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

The Willingness to Pay for Basic Health Insurance in the Netherlands: Quantitative and Qualitative Insights

BACKGROUND

Rising healthcare costs could undermine people's willingness to contribute to the healthcare system. Therefore, we investigated people's willingness to pay (WTP) for basic health insurance. We also studied reasons for the willingness or unwillingness to pay.

METHODS

A mixed methods study was performed. An online survey was sent out to 1500 members of the Dutch Health Care Consumer Panel in May 2023 (51% response rate, N = 760). WTP was assessed using the contingent valuation methodology. Reasons for the willingness or unwillingness to pay were obtained via 15 semi-structured interviews. Thematic analysis was used to analyse the interviews.

RESULTS

People were, on average, willing to pay €160 per month for basic health insurance (€153-167 95% CI). Of the respondents, 58% (N = 443) was willing to pay more than the lowest monthly premium of €140 in 2023. WTP was positively correlated to income, age, and education. The interviews indicated that the ability to pay, healthcare consumption, care included in the basic health insurance package, organisation of the health insurance system, coverage of risk, and accessibility of care play a role in people's willingness or unwillingness to pay.

CONCLUSIONS

Most people in the Netherlands were willing to pay more for basic health insurance than the current lowest premium. People valued that health insurance allowed them and others to access healthcare services. As the premium is expected to increase in the coming years, support for the healthcare system may erode, as interviews indicated that the ability to pay is an important condition of the WTP.

Factors associated with household willingness to pay for Universal Health Coverage in Cameroon: a nationwide cross-sectional analysis

BACKGROUND

Sustained financing for Universal Health Coverage (UHC) has been a concern for the Cameroon government. Household contributions have been considered as a financing mechanism, but this raises concerns on the willingness of households to pay for UHC. The current study assessed factors associated with the willingness to pay (WTP) for UHC in Cameroon.

METHODS

Community based, cross-sectional analysis of data from households (selected via multi-stage, randomized, cluster sampling) across all ten regions of Cameroon, during July 2020. Factors associated with WTP for UHC were determined using a multinominal logistic regression model, tested at varying significance levels (1%, 5%, and 10%) to enhance its ability to detect meaningful and practical value associations.

RESULTS

Overall, 5,014 households were surveyed, 64.3% and 35.6% from rural and urban areas respectively. Household heads were 40.2 ± 10.1 years old and mostly male (60.6%). Most surveyed households (72%) were willing to contribute for UHC. Amongst these willing households, WTP varied with the sex (females opted for lower payments) and educational level (those with ≥ high school education opted for contributions ≥ US$ 165.6 annually, p < 0.01) of the household head. WTP also varied proportionally with household income and was influenced by the sector of activity (formal secondary/tertiary and informal sector workers opted for contributions > US$ 165.6 annually, p < 0.01) of the household head. Other factors affecting WTP included household size (households with ≥ 13 persons opted for contributions ≥ US$ 165.6, p < 0.01) and the age of the household head (those ≥ 55 years opted for higher contributions; US$ 33.1-82.6, p < 0.01). WTP varied positively with knowledge on UHC and affiliation to a health insurance scheme. Household who did not resort to self-medication/prayers when in need of healthcare services opted for higher contributions (US$ 82.6- 165.6, p < 0.01).

CONCLUSION

UHC implementation in Cameroon will require that factors shown here-in to influence WTP be carefully considered. Modifiable factors such as self-medication/prayers and poor knowledge on UHC, underlines the need for greater sensitization on UHC. Given the high WTP from the informal sector, characterization of the sector could go a long way to increase the financial envelope allocated for UHC.

What is the coverage of your health insurance plan? An audit of hospital billing

The provocative advice of health policymakers in endorsing private health insurance, as a critical tool for health reforms, is well-reckoned as a deterrent to mounting healthcare expenditure in the wake of the public health insurance quagmire. However, scholarly evidence has condemned the ineffectiveness of private health insurance in containing out-of-pocket expenditure. In this backdrop, we carried out a nuanced investigation of the coverage pattern of private health insurance policies. We examined the one-year billing information of private health insurance holders hospitalized in a multi-specialty teaching hospital. We found that private health insurance fails to provide full coverage, leading to underinsurance though minimal financial protection was extended. Moreover, reimbursement patterns under various cost heads are also discussed. We conclude by emphasizing the need for future research to fill the knowledge gap. We claim methodological novelty in its approach to data collection.

