (WTP) values obtained, distinguishing genuine null values from protest values. To correct for potential selection issues arising from protest answers, we estimate an ordered‐Probit‐selection model and compare it with the standard Tobit and Heckman sample selection models.

Results

Our results support the presence of self‐selection and, by predicting protesters' WTP, allow the “true” sample mean WTP to be computed. This appears to be about 14% higher than the elicited mean WTP.

Conclusion

The WTP of the poorest non‐covered respondents represents about one and a half times the current contributions of the poorest formal sector enrolees, suggesting that voluntary participation in the formal HIS is feasible.

We study how protest positions may impact affiliation to formal health insurance

We apply a contingent valuation survey to a non‐healthcare‐covered population

We account and correct for selection issues with appropriate econometric models

Accounting for protest positions is found to impact the implementation of UHC

An overview of the methodological aspects and policy implications of willingness-to-pay studies in oral health: a scoping review of existing literature

Background

Demands for dental services seem to be beyond the capacities of most healthcare systems these days. Patient preferences have been increasingly emphasized to be considered in the joint decision-making process. Willingness-to-pay (WTP) is a recommended method for measuring the utility of health services; increasingly being used in recent decades. Taking these points into consideration, this article aims to provide an overview of the methodological aspects and policy implications of WTP studies in the field of oral health.

Methods

The research was conducted in ISPOR, PubMed and Google Scholar databases. In addition, reference lists of included articles were checked to identify the relevant studies. All studies published were included that were in the English language and reported using WTP for oral health-related goods and services. A data-charting form was developed by a focus group discussion panel of seven experts to derive the main methodological aspects of WTP. Also, Core policy suggestions were categorized through thematic content analysis of the included papers.

Results

The search strategy yielded 389 studies of which 52 were included. WTP studies in oral health show an increasing trend in global publications. The UK and Canada have a greater share in published material than in any other country. The dominant field of these researches is in restorative and prosthetic dentistry, and a wide range of different methodological aspects was documented. Policy suggestions were categorized in three main themes: (A) setting new tariffs or subsidizing the item, (B) provision of the item due to population preferences, and (C) improving literacy regarding the item.

Conclusions

An urgent need for a common framework regarding the design of WTP studies in dentistry seems paramount. Some policy suggestions seem not to be applicable, perhaps due to insufficient familiarity of the researchers with the complexities of the public policymaking process.

Barriers to attendance of canine rabies vaccination campaigns in Haiti, 2017

We conducted a cross-sectional survey to better understand the barriers to attendance at canine rabies vaccination campaigns in Haiti. A structured community-based questionnaire was conducted over a 15-day period during May-June 2017, focused on socio-economic status correlated with participation at canine rabies vaccination campaigns. Questions phrased as a bidding game were asked to determine individuals' willingness to pay (WTP) for dog rabies vaccination and willingness to walk (WTW) to fixed-point vaccination campaigns. The Kaplan-Meier estimator was applied to determine relationships between survey variables. Logistic regression was used to examine factors associated with participants' WTP and WTW. A total of 748 households from eight communities were surveyed. Respondents were predominantly female (54.4%) and had a median age of 45 years. The total number of owned dogs reported from households was 926, yielding a human-to-dog ratio in dog-owning households of 5.2:1. The majority of dogs (87.2%) were acquired for security, and 49% were allowed to roam freely; 42.0% of dog owners reported that they were unable to manage (or restrain) their dogs using a leash. Seventy per cent of dog owners were willing to pay up to 15.9 gourdes (0.25 USD) and/or walk up to 75 m to vaccinate their dogs. Households that owned free-roaming dogs, owned dogs for the purpose of companionship and owned dogs that they were unable to walk on a leash were associated with a higher WTP for vaccination. Living in Artibonite Department, having a middle or higher household income, and owning a dog for security purpose were associated with a higher WTW for vaccination. Low leash use and propensity for dogs to roam freely are barriers to successful fixed-point vaccination methods in Haiti, and alternative methods such as door to door (DD), capture-vaccinate-release (CVR) or oral vaccination should be explored. There may be some prospect for fee-for-service vaccination in Haiti; however, this programme should be introduced as a supplement, rather than a replacement for free rabies vaccination programmes so that mass dog vaccination is not discouraged.

