Willingness to pay for child survival: results of a national survey in Central African Republic

The Malaysian community's acceptance and willingness to pay for a National Health Financing Scheme

OBJECTIVES

Currently, Malaysia faces great challenges in allocating adequate resources for healthcare services using a tax-based system. Therefore, Malaysia has no choice but to reform its healthcare financing system. The objective of this study is to assess Malaysian household willingness to pay and acceptance levels to the proposed National Health Financing Scheme.

STUDY DESIGN

This is a cross-sectional study.

METHODS

In total, 774 households from four states in Malaysia completed face-to-face interviews. A validated structured questionnaire was used, which was composed of a combination of open-ended questions, bidding games and contingent valuation methods regarding the participants' willingness to pay.

RESULTS

The study found that the majority of households supported the establishment of the National Health Financing Scheme, and half proposed that a government body should manage the scheme. Most (87.5%) of the households were willing to contribute 0.5-1% of their salaries to the scheme through monthly deductions. Over three-quarters (76.6%) were willing to contribute to a higher level scheme (1-2%) to gain access to both public and private healthcare basic services. Willingness to pay for the National Health Financing Scheme was significantly higher among younger persons, females, those located in rural areas, those with a higher income and those with an illness.

CONCLUSION

There is a high level of acceptance for the National Health Financing Scheme in the Malaysian community, and they are willing to pay for a scheme organised by a government body. However, acceptance and willingness to pay are strongly linked to household socio-economic status. Policymakers should initiate plans to establish the National Health Financing Scheme to provide the necessary financing for a sustainable health system.

A systematic review of stated preference studies reporting public preferences for healthcare priority setting

BACKGROUND

There is current interest in incorporating weights based on public preferences for health and healthcare into priority-setting decisions.

OBJECTIVE

The aim of this systematic review was to explore the extent to which public preferences and trade-offs for priority-setting criteria have been quantified, and to describe the study contexts and preference elicitation methods employed.

METHODS

A systematic review was performed in April 2013 to identify empirical studies eliciting the stated preferences of the public for the provision of healthcare in a priority-setting context. Studies are described in terms of (i) the stated preference approaches used, (ii) the priority-setting levels and contexts, and (iii) the criteria identified as important and their relative importance.

RESULTS

Thirty-nine studies applying 40 elicitation methods reported in 41 papers met the inclusion criteria. The discrete choice experiment method was most commonly applied (n = 18, 45.0 %), but other approaches, including contingent valuation and the person trade-off, were also used. Studies prioritised health systems (n = 4, 10.2 %), policies/programmes/services/interventions (n = 16, 41.0 %), or patient groups (n = 19, 48.7 %). Studies generally confirmed the importance of a wide range of process, non-health and patient-related characteristics in priority setting in selected contexts, alongside health outcomes. However, inconsistencies were observed for the relative importance of some prioritisation criteria, suggesting context and/or elicitation approach matter.

CONCLUSIONS

Overall, findings suggest caution in directly incorporating public preferences as weights for priority setting unless the methods used to elicit the weights can be shown to be appropriate and robust in the priority-setting context.

Willingness to pay for public health services in rural Central Java, Indonesia: methodological considerations when using the contingent valuation method

In the health sectors of low- and middle-income countries, contingent valuation method (CVM) studies on willingness to pay (WTP) have been used to gather information on demand variation or financial perspectives alongside price setting, such as the introduction of user fees and valuation of quality improvements. However, WTP found in most CVM studies have only explored the preferences that consumers express through their WTP without exploring whether they are actually able to pay for it. Therefore, this study examines the issues pertaining to WTP estimation for health services using the conventional CVM. We conducted 202 household interviews in 2008, in which we asked respondents about three types of public health services in Indonesia and assessed WTP estimated by the conventional CVM as well as in the scenario of "resorting to debt" to recognize their budget constraints. We find that all the demand curves for both WTP scenarios show gaps. Furthermore, the gap for midwife services is negatively affected by household income and is larger for the poor. These results prove that CVM studies on WTP do not always reveal WTP in the latter scenario. Those findings suggest that WTP elicited by the conventional CVM is different to that from the maximum price that prevents respondents from resorting to debt as their WTP. In order to bridge this gap in the body of knowledge on this topic, studies should improve the scenarios that CVM analyses use to explore WTP. Furthermore, because valuing or pricing health services based on the results of CVM studies on WTP alone can exacerbate the inequity of access to these services, information provided by such studies requires careful interpretation when used for this purpose, especially for the poor and vulnerable sections of society.

