Willingness to Pay for Social Health Insurance and Associated Factors among Health Care Providers in Addis Ababa, Ethiopia

Willingness to Pay for Social Health Insurance Among Public Health Workers in Gedeo Zone, Southern Ethiopia

In Ethiopia, Social Health Insurance (SHI) implementation was delayed repeatedly due to employees' unwillingness to pay 3% of their monthly salary and fear related to the scheme's healthcare coverage. However, provisions of comprehensive training for health workers on health insurance and inclusion of healthcare financing methods in health practitioner education curriculum make their level of willingness to pay for SHI schemes uncertain. Thus, this study aimed to assess willingness to pay for the SHI scheme and its determinant factors among Healthcare providers in the Gedeo zone. From July 1 to 15, 2022, we carried out an institution-based cross-sectional study among 430 healthcare providers recruited using a multistage sampling technique. A multivariable logistic regression model was used to determine the factors associated with willingness to pay for Social Health insurance. Adjusted odds ratio (AOR) and P values of <.05 with 95% confidence intervals (CIs) were used to declare statistical significance. Out of 73.4% (95% CI: 68.8%, 77.6%) healthcare providers willing to join the SHI program, only 47.3% (95% CI: 41.5%, 53.2%) were willing to pay for the proposed 3% premium of their monthly salary. Healthcare providers who had >10, 000 Birr monthly salary (AOR = 2.45, 95% CI: 1.14, 5.26), difficulty in paying for healthcare (AOR = 3.55, 95% CI: 1.22, 10.29), history of chronic conditions (AOR = 4.61, 95% CI: 2.41, 8.82), positive attitude (AOR = 3.16, 95% CI: 1.62, 6.18), and good knowledge of the social health insurance scheme (AOR = 2.35, 95% CI: 1.17, 4.72) were more likely to pay for the social health insurance. More than half of the healthcare providers expressed a lack of willingness to pay for the social health insurance scheme. So, the government should provide an awareness creation program on the concepts and principles of the SHI scheme to improve the willingness to pay for the scheme.

Spatial distribution and geographical heterogeneity factors associated with households' enrollment level in community-based health insurance

Background

Healthcare service utilization is unequal among different subpopulations in low-income countries. For healthcare access and utilization of healthcare services with partial or full support, households are recommended to be enrolled in a community-based health insurance system (CBHIS). However, many households in low-income countries incur catastrophic health expenditure. This study aimed to assess the spatial distribution and factors associated with households' enrollment level in CBHIS in Ethiopia.

Methods

A cross-sectional study design with two-stage sampling techniques was used. The 2019 Ethiopian Mini Demographic and Health Survey (EMDHS) data were used. STATA 15 software and Microsoft Office Excel were used for data management. ArcMap 10.7 and SaTScan 9.5 software were used for geographically weighted regression analysis and mapping the results. A multilevel fixed-effect regression was used to assess the association of variables. A variable with a p < 0.05 was considered significant with a 95% confidence interval.

Results

Nearly three out of 10 (28.6%) households were enrolled in a CBHIS. The spatial distribution of households' enrollment in the health insurance system was not random, and households in the Amhara and Tigray regions had good enrollment in community-based health insurance. A total of 126 significant clusters were detected, and households in the primary clusters were more likely to be enrolled in CBHIS. Primary education (AOR: 1.21, 95% CI: 1.05, 1.31), age of the head of the household >35 years (AOR: 2.47, 95% CI: 2.04, 3.02), poor wealth status (AOR: 0.31, 95% CI: 0.21, 1.31), media exposure (AOR: 1.35, 95% CI: 1.02, 2.27), and residing in Afar (AOR: 0.01, 95% CI: 0.003, 0.03), Gambela (AOR: 0.03, 95% CI: 0.01, 0.08), Harari (AOR: 0.06, 95% CI: 0.02, 0.18), and Dire Dawa (AOR: 0.02, 95% CI: 0.01, 0.06) regions were significant factors for households' enrollment in CBHIS. The secondary education status of household heads, poor wealth status, and media exposure had stationary significant positive and negative effects on the enrollment of households in CBHIS across the geographical areas of the country.

Conclusion

The majority of households did not enroll in the CBHIS. Effective CBHIS frameworks and packages are required to improve the households' enrollment level. Financial support and subsidizing the premiums are also critical to enhancing households' enrollment in CBHIS.