Development, Validity, and Reliability of the Women's Capabilities Index

We report the results of a series of validity and reliability tests performed during the development of the Women's Capabilities Index (WCI) in Malawi. The WCI is a multidimensional measure based on Sen's capability framework for assessing women's quality of life. Construct validity was assessed by investigating the expected relationships of the dimensions with key socioeconomic characteristics. The majority of hypothesized associations were found to be statistically significant in the expected direction. This provides evidence that the index is measuring quality of life as intended in the conceptual model. Further evidence in support of the index's validity was given by the high degree of correlation between the WCI and another scale measuring comparable (but not identical) domains of quality of life. The results from the internal consistency and the test-retest repeatability also offered encouraging evidence on the reliability of the instrument. This is the first study to rigorously and comprehensively test for validity and reliability a capabilities index for a low-income setting. The results of the validity and reliability tests provide supportive evidence that a locally developed measure of capabilities can be used as a robust tool for the assessment of women's quality of life.

Acceptability and willingness to pay for telemedicine services in Enugu state, southeast Nigeria

Background

This study examines the level of awareness, acceptability and consumers’ willingness to pay (WTP) for telemedicine services using the contingent valuation method (CVM). This work is important as it elicits the value that consumers attach to telemedicine given there is a gap in this knowledge in many sub-Saharan countries such as in Nigeria.

Methods

The study was based on primary data obtained through an interviewer-administered questionnaire of 370 individuals including both males and females from 25 years and over, to collect data on respondents’ awareness of, acceptability of, and WTP for telemedicine, using the bidding game question format. A socioeconomic status (SES) index was created, based on information on household assets, and was used to categorize respondents into SES quartiles. The data were analyzed using a combination of descriptive techniques, logistics and the Tobit regression model (Tobit Type 1) methods.

Results

The study found that majority of the people (58.9%) had no knowledge of telemedicine. However, 48.7% of the respondents were willing to pay for telemedicine. The mean WTP for a telemedicine was US$2.04 for each visit. Tobit regression analysis showed that respondents’ socioeconomic status (SES) was the main statistically significant variable that explained their WTP for telemedicine.

Conclusion

The study has shown that there is a low-level awareness of and WTP for telemedicine services in Enugu State, South East of Nigeria. The finding of a positive relationship between SES and WTP implies that the poor may not be able to pay for telemedicine and may need government subsidies to be able to benefit from such service. Also, government and their partners need to undertake wide scale campaign before the introduction of telemedicine.

Preference and willingness to pay for nutritional counseling services in urban Hanoi

Background: Despite substantial achievement in reducing malnutrition rates in Vietnam, there has been an increasing rate of overweight individuals in urban areas, which may result in a high burden of non-communicable diseases. Nutritional counseling clinics have been introduced in several settings; however, little is known about the preference for this service among urban clients. This study aimed to assess the preference and willingness to pay (WTP) for nutritional counseling services among urban clients. Methods: We interviewed 429 clients who attended Hanoi Medical University Nutritional Counseling Clinic (Hanoi, Vietnam). WTP was determined using double-bounded dichotomous-choice questions and open-ended questions. Results: In total, 78.6% respondents were willing to use nutritional counseling services. The mean amount of WTP for one-time service and one-year package was 96,100VND (~$4.3) and 946,400VND (~$41.9), respectively. Clients' willingness to use the service was higher among females, those seeking counseling for elderly people and those who preferred face-to-face counseling services (p<0.05). WTP was higher among those who were over 35 years old, those seeking services for the elderly people, those having poor nutritional status, and those having under-6 year old children (p<0.05). Conclusions: The preference and WTP for nutritional counseling services in urban Hanoi were relatively high. Scaling up this service is necessary to actively prevent and control the spread of non-communicable diseases.

