Hindawi

BioMed Research International

Volume 2020, Article ID 8412957, 7 pages
https://doi.org/10.1155/2020/8412957

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

Abel Mekonne ,1 Benyam Seifu ,2 Chernet Hailu,3 and Alemayehu Atomsa3

1
Oromia Developmental Association, Ethiopia
2
College of Medicine and Health Sciences, Ambo University, Ethiopia
3
Department of Epidemiology, Faculty of Public Health, Jimma University, Ethiopia

Correspondence should be addressed to Benyam Seifu; benyamseifu77@gmail.com

Received 2 March 2020; Accepted 1 April 2020; Published 14 April 2020

Academic Editor: Hideo Inaba

Copyright © 2020 Abel Mekonne et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background. Cost sharing between beneficiaries and government is critical to attain universal health coverage. The government of
Ethiopia introduced social health insurance to improve access to quality health services. Hence, HCP are the ultimate frontline
service provider; their WTP for health insurance could influence the implementation of the scheme directly or indirectly.
However, there is limited evidence on willingness to pay (WTP) for social health insurance (SHI) among health professionals.
Methods. A cross-sectional study was conducted in Addis Ababa, Ethiopia, from May 1st to August 15th, 2019. A total sample
of 480 health care providers was selected using a multistage sampling method. The collected data were entered into Epi Info
version 7.1 and analyzed with SPSS version 23. Binary and multiple logistic regression analysis was carried out to identify the
associated factor outcome variable. The association was presented in odds ratio with 95% confidence interval and significance
determined at a P value less than 0.05. Result. A total of 460 health care providers responded to the questionnaire, making a
95.8% response rate. Of the respondents, only 132 (28.7%) were WTP for SHI. Higher educational status [AOR = 2:9, 95% CI
(1.2-7.3)], higher monthly income [AOR = 2:2, 95% CI (1.2-4.3)], recent family illness [AOR = 2:4, 95% CI (1.4-4.4)], and a
good awareness about SHI [AOR = 4:4, 95% CI (2.4-7.8)] showed significant association with WTP for SHI. The main reasons
for not WTP were thinking the government should cover the cost, preferring out-pocket payment and the provided SHI scheme
does not cover all the health care costs health care providers lost interest in pay for SHI. Conclusion and Recommendation. The
majority of health care providers were not willing to pay for the introduced SHI scheme. The provided SHI scheme should be
clear and provide special consideration for health care providers as the majority of them receives free health care service from
their employer health care institution. Also, the government, health professional associations, and other concerned stakeholders
should provide awareness creation programs by targeting low and middle-level health professionals in order to increase WTP
for SHI among health care providers.

1. Background patients will be able to afford services and that a higher vol-
ume of services will justify new provider investments (1, 2).
Health care spending increased worldwide from time to time. Also, this additional financial protection is seen as a way of
However, in developing countries, health care spending allowing more people to use needed services without incur-
depends on out-of-pocket payment (1, 2). According to ring high OOP payments, effectively moving closer to univer-
WHO 2012 report, in low-income countries, the share of sal coverage (1).
out-of-pocket payment (OOP) measured in USD ($) terms Health care finance is a scheme that helps to make fund-
was 48% of total expenditure compared to 14% in countries ing available to guarantee that everyone has the right to use
with higher incomes. Pooling reduces uncertainty for both public health and personal health care. It also comprises the
citizens and providers. By increasing and stabilizing demand foundation of finance to health, the time when it is available,
and the flow of funds, pooling can increase the likelihood that and how the capital raised is utilized (2–4). It can be national,
2 BioMed Research International