Willingness to Pay for Social Health Insurance Among Health Care Professionals in North Wollo Zone, Amhara Region, Ethiopia: Mixed Method Study

Background

Ethiopia introduced a social health insurance (SHI) scheme for the formal sector that will cost 3% of the monthly salary as a premium and provide universal health coverage. Since health care professionals (HCP) are the primary front-line service providers, their willingness to pay (WTP) for SHI may have a direct or indirect impact on how the programme is implemented. However, little is known about WTP for SHI among HCP.

Objective

To assess WTP for SHI and associated factors among government employee HCP in the North Wollo Zone, Northeast Ethiopia.

Methods

Using the contingent valuation method, a mixed approach and cross-sectional study design were applied. For the qualitative study design, in-depth interviews were performed with focal persons and officers of health insurance. Multistage systematic random sampling was used to select 636 healthcare professionals. Logistic regression analysis was used to determine independent predictors of WTP for SHI. Qualitative data were analyzed using thematic analysis.

Results

A response rate of 92.45% was achieved among the 636 participants, with 588 healthcare professionals completing the interview. The majority (61.7%) of participants were willing to join and pay the suggested SHI premium. Participants' WTP was significantly positively associated with the presence of under five years of children but their willingness to pay was significantly negatively associated with the female gender and increasing monthly salary. On the other hand, on the qualitative side, the amount of premium contribution, benefits package, and quality of service were the major factors affecting their WTP.

Conclusion

The majority of healthcare professionals were willing to pay for the SHI scheme, almost as much as the premium set by the government. This suggests proof that healthcare financing reform is feasible, particularly for the implementation of the SHI system.

Willingness to pay for social health insurance in Ethiopia: A systematic review and meta-analysis

Background

Ethiopia plans to introduce social health insurance with the aim of giving recipients high-quality, long-term universal health care. It was anticipated to be fully operational in 2014. However, due to strong opposition from public employees, the implementation has been delayed multiple times. As a result, more and more studies have been conducted to collect evidence about the issue. However, there is no national pooled evidence regarding the willingness to pay for the scheme. Thus, this review aimed to evaluate the willingness to pay for social health insurance and associated factors in Ethiopia.

Methods

On September 1, 2022, database searches were conducted on Scopus, Hinari, PubMed, Google Scholar, and Semantic Scholar. Based on this search, 19 studies were included in the review. The risk of bias for the included studies was assessed using Joana Briggs Institute checklists. The data were extracted using Microsoft Excel. RevMan-5 was used to conduct the meta-analysis. The effect estimates assessed were the odds ratios at a p-value <0.05 with a 95% CI using the random effect model.

Results

The pooled willingness to pay for social health insurance was 42.25% and was found to be affected by sociodemographic, health and illness status, health service related factors, awareness or knowledge level, perception or attitude toward the scheme, and factors related to the scheme. The pooled result showed that the willingness of participants to pay for the scheme was 16% less likely (OR = 0.84; 95% CI: 0.52-1.36). When the outlier was unchecked, the willingness to pay became 42% less likely (OR = 0.58; 95% CI: 0.37-0.91). The lowest willingness to pay for the scheme was in the Oromia region, while the highest was in Harar. Professionally, teachers were 3.22 times more likely to pay for the scheme (OR = 3.22; 95% CI: 1.80-5.76) than health professionals.

Conclusion

The willingness to pay for social health insurance was low, <50%, particularly among health professionals, which urges the Ethiopian health insurance service to deeply look into the issue.

Factors Associated with Willingness to Pay for Cost-Sharing under Universal Health Coverage Scheme in Yogyakarta, Indonesia: A Cross-Sectional Survey

BACKGROUND

National Health Insurance (NHI) in Indonesia requires an appropriate cost-sharing policy, particularly for diseases that require the largest financing. This study examined factors that influence willingness to pay (WTP) for cost-sharing under the universal health coverage scheme among patients with catastrophic illnesses in Yogyakarta, Indonesia.

METHODS

This was a cross-sectional study using structured questionnaires through direct interviews. The factors related to the WTP for cost-sharing under the NHI scheme in Indonesia were identified by a bivariable logistic regression analysis.