Willingness to pay for hypothetical malaria vaccines in rural Burkina Faso

Aims: This study aims to set priorities for anti-disease malaria vaccines by determining community preference in a hyperendemic area. Methods: A bidding game technique was used to elucidate willingness to pay in rural Burkina Faso and 2,326 adults were interviewed. Results: It is shown that there are significant differences between community preference for an anti-disease vaccine aimed at reducing pathology in pregnant women, and for a vaccine directed against childhood malaria. While the target population was willing to pay CFAfr 2101 for a vaccine against maternal malaria, its members were prepared to pay only CFAfr 1433 for a vaccine against childhood malaria. Conclusions: Whilst it is increasingly likely that anti-disease malaria vaccines will become available in the foreseeable future, lessons from the past suggest that a lack of acceptance and support from the intended recipients may lead to less than optimal compliance, and hence efficacy. For the planning of vaccine development and application strategies, it is therefore highly important to take community views into account. Here it is argued that such information could help researchers and funding agencies to set priorities for future vaccine research.

Willingness to Pay for Dog Rabies Vaccine and Registration in Ilocos Norte, Philippines (2012)

BACKGROUND

The Philippines is one of the developing countries highly affected by rabies. Dog vaccination campaigns implemented through collaborative effort between the government and NGOs have played an important role in successfully reducing the burden of disease within the country. Nevertheless, rabies vaccination of the domestic animal population requires continuous commitment not only from governments and NGOs, but also from local communities that are directly affected by such efforts. To create such long-term sustained programs, the introduction of affordable dog vaccination and registration fees is essential and has been shown to be an important strategy in Bohol, Philippines. The aim of this study, therefore, was to estimate the average amount of money that individuals were willing to pay for dog vaccination and registration in Ilocos Norte, Philippines. This study also investigated some of the determinants of individuals' willingness to pay (WTP).

METHODS

A cross-sectional questionnaire was administered to 300 households in 17 municipalities (out of a total of 21) selected through a multi-stage cluster survey technique. At the time of the survey, Ilocos Norte had a population of approximately 568,017 and was predominantly rural. The Contingent Valuation Method was used to elicit WTP for dog rabies vaccination and registration. A 'bidding game' elicitation strategy that aims to find the maximum amount of money individuals were willing to pay was also employed. Data were collected using paper-based questionnaires. Linear regression was used to examine factors influencing participants' WTP for dog rabies vaccination and registration.

KEY RESULTS

On average, Ilocos Norte residents were willing to pay 69.65 Philippine Pesos (PHP) (equivalent to 1.67 USD in 2012) for dog vaccination and 29.13PHP (0.70 USD) for dog registration. Eighty-six per cent of respondents were willing to pay the stated amount to vaccinate each of their dogs, annually. This study also found that WTP was influenced by demographic and knowledge factors. Among these, we found that age, income, participants' willingness to commit to pay each year, municipality of residency, knowledge of the signs of rabies in dogs, and number of dogs owed significantly predicted WTP.

A systematic review of factors that affect uptake of community-based health insurance in low-income and middle-income countries

BACKGROUND

Low-income and middle-income countries (LMICs) have difficulties achieving universal financial protection, which is primordial for universal health coverage. A promising avenue to provide universal financial protection for the informal sector and the rural populace is community-based health insurance (CBHI). We systematically assessed and synthesised factors associated with CBHI enrolment in LMICs.

METHODS

We searched PubMed, Scopus, ERIC, PsychInfo, Africa-Wide Information, Academic Search Premier, Business Source Premier, WHOLIS, CINAHL, Cochrane Library, conference proceedings, and reference lists for eligible studies available by 31 October 2013; regardless of publication status. We included both quantitative and qualitative studies in the review.