A systematic review and meta-analysis of willingness-to-pay values: the case of malaria control interventions

The increasing use of willingness to pay (WTP) to value the benefits of malaria control interventions offers a unique opportunity to explore the possibility of estimating a transferable indicator of mean WTP as well as studying differences across studies. As regression estimates from individual WTP studies are often assumed to transfer across populations it also provides an opportunity to question this practice. Using a qualitative review and meta analytic methods, this article determines what has been studied and how, provides a summary mean WTP by type of intervention, considers how and why WTP estimates vary and advises on future reporting of WTP studies. WTP has been elicited mostly for insecticide-treated nets, followed by drugs for treatment. Mean WTP, including zeros, is US$2.79 for insecticide-treated nets, US$6.65 for treatment and US$2.60 for other preventive services. Controlling for a limited number of sample and design effects, results can be transferred to different countries using the value function. The main concerns are the need to account for a broader range of explanators that are study specific and the ability to transfer results into malaria contexts beyond those represented by the data. Future studies need to improve the reporting of WTP.

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.

Change in willingness to pay for normal delivery and caesarean section during pregnancy and after delivery in Kathmandu

SUMMARY OBJECTIVES

To determine the change in willingness to pay (WTP) measured at pregnancy and at postpartum before and after knowing hospital costs among women who gave birth by normal delivery (NL) and caesarean section (CS) and to identify factors affecting the change in WTP.

METHODS

A prospective study was conducted from May to August 2009 at Tribhuvan University Teaching Hospital, Kathmandu, Nepal. WTP for total costs was measured by double-bound dichotomous contingent valuation and an open-ended technique. The trend of WTP over time was tested using longitudinal analysis. Associated factors to the positive or negative change in WTP were analysed by logistic regression.

RESULTS

Of 438 pregnant women followed up both at pregnancy and postpartum, two-thirds were willing to pay for services at the initial bid of the double-bound method by $60-$85 for NL and $110-$170 for CS. There were no significant differences in the median WTP measured during pregnancy between NL and CS. The WTP of both groups changed significantly over time (P < 0.001). Caesarean section, perception of good care, information provided on delivery costs and discussion with family about cost were significantly associated with changes from pregnancy to the postpartum period.

CONCLUSIONS

In low-income countries such as Nepal, where out-of-pocket health care expenditures are common, women perceived the health benefit of delivery care in hospital, especially for emergency CS. Their WTP had changed substantially after delivery, and awareness of the associated factors is essential for further policy and planning to improve the services and utilization.

Cost effectiveness in low- and middle-income countries: a review of the debates surrounding decision rules

Cost-effectiveness analysis (CEA) is increasingly important in public health decision making, including in low- and middle-income countries. The decision makers' valuation of a unit of health gain, or ceiling ratio (lambda), is important in CEA as the relative value against which acceptability is defined, although values are usually chosen arbitrarily in practice. Reference case estimates for lambda are useful to promote consistency, facilitate new developments in decision analysis, compare estimates against benefit-cost ratios from other economic sectors, and explicitly inform decisions about equity in global health budgets. The aim of this article is to discuss values for lambda used in practice, including derivation based on affordability expectations (such as $US150 per disability-adjusted life-year [DALY]), some multiple of gross national income or gross domestic product, and preference-elicitation methods, and explore the implications associated with each approach. The background to the debate is introduced, the theoretical bases of current values are reviewed, and examples are given of their application in practice. Advantages and disadvantages of each method for defining lambda are outlined, followed by an exploration of methodological and policy implications.