Factors Associated With Willingness to Pay for Primary Health Care Services in South Africa: A Cross-Sectional Survey of Medical Schemes Members

The cost of healthcare is an issue of concern for both consumers and funders of healthcare in South Africa. The country spends approximately 8% of GDP on health care. Health care is financed through the public sector which covers 86% of the population and the private sector which covers 14% of the population. Medical schemes are the main source of healthcare financing in the private sector. Services covered by medical schemes include chronic diseases, emergencies, diagnosis, and treatment of a selected number of diseases. Primary health care services such as screening are limited. The aim of this study was to assess factors associated with members of medical schemes' willingness to pay for a primary health care package in the private sector. A cross-sectional survey was conducted amongst principal members of medical schemes between July and September 2020. All principal members with access to an online questionnaire were eligible to participate in this study. Logistic regression was used to identify factors associated with willingness to pay for primary health care services. A total of 6512 members of medical schemes participated in the study. Thirty-five percent of the participants were willing to pay for the primary health care package. Factors influencing willingness to pay included marital status, employment status, income and household size. The study highlights the need for policymakers to consider socioeconomic factors when designing health care policies.

Households’ Willingness to Pay for Community-Based Health Insurance in the Southwest Region of Bangladesh

In Bangladesh, especially the informal sector workers are deprived of proper healthcare owing to high cost and lack of security like health insurance. The study aims to estimate the willingness to pay (WTP) of the informal sector workers for premium-based health insurance on the basis of data collected from 210 households, where double bounded dichotomous choice (DBDC) model was applied. The study estimates that this working-class people are willing to pay a monthly premium of on average around BDT (Bangladeshi Taka) 315 (USD 3.66) in response to enjoy the facilities of health insurance scheme for a household comprising up to four family members. Moreover, the per household estimated average monthly optimum tariff rate of almost BDT 300 (USD 3.54) and monthly mean social optimum tariff rate of about BDT 100 (USD 1.18) indicate the assurance of socially desirable welfare for all of the market participants. By charging this tariff, approximately 97 percent of the people would enjoy access to community-based health insurance, in addition to generating revenue that is around 1.13 times the project’s cost. Even by charging this monthly mean social optimum tariff, approximately 97 percent of the households would enjoy the access to community-based health insurance; the generating revenue through that tariff rate is around 1.13 times of the probable cost for high service package health scheme. In order to alleviate the burden of the out-of-pocket (OOP) costs for this vulnerable community, the study advises policymakers to initiate health insurance scheme by maintaining effective supervision over market dynamics and fixing the best fit premium rate.

Eliciting relative preferences for the attributes of health insurance schemes among rural consumers in India

There is a limited understanding of the preferences of rural consumers in India for health insurance schemes. In this article, we investigate the preferences of the rural population for the attributes of a health insurance scheme by implementing a discrete choice experiment (DCE). We identified six attributes through qualitative and quantitative study: enrollment, management, benefit package, coverage, transportation facility, and monthly premium. A D-efficient design of 18 choices has been constructed, each comprising two health insurance choices. We collected the representative sample from 675 household heads of the rural population through personal interviews. The preferences for the attributes and attribute levels were estimated using the multinomial logit (MNL) and random-parameter logit (RPL) models. The analysis shows that all attribute levels significantly affect the choice behavior (P < 0.05). The relative order of preferences for attributes are; enrollment, benefit package, monthly premium, management, coverage, and transportation.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Health insurance coverage in Ethiopia: financial protection in the Era of sustainable cevelopment goals (SDGs)

BACKGROUND

Health insurance is among the healthcare financing reforms proposed to increase the available healthcare resources and to decrease the risk of household financial crisis. Recently, Ethiopia has been implementing community-based health insurance which mainly targets the very large rural agricultural sector and small and informal sector in urban settings. Therefore, this study was aimed to assess the coverage of health insurance and its determinants in Ethiopia.

METHODS

Data were extracted from the 2019 mini Ethiopian Demographic and Health Survey (EDHS) to assess determinants of health insurance coverage in Ethiopia. The analysis included a weighted sample of 8663 respondents. Multivariable logistic regression analysis was conducted and the results were presented as adjusted odds ratio (AOR) at 95% confidence interval (CI), statistical significance was declared at a p-value < 0.05 in all analyses.