RESULTS

Two out of every five (41.2%) participants had willingness to pay for cost-sharing. Sex [AOR = 0.69 (0.51, 0.92)], education [AOR = 1.54 (0.67, 3.55)], family size [AOR = 1.71 (1.07, 2.73)], occupation [AOR = 1.35 (0.88, 2.07)], individual income [AOR = 1.50 (0.87, 2.61)], household income [AOR = 1.47 (0.90, 2.39)], place of treatment [AOR = 2.54 (1.44, 4.45)], a health insurance plan [AOR = 1.22 (0.87, 1.71)], and whether someone receives an inpatient or outpatient service [AOR = 0.23 (0.10, 0.51)] were found to affect the WTP for a cost-sharing scheme with p < 0.05.

CONCLUSION

Healthcare (place of treatment, health insurance plan, and whether someone receives an inpatient or outpatient service) and individual socioeconomic (sex, educational, family size, occupational, income) factors were significantly related to the WTP for cost-sharing.

The effects of individual and community-level factors on community-based health insurance enrollment of households in Ethiopia

Introduction

Community-based health insurance (CBHI) is a type of volunteer health insurance that has been adopted all over the world in which people of the community pool funds to protect themselves from the high costs of seeking medical care and treatment for the disease. In Ethiopia, healthcare services are underutilized due to a lack of resources in the healthcare system. The study aims to identify the individual and community level factors associated with community-based health insurance enrollment of households in Ethiopia.

Methods

Data from the Ethiopian mini demographic and health survey 2019 were used to identify factors associated with community-based health insurance enrollment of households in Ethiopia. Multilevel logistic regression analysis was used on a nationally representative sample of 8,663 households nested within 305 communities, considering the data’s layered structure. We used a p-value<0.05 with a 95% confidence interval for the results.

Result

The prevalence of community-based health insurance enrollment in Ethiopia was 20.2%. The enrollment rate of households in the scheme was high in both Amhara (57.9), and Tigray (57.9%) regions and low (3.0%) in the Afar region. At the individual level; the age of household heads, number of children 5 and under, number of household members, has land for agriculture, has a mobile telephone, receiving cash of food from the safety Net Program, Owning livestock, and herds of farm animals, wealth index, and at the community level; the region had a significant association with community-based health insurance enrollment.

Conclusion

Both individual and community-level characteristics were significant predictors of community-based health insurance enrollment in households. Furthermore, the ministry of health, health bureaus, and other concerning bodies prioritize clusters with low health insurance coverage to strengthen health system financing and intervene in factors that negatively affect the CBHI enrollment of households.

Socio-Demographic Predictors of Willingness to Pay for Premium of National Health Insurance: A Cross-sectional Survey of Six Districts in Sierra Leone

BACKGROUND

The government of Sierra Leone introduced Social Health Insurance Scheme as a measure to remove financial barriers that beset the people in accessing health to ensure universal coverage. Under this policy, the citizens were encouraged to subscribe to the scheme to avoid out of pocket payment for healthcare at the point of use. This study was conducted to find out the predictors of willingness among the people to pay for health insurance premium.

METHODS

A cross-sectional study design was employed in six selected districts in Sierra Leone. Quantitative data was collected for this study through the use of semi-structured questionnaire with a sample size of 1185 respondents. Data was analysed into descriptive and inferential statistics using the contingent valuation model. Statistical analysis was run at 5% significant level using Stata version 14.0 software.

RESULTS

The results showed that majority of the respondent are willing to join and pay a monthly premium of Le 10 000 (US$1.03) with an estimated mean contribution of about Le 14 089 (US$1.44) and the top five predictors of willingness to pay (WTP) were household monthly income, age, district of resident, gender, and educational qualification.

CONCLUSION

The findings on predictors of WTP premium of Sierra Leone National Social Health Insurance (SLeNSHI), suggests that the socio-demographic characteristics of the population are important in premium design and payment. Efforts at improving the socio-economic statuses of the population could be helpful in premium design and payment.

Willingness to pay for social health insurance among public civil servants: A cross-sectional study in Dessie City Administration, North-East Ethiopia

Background

The readiness to pay for health insurance has an impact on universal health care. This study investigated the willingness of public civil servants in Dessie City Administration, North-East Ethiopia, to pay for social health insurance and associated factors.

Methods

From April to May 2021, a cross-sectional study was undertaken. The sectors from which the samples were proportionately allocated were chosen using a multistage sampling procedure. Using their payroll list as a sampling frame, simple random sampling was done to recruit them. A semi-structured self-administered questionnaire was used to collect data. Epi Data version 3.1 was used to enter, code, and clean the data, which was then exported to SPSS version 23 for analysis. To determine relationships, bi-variable and multivariable analyses were utilized. Candidates for multivariable analysis were variables with a p-value ≤ 0.3 in bi-variable analysis. AOR with a 95% CI was used to determine the strength and direction of association. Statistical significance was defined at p-value < 0.05.