Demand assessment and price-elasticity estimation of quality-improved primary health care in Palestine: a contribution from the contingent valuation method

This paper proposes a new methodology to assess demand and price-elasticity for health care, based on patients' stated willingness to pay (WTP) values for certain aspects of health care quality improvements. A conceptual analysis of how respondents consider contingent valuation (CV) questions allowed us to specify a probability density function of stated WTP values, and consequently, to model a demand function for quality-improved health care, using a parametric survival approach. The model was empirically estimated using a CV study intended to assess patients' values for improving the quality of primary health care (PHC) services in Palestine. A random sample of 499 individuals was interviewed following medical consultation in four PHC centers. Quality was assessed using a multi-attribute approach; and respondents valued seven specific quality improvements using a decomposed valuation scenario and a payment card elicitation technique. Our results suggest an inelastic demand at low user fees levels, and when the price-increase is accompanied with substantial quality-improvements. Nevertheless, demand becomes more and more elastic if user fees continue to rise. On the other hand, patients' reactions to price-increase turn out to depend on their level of income. Our results can be used to design successful health care financing strategies that include a consideration of patients' preferences and financial capacities.

Increasing coverage of insecticide-treated nets in rural Nigeria: implications of consumer knowledge, preferences and expenditures for malaria prevention

Background

The coverage of insecticide-treated nets (ITNs) remains low despite existing distribution strategies, hence, it was important to assess consumers' preferences for distribution of ITNs, as well as their perceptions and expenditures for malaria prevention and to examine the implications for scaling-up ITNs in rural Nigeria.

Methods

Nine focus group discussions (FGDs) and questionnaires to 798 respondents from three malaria hyper-endemic villages from Enugu state, south-east Nigeria were the study tools.

Results

There was a broad spectrum of malaria preventive tools being used by people. The average monthly expenditure on malaria prevention per household was 55.55 Naira ($0.4). More than 80% of the respondent had never purchased any form of untreated mosquito net. People mostly preferred centralized community-based sales of the ITNS, with instalment payments.

Conclusion

People were knowledgeable about malaria and the beneficial effects of using nets to protect themselves from the disease. The mostly preferred community-based distribution of ITNs implies that the strategy is a potential untapped additional channel for scaling-up ITNs in Nigeria and possibly other parts of sub-Saharan Africa.

Do divergences between stated and actual willingness to pay signify the existence of bias in contingent valuation surveys?

This study's objective is to determine the factors that cause divergences over time (differences) between stated willingness to pay (WTP) and actual WTP (purchase behaviour), and consider whether any divergence signifies the presence of bias in contingent valuation studies. Stated WTP for insecticide-treated bed-nets (ITNs) was elicited from a random sample of respondents using three question formats in Nigeria. The question formats were the bidding game (BG), binary with follow-up (BWFU) and a novel structured haggling (SH) technique. The sales of the nets and a second survey were conducted 1 month after the first survey. In the second survey, factors that might explain the divergences were built into the questionnaire and these together with socio-economic variables were examined for causes of divergences in WTP. Data were analysed using non-parametric tests, testing of means and cross-tabulations. There were divergences in WTP in all three question formats: 69.4% in the BG, 78.7% in the BWFU and 48.8% in the SH. The higher the stated WTP, the more likely the divergence between stated and actual WTP. The attitude of the community leaders to the ITNs in the BG (p<0.05), the time respondents had to think about their WTP (p<0.05) and the external information they received about the ITNs in the BWFU (p<0.05) all led to divergences in WTP. We conclude that there are genuine causes of divergences between stated and actual WTP across the three question formats, and that the lesser the criterion validity score, the more the level of divergence in WTP. Studies that compare stated and actual WTP should explicitly determine the causes of divergences in order to assess the role of bias in the divergences.

Can we use contingent valuation to assess the demand for childhood immunisation in developing countries?: a systematic review of the literature