RESULTS

The health insurance coverage in Ethiopia was 28.1% (95%CI: 27.2%, 29%). Administration regions (Tigray: AOR = 16.9, 95%CI: 5.53, 51.59, Amhara: AOR = 25.8, 95%CI: 8.52, 78.02, Oromia, AOR = 4.27, 95%CI: 1.41, 12.92, Southern Nations, Nationalities and Peoples region, AOR = 4.06, 95%CI: 1.34, 12.32, Addis Ababa, AOR = 4.65, 95%CI: 1.46, 14.78), place of residence (rural, AOR = 1.38, 95%CI: 1.17, 1.63), sex of household head (male; AOR = 1.23, 95%CI: 1.07, 1.41), wealth index (middle, AOR = 1.75, 95%CI: 1.46, 2.09, richer, AOR = 1.86, 95%CI: 1.55, 2.24), family size (≥ 5 members, AOR = 1.17, 95%CI: 1.03, 1.33), having under-five children (AOR = 1.22, 95%CI: 1.076, 1.38), and age of household head (31-40 years, AOR = 1.71, 95%CI: 1.45, 2.01, 41-64 years, AOR = 2.49, 95%CI: 2.12, 2.92, 65 + years, AOR = 2.43, 95%CI: 2.01, 2.93) were factors associated with health insurance coverage.

CONCLUSIONS

Less than one-third of Ethiopians were covered by health insurance. Socio-economic factors and demographic factors were found to associate with health insurance coverage in Ethiopia. Therefore, enhancing health insurance coverage through contextualized implementation strategies would be emphasized.

Willingness to pay for a National Health Insurance (NHI) in Saudi Arabia: a cross-sectional study

Background

Healthcare services in Saudi Arabia are provided free of charge to its citizens at the point of use. Recently, however, the government has realized that this model is unsustainable in the long run. Therefore, Saudi decision-makers are seeking to have a sustainable health system through the introduction of a contributory National Health Insurance that require making regular financial contributions from its members.

Objective

This study aims to explore the people’s willingness to pay for a National Health Insurance system in Saudi Arabia. The study also aims to understand the factors affecting their willingness or unwillingness to pay NHI, such as, their demographic and socio-economic characteristics, the type of their usual health care provider, and their satisfaction with the current healthcare services.

Methods

A cross-sectional study design with Contingent Valuation (CV) technique was used to measure the value of National Health Insurance based on an individual’s willingness to pay. The data were collected from 475 participants using an online survey via Google Forms between March 2021 and April 2021. Frequencies, logistic regression, and linear regression, were conducted to answer the research questions.

Results

The number of individuals who was willing to pay for NHI was higher than those who were not willing to pay (62.9, 95% CI = 58.4-67.3%) vs (37.1, 95% CI = 32.7-41.6%). A binomial test found this difference was statistically significant (p < 0.001). There was a significant association between the likelihood of paying for NHI and type of usual healthcare provider (OR = 3.129, 95% CI = 1.943-5.039, p < 0.001); as individuals using public health services were more likely to pay for NHI. Also, with satisfaction with health services (OR = 14.305, 95% CI = 3.240-63.153, p < 0.001), as individuals who were very satisfied with the healthcare services were more likely to pay for NHI. The median amount of money the people were willing to pay as a monthly contribution for NHI was 100 SAR (26.5 USD) with the average being 152 SAR (40 USD). There was a significant association between the maximum amount the participants were willing to pay and age, region, and education. Specifically, 30–39-year-olds were willing to pay more for NHI compared to participants aged 50 or older (ß = 103.55, 95% CI = 26.27- 199.29); participants from central region more than participants from northern region (ß = 70.71,95% CI = 2.14- 138.58); and participants with masters degree more than participants with PhDs (ß = 227.46, 95% CI = 81.59- 399.28).

Conclusion

This study provided some evidence that more people were willing to pay for NHI than those who declined. Individuals who frequently used public health services and were very satisfied with these services were more willing to pay for NHI. Younger population, those with master’s degree, and from the central region were willing to pay more amount of money for NHI. These results could help policy makers shape their decisions and anticipate problems that may arise with NHI implementation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13353-z.

Factors Associated With Community Based Health Insurance Healthcare Service Utilization of Households in South Gondar Zone, Amhara, Ethiopia. A Community-Based Cross-Sectional Study

In Ethiopia, community-based health insurance was implemented to promote equitable access to sustainable quality health care and increase financial protection. The purpose of this study was to identify factors associated with community-based Health Insurance, Health Care Service Utilization of Households in the South Gondar Zone. A community-based cross-sectional study was employed. Data were collected among 619 randomly selected households in the south Gondar zone. Chi-square and binary logistic regression analyses with a P-Value of less than .05 were used to determine the association. Out of the total households, 511(82.6%) were using the CBHI scheme for health care service utilization. Residence, marital status, education level, occupation status, family size, presence of under-five children in the household, presence of elders in the households, nearest health institution, presence of chronic illness in the household's, time taken to reach health institution, an attitude of a household were the determinant factors of community-based health insurance scheme health care service utilization of households. It is recommended that the local, regional and national governments, policymakers on optimal actions, NGOs, and other supporting organizations shall improve or scale-up the scheme by providing awareness to the community based on these significant factors and the attitude of households.