community, or private. They can also be mandatory or vol- office, an estimated 30,000 HCP are engaged in clinical and
untary. Mandatory schemes are usually national, in which other related works in Addis Ababa.
there is a legal obligation for people to pay into them and The sample size was calculated by Epi info version 7.1
are based on the principle of social solidarity (2, 5). SHI is considering the following parameters; P: 74.4% of WTP for
the possible organizational opportunities for levitation and SHI (16), d = margin of error is 5%, 95% CI = Za/2 = 1:96%,
pooling funds to finance health services (1, 6, 7). Its establish- 10% nonresponse rate, design effect: 1.5, and the final sample
ment has been advocated by the WHO as a key to achieving size became 480. Multistage sampling was used to select study
universal coverage of health care and to ensure access to participants. First, 15 hospitals randomly selected (5 govern-
health services, particularly for the disadvantaged in less ment, 9 private, and 1 NGO) from the 45 hospitals found in
developed countries (1, 4). Addis Ababa. Second, the sample was proportionally allocated
In Ethiopia, OOP spending accounts for a significant for the selected hospitals and the actual study participants were
proportion of health sector spending. In 2013, 90.6% of selected using the lottery method.
private health expenditure in Ethiopia were from out-of- Data was collected using an interview questionnaire
pocket (8). Given the country level of development, it is likely which was prepared by reviewing similar WTP studies and
that households who decide to use health services could easily modified to fit the local context (8, 11, 16–22). It was pre-
slip into poverty. Health spending took a substantial propor- tested among 10% of the sample size of the study partici-
tion of household disposable income, and this level of pants, which were not included in the actual study. The
spending could be prohibitive for accessing health care data were collected by five public health officers and super-
services (9–11). Ethiopian Demographic and Health Survey vised by two assistant professors. Respondents were asked
(EDHS) 2016 shows that the Health insurance coverage is about their maximum WTP for SHI when they first
extremely low; 95% of women and 94% of men are not cov- expressed their willingness to join. Subsequently, respon-
ered by any type of health insurance (12). dents were invited to choose a lottery ticket from a stack of
In order to alleviate the low level of health care service unmarked envelopes. Each respondent was randomly
utilization, improving access to quality health services in an assigned to one of three initial values; 3%, 4% of monthly sal-
“equitable,” efficient, and sustainable way, the government ary, and 5% of monthly salary. A maximum of three trials
of Ethiopia has launched two health insurance schemes. were performed with each respondent if the respondent was
The first one is community-based health insurance for agri- not satisfied with the results of the earlier bids. If the answer
culture and informal sector. And the second scheme was was “yes,” the interviewer increased the bid by 1% until the
SHI, which is aimed for the formal sector. The SHI was estab- respondent says “no” and vice versa. Finally, those who chose
lished under Article 55 (1) of the Constitution of the Federal 3% and above are considered as WTP yes (16, 17, 23).
Democratic Republic of Ethiopia under Proclamation The data were entered into Epi info version 7.1 and
No.690/20 (11, 13). The strategy includes health insurance exported to SPSS version 23 for data processing and analysis.
as a mechanism to generate an additional source of revenue Descriptive data were presented in frequency with percent
to secure financial protection for its citizens (3, 14). However, and mean with standard deviation. Logistic regression analy-
the willingness to pay (WTP) for SHI in the country is uncer- sis was carried out and all explanatory variables that were sig-
tain (3, 9). From the formal sector, health care providers nificantly associated with the outcome variable in the
(HCP) received a fee waiver from the hospitals they have bivariate analyses (P < 0:05) were entered into multivariate
been working. But the fee waiver only applied for the service logistic regression model. Crude and adjusted odds ratios
they obtain from their employer hospital only, and the ser- with their 95% confidence interval (CI) were determined,
vice package is not uniform (9, 15). This makes HCP differ- and statistically significant association was asserted based
ent from other formal sector. Hence, HCP are the ultimate on P value less than 0.05. Model fitting test was performed
frontline service provider; their WTP for health insurance using the likelihood ratio test, and multicollinearity was
could influence the implementation of the scheme directly checked using the variance inflation factor.
or indirectly. Besides, it is believed that they are aware of
new laws related to health and they can be role models for
their clients and the general community to adopt new behav- 3. Results
iors. But there is limited evidence about HCP WTP for SHI.
Therefore, this study tries to fill this evidence gap by acces- 3.1. Sociodemographic Characteristics. A total of 460 health
sing the level of WTP for SHI and its associated factors professionals were participated in the study making a
among HCP. response rate of 95.8%.
The majority of the respondents were male 267 (58.0%),
2. Methods and the mean age of the respondents was 29.8 years with
SD for 4.8 years. From the study participants, 169 (36.7%)
A cross-sectional study was employed from May 1st to were Orthodox Christian by religion and 187 (36.7%) were
August 15th, 2019 in Addis Ababa, the capital city of Ethio- Oromo by ethnicity. Regarding the educational status, 265
pia. The total population of the city was 2,738,248 consisting (57.6%) were degree holders, the majority of them were gov-
of 1,304,518 men and 1,433,730 women. A total of 45 hospi- ernment employees, and 122 (26.5%) were nurses. The mean
tals (11 governmental, 31 private, and 3 NGO) are found in monthly salary of the respondents was 6034 ± 304 Ethiopian
the city. According to the Addis Ababa health administration Birr (ETB) (Table 1).
BioMed Research International 3