Childhood immunisation is one of the most cost-effective public health interventions, yet its population coverage in low- and middle-income countries is severely limited by the fiscal constraints that health services face. A recent proposal suggested that commitments to purchase vaccines and make them available to developing countries for modest co-payments could solve the problem. However, this is dependent on communities being willing and able to share the cost in this way, which is difficult to assess. One possible method to assess this demand is contingent valuation (CV). This article evaluates the usefulness of using CV in this way, by reviewing applications of CV in developing countries against current 'standards' for CV of immunisation in the literature. A structured review was adopted with reference to the standard frameworks for methodological evaluation. A set of five criteria were developed for evaluating an 'acceptable' CV study: (i) response rate; (ii) association between willingness to pay (WTP) and socioeconomic status (SES); (iii) sensitivity of WTP to benefit scale/scope; (iv) predictive validity; and (v) reliability in elicitation formats. Two strands of literature search were conducted using electronic databases (MEDLINE, EMBASE, HEALTHSTAR and Econlit) from 1966 to 2003, one for CV studies of immunisation and one for CV studies in developing countries. Twelve CV studies of vaccination and 13 CV studies undertaken within developing countries were identified and reviewed. The quality of existing CV studies conducted in developing countries exceeded the benchmark standard set by studies of immunisation in the developed world in four of the five criteria. WTP estimates appeared both internally valid (i.e. associations with SES) and externally valid (i.e. predictive validity), reliability in developing countries was no less than that of the benchmark level in the existing literature, and the high response rates suggested that CV can be administered to a rural, and perhaps less literate, population. Only sensitivity to scale/scope was not well demonstrated. Our assessment indicated that the CV technique offers a promising tool to estimate the demand for childhood immunisation in low- and middle-income countries. International agencies are therefore encouraged to devote resources to such an application when designing their support to the immunisation programmes.

Factors affecting decisions to seek treatment for sick children in Kerala, India

The purpose of this study was to measure the effects of social and economic variables, disease-related variables, and child gender on the decisions of parents in Kerala, India, to seek care for their children and on their choice of providers in the allopathic vs. the alternative system. A case-control analysis was done using data from the Kerala section of the 1996 Indian National Family Health Survey, a cross-sectional survey of a probability sample of households conducted by trained interviewers with a close-ended questionnaire. Of the 469 children who were eligible for this study because they had at least one common symptom suggestive of acute respiratory illness or diarrhea during the 2 weeks before the interview, 78 (17%) did not receive medical care, while the remaining 391 (83%) received medical care. Of the 391 children who received medical care, 342 (88%) received allopathic medical care, and 48 (12%) received alternative medical care. In multivariable analyses, parents chose not to seek medical care for their children significantly more often when the illness was mild, the child had a specific diagnosis, the mother had previously made fewer antenatal visits, and the family had a higher economic status. When parents sought medical care for their children, care was sought significantly more often in the alternative provider system when the child was a boy, the family lived in a rural area, and the family had a lower social class. We conclude that, in Kerala, disease severity and economic status predict whether children with acute respiratory infection or diarrhea are taken to medical providers. In contrast, most studies of this issue carried out in other populations have identified economic status as the primary predictor of medical system utilization. Also in Kerala, the gender of the child did not influence whether or not the child was taken for treatment but did influence whether care was sought in the alternative or the allopathic system.

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

The test-retest reliability of the bidding game and the take-it-or-leave-it (TIOLI) approaches to eliciting willingness-to-pay (WTP) are compared. A random sample of households in the Nouna area of Burkina Faso were interviewed twice with an interval of around 4-5 weeks. One thousand one hundred and eight individuals were asked their individual WTP for community-based health insurance. Three hundred and forty eight of these individuals were household heads who were in addition asked about their WTP for health insurance for the whole household. Median and the mean WTP were higher in the test than in the retest. Despite these differences both methods displayed moderate to good reliability (kappa values ranged from 0.467 to 0.621, Spearman correlations ranged from 0.653 to 0.701 and Pearson correlations ranged from 0.593 to 0.675). There was some evidence that the bidding game was more reliable than the TIOLI method. This study is based on larger sample size than previous studies and also is one of the first studies of the reliability of WTP in a developing country.

Overcoming barriers to HIV testing: preferences for new strategies among clients of a needle exchange, a sexually transmitted disease clinic, and sex venues for men who have sex with men

OBJECTIVE

To determine strategies to overcome barriers to HIV testing among persons at risk.

METHODS

We developed a survey that elicited testing motivators, barriers, and preferences for new strategies among 460 participants at a needle exchange, three sex venues for men who have sex with men, and a sexually transmitted disease clinic.