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

BACKGROUND

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

AIM

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

METHODS

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

FINDINGS

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

CONCLUSION

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

Delivering health insurance through informal financial groups: Evidence on moral hazard and adverse selection

Moral hazard and adverse selection are potential explanations for missing health insurance in low-income countries. In recent years, informal financial institutions have attempted to complete health insurance markets by offering micro health insurance (MHI). We evaluate an MHI offered through informal financial institutions (Self-Help Groups) in Maharashtra, India. Exploiting random assignment of when villages were offered the MHI, we do not find support for MHI increasing health care utilization. In contrast, we do find evidence for adverse selection: enrollees are significantly more likely than non-enrollees to report poor health prior to the introduction of MHI. This adverse selection persists even when the MHI is offered as a group insurance to Self-Help Groups, as opposed to individual insurance. Our results suggest that MHI offered through informal financial groups may not suffer from moral hazard, but does fall short of eliminating adverse selection.

Exploring willingness to pay for health insurance and preferences for a benefits package from the perspective of women from low-income households of Karachi, Pakistan

Background

Achieving universal health coverage (UHC) and reduction in out of pocket (OOP) expenditures on health, is a critical target of the Sustainable Development Goals (SDG). In low-middle income countries, micro-health insurance (MHI) schemes have emerged as a useful financing tool for laying grounds for Universal Health Coverage. The aim of this study was to provide evidence for designing a feasible health insurance scheme targeted at urban poor, by exploring preferences for an insurance benefits package and co-payments among women from low-income households in Karachi, Pakistan.

Methods

This was a descriptive cross-sectional study, conducted using household surveys between July–August 2015. A total of 167 female beneficiaries of Benazir Income Support Programme (BISP), a large-scale cash transfer scheme targeted at low-income households, were recruited in Karachi through a mix of convenience and snowball sampling. Hypothetical insurance benefits packages for a prospective health insurance scheme were formulated to capture respondents’ preferences for health insurance benefits package and co-payments. All data was analyzed using Stata (version 13).

Results

Respondents reporting expenditure on OPD and hospitalization in the last 2 weeks were 93.4 and 11.9% respectively. The highest median expenditure was incurred on medicines. Out of the proposed benefits package, a majority (53%) of the study participants opted for the comprehensive benefits package that provided coverage for emergency care, hospitalization, OPD consultation, diagnostic tests and transportation. For the co-payment plan, 38.9% participants preferred no co-payments that is 100% insurance coverage of medicines followed by hospitalization (25.9%). Nearly half of the respondents (49.4%) chose outpatient consultation for 50% co-payment. A majority of the participants (65.3%) agreed to 100% co-payment for the transportation cost.

Conclusion

Health insurance schemes can be introduced in urban areas, against collection of micro-payments, to prevent low-income households from facing financial catastrophe. A comprehensive benefits package covering emergency care, hospitalization, OPD consultation, diagnostic tests and transportation, is the most preferred among low-income beneficiaries.

Can National Health Insurance Pave the Way to Universal Health Coverage in Sub-Saharan Africa?

Countries of sub-Saharan Africa are increasingly turning to public contributory health insurance as a mechanism to advance UHC goals. Eight countries in sub-Saharan Africa have introduced national health insurance (NHI) systems, and at least seven more have plans or have passed legislation to establish NHI. Examining the experience of countries that have taken this path, some lessons emerge about whether and how contributory national health insurance may or may not be a viable path toward UHC in sub-Saharan Africa. Only Gabon, Ghana and Rwanda have been able to extend NHI coverage to a significant share of the population. None of the countries with NHI have peformed better on other UHC indicators-resource mobilization, service coverage and financial protection-than higher performing countries of Africa that did not introduce NHI. The experience of Gabon, Ghana and Rwanda provide lessons for what may be required to make NHI a viable path to UHC-there need to be explicit objectives and an understanding of why NHI can meet those objectives in the country's particular context; it must include key pro-equity design elements; and NHI needs to be supported by widespread political commitment and ongoing learning and adaptation. For many governments, achieving this kind of enabling environment for NHI may be particularly challenging for various political, economic, or social reasons. In these contexts, health sector leaders may consider looking inward to their existing health financing systems for ways to improve and be more effective.