Table 1: Sociodemographic characteristics of health professionals in Addis Ababa, Ethiopia, April-May 2019.

Variables Response Frequency Percent

Male 193 42.0
Sex of participant
Female 267 58.0
20 to 29 years old 283 61.5
Age category 30 to 39 years old 152 33.0
40 and older 25 5.4
Orthodox Christian 169 36.7
Muslim 129 28.0
Religion of participant
Protestant 156 33.9
Other∗ 6 1.3
Oromia 178 38.7
Amhara 159 34.6
Ethnicity of participant Tigray 67 14.6
Gurage 48 10.4
Other∗∗ 8 1.7
Diploma 165 35.9
Education of participant Degree 265 57.6
Master’s degree and above 30 6.5
Government employee 310 67.4
Occupation Private employee 125 27.2
NGO employee 25 5.4
Medical doctor 63 13.7
Nurse 122 26.5
Health officer 97 21.7
Profession
Laboratory technician 68 14.7
Midwife 88 19.1
Other∗∗∗ 22 4.7
2500-4500 170 37.0
Monthly salary in ETB (1 USD = 29:5 ETB) 4501-6500 154 33.5
> = 6501 136 29.6
∗
Atheist and Wakefata; ∗∗ Wolita, Ethiopia Somali; ∗∗∗ Radiologist, Physiotherapist, and anesthesiologist.

3.2. Health Status and Health-Related Characteristics. Of the SHI scheme is confusing, and it overlaps with the free health
total respondents, 88 (19.1%) have been getting sick in the care service they get from their employee hospitals (Figure 1
past three months and 87 (18.9%) of them reported that their and Table 3).
family members faced illness in the past three months. 86
(18.7%) of them received medical treatment at health institu- 3.4. Factors Associated with for SHI. The independent factors
tions. Of the respondents who faced illness, the majority of associated with WTP for SHI with P value less than 0.05 were
them self-paid the cost of the medical treatment 68 (80%) educational status, place of occupation, monthly income, his-
(Table 2). tory of illness in the past three months, history of illness of
family member in the past three months, and awareness of
3.3. Level of WTP for SHI. The majority of the respondents SHI. In multivariate analysis, four variables found to be sig-
had taken orientation about SRH, and 290 (63%) of them nificantly associated with WTP for SHI with P value less than
are aware of SHI. However, only 132 (28.7%) of them are 0.05. The model fitting test was performed using the likeli-
willing to pay at least 3% of their monthly salary for SHI. hood ratio test, and multicollinearity diagnosis was per-
The main reasons for not WTP were thinking the govern- formed using variance inflation factor and none is detected.
ment should cover the cost, preferring out-pocket payment Study participants who had a master’s degree or more were
and the provided SHI scheme does not cover all the health almost three times more likely to have WTP for SHI than
care costs health care providers lost interest in pay for SHI. who is a diploma holder [AOR = 2:9, 95% CI (1.2-7.3)].
And few health care providers reported that the current Study participants whose monthly income was 4500-6500
4 BioMed Research International

Table 2: Health status and health-related characteristics of health professionals in Addis Ababa, Ethiopia, April-May 2019.

