Abstract
Background. As part of the efforts being made to achieve universal health coverage, Ethiopia plans to introduce a social health insurance scheme for the formal sector. Although the contribution will be collected as 3% of an employee’s gross salary from both the employee and employer, there is a concern that the premium may not be affordable for the majority of civil servants and that there could be limited interest in joining the scheme. As a result, the purpose of this study was to assess public servants’ awareness, willingness to join, and affordability of social health insurance in Arba Minch, south Ethiopia. Methods and Materials. A cross-sectional study design was used with 713 randomly chosen public employees from Arba Minch town from January 1 to 30, 2019. The survey participants were selected based on a multistage stratified random sampling method. Descriptive statistics were used to summarize awareness and affordability of the scheme, and both bivariate and multivariable logistic regressions were used to examine factors driving the outcome variables. Variables that had a value of less than 0.25 in bivariate analysis were changed to multivariate analysis, and a value of less than 0.05 was cutoff point for multivariate analysis. The odds ratio and 95% CI were used to report the findings. Result. In this study, 692 people voluntarily participated, which corresponds to a response rate of 97%. As the results revealed, 347 (50.1%) respondents had never heard of SHI before, 607 (87.7%) were able to afford the 3% of gross salary per month as a scheme premium, and 254 (36.7%) were willing to join the scheme. Working sector, regularly listening for health information through mass media, and social network participation were significantly associated with awareness of the SHI scheme. Also, educational status, family size, and net income were found to be significant factors associated with the affordability of the SHI scheme. On the other hand, awareness of SHI, family size, regularly listening for health information, and participation in social networks were significantly associated with willingness to join SHI during multivariate analysis. Conclusion. Half of the participants were unaware of social health insurance, suggesting that the program is not well known. Although only one-third of respondents were willing to join and pay for the program, the majority were able to afford the proposed contribution of 3% of gross wages per month.
1. Introduction
A low socioeconomic level forces people to buy healthcare insurance mostly out of their own pockets, which results in catastrophic health costs and jeopardizes basic life investments [1]. In most developing countries, out-of-pocket payments for healthcare services account for more than 40% of total expenditure, limiting access to healthcare and leading to complicated health problems [2]. In the case of Ethiopia, out-of-pocket expenses cover a large portion of the country’s healthcare spending, which is around 37% [3].
To ensure universal health coverage, the World Health Organization (WHO) set a strategy to mobilize more domestic resources for health, different mechanisms for risk pooling, ways to increase access to healthcare for the poor, and ways to deliver quality healthcare in all its member states, but special attention was given to low-income countries [4].
The universal health coverage (UHC) strategy adopted by the government of Ethiopia intends to work to overcome financial catastrophe by providing financial protection through two forms of health insurance platforms, the social health insurance (SHI) and community-based health insurance (CBHI) schemes. The SHI scheme will provide financial coverage for formal sector employees, pensioners, and their families with 3% employee payroll tax and 3% employer payroll tax, while the CBHI scheme will target urban informal sector employees and rural residents [5].
Although the SHI scheme has yet to be installed, as of December 2017, over 16.7% of Ethiopia’s population were covered by CBH [6]. This shows that Ethiopia has a lot to do on SHI in its transition to universal health coverage. Despite the fact that the evidence on the scheme is limited, all of them addressed willingness to pay rather than affordability, and there is a perception that the premium will be unaffordable. The absence of social health insurance will lead households to catastrophic healthcare expenditure, which interferes with effort to ensure universal health coverage.
As a result, the purpose of this study was to assess public servants’ awareness, willingness to join, and affordability of social health insurance in Arba Minch town, south Ethiopia, and, to the best of my knowledge, this will provide important information for policymakers in order to accelerate SHI implementation and also serve as the baseline literature for future scholars in the field.