RESULTS

Both quantitative and qualitative studies demonstrated low levels of income and lack of financial resources as major factors affecting enrolment. Also, poor healthcare quality (including stock-outs of drugs and medical supplies, poor healthcare worker attitudes, and long waiting times) was found to be associated with low CBHI coverage. Trust in both the CBHI scheme and healthcare providers were also found to affect enrolment. Educational attainment (less educated are willing to pay less than highly educated), sex (men are willing to pay more than women), age (younger are willing to pay more than older individuals), and household size (larger households are willing to pay more than households with fewer members) also influenced CBHI enrolment.

CONCLUSION

In LMICs, while CBHI schemes may be helpful in the short term to address the issue of improving the rural population and informal workers' access to health services, they still face challenges. Lack of funds, poor quality of care, and lack of trust are major reasons for low CBHI coverage in LMICs. If CBHI schemes are to serve as a means to providing access to health services, at least in the short term, then attention should be paid to the issues that militate against their success.

Maternal willingness to pay for infant and young child nutrition counseling services in Vietnam

Background

Alive & Thrive Vietnam, a 6-year initiative (2009–2014), has developed and incorporated elements of social franchising into government health services to provide high-quality nutrition counseling services to improve infant and young child feeding practices. One element of franchising that has not yet been implemented is fee for service, which is a potential financing mechanism for sustaining services in the long run.

Objective

This research aims to estimate maternal willingness to pay (WTP) for nutrition counseling services and to examine potential factors associated with their WTP.

Design and methods

Data were drawn from an impact evaluation survey of 2,511 women with a child <2 years old from four provinces in Vietnam. An iterative bidding technique was employed to explore individual WTP. The first bid was defined as VND 20,000 (~US$ 1), which was approximately the level of the actual service cost. Depending on the participant response, the bid increased or decreased. Finally, the respondents were asked about the highest price they would be willing to pay for the service.

Results

Overall, 92.6% of clients reported a need for nutrition counseling services for children <2 years. The WTP rates at bid levels of VND 5,000, 10,000, 20,000, 40,000, and 100,000 were 95.2, 94.4, 90.7, 68.9, and 33.4%, respectively. The mean and median of the maximum WTP were VND 58,500 and 50,000, respectively. In multiple regression models, WTP rates were higher among younger women, the Kinh majority group, and better educated and wealthier women.

Conclusion

A high demand for nutrition counseling coupled with a WTP by almost all segments of society would potentially cover costs of delivery for nutrition counseling services in Vietnam.

Willingness to participate and Pay for a proposed national health insurance in St. Vincent and the grenadines: a cross-sectional contingent valuation approach

BACKGROUND

Numerous Caribbean countries are considering implementing National Health Insurance (NHI) and pooling resources to finance their health sectors. Based on this increased interest in health insurance, we investigated the willingness to participate and to pay for NHI in St. Vincent and the Grenadines, an upper-middle-income Caribbean country.

METHODS

Four hundred heads of household in St. Vincent and the Grenadines were interviewed in August 2012 and September 2012. The samples were selected through simple random sampling, including the stratification of rural, semiurban, and urban communities to ensure the representativeness of the sample. A contingent valuation method with a pretested interviewer-led questionnaire was used. Respondents were presented with a hypothetical NHI plan. Chi-squared analysis was performed to identify factors that are associated with the willingness to participate. Multiple logistic regression was used to explore the factors that influence respondents' willingness to pay.

RESULTS

In total, 69.5% (n = 278) of the respondents indicated that they were willing to participate in the proposed NHI plan, of whom 72.3% were willing to pay for the first bid (EC$50). When the bid was reduced to EC$25, all of the remaining respondents who indicated they were willing to participate were willing to pay this lowered bid. Overall, the respondents were willing to pay EC$77.83 (US$28.83) per month for each person to enroll in the NHI plan. Age, income, and having some form of health insurance were significantly associated with a willingness to participate in the plan.

CONCLUSIONS

A higher socioeconomic status was the principal determinant factor for the willingness to participate. This is similar to studies on developing economies. The government can use these findings to guide the successful implementation of the proposed NHI program. People with a lower socioeconomic status must be engaged from the start of and throughout the development process to enhance their understanding of and participation in the plan.