Variables Response Frequency Percent

Yes 88 19.1
History of illness in the past 3 months
No 372 80.9
Yes 87 18.9
Members who were ill
No 373 81.1
Yes 86 18.7
Received treatment in the last 3 months
No 374 81.3
NGO-owned health facility 13 15.1
Where did you get treatment? Government-owned health facility 44 51.2
Private-owned health facility 29 33.7
Self 68 80.0
Who covered health care cost? Government 12 14.1
NGO 5 5.9
Dissatisfied 8 9.5
Satisfaction of health care cost Neutral 22 26.2
Satisfied 54 64.3
Yes 13 2.8
Did you borrow money to pay for health service?
No 447 97.2

the HCP does not have a WTP for SHI. Even though most
Willingness to pay for SHI of the studies regarding WTP for SHI are conducted at either
community level or nonhealth professionals, and the preva-
lence of WTP for SHI in this study found to be lower than
the finding of most of low and middle income Asian and
29% Sub-Saharan African country studies. For instance, in Ban-
gladesh, 87.6% of informal workers were willing to pay for
SHI (24) and in Vietnam (72%) (25). A study conducted
from Sub-Saharan African countries like Namibia shows that
71% 87% of the study participants have WTP for SHI (16), South
Sudan (68.8%) (19), southern Ethiopia (55%) (16), and in
north west Ethiopia (80%) (26). The main reason for the
lower prevalence of WTP for SHI among HCP in this study
Yes is that all government hospitals and most of private hospitals
No in Addis Ababa provide free health services for their
employees and immediate family members. Because of this
Figure 1: Level of WTP for SHI of health professionals in Addis reason, HCP rely on the free health service rather than using
Ababa, Ethiopia, April-May 2019.
SHI. But, if the health problem they face is beyond the hospi-
tal service coverage or its level, they will be forced to pay for
and more than 6500 ETB are two times more likely to have a the advanced health care they received from another hospital.
WTP for SHI [AOR = 2:2, 95% CI (1.2-4.3)] and [AOR = 2:1, However, the prevalence of WTP for SHI in this study was
95% CI (1.2-3.6)], respectively. Study participants whose almost similar to a study conducted in Tanzania (30%) (27).
family members faced illness in the past three months were Regarding factors associated with WTP, educational sta-
two times more likely willing to pay for SHI [AOR = 2:4, tus is found to be positively associated with WTP for SHI.
95% CI (1.4-4.4)]. Finally, study participants who had a good This is also evidenced from studies conducted among
awareness about SHI are four times more likely to have a teachers in southern Ethiopia; which explains that teachers
WTP for SHI [AOR = 4:4, 95% CI (2.4-7.8)] (Table 4). with higher educational status are more likely WTP for SHI
(13). A higher educational status also showed a positive asso-
4. Discussion ciation with WTP in different studies conducted in Iran, Ban-
gladesh, Nigeria, and Northern Ethiopia (14, 18, 20, 21).
This study provides important information regarding the Systematic review of WTP for health insurance in low and
newly launched Ethiopian SHI from HCP personal perspec- middle-income countries also indicated that the level of edu-
tive. The finding of this study shows that the majority of cation affects WTP (7). Furthermore, the study conducted in
BioMed Research International 5

Table 3: Level of WTP for SHI of health professionals in Addis Ababa, Ethiopia, April-May 2019.

Variables Response Frequency Percent

Yes 290 63.0
Awareness on SHI
No 170 37.0
Yes 132 28.7
Willingness to pay
No 328 71.3
Responsibility of government to cover about the scheme 47 14.3
Out of pocket payment is better 10 3.0
Do not need health insurance 30 9.1
Reason for not willing to pay for the scheme∗
Do not cover all needy service 97 29.6
Health insurance is confusing scheme 19 5.8
Always in a good health 125 38.1
∗
Multiple responses were possible.

Table 4: Factors associated with WTP for SHI among health professionals in Addis Ababa, Ethiopia, April-May 2019.