RESULTS

Barriers to testing included factors influenced by individual concern (fear and discrimination); by programs, policies, and laws (named reporting and inability to afford treatment); and by counseling and testing strategies (dislike of counseling, anxiety waiting for results, and venipuncture). The largest proportions of participants preferred rapid testing strategies, including clinic-based testing (27%) and home self-testing (20%); roughly equal proportions preferred oral fluid testing (18%), urine testing (17%), and standard blood testing (17%). One percent preferred home specimen collection. Participants who had never tested before were significantly more likely to prefer home self-testing compared with other strategies. Blacks were significantly more likely to prefer urine testing.

CONCLUSIONS

Strategies for improving acceptance of HIV counseling and testing include information about access to anonymous testing and early treatment. Expanding options for rapid testing, urine testing, and home self-testing; providing alternatives to venipuncture; making pretest counseling optional; and allowing telephone results disclosure may encourage more persons to learn their HIV status.

Understanding household demand for indoor air pollution control in developing countries

More than 2 billion people rely on solid fuels and traditional stoves or open fires for cooking, lighting, and/or heating. Exposure to emissions caused by burning these fuels is believed to be responsible for a significant share of the global burden of disease. To achieve widespread health improvements, interventions that reduce exposures to indoor air pollution will need to be adopted and consistently used by large numbers of households in the developing world. Given that such interventions remain to be adopted by large numbers of these households, much remains to be learned about household demand for interventions designed (in part at least) to reduce indoor air pollution. A general household framework is developed that identifies in detail the determinants of household demand for indoor air pollution interventions, where demand for an intervention is expressed in terms of willingness to pay. Household demand is shown to be a combination of three terms: (1) the direct consumption effect; (2) the child health effect; and (3) the adult health effect. While micro-level data are not available to estimate directly this model, existing data and information are used to estimate just the health effects component of household demand. Based on such existing information, it might be concluded that household demand should seemingly be strong given that willingness to pay, based on existing information, is seemingly large compared to costs for common interventions like improved stoves. Given that household demand is not strong for existing interventions, this analysis shows that more clearly focused research on household demand for interventions is needed if such interventions are going to be demanded (i.e. adopted and used) by large numbers of households throughout the developing world. Four priority areas for future research are: (1) improving information on dose-response relationships between indoor air pollution and various health effects (e.g. increased mortality and morbidity risks); (2) improving information on impacts from interventions in terms of air pollution reductions and also cooking times, fuel use, and heat intensities; (3) improving information on household shadow values for improved health, with separate information for adult and child health; and (4) considering more directly household information, and its adequacy, for their ability to evaluate the relationships between fuel use and health.

Hypothetical and actual willingness to pay for insecticide-treated nets in five Nigerian communities

OBJECTIVES

To determine the hypothetical and actual willingness of households to pay (WTP) for insecticide-treated nets (ITNs), and compare these in areas with and without previous exposure to free ITNs.

METHODOLOGY

The contingent valuation method was used to determine the willingness of the heads of 1908 randomly selected households from five communities in south-east Nigeria to pay for two sizes of ITNs. Two communities previously had free access to ITNs. Validity was assessed using multiple regression analyses, and by offering ITNs for sale to 200 randomly selected people drawn from the original sample. The data was collected between March and September 1998.

FINDINGS

Most respondents were willing to pay for ITNs: Mbano (93.26%), Ugwogo (97.69%), Orba (83.24%), Alor-uno (95.37%), and Ibagwa-ani (87.34%). In multivariate analyses, WTP was significantly associated with the number of people living in a household, sex of the respondent, average yearly expenditure on gifts and the type of savings scheme (P < 0.05). Some of the residences were also statistically significant in the two models used, and those with prior exposure to free ITNs were negatively related to WTP. Seventy-six percent of those who were hypothetically willing to pay actually purchased them, and the WTP technique correctly predicted the choices of 80% of the respondents.

CONCLUSION

There was good evidence that stated WTP could be translated into actual WTP. However, peoples' perception of affordability of the nets and its link to their WTP needs further exploration. The WTP technique is a potentially valid tool for market research in healthcare, as it was able to predict the direction of actual WTP for the ITNs. The hypothetical WTP amounts could be used as guide to know either the optimal price to charge for the ITNs or the level of subsidy to introduce.