2. Methods and Materials
2.1. Study Area and Period
The study was conducted from January 1 to 30, 2019, in Arba Minch town, which is located 550 km south of Addis Ababa, the capital of Ethiopia, and 270 km from Hawassa, the capital city of the Southern Nation, Nationalities, and People’s Region. The town is the center of Gamo Zone administration and is gifted with different tourist sites like more than forty springs, a crocodile market, God’s bridge, Abay and Chamo lakes, and Nechisar National Park. The town has four subcities: Sekela, Secha, Nechsare, and Abay, with a total population of 125,411. According to the Social Security Affairs Office, in 2019, nearly 4.2% (5,281) of the total population in the public sector was without health insurance coverage. In the town, there are different types of federal and state institutions, public health facilities, and town administration offices.
2.2. Study Design
An institution-based, cross-sectional design was used to assess factors associated with public servants’ awareness, affordability, and willingness to join SHI in Arba Minch town.
2.3. Source Population and Study Population
The source was all Arba Minch Tow public employees who did not have health insurance. Public employees in selected public sectors who were available during the data collection period were the study population.
2.4. Inclusion Criteria
Permanent public employees who are Ethiopian citizens and were present during the time of data collection were included.
2.5. Exclusion Criteria
Public employees whose service years were below six months were excluded from the study.
2.6. Sample Size Determination
The required sample size was computed using a single population proportion formula for the dependent variable “awareness of SHI.” The prevalence was taken from a study conducted on willingness to join and pay for the SHI scheme among teachers in Wolaita Sodo town, in which 45% of participants were aware of the scheme [7]. Since we used a multistage stratified sampling technique, we considered a design effect of 2, and we also used a 95% confidence interval (1.96), a margin of error of 5%, and a power analysis to determine the sample:
With a 10% nonresponse rate, the total sample size was 427.
For the dependent variable “affordability,” we considered the prevalence as 50%, 95% confidence interval (1.96), with a margin of error (5%), and a design effect of “2”:
With a 10% nonresponse rate, the total sample size was 431.
Based on a previous study, the prevalence of willingness to join for social health insurance among health workers at St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia, was 9.8% (21). Besides, we used a 95% confidence interval (1.96), with a margin of error (5%), and a design effect of “2”:
With a 10% nonresponse rate, the total sample size was 713.
Therefore, among the samples of three variables, the largest was chosen as the sample of the study, which is 713, including the nonresponse rate.
2.7. Sampling Procedure
Multistage stratified random sampling techniques were used to select study participants. In order to accommodate heterogeneity of income, the first stratum categorized the public servants of the town into three strata: higher academic institutions servants, health facilities servants, and town administration office servants. Using the lottery method, among three public health facilities, Arba Minch General Hospital and Arba Minch Health Center were selected, among three higher academic institutions in the town, Arba Minch Health Science College and Arba Minch Teachers Training College were selected, and among sixteen town administration offices, the Municipality, Education Office (EO), Health Office (HO), Public Service and Human Resource Office (PSHRO), and Culture, Truth, and Communication Office (CTCO) were selected. The second stratum categorized employees in academic institutions into two strata: academic staff and administrative/supportive staff and also servants of health facilities into two strata: professional staff and administrative staff, whereas since servants in town are homogenous, there is no need for further stratification. The total number of servants in Arba Minch Health Science College was 260 (administrative and supportive staff were 98, and academic staff were 152), 276 (administrative and supportive staff were 126, and academic staff were 150), 563 (administrative and supportive staff were 265, and professionals were 301), and 134 (administrative and supportive staff were 265, and professionals were 301). The municipality office had 65 employees, the EO had 24, the HO had 31, the PISHRO had 18, and the CTCO had 16.
According to the proportion of each stratum to the total sample size, the study participants from Arba Minch General Hospital were 563/1378 × 713 = 291 (Admin, 134 and professionals, 157), those from Arba Minch Health Center were 134/1378∗713 = 69 (Admin, 13 and professionals, 56), and those from Arba Minch Health Science College were 260/1378 × 713 = 135 (Admin, 51 and academic, 84); after obtaining a list of employees for each stratum, participants from each stratum were selected by simple random sampling using computer-generated random numbers (Figure 1).
2.8. Study Variables
2.8.1. Dependent Variables
The dependent variables used in this study were affordability, awareness, and willingness to join for SHI.