Understanding family-based health insurance enrolment among informal sector workers in a rural district of Vietnam: Adverse selection and key determinants

Background: Challenges remain in the implementation of family-based health insurance (FHI) - the key strategy for achieving universal health coverage in Vietnam. Objectives: To explore the experiences of and factors influencing enrolment in FHI among informal sector workers (ISW) in a rural district in Vietnam. Methods: A cross-sectional study was conducted from January to June 2016 in Tien Du, a rural district in Bac Ninh province. Secondary data were extracted from provincial social insurance databases to identify the rate of FHI among ISW in the district. Qualitative data were collected from 55 participants: 20 semi-structured in-depth interviews (IDI) and 6 focus group discussions (FGD). Data were transcribed verbatim. Thematic analysis was conducted. Results: Only 25.1% of ISW had FHI. Those individuals with FHI tended to be older or already experiencing health problems or have 'risky' jobs. The key determinants of adverse selection from different levels included: individual, family and health system. Conclusions: Low health insurance uptake remains an issue for ISW. Policy makers should consider raising awareness of FHI and improve the quality of primary health services, simplify the procedures of enrolment and claim for ISW. Additional government premium subsidy is required to increase FHI enrolment among ISW.

Willingness to Pay for Community-Based Healthcare Insurance Schemes in Developing Countries: A Case of Lahore, Pakistan

Background

Healthcare costs and poverty are significant barriers to achieving universal access to healthcare. Thus, Community-Based Health Insurance Schemes (CBHIS) are regarded as an influential instrument for providing access to healthcare. For this purpose, this study was carried out in order to assess the community's Willingness to Pay (WTP) for CBHIS and its determinants among the residents of Lahore City.

Methods

A cross-sectional study was adopted during the period of May 2018 to August 2018 to conduct a standardized questionnaire survey among targeted population of Lahore. A total of 250 households from lower, middle and upper-middle-class areas were approached randomly from which 200 participated in the survey, rendering a response rate of 90.9%. Sample size was determined by using single population proportion formula assuming 5% margin of error and 95% Confidence Interval (CI). Moreover, multiple regression analysis, Pearson's correlation and t-test were employed to determine relationships between different variables affecting WTP.

Results

Sixty-four percent of the respondents were willing to pay for CBHIS. Among the remaining thirty-six% of unwilling the community, income level (p< 0.05, CI=0.34 to 1.11) and education level (p< 0.05, CI=0.52–1.37) were significant predictors of WTP. Moreover, strong positive relation (p<0.05) between people's awareness and WTP for CBHIS was witnessed. The findings further suggested that the larger population of the willing community was not willing to pay more than 5000 Rs annually.

Conclusion

Henceawareness level of the community regarding the benefits of CBHIS is a major hindrance. The key policy priority is to increase the community's awareness regarding the benefits of CBHIS and to increase willingness to pay rate among public.

Enrolment of informal sector workers in the National Health Insurance System in Indonesia: A qualitative study

One of the main challenges facing the expansion of universal health coverage (UHC) in developing countries like Indonesia is the high prevalence of those working in the informal sector who must voluntarily register in the National Health Insurance System (NHIS). This condition hinders some from being covered by the NHIS. Following Bourdieu's concepts of field, capital and habitus, this research aims to analyse some aspects that influence the decision of informal sector workers to join the NHIS in Indonesia. We conducted qualitative methods, including in-depth interviews of 29 informants and Focus Group Discussion (FGD) in the three selected regions of Deli Serdang (North Sumatera), Pandeglang (Banten) and Kupang (East Nusa Tenggara). Using thematic content analysis and several triangulation processes, this study found that three main factors influence the decisions of those working in the informal sector to join the NHIS: health conditions, family and peers, and existing knowledge and experience. The stories provided by the informants regarding their decision-making processes in joining NHIS also reveal the necessary and sufficient conditions that enable informal sector workers to join the NHIS, which are individual-specific and which may differ between people, depending on individual characteristics, regional socioeconomic and demographic characteristics and belief systems. These three factors are all necessary conditions to support the joining of informal sector workers into the NHIS. This study suggests that one possible route for expanding the UHC coverage of informal sector workers is through maximising the word-of-mouth effect by engaging local or influential leaders.

Economic valuation of setting up a social health enterprise in urban poor-resource setting in Kenya

The failure of the market and government to provide quality healthcare services have been the motivation to set up social health enterprise. However, the value for money associated with setting up a social health enterprise in sub-Sahara African countries has been relatively unexplored in the literature. The study presents the first empirical estimates of the mean willingness-to-pay (WTP) for setting up a social health enterprise that will simultaneously run a health center and provide health insurance scheme in an urban resource-poor setting and explores whether the benefits outweigh the costs. The contingent valuation method is used to estimate the mean WTP for the health insurance scheme proposed by the social health enterprise in Viwandani slum (Nairobi, Kenya). The survey was conducted between June and July 2018 on 300 households. We find that the feasibility of setting up a social health enterprise could be promising with 97 percent of respondents willing to pay about US$ 2 per person per month for a scheme that would provide quality healthcare services. More importantly, setting up the social health enterprise will yield a positive net profit, and investors could expect US$ 1.11 in benefits for each US$ 1 of costs of investment in setting up the social health enterprise. We, therefore, conclude that this health policy in this urban resource-poor setting could be a viable solution to reach the neglected urban households in the Kenyan slums.