Assessing willingness to pay for improved sanitation in rural Vietnam

OBJECTIVE

The willingness to pay (WTP) for the construction of bathrooms with a flush toilet was assessed in households in a rural community in northern Vietnam. We also examined the effects of socio-economic factors on the WTP.

METHODS

The contingent valuation method, an economic survey technique, was used. We used the iterative bidding game technique to elicit household WTP that involved a sequence of dichotomous choice questions followed by a final open-ended question. A total of 370 households that did not have toilets were selected for this study. Respondents to the questionnaire were the primary income earners and decision-makers of their respective household.

RESULTS

Of those responding to the questionnaire, 62.1 % reported being willing to pay for the construction of bathrooms with a flush toilet. The mean and median of maximum WTP amounts were Viet Nam Dong (VND) 15.6 million and VND 13.0 million, respectively (minimum VND 2.0 million; maximum VND 45.0 million). Significant correlates of the WTP rate were: (1) gender of the head of household, (2) age of the head of household, (3) economic status of household, (4) type of current toilet, (5) satisfaction with existing toilet, and (6) knowledge of health effects of poor sanitation. The significant determinants of WTP amount were (1) geographic location and (2) economic status of household.

CONCLUSION

About two-third of the households in the study area were willing to pay for an improvement in their current sanitation arrangements. Both WTP rate and WP amount were strongly influenced by the economic status of the households and health knowledge of the study respondents.

Willingness-to-pay for a rapid malaria diagnostic test and artemisinin-based combination therapy from private drug shops in Mukono District, Uganda

In Uganda, as in many parts of Africa, the majority of the population seek treatment for malaria in drug shops as their first point of care; however, parasitological diagnosis is not usually offered in these outlets. Rapid diagnostic tests (RDTs) for malaria have attracted interest in recent years as a tool to improve malaria diagnosis, since they have proved accurate and easy to perform with minimal training. Although RDTs could feasibly be performed by drug shop vendors, it is not known how much customers would be willing to pay for an RDT if offered in these settings. We conducted a contingent valuation survey among drug shop customers in Mukono District, Uganda. Exit interviews were undertaken with customers aged 15 years and above after leaving a drug shop having purchased an antimalarial and/or paracetamol. The bidding game technique was used to elicit the willingness-to-pay (WTP) for an RDT and a course of artemisinin-based combination therapy (ACT) with and without RDT confirmation. Factors associated with WTP were investigated using linear regression. The geometric mean WTP for an RDT was US$0.53, US$1.82 for a course of ACT and US$2.05 for a course of ACT after a positive RDT. Factors strongly associated with a higher WTP for these commodities included having a higher socio-economic status, no fever/malaria in the household in the past 2 weeks and if a malaria diagnosis had been obtained from a qualified health worker prior to visiting the drug shop. The findings further suggest that the WTP for an RDT and a course of ACT among drug shop customers is considerably lower than prevailing and estimated end-user prices for these commodities. Increasing the uptake of ACTs in drug shops and restricting the sale of ACTs to parasitologically confirmed malaria will therefore require additional measures.

Willingness to pay for maternal health outcomes: are women willing to pay more than men?

BACKGROUND

Only a limited number of studies have specifically sought to analyse and try to understand sex differences in willingness to pay (WTP).

OBJECTIVE

To identify the role of sex in determining monetary values placed upon improvements in maternal health in Burkina Faso, West Africa.

METHODS

A contingent valuation survey using the bidding game method was conducted in the district of Nouna in 2005; a sample of 409 male heads of households and their spouses were asked their WTP for a reduction in the number of maternal deaths in the Nouna area. Ordinary least squares regression analysis was employed to examine the determinants of WTP.