2.9. Independent Variables
Independent variables were sex, age, marital status, number of family members, income, level of education, work sector, history of illness in the household in the last 12 months, seeking and getting medical treatment, place of treatment, reasons for going to treatment, healthcare costs, coverage of the households for healthcare costs, means of getting money for healthcare, any healthcare coverage, perception of the availability and quality of healthcare service from public providers, access to information on health and insurance, and experience participating in different social networks.
2.10. Data Collection Tool
A structured, pre-tested questionnaire was used to collect data. The questionnaire was prepared in English and translated into Amharic. Again, it was changed back to English to check for consistency. Both closed-ended and open-ended questions were used. The questionnaire contains five sections: sociodemographic variables (age, sex, marital status, religion, monthly income, educational status, and occupation), health status and expenditure variables, awareness and perceptions towards SHI and WTJ, and affordability variables.
2.11. Data Collection Procedure
The data collection process took place from January 1 to 30, 2019, using structured questionnaires. Intensive three-day training was given for data collectors and supervisors on data collection tools, cleaning, precautions to be taken while collecting, the approach, and the most common mistakes committed during data collection. Then, afterward, using an Amharic version of the questionnaire, six diploma holders and two supervisors were used for data collection.
2.12. Data Quality Control
Data consistency and completeness were checked, and data entries were performed on a daily basis by assigned supervisors with immediate corrections. Moreover, the principal investigator and supervisors were supervised during the data collection process to check the accuracy and validity of the questionnaire; pretesting of the questionnaire was performed at Arba Minch Polytechnic College on five percent (5%) of the actual sample prior to the actual study period. After pretesting of the questionnaire, Cronbach’s alpha was calculated using SPSS Window version 25 to test the internal consistency (reliability) of the item.
2.13. Data Analysis
Data were cleaned, coded, and entered into EPI Data version 3.1 and exported to the SPSS version 25 statistical package for analysis. A descriptive statistical analysis was performed to show the characteristics of survey participants.
Binary logistic regression was used to identify factors associated with awareness, affordability, and WTJ of the scheme. The crude and adjusted odds ratios with their corresponding 95% confidence intervals were computed.
According to the recommendation of Hosmer and Lemeshow, a value of 0.25 should be used as a screening criterion for variable selection [8]. Therefore, variables that had a value of less than 0.25 in bivariate analysis were changed to multivariate analysis. The results were presented in text and tables based on the type of data.
2.14. Measuring Affordability
Although the “affordability” of healthcare is a common concern, the term is rarely defined. Fundamentally, affordability is a function of income, spending, and judgments about the value of goods and services for their price [9].
With regard to economic measurement of affordability, here we used a normative approach that states that a household can “afford” to pay for health insurance if it would have minimum income left over to meet its other socially defined minimum needs, such as food and shelter. Hence, this is considered for the proposed SHI premium contribution, the federal poverty line (FPL), and family size [10].
According to the 2015/16 poverty analysis of Ethiopia, the poverty line is birr 7184 per year per person [11]. When an individual’s net income after meeting the poverty line can cover the proposed 3% SHI premium, the scheme is affordable. According to the review of concepts to guide policymakers, the affordability of the scheme was assessed as below.
If a person’s net income [household size × (per capita income less the poverty line)] is greater than 3% of his gross salary, he can afford to pay 3% of his gross salary for SHI. If the person’s net income is less than [household size × (per capita income less the poverty line)] 3% gross salary, he cannot afford to pay 3% of his gross salary for SHI.
2.15. Operational definition
Willingness to pay is willing to pay the proposed premium contribution of 3% of gross monthly salary for social health insurance.
The poverty line for Ethiopia is birr 7184 per year per person, which is used to determine financial eligibility for social health insurance.
Net income is the sum of the cumulative monthly salary and the monthly income from other sources.
Affordability is the ability to pay the proposed premium contribution of 3% of gross monthly salary for social health insurance without falling below the poverty line.
Awareness: the term “awareness” is defined as knowledge or understanding of social health insurance.