Willingness to pay for the retreatment of mosquito nets with insecticide in four communities of south-eastern Nigeria

OBJECTIVES

To determine the willingness to pay (WTP) for the retreatment of insecticide-treated nets (ITN) in four malaria holoendemic communities of Nigeria.

METHODS

Contingent valuation method. The study tool was a pretested interviewer-administered questionnaire. Randomly selected households were the study units and household heads or their representatives were interviewed by locally trained interviewers.

RESULTS

Most households were willing to pay for annual ITN retreatment in all four communities. The proportion of those willing to pay ranged from 79% to 91%. WTP amounts ranged from $0.05 to $5.26. The median from the aggregated data from the four communities was $0.21. Multivariate analysis showed that many explanatory variables were statistically significantly related to WTP for ITN retreatment.

CONCLUSION

WTP for ITN retreatment exists. The difficulty lies in implementing this. One possibility would be a community-based ITN retreatment programme.

Providing low-cost sexually transmitted diseases services in two semi-urban health centers in Central African Republic (CAR): characteristics of patients and patterns of health care-seeking behavior

BACKGROUND

While treatment of symptomatic sexually transmitted diseases (STDs) has been shown to reduce the incidence of HIV infection, there are few published reports describing the delivery of high quality STD care in Africa.

GOAL

To test the feasibility of providing comprehensive, affordable STD services through the existing primary care infrastructure.

DESIGN

STD treatment services using a syndromic' approach were established in two semi-urban hospital outpatient departments (OPD) in Central African Republic (CAR). A dedicated paramedical provider took a clinical history, performed an examination, explained the diagnosis and the importance of referring partners, dispensed drugs, and offered partner referral vouchers. A fee-for-service system was used to resupply drugs initially purchased with project funds.

RESULTS

Of 9,552 visits by index patients and partners over a 28-month period starting in October 1993, 60% were made by women; of these women, 90% were symptomatic, 77% had "vaginal discharge," 70% "lower abdominal pain," and 7% "genital ulcer." Among men, 64 % were symptomatic, 38 % had "urethral discharge," and 14% "genital ulcer." Half of all symptomatic patients presented within 1 week of the onset of symptoms; 44% of men compared to 18% of women had sought care elsewhere before the clinic visit. The average cost per STD treated with recommended drugs was $3.90. Etiologic data from subpopulations in both sites suggest that a high proportion of patients was infected with an STD.

CONCLUSIONS

Comprehensive yet affordable care for STDs in persons (and their partners) who recognize symptoms is feasible and should be widely implemented in primary care systems to prevent the spread and complications of STDs and HIV in Africa.

The contingent valuation method in health care

The contingent valuation method (CVM) is a survey-based, hypothetical and direct method to determine monetary valuations of effects of health technologies. This comprehensive review of CVM in the health care literature points at methodological as well as conceptual issues of CVM and on willingness to pay as a measure of benefits compared with other measures used in medical technology assessment. Studies published before 1998 were found by searching computerised databases and former review literature. Studies were included, when performing CVM using original data and meeting qualitative criteria. Theoretical validity of CVM was sufficiently shown and there were several indications of convergent validity. No results on criterion validity and only a few on reliability were found. There was widespread use of different elicitation formats, which make comparisons of studies problematic. Direct questions were seen problematic. First bids used in bidding games influenced the monetary valuation significantly (starting point bias). There were indications that the range of bids of payment cards also affected the valuation (range bias). However, no strategic bias was found. The influence of different states of valuation (ex-ante, ex-post) and of payment methods, as well as the possible aggregation of the results of decomposed scenarios rather than more complex holistic scenarios, were rarely investigated. Further methodological analysis and testing seems to be necessary before CVM may be used in health care decision making. Important research topics are the connection of assessment of different elicitation methods and criterion validity as well as tests on reliability according to methodological issues. Concerning conceptual issues, the analysis of the influence of different states of evaluation and of the status of the respondents as diseased or non-diseased, as well as the aggregation of results of decomposed scenarios, proved to be topics of further research.