RESULTS

Men were willing to pay significantly more than women (3127 vs 2273 West African francs), although this represented a significantly smaller proportion of their annual income (4% vs 11%). In the multivariate analyses of all respondents there was a significant positive relationship between WTP values and both starting bid and whether there had been a previous maternal complication in the respondent's household. However, there was a significant negative relationship between WTP and female sex. Once interactions between sex and income were taken into account, income did affect valuations, with a positive relationship between higher-income women and WTP values.

CONCLUSION

In absolute terms, men were willing to pay more than women, while women were willing to pay a greater proportion of their income. Differences between men and women in their WTP, both in absolute terms and in terms of proportion of income, can be explained by a household effect. Future studies should distinguish between individual income and command over decision making with respect to use of individual and household income, and gain further insight into the strategies used by respondents in answering bidding game questions.

A game of two halves? Incentive incompatibility, starting point bias and the bidding game contingent valuation method

The bidding game (BG) method of contingent valuation is one way to increase the precision of willingness to pay (WTP) estimates relative to the single dichotomous choice approach. However, there is evidence that the method may lead to incentive incompatible responses and be associated with starting point bias. While previous studies in health using BGs test for starting point bias, none have also investigated incentive incompatibility. Using a sample of respondents resident in Burkina Faso, West Africa, this paper examines whether the BG method is associated with both incentive incompatibility and starting point bias. We find evidence for both effects. However, average WTP values remained largely unaffected after accounting for both factors in multivariate analyses. The results suggest that the BG method is an acceptable technique in settings where prices for goods are flexible.

A comparison between willingness to pay and willingness to give up time

We compared the willingness-to-pay and willingness to give up time methods to assess preferences for digital subtraction angiography (DSA), computed tomography angiography (CTA) and magnetic resonance angiography (MRA). Respondents were hypertensive patients suspected of having renal artery stenosis. Data were gathered using telephone interviews. Both the willingness-to-pay and willingness to give up time methods revealed that patients preferred CTA to MRA in order to avoid DSA. The agreement between willingness-to-pay and willingness to give up time responses was high (kappa 0.65-0.85). The willingness-to-pay method yielded relatively more protest answers (12%) as compared to willingness to give up time (2%). So, our results provided evidence for the comparability of willingness to pay and willingness to give up time. The high percentage of protest answers on the willingness-to-pay questions raises questions with respect to the application of the willingness-to-pay method in a broad decision-making context. On the other hand, the strength of willingness-to-pay is that the method directly arrives at a monetary measure well founded in economic theory, whereas the willingness to give up time method requires conversion to monetary units.

Valuation of crop genetic resources in Kaski, Nepal: farmers' willingness to pay for rice landraces conservation

Crop genetic resources constitute an important aspect of biodiversity conservation, both because of their direct value to the farmers and due to their indirect global value. This study uses the contingent valuation method to document the economic value of crop genetic resources based on the farmers' willingness to pay for conservation. A total of 107 households in Kaski, Nepal were surveyed in November 2003. Their mean willingness to pay was USD 4.18 for in situ and USD 2.20 for ex situ conservation per annum. Landholding size, household size, education level, socio-economic status, sex of respondent, number of crop landraces grown, and knowledge on biodiversity influenced the willingness to pay for in situ conservation, whereas only landholding size and household size influenced the willingness to pay for ex situ conservation. The respondents were willing to contribute more for in situ than ex situ conservation because of the additional effect of direct use and direct involvement of the farmers in in situ conservation. This study supports the view that economic valuation of crop genetic resources can assist the policy makers in setting conservation priorities.

Reliability of self-reported willingness-to-pay and annual income in patients treated for toenail onychomycosis

BACKGROUND

Willingness-to-pay (WTP) is a health economics measure that has recently been used for skin diseases to evaluate patients' quality of life. However, the reliability of this measure has not been investigated in the dermatology literature and is essential in validating its use in health services research.

OBJECTIVES

This study evaluated the test-retest reliability of self-reported annual income and WTP, a health economics measure of disease impact, in patients with toenail onychomycosis.