3. Result
3.1. Sociodemographic Characteristics of the Respondents
In this study, 692 people voluntarily participated, which corresponds to a response rate of 97%. The mean age was 32 years with SD (±7.7). In terms of sex, 442 (63.9%) were male, and 443 (64%) were married. About 386 (54.8%) were Orthodox Christians, followed by 263 (38%). It was found that 276 were under a family size of 1-2, and the average size was 3 (±1.926 SD). Out of the total respondents, 300 (43.4%) earned less than 4000 ETB per month, with a median net income of 4,631 ETB.
More than half, 405 (58.5%), were degree and above holders, and 360 (52%) of them were working in health facilities, with a mean service year of 9.5 (+7.288 SD). The proportion of respondents who had legitimate authority in their working institution was 78 (11.3%), while 33.1% lived in rented housing (Table 1).
3.2. Health Status and Health Expenditure
One third of the respondents got sick in the 12-month recall period and received modern healthcare. It was found that 122 (17.6%) visited public health facilities and that 165 (23.8%) visited modern healthcare facilities less than twice in the recall period. Besides, 152 (22%) spent less than 1000 ETB, and 220 (31.8%) covered their healthcare expenses from their OOP, whereas 16 (2.3%) were forced to borrow from relatives.
3.3. Awareness of the SHI Scheme
It was found that 347 (50.1%) respondents had never heard of SHI before, and out of them, 76.8% were working at different town administration offices. However, 379 (54.8%) respondents get health information from the media on a regular basis, and 507 (73.3%) use social networking. More than half of those who participate in social networking and 77% of those who regularly get health information were aware of the scheme. Among the 356 (49.9%) respondents who heard about SHI, 31.5% used social media as a source of information, and the least used was training and newspapers (1.7%). Regarding knowledge of SHI, more than one third (397, 39%) knew about the benefit package, whereas 9.8% knew about the amount of the premium contribution (Figure 2).
The study revealed that only 81 (11.7%) and 70 (10.1%) respondents strongly agreed or disagreed with the introduction of SHI as a means of getting healthcare for public servants, respectively. Besides, 172 (24.9%) strongly disagreed with the mandatory contribution and being a member of the SHI scheme, and only 66 (9.5%) strongly agreed with the stated means of membership. About 175 people (25.3%) believed that introducing SHI would improve their healthcare quality, whereas 176 (25.4%) did not believe in the importance of introducing SHI as a means to improve healthcare quality. Furthermore, 184 (26.6%) trusted EHIA to manage premium contributions properly, whereas 152 (22%) did not.
3.4. Factors Associated with Awareness of the SHI Scheme
In the bivariate analysis, the type of working sector, education status, service year, regularly getting health information through mass media, and social network participation were identified as independent factors associated with awareness of the scheme.
The multivariable analysis revealed that, in the working sector, regularly listening for health information through mass media and social networking platforms was significantly associated with awareness of the SHI scheme. Civil servants who work in health facilities were three times more likely to be aware of the scheme than those working in town administration sectors. (AOR = 3.12; 95% CI = 1.35, 7.22). Respondents who get health information regularly from mass media were 15 times more likely to be aware than those who do not regularly listen to health information (AOR = 15.21; 95% CI: 10.41, 23.6). The odds of respondents who participate in social networks being 2 times more likely to be aware of SHI were 2 times higher than those who do not participate in social networks (AOR = 2.097; 95% CI: 1.33, 3.38) (Table 2).
3.5. Affordability of Social Health Insurance
With regard to net income, 300 (43.4%) had a monthly net income of less than or equal to 4000 ETB, 200 (28.9%) had 4000–6000 ETB, and 192 (27.7%) had a monthly net income of greater than or equal to 6500 ETB. Furthermore, 212 respondents (30.6%) had income from other sources that supplemented their salary, and all of them can afford the scheme when compared to respondents living solely on salary. Of the total respondents, 607 (87.7%) were able to afford the newly proposed 3% of gross salary per month as the SHI scheme premium (Figure 3). Of the 50 participants working in the town administration office, 50 (89.3%) were able to afford the scheme, and the majority of those who could afford the scheme were married and had a family size of at least two. On the other hand, 395 (97.5%) of the respondents with an educational status of degree or above were found to be able to afford the scheme.