Results

A total of 796 employees took part in the study, with a 94.42% response rate. Overall, 29.60% of them were willing to pay for the scheme (95% CI: 26.4, 33%). The decision to pay was influenced by favorable perception (AOR = 2.43, 95% CI: 1.72, 3.44), household income < Birr 5,000 (AOR = 0.26, 95% CI: 0.14, 0.48), acute illness (AOR = 0.48, 95% CI: 0.32, 0.72), bachelor level education (AOR = 0.44, 95% CI: 0.28, 0.70), master and above level education (AOR = 0.26, 95% CI: 0.14, 0.49), and age 25–29 years (AOR = 1.97, 95 % CI: 1.08, 3.57).

Conclusion

The willingness of the civil servants to pay for social health insurance was low, and it was influenced by their attitudes toward the scheme, the occurrence of severe illness, income level, educational status, and age.

Contributions and challenges of healthcare financing towards universal health coverage in Ethiopia: a narrative evidence synthesis

Background

High burden of healthcare expenditure precludes the poor from access to quality healthcare services. In Ethiopia, a significant proportion of the population has faced financial catastrophe associated with the costs of healthcare services. The Ethiopian Government aims to achieve universal health coverage (UHC) by 2030; however, the Ethiopian health system is struggling with low healthcare funding and high out-of-pocket (OOP) expenditure despite the implementation of several reforms in health care financing (HCF). This review aims to map the contributions, successes and challenges of HCF initiatives in Ethiopia.

Methods

We searched literature in three databases: PubMed, Scopus, and Web of science. Search terms were identified in broader three themes: health care financing, UHC and Ethiopia. We synthesised the findings using the health care financing framework: revenue generation, risk pooling and strategic purchasing.

Results

A total of 52 articles were included in the final review. Generating an additional income for health facilities, promoting cost-sharing, risk-sharing/ social solidarity for the non-predicted illness, providing special assistance mechanisms for those who cannot afford to pay, and purchasing healthcare services were the successes of Ethiopia’s health financing. Ethiopia's HCF initiatives have significant contributions to healthcare infrastructures, medical supplies, diagnostic capacity, drugs, financial-risk protection, and healthcare services. However, poor access to equitable quality healthcare services was associated with low healthcare funding and high OOP payments.

Conclusion

Ethiopia's health financing initiatives have various successes and contributions to revenue generation, risk pooling, and purchasing healthcare services towards UHC. Standardisation of benefit packages, ensuring beneficiaries equal access to care and introducing an accreditation system to maintain quality of care help to manage service disparities. A unified health insurance system that providing the same benefit packages for all, is the most efficient way to attain equitable access to health care.

Willingness to pay for complementary health insurance in Iran: Contingent valuation approach

BACKGROUND

The Iranian health system is based on social health insurance, which is responsible for providing access to basic health care. In addition to basic treatment insurance, complementary health insurance (CHI) offers introductory packages that include surplus services. We recently observed an increase in Iran's health insurance loss coefficient, from 16.5% to 90.4% in 2017.

AIM

To determine the willingness to pay (WTP) for (CHI).

METHODS

We attempted to determine the WTP for CHI in this study to understand better the potential market and the factors that influence CHI demand. The study surveyed 1023 households in the Kerman Province. A questionnaire developed by the researcher was used in this study, based on the principles of contingent valuation and the bidding game method principles. In each scenario, the factors affecting people's WTP, the demand function, and the effective factors on demand were determined using linear multivariate regression using the ordinary least squares method.

FINDINGS

The average WTP was $ 7.01, $ 12.57, $ 16.19, and $ 18.73 for the first to fourth scenarios, respectively. The demand elasticity for health insurance increased from the first to the fourth scenario, indicating that demand is expandable. On the other hand, it was observed that risk aversion dictates the demand for CHI.

CONCLUSION

Contrary to the insurance claims theory, demand for CHI did not reverse. To this end, insurance fund policymakers can avoid risks and high financial costs by identifying risk-averse individuals.