METHODS

Forty-six patients enrolled in a randomized clinical trial comparing two different dosing regimens of terbinafine completed a self-administered questionnaire at baseline and 1 month later. The questionnaire asked: (i) how much patients would be willing to pay for a theoretical treatment with a cure rate of 85% for their current onychomycosis (10 categories: $0-50, $51-100, to > $800); and (ii) annual income (10 categories: $0-10,000 to > $200,000).

RESULTS

Forty-four patients reported WTP at both visits, and 55% reported the same WTP. The quadratic-weighted (Fleiss-Cohen) kappa statistic indicated moderate agreement (kappa = 0.50, 95% confidence interval, CI 0.24-0.75, P < 0.01) as did the Spearman rank-order correlation coefficient (r(s) = 0.57, P < 0.01; median difference = 0, P = 0.50). Strong agreement was shown among the 42 patients who reported income at both visits; 71% reported the same annual income category (kappa = 0.72, 95% CI 0.47-0.96, P < 0.01; r(s) = 0.68, P < 0.01; median difference = 0, P = 0.77). Age, disease severity and duration, previous therapy, self-reported annual income, and medication side-effects were not statistically associated with the reliability of WTP.

CONCLUSIONS

WTP and annual income demonstrated moderate and strong test-retest reliability, respectively. Self-reported WTP can serve as a reliable measure for future health economics research on onychomycosis.

Willingness to pay for health insurance among rural and poor persons: field evidence from seven micro health insurance units in India

This study, conducted in India in 2005, provides evidence on Willingness to pay (WTP), gathered through a unidirectional (descending) bidding game among 3024 households (HH) in seven locations where micro health insurance units are in operation. Insured persons reported slightly higher WTP values than uninsured. About two-thirds of the sample agreed to pay at least 1%; about half the sample was willing to pay at least 1.35%; 30% was willing to pay about 2.0% of annual HH income as health insurance premium. Nominal WTP correlates positively with income but relative WTP (expressed as percent of HH income) correlates negatively. The correlation between WTP and education is secondary to that of WTP with HH income. Household composition did not affect WTP. However, HHs that experienced a high-cost health event and male respondents reported slightly higher WTP. The observed nominal levels of WTP are higher than has been estimated hitherto.

"Quick and dirty numbers"? The reliability of a stated-preference technique for the measurement of preferences for resource allocation

We investigated the reliability of an internet-based stated-preference survey to elicit preferences for priority setting using a conjoint study like approach. Preferences were elicited among members of an Internet survey panel in an experimental "allocation of points" task at two times. The main finding is that the survey showed good reliability and most participants consistently adjusted their allocations of points to differences in presented scenarios. At the repetition of the survey, respondents were more likely to prioritize between new treatment programs competing for funding and those that did prioritize discriminated stronger between programs. We found no evidence that respondents were making easy choices or arbitrarily "clicked" through the survey.

Willingness-to-Pay and Demand Curves: A Comparison of Results Obtained Using Different Elicitation Formats

Health economists use "willingness-to-pay" to assess the prospective value of novel interventions. The technique remains controversial, not least with respect to the formats under which values are elicited. The paper analyses the results of a series of studies of the same intervention valued by the same population, in which different elicitation formats were employed. The findings support the hypothesis that data collected using different formats give rise to different demand curves, from which different inferences about demand elasticity, profitability and consumer surplus will be derived. Judgements as to the relative merits of rival interventions depend crucially upon whichever format has been used to evaluate each intervention.