3.6. Factors Associated with the Affordability SHI Scheme
In bivariate analysis, marriage status, educational status, family size, and net income were found to be significant factors associated with the affordability of the SHI Scheme. Despite marital status, all other variables were shown to have a significant association with the affordability of the scheme in multivariate analysis. Respondents with a family size of 1--2 were three times more able to afford the premium than those with a family size of >4 (AOR = 3.02; 95% CI: 2.05, 7.13). According to the findings, public employees with a degree or higher were 75% more likely to be able to afford the scheme than those with certificates or lower (AOR = 1.75; 95% CI: 1.22, 3.16). A diploma level was not found to be significantly related to the scheme’s affordability. With regard to their net income, those who earned a monthly net income of ≥6500 ETB were two times more able to afford the insurance scheme than servants with a monthly net income of 4000 ETB (AOR = 2.042; 95% CI: 1.01, 6.15). Net income between 4000 and 6500 ETB, on the other hand, was not significantly related to scheme affordability (Table 3).
3.7. Willingness to Join SHI
Only one third, 254 (36.7%), of the respondents were willing to join the newly proposed SHI, and among the willing respondents, more than half (65.35%) were male, and again, more than half (157 or 63.35%) worked at health facilities (Figure 4).
The main reasons for not wanting to join SHI were poor quality public health facility service, a small monthly salary, a lack of trust in the agency governing the contribution, a preference for using private health facilities, and a lack of enough information about SHI. Out of 254 respondents who were willing to join SHI, 171 (24.7%) respondents were willing to pay less than 1%, 42 (6.1%) were willing to pay 1-2%, and 41 (5.5%) respondents were willing to pay 2-3% of their gross monthly salary per month, with a mean of 1.47% (±0.766) monthly gross salary (Figure 5).
3.8. Factors Associated with Willingness to Join SHI
During bivariate analysis, religion, working sector, family size, history of getting sick in the last 12 months, institution where healthcare is provided, knowledge about SHI, amount of OOP healthcare expenditure, regularly getting health information from mass media, and social network participation all had significant associations with willingness to join SHI. However, awareness of SHI, family size, regularly listening for health information, and participation in social networks were significantly associated with willingness to join SHI during multivariate analysis. Public servants who heard about SHI were 2.3 times more likely to join and pay for SHI than those who did not hear about the scheme (AOR = 2.392; 95% CI: 1.599, 3.759). Participants with a family size of more than four were 52 percent more likely to join than respondents with a family size of less than two (AOR = 1.52; 95% CI: 1.324, 8.829).
The odds of those who participated in social networking were 1.5 times higher than those who were not willing to join SHI (AOR = 1.569; 95% CI: 1.040, 2.367). Respondents who regularly followed for health information were 1.5 times more likely than those who did not (AOR = 1.509; 95% CI: 1.004, 2.270) (Table 4).
3.9. Association between Affordability and Willingness to Join
Among those who could afford the scheme, 386 (63.6%) were not willing to join the scheme. Conversely, out of those who cannot afford the scheme, nearly 33 (39%) were willing to join the proposed SHI scheme.
4. Discussion
The current paper examines awareness, affordability, and perceptions of being involved in the proposed social health insurance scheme in Arba Minch town. A study conducted on demand for health insurance in India showed that awareness and understanding of the concept of health insurance were positively associated with membership [12].
In this study, it was found that half of the participants had never heard of the scheme. This result more or less coincides with a study conducted in the town of Debre Markos, where 347 (50.1%) had never heard of SHI [13]. However, it is remarkably higher than studies conducted in Addis Ababa, central Vietnam, the rural population of Bangalore, India, northwest Ethiopia, east Delhi, Andhra Pradesh, and Nigeria [7, 14–20]. This could be due to the difference in sociodemographic characteristics between the previous studies and the current study area; Addis Ababa, Vietnam, India, and Nigeria might have great accessibility to getting information from different media as compared to the current study area.