Acceptance for Social Health Insurance among Health Professionals in Government Hospitals, Mekelle City, North Ethiopia

Background. Ethiopia is one of the countries with high out-of-pocket payments leading to catastrophic health expenditure. The government of Ethiopia introduced social health insurance (SHI) scheme with the overall objective of achieving universal health care access. Studying health professionals’ acceptance to pay for social health insurance is crucial for the successful implementation of the scheme. Therefore, this study aimed to assess the acceptance of social health insurance and its associated factors among health professionals in government hospitals, Mekelle city, North Ethiopia. Methods. An institution-based cross-sectional study design was used. The study participants were selected using systematic random sampling. Data were collected using a structured interviewer-administered questionnaire and analyzed using SPSS version 20. Bivariable and multivariable logistic regression models at a 5% level of significance, and odds ratios with 95% CI level were used to determine the association between the health professionals’ acceptance of health insurance and explanatory variables. Results. The study revealed that 62.5% of the respondents were willing to participate in the SHI scheme in which 74.9% were willing to pay 3% or more of their monthly salary. Health professionals’ acceptance for SHI significantly associated with monthly salary (AOR = 9.49; 95% CI: 2.51, 35.86), awareness about SHI (AOR = 3.89; 95% CI: 1.05, 14.28), history of difficulty in covering medical bills (AOR = 6.2; 95% CI: 2.42, 15.87), attitudes towards social health insurance (AOR = 7.57; 95% CI: 3.14, 18.21), and perceived quality of health care services if SHI implemented (AOR = 2.89; 95% CI: 1.18, 7.07). Conclusion. The study indicated that there were still a high proportion of health professionals who were not willing to pay for SHI. Therefore, strengthening awareness creation, creating awareness about SHI, promoting the scheme using the different channels of communication to bring about favorable attitude, and providing health care services with required standard quality could help to increase the acceptance of SHI by health professionals.

Estimating Willingness to Pay for a Future Recreational Park Atop the Current Jakuševec Landfill in Zagreb, Croatia

The main purpose of this study is to investigate the economic value potentially accrued by a prospective city park, which is planned to be built as a result of strategic land reclamation of a current landfill in Croatia, based on parkgoers’ marginal willingness to pay. The idea of this land transformation is inspired by recent debate on the issue of how to address air quality and other environmental concerns over the disposal of the landfill site in the city. Like any other nonmarket valuation studies, choosing a proper survey method is a critical step for a successful economic valuation study. We adopted a double bounded dichotomous choice contingent valuation method in survey design and data collection, followed by parameter estimation using the logit model. The study reveals—(1) the support of 70% of respondents was estimated; (2) as much as 96% of the respondents are willing to visit the park being presented to the respondents along with the survey questionnaire. The economic valuation indicates that the city residents are willing to pay €3.63 per person for the park’s entrance fees, which can be translated into an aggregate of €2,867,762. By referring this value information to the park budget, we may persuade policy makers to commit to a transformation of the current landfill.

Factors affecting the willingness to join community-based health insurance (CBHI) scheme: A case study survey from Savannakhet Province, Lao P.D.R

PURPOSE

Community-based health insurance (CBHI) targets independent worker (self-employed) is currently struggling with inadequate size of risk pooling, low enrollment, and high dropout rate as well as financial sustainability. The objective of this study is to find out the factors that significantly affect the CBHI enrollment incentive. The study applied cross-sectional study design to perform situation analysis, in which the Andersen behavioral model was used as a guideline to identify preliminary characteristics that involved with enrolling incentive.

FINDINGS

The model found that existence of both outpatient department (OPD) and inpatient department (IPD) health service utilization had significant impact on the CBHI enrollment, this statement is strongly related to adverse selection issues. Households resides in Kaysone Phomvihane district had higher probability of joining the scheme in comparison with relatively less-developed Champhone district. Households with no CBHI knowledge were also more likely to enroll the scheme. Occupation was also found to be a significant factors; of which farmers and laborers had lower possibility enrollment.