WTP for SHI

Variables Frequency (%) COR (95% CI) AOR (95% CI)
Yes No
Educational status
Diploma 42 (25.5%) 123 (74.5%) 1 1
Degree 71 (26.8%) 194 (73.2%) 5.1 (2.2-11.4)∗∗ 2.3 (0.8-6.2)
Master’s degree and above 19 (63.3%) 11 (36.7%) 4.7 (2.1-10.4)∗∗ 2.9 (1.2-7.3)∗
Place of occupation
Government hospital 101 (32.6%) 209 (67.4%) 1 1
Private hospital 20 (16.0%) 105 (84.0%) 1.6 (0.7-3.7) 0.7 (0..-2.1)
NGO hospital 11 (44.0%) 14 (56.0%) 4.1 (1.6-10.3)∗ 2.3 (0.7-6.9)
Monthly income in ETB
2500-4500 34 (20.0%) 136 (80.0%) 1 1
4501-6500 41 (26.6%) 113 (73.4%) 2.8 (1.7-4.7)∗∗ 2.2 (1.2-4.3)∗
≥6501 57 (41.9%) 79 (58.1%) 2.0 (1.2-3.2)∗∗ 2.1 (1.2-3.6)∗
History of illness in the past 3 months
Yes 43 (49.4%) 44 (50.6%) 3.0 (1.8-4.9)∗∗ 1.5 (0.7-20.2)
No 89 (23.9%) 248 (76.1%) 1 1
Family members has been ill in the past 3 months
Yes 43 (49.4%) 44 (50.6%) 2.7 (1.9-5.1)∗∗ 2.4 (1.4-4.1)∗∗
No 89 (23.9%) 248 (76.1%) 1 1
Awareness of SHI
Yes 115 (39.7%) 175 (60.3%) 5.9 (3.4-10.2)∗∗ 4.4 (2.4-7.8)∗∗
No 17 (10.0%) 153 (90.0%) 1 1
∗ ∗∗
P value less than 0.05, P value less than 0.001.

Bangladesh concluded that “educational interventions can be income, many studies conducted in low and middle-income
used for increasing demand for health insurance scheme” countries supported that better income has a positive associ-
(22). But on the contrary, a study from Mekele, Ethiopia, ation with WTP (7, 17, 18, 20, 23–27). For instance, a study
showed that the WTP decreases as the level of education conducted in Bangladesh revealed that WTP increased
increases (23). This disparity in the study from Mekele con- 0.196% with each 1% increase in monthly income (14). In
siders HCP as higher educational status among their study this study, study participants whose family members faced
participants. The fact that HCP are getting health services illness in the past three months were two times more likely
for free, the WTP among higher educational status in this willing to pay for SHI. This is similar with a study conducted
case HCP is found to be lower. Regarding family monthly in Southern Ethiopia which reviled. Study participants whose
6 BioMed Research International

family members were ill and paid for their health care service that all of their responses are confidential and anonymous,
are twice more likely WTP for SHI (16). This is also found to and they have all the right not to be involved in the study
be similar with the findings of a study conducted in Nigeria or not to answer any of the questions.
(18). Awareness about SHI is found to be associated with
WTP for SHI. A study conducted in South Sudan also Conflicts of Interest
showed that WTP was affected by study participants’ aware-
ness of SHI (17). A study from India indicated that not only The authors declare that they have no conflict of interests.
WTP is affected by awareness of SHI but awareness of SHI
and WTP for SHI are also affected by similar determinant Authors’ Contributions
factors like gender, age, and five other sociodemographic
and economic factors (24). Another study indicated that AM, CH, and AA contributed to the design of the study and
awareness about SHI not only affect WTP, but it also affects the interpretation of data. BS performed the data analysis and
the amount to pay for SHI (15). drafted the manuscript. All authors critically revised the
manuscript and approved the final manuscript.
5. Conclusion and Recommendation
Acknowledgments
The majority of health care providers were not willing to pay
for the introduced SHI scheme. The provided SHI scheme We would like to express deepest heartfelt thanks to Jimma
should be clear and provide special consideration for health University for providing institutional ethical clearance to
care providers as the majority of them receives free health conduct this study. We also like to thank Addis Ababa city
care service from their employer health care institution. Also, health office. Finally, we send our gratitude for all individuals
the government, health professional associations, and other and institutions that helped us, including data collectors,
concerned stakeholders should provide awareness creation supervisors, and study participants.
programs by targeting low and middle-level health profes-
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