Awareness of SHI is significantly associated with the working sector, which regularly listens for health information through mass media and social network precipitation. The findings are consistent with those of previous research in Bangalore, India, and Andhra Pradesh [14, 19, 20]. Public servants working in health facilities were found to be more aware of the SHI scheme. This finding is complemented by a study conducted on health professionals in Addis Ababa [15]. This might be due to the accessibility of information, as their profession is somehow linked to the scheme.
Public servants who regularly follow the mass media were found to be more aware of the scheme than those who did not follow the media. The finding is complemented by studies conducted on the role of the mass media in healthcare development and the importance of the mass media in health communication in India [21, 22]. The mass media can provide the opportunity to obtain health insurance advocacy.
Also, public servants who were actively participating in social networking were found to be more aware of the SHI scheme than those who were not participating. This finding is supported by a study conducted in Dessie, Ethiopia, in which the “Eddir” association increased the initiation of health insurance schemes [5]. This might be attributed to the fact that social network participation provides an opportunity to discuss with peers and other people in different social gatherings, thereby supporting the sharing of knowledge. Furthermore, attitudes among themes, particularly “Eddir,” play a role in the character of risk pooling, which aids the poster’s understanding of health insurance.
Despite the low interest in joining SHI, the majority of the public servants in the study area can afford 3% of their gross salary for health insurance coverage. It was found in this study that educational status, family size, and net income were significantly associated with the affordability of the SHI scheme. This finding is consistent with studies conducted in America on the uninsured and the affordability of health insurance coverage, as well as studies conducted on the refusal to enroll in Ghana’s national health insurance scheme [23, 24].
Participants with better net income were more able to afford the scheme than their counterparts. The study conducted in India also confirmed that higher income increases the probability of purchasing health insurance [12]. Respondents with a smaller family size were more able to afford the premium than those with a larger family size. The finding is also in line with the finding of a study conducted in Ghana, which revealed that the unaffordable had a mean household size of 5.5, larger than the mean household size of 4.4 [24]. As expected, the cost of living will increase with an increasing family size, which might interfere with the affordability of the scheme.
According to the findings, public employees with a bachelor’s degree or higher were more able to afford the scheme. This finding is found to be similar to the finding of a study conducted in Boston [3]. This is mainly because as the educational status of public servants improves, their careers as well as their monthly income will also improve.
With regard to willingness, in the current study, only one third of the respondents were willing to join the newly proposed SHI scheme. This finding is more consistent than the finding of a study conducted in St. Paul’s Hospital, Millennium Medical College, Addis Ababa, Ethiopia, in which only 17% were willing to pay for the scheme [15]. This gap might be related to the selection of only health professionals as study units in the previous study as compared with our study. On the other hand, the current finding is less consistent than findings of studies conducted on government employees in Mekelle City, teachers in Wolaita Sodo, and civil servants in northwest Ethiopia, Kampala (Uganda), and Malaysia [13, 18, 25–27]. Since awareness of the scheme drives demand, this might be attributed to low awareness of the scheme in our study area. In the current study, two-thirds of the majorities were not willing to join the scheme. The main reasons for not wanting to join SHI were perceptions related to poor quality public health facility service, a small monthly salary, a lack of trust in the agency governing the contribution, a preference for using private health facilities, and a lack of enough information about SHI.
Among respondents who were willing to join the scheme, only one-fourth were willing to pay less than or equal to 1%, and few respondents were willing to pay between 1% and 3% of their gross monthly salary per month. The finding is more or less consistent with a study conducted in Mekelle city, northern Ethiopia [25]. Conversely, it is less consistent than the findings seen in studies conducted in Wolaita Sodo and Vietnam, in which nearly half and a majority were willing to pay 3% and 4%, respectively [7, 28]. The difference in the study’s finding may be explained by differences in awareness of the scheme, participants’ professional backgrounds, net income, and trust in the agency overseeing the scheme.
In the current study, adequate information about SHI, family size, and active engagement in different social networks significantly determined the willingness of respondents to join the SHI scheme. It was found that participants with a large family size were more willing than those with a small one. The finding is supported by studies conducted in Debre Markos, Nigeria, India, and Uganda [13, 17, 21, 22, 24]. While family size increases, the probability of illness will also increase, which might drive a need for healthcare security.