Willingness to Pay for a Contributory Social Health Insurance Scheme: A Survey of Rural Residents in Akwa Ibom State, Nigeria

Background: Health insurance is seen as a pathway to achieving Universal health coverage in low- and middle-income countries. The Nigeria Government has mandated states to set up social health insurance as a mechanism to offer financial protection to her citizens. However, the design of these schemes has been left to individual states. In preparation for the set-up of a contributory social health insurance scheme in Akwa Ibom State, Nigeria. This study assesses the willingness-to-pay for a social health insurance among rural residents in the state. Methods: The study was conducted in three local government areas in Akwa Ibom State, South south Nigeria. It was a cross-sectional study with multi-stage data collection using a demand questionnaire. Interviews were conducted with 286 household heads who were bread winners. Contingent valuation using iterative bidding with double bounded dichotomous technique was used to elicit the WTP for health insurance. Multiple regression using least square method was used to create a model for predicting WTP. Findings: About 82% of the household heads were willing to pay insurance premiums for their households. The median WTP for insurance premium was 11,142 Naira ($29), 95% CI: 9,599-12,684 Naira ($25-$33) per annum. The respondents were predominantly middle-aged (46.8%), Ibibio men (71.7%) with an average household size of five persons and bread winners who had secondary education (43.0%) and were mainly pentecostals (51.5%). The mean age of respondents was 46.4 ± 14.5 yrs. The two significant predictors of WTP for insurance premium amongst these rural residents were income of breadwinner (accounts for 79%) and size of household (2%). The regression coefficients for predicting WTP for insurance premium are intercept of 2,419, a slope of 0.1763 for Bread winner income and a slope of 741.5 household size, all values in Naira and kobo. Conclusion: Majority of rural residents in Akwa Ibom State were willing to pay for social health insurance. The amount they were willing to pay was significantly determined by the income of the breadwinner of the household and the size of the family. These findings are relevant to designing a contributory social health insurance scheme that is affordable and sustainable in order to ensure universal health coverage for the citizens.

Why did informal sector workers stop paying for health insurance in Indonesia? Exploring enrollees' ability and willingness to pay

Indonesia faces a growing informal sector in the wake of implementing a national social health insurance system-Jaminan Kesehatan Nasional (JKN)-that supersedes the vertical programmes historically tied to informal employment. Sustainably financing coverage for informal workers requires incentivising enrolment for those never insured and recovering enrolment among those who once paid but no longer do so. This study aims to assess the ability- and willingness-to-pay of informal sector workers who have stopped paying the JKN premium for at least six months, across districts of different fiscal capacity, and explore which factors shaped their willingness and ability to pay using qualitative interviews. Surveys were conducted for 1,709 respondents in 2016, and found that informal workers' average ability and willingness to pay fell below the national health insurance scheme's premium amount, even as many currently spend more than this on healthcare costs. There were large groups for whom the costs of the premium were prohibitive (38%) or, alternatively, they were both technically willing and able to pay (25%). As all individuals in the sample had once paid for insurance, their main reasons for lapsing were based on the uncertain income of informal workers and their changing needs. The study recommends a combination of strategies of targeting of subsidies, progressive premium setting, facilitating payment collection, incentivising insurance package upgrades and socialising the benefits of health insurance in informal worker communities.

Willingness to Pay for Social Health Insurance and Its Predictors among Government Employees in Mujja Town, Ethiopia

Background

Social health insurance is one of the possible organizational mechanisms for raising and pooling funds to finance health services, private health insurance, community insurance, and others.

Objective

The study was aimed to assess willingness to pay for social health insurance and associated factors among government employees in Mujja town, Ethiopia.

Methods

An institutional-based cross-sectional study was conducted on the total sample size of 375 study respondents. A simple random sampling technique was employed. Data were entered into EPI info 7 and analyzed by Statistical Package for Social Sciences version 22.0. Multivariable logistic regression was used to identify independent predictors by controlling confounding variables. Statistical significance was declared at p < 0.05.

Results

This study revealed that 37.6% (95% CI: 33.1%, 42.61%) respondents were willing to pay for social health insurance. In the final model, respondents who ever heard about health insurance schemes were seven times (AOR = 7.205; 95% CI: 1.385, 37.475) more likely willing to pay for social health insurance. Thos who had history of difficulty and having other source to cover medical bills were 92.6% (AOR = 0.074; 95% CI: 0.009, 0.612) and 94.6% (AOR = 0.054; 95% CI: 0.011, 0.257) less likely to pay, respectively.

Conclusions

Willingness to pay for social health insurance was low. Being heard about health insurance, history of difficulty, and having other sources to cover medical bills were associated factors. Thus, it is recommended that media promotion and these factors should be considered for the successful implementation of the scheme.