CONCLUSIONS

Economic condition of the district has a significant impact on enrolment. However, the increase in personal income does not directly enhance the desire for enrolment. Most of the high-income households prefer to use a local, private clinic, and foreign hospitals in Thailand or Vietnam. Households with unemployed heads had the highest possibility of enrolling. The reason is the unemployed respondents include the elderly who stay at home without performing major tasks in exchange for their living. That group of people has the highest probability of either OPD or IPD.

Uptake of health insurance by the rural poor in Ghana: determinants and implications for policy

Introduction

Financing access to healthcare services in developing countries remains a major challenge despite recent advances towards implementation of various health insurance policies in many low and middle-income countries. The use of health insurance is considered an important means to achieve universal health coverage. However, uptake of health insurance in most developing countries remains low as a result of several challenges. Empirical evidence of factors restraining enrolment is rare in many developing countries including Ghana. This paper therefore sought to investigate the factors associated with the uptake of health insurance products and the implications thereof for policy, using Awutu Senya West District of Ghana as case study.

Methods

A logit model was used to analyze data from 178 respondents randomly selected from two microfinance groups operating in the study area.

Results

The results indicate that insurance uptake is higher among younger people, but lower among women. Older women are however more likely to take up health insurance compared to older men. In addition, the study reveals that insurance uptake increases with level of education but decreases with household size.

Conclusion

The study concludes that even though the premium on health insurance coverage in Ghana is arguably low, socio-demographic characteristics such as age, sex, literacy level and household size affect the decision to enroll. Adequate public sensitization on the benefits of the scheme and decreasing the statutory age for exemption from premium payment, especially in rural localities, are some of the measures suggested to enhance health insurance uptake in Ghana and other developing countries.

Family-Based Social Health Insurance for Informal Workers in Vietnam: Willingness to Pay and Its Determinants

The study aimed to assess willingness to pay for family-based social health insurance and its determining factors among informal workers in Vietnam. A double-bounded dichotomous choice approach was used to elicit the willingness to pay of 391 heads of uninsured households. The study indicates that 48.8% of 391 uninsured households were willing to pay for family-based health insurance. The households were willing to pay about 921.9 thousand Vietnamese dongs per household per year (US$42). The factors that significantly affected willingness to pay were household income, number of uninsured members in a household, and sickness of the household head. The study suggests that a feasible premium for family-based health insurance supported by government subsidy, along with attention to the quality improvements of health services, could be an effective means to increase coverage among the informal sector workers.

Public's Willingness to Pay Towards a Medical Device for Detecting Foot Ulceration in People with Diabetes

OBJECTIVES

Diabetic foot ulceration (DFU) is a common and serious complication among diabetic patients. A medical device has been developed to prevent the occurrence of DFU. The aim of this study was to investigate the willingness to pay (WTP) for this device among the general public in the UK.

METHODS

A contingent valuation survey was administered to 1051 participants through an online survey including questions on socio-demographic characteristics, self-reported health, knowledge of diabetes and medical devices, and WTP. A two-part model was used to analyse determinants of WTP, including a logistic model in the first part and a generalised linear model with a log-transformed WTP in the second part.

RESULTS

More than half (55.9%) of the participants expressed a positive WTP. The annual mean (standard deviation) and median (interquartile range) WTP values were £76.9 (69.1) and £50 (80), respectively. Older age, middle-level education, good/excellent self-reported health, visiting doctors once/2-5 times, diabetes experience, medical device experience and more than average self-perceived likelihood of using similar devices were associated with a higher likelihood of willingness to pay. Younger age, male gender and higher household income were associated with higher WTP values.

CONCLUSION

This study demonstrated that people are willing to pay for this device and they tend to contribute when they have experience of diabetes or similar devices and perceive self-benefit.

Investigating the Willingness to Pay for a Contributory National Health Insurance Scheme in Saudi Arabia: A Cross-sectional Stated Preference Approach

BACKGROUND

The Saudi Healthcare System is universal, financed entirely from government revenue principally derived from oil, and is 'free at the point of delivery' (non-contributory). However, this system is unlikely to be sustainable in the medium to long term. This study investigates the feasibility and acceptability of healthcare financing reform by examining households' willingness to pay (WTP) for a contributory national health insurance scheme.

METHODS

Using the contingent valuation method, a pre-tested interviewer-administered questionnaire was used to collect data from 1187 heads of household in Jeddah province over a 5-month period. Multi-stage sampling was employed to select the study sample. Using a double-bounded dichotomous choice with the follow-up elicitation method, respondents were asked to state their WTP for a hypothetical contributory national health insurance scheme. Tobit regression analysis was used to examine the factors associated with WTP and assess the construct validity of elicited WTP.