As the study report revealed, those who heard about the scheme were more willing to join it. This finding is complemented by studies conducted on teachers’ WTP in Wolaita Sodo, civil servants’ demand for SHI in Bahir Dar city, and the knowledge and attitude of civil servants in Osun state of Nigeria [18, 27, 29]. Whenever there is better information and understanding about the scheme, people will be driven to make it a priority. As identified, the other determinant of willingness is social network participation; those who participate in social networks like “Eddir” and “Ekub” are more willing to join the scheme. This conclusion is supported by a study conducted in Nigeria [17].
The observation of social network participation in the study provided the opportunity to discuss with peers and other people in different social gatherings, thereby supporting the sharing of knowledge and attitudes among themes and also, especially, the “Eddir” function in the character of risk pooling that the poster understands of insurance.
Regarding the relationship between affordability and willingness to join, even though the correlation is not significant, 87% of the respondents who were able to afford the scheme were not willing to join the insurance scheme. The study discovered that willingness is determined not only by the scheme’s affordability but also by family size, knowledge of the scheme, and social network engagement.
4.1. Limitations and Strength of the Study
The study used an open-ended contingency evaluation approach to assess participants’ willingness to pay an amount. It is subject to nonresponse and is also affected by rounding errors.
This study is the first of its kind to assess the affordability of proposed social health insurance premiums.
4.2. Conclusion and Recommendation
According to the report, half of the participants were unaware of social health insurance, and this suggests that there is a dearth of awareness about the program. It is advisable to work on raising public awareness about the scheme prior to starting the enrollment process. Working in the healthcare sector, as well as regularly seeking health-related information through the media and social networks, had a significant impact on public awareness of the SHI scheme.
Even though only one third of the respondents were willing to join and pay for the scheme, the majority were able to afford the proposed 3% of gross salary per month contribution as the social health insurance scheme premium. Family size, net income, and educational background all had a substantial impact on a participant’s affordability status.
The majority of respondents were not willing to join and pay for the scheme. Poor quality service in public health facilities, a meager monthly salary, a lack of confidence in the agency overseeing the contribution, a preference for private health facilities, and a lack of knowledge about SHI were the top deterrents to joining and paying. Therefore, it is better to work on the identified reasons to increase the willingness to participate in the scheme.
Abbreviations
| AOR: | Adjusted odds ratio |
| CBHI: | Community-based health insurance |
| CI: | Confidence interval |
| COR: | Crude odd ratio |
| EHIA: | Ethiopian Health Insurance Agency |
| PHF: | Public health facility |
| HHS: | Household size |
| OOP: | Out of pocket |
| SHI: | Social health insurance |
| UHC: | Universal health coverage |
| WTJ: | Willingness to join |
| WTP: | Willingness to pay. |
Data Availability
All data used to support the results of this research are available. All the reference of the preprint is included in the reference list to this new version.
Ethical Approval
This study was conducted after getting ethical approval from Addis Ababa University’s ethical review board. Permission was obtained from Arba Minch City Administration and selected institutions before starting the study.
Consent
Informed consent before data collection was obtained from each participant. In order to ascertain anonymous linkage, only the codes were recorded on the data collection tool.
Disclosure
The older version was published as a preprint [doi.org/10.21203/rs.3.rs-22331/v1(26) [30].
Conflicts of Interest
The authors declare that they have no conflicts of interest.
Authors’ Contributions
All the authors made substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data, took part in drafting the article or revising it critically for important intellectual content, agreed on the journal to which the article would be submitted, gave final approval of the version to be published, and agreed to be accountable for all aspects of the work.
Acknowledgments
The authors would like to acknowledge the support of Arba Minch City Administration, selected institutions in the city, and Addis Ababa University.
Supplementary Materials
1. Information sheet which describes the overall purpose, procedure, benefit of the study, confidentiality, risk of the study, and declaring participants’ right to refuse or withdraw from the study. 2. Declaration of the informed voluntary consent form that is used for declaration of their willingness for each participant during data collection. 3. The English version data collection questionnaire used to collect data from study participants. (Supplementary Materials)