Understanding consumers' preferences and decision to enrol in community-based health insurance in rural West Africa

This paper presents a qualitative investigation of consumers' preferences regarding the single elements of a community-based health insurance (CBI) scheme recently implemented in a rural region in west Africa. The aim is to provide adequate policy-guidance to decision makers in low and middle income countries by producing an in-depth understanding of how consumers' preferences may affect decision to participate in such schemes. Although it has long been suggested that feeble levels of participation may very well be an expression of consumers' dissatisfaction with scheme design, little systematic efforts have so far been channelled towards supporting such argument with empirical evidence. Consumers' preferences were explored through means of 32 individual interviews with household heads. Analysis used the method of constant comparison and was conducted by two independent researchers. Data from 10 focus group discussions provided an additional valuable source of triangulation. Findings suggest that decision to enrol is closely linked to whether the single elements of the scheme match consumers' needs and expectations. In particular, consumers justified decision to join or not to join the insurance scheme in relation to their preference for the unit of enrolment, the premium level and the payment modalities, the benefit package, the health service provider network and the CBI managerial structure. The discussion of the findings focuses on how understanding consumers' preferences and incorporating them in the design of a CBI scheme may result in increased participation rates, ensuring that poor populations gain better access to health services and enjoy greater protection against the cost of illness.

Inter-rater and test-retest reliability of three contingent valuation question formats in south-east Nigeria

This paper examines the inter-rater and test-retest reliability of willingness to pay (WTP) for insecticide-treated mosquito nets and net re-treatment using the bidding game (BG), binary with follow-up (BWFU) and a novel structured haggling technique (SH). Inter-rater reliability was evaluated by having two sets of interviewers administer questionnaires to 109 (BG), 110 (BWFU) and 103 (SH) randomly selected household heads. Test-retest reliability was investigated by repeating interviews on 146 (BG), 161 (BWFU) and 139 (SH) household heads one month after an initial survey. Data analysis used testing of means, Spearman's correlation and Pearson's correlation coefficient for test of reliability, while non-parametric analysis was used to determine factors causing a variation in WTP. The study was conducted in Southeast Nigeria. Inter-rater reliability coefficients were estimated for the individual's WTP for own nets, WTP for others and WTP for re-treatment. Using WTP for own nets as the best reliability estimate, the coefficients were high at values of 0.77 (C.I. 0.72-0.86), 0.75 (C.I. 0.64-0.81) and 0.74 (C.I. 0.63-0.82) in the BG, BWFU and SH, respectively. In test-retest reliability coefficients, the coefficients for WTP for own nets were low-to-moderate at values of 0.51 (C.I. 0.40-0.62), 0.41 (C.I. 0.28-0.53) and 0.56 (C.I. 0.41-0.65) for the BG, BWFU and SH groups, respectively. Factors such as gender, change in income, unplanned expenditures, stated WTP in first survey, time-to-think, external information, and subjecting respondents to more than one interview explained the lower test-retest reliability coefficients. We conclude that the CVM was reliable in the study area and the question formats had similar levels of reliability. The lower coefficients in the test-retest reliability were due to the influence of factors affecting demand that had changed in the intervening period. Standard formats for determining reliability within CVM should be developed for easy comparison of results from different studies.

The feasibility of community-based health insurance in Burkina Faso

To ensure the acceptability of community-based insurance (CBI) by the community and its sustainability, a feasibility study of CBI was conducted in Burkina Faso, including preference for benefit package of CBI, costing of health services, costing of the benefit package and willingness-to-pay (WTP) for the package. Qualitative methods were used to collect information about preferences for the benefit package. Cost per unit health services, health demand obtained from household survey and physician-judged health needs were used to estimate the cost of the benefit package. The bidding game method was used to elicit household head's WTP for the package. We found that there were strong preferences for inclusion of high-cost healthservices such as operation, essential drugs and consultation fees in the benefit package. It is estimated that the cost of the package per capita was 1673 CFA (demand-based) and 9630 CFA (need-based), including 58% government subsidies (euro 1 = 655 CFA). The average household head with eight household members agreed to pay from 7500 (median) to 9769 CFA (mean) to join the CBI for his/her household. The WTP results were influenced by household characteristics, such as location, household size and age composition. Under certain assumptions (household as the enrolment unit, median household head's WTP as premium for the average household, 50% enrolment rate), it would be feasible to run CBI in Nouna, Burkina Faso if enrolees' health demand did not increase by more than 28% or if the underwriting of the initial losses was covered by extra funds.