RESULTS

Over two-thirds (69.6%) indicated that they were willing to participate in and pay for a contributory national health insurance scheme. The mean WTP was 50 Saudi Riyal (US$13.33) per household member per month. Tobit regression analysis showed that household size, satisfaction with the quality of public healthcare services, perceptions about financing healthcare, education and income were the main determinants of WTP.

CONCLUSIONS

This study demonstrates a theoretically valid WTP for a contributory national health insurance scheme by Saudi people. The research shows that willingness to participate in and pay for a contributory national health insurance scheme depends on participant characteristics. Identifying and understanding the main influencing factors associated with WTP are important to help facilitate establishing and implementing the national health insurance scheme. The results could assist policy-makers to develop and set insurance premiums, thus providing an additional source of healthcare financing.

Identification determinant factors on willingness to pay for health services in Iran

BACKGROUND

A common method used to examine the relationship between internal preferences and caring externalities is willingness to pay (WTP) approach. We aimed to estimate WTP for health status with different severity level and identify determinant factors on WTP.

METHODS

For determining main factors in WTP, a cross-sectional study was conducted in Shiraz in the southeast of Iran, in March to April 2015. The open-ended method was used to estimate monthly WTP in private and altruistic section. Multivariate regression analyses using ordinary least squares were applied to examine the effect of Scio-demographic factors on WTP using SPSS software 21.

RESULTS

Participants were willing to pay an average amount of $ 295 in health status 1 and an average amount of $ 596 in health status 6 (worst status) for internal preferences. Altruistic WTP for health status 1 was $ 294 and participants were willing to pay an average amount of $ 416 in health status 6. Multiple regression analysis identified monthly income as the key determinant of WTP for internal preferences and caring externalities (P < 0.01). With an increase of 1% in income, private WTP increase 1.38% in health status 1.

CONCLUSIONS

The finding indicates that the mean of WTP increases at severe health status; therefore, health policy maker should allocate resources toward severe health status.

Applying a community-based participatory research approach to improve access to healthcare for Eritrean asylum-seekers in Israel: a pilot study

BACKGROUND

Israel hosts approximately 50,000 asylum seekers, most of them from Eritrea. Exclusive policies restrict their access to healthcare. In 2013, local activists partnered with Eritrean asylum seekers to assess health needs as well as willingness to pay for health insurance among the Eritrean communities. This initiative was meant as a step towards jointly advocating access to Israel's public healthcare system and towards strengthening collective efficacy among the asylum-seeking communities, as well as a first attempt to apply a community-based participatory research (CBPR) approach to migrant health research in Israel.

METHODS

Applying a CBPR approach, a 22-item survey was developed by a team of activists, academics and community members. It was administered by community members in four different cities. Cell weighting was applied to align sample estimates with the population distribution. The results were analyzed by means of a Generalized Linear Model. Six follow-up interviews and two focus group discussions helped interpret the quantitative findings and provided additional information.

RESULTS

The results from 445 questionnaires show that most (95%) asylum seekers are interested in purchasing health insurance. To this end, more than half of the respondents are willing to invest up to 300 NIS monthly, which represents a significant part (5-7.5%) of their median monthly income. Willingness to pay for health coverage was independent from employment and income; it was significantly associated with city of residence - which translates into current healthcare options - understanding of health insurance, and health seeking motives. The study further highlights the role of labor policies in shaping not only asylum seekers' access to care but also psychosocial wellbeing.

CONCLUSIONS

The study provides initial evidence for asylum seekers' willingness to pay monthly contributions into a public health insurance scheme, in spite of economic hardship, and it points to understanding of and trust in the healthcare system as a central factor influencing willingness to pay. The outcomes of this initiative further offer some support for the potential of CBPR to enhance research into the health of marginalized populations and, moreover, to counter their social exclusion through capacity building and strengthening of collective efficacy.

Reforming voluntary drug insurance in Russian healthcare: does social solidarity matter?

With low take-up of both private health insurance and the existing public drug reimbursement scheme, it is thought that less than 5% of the Russian population have access to free outpatient drug treatment. This represents a major policy challenge for a country grappling with reforms of its healthcare system and experiencing low or no economic growth and significant associated reductions in spending on social services. In this paper, we draw on data from a 2011 Levada-Center survey to examine the attitudes and social solidarity of the Russian population towards drug policies in general and towards the introduction of a proposed voluntary drug insurance system in particular. In addition to being among the first to explore these important questions in the post-Communist setting, we make three important contributions to the emerging policy debates. First, we find that, if introduced immediately and without careful planning and preparation, Russia's voluntary drug insurance scheme is likely to collapse financially due to the over-representation of high-risk unhealthy individuals opting in to the scheme. Second, the negative attitude of higher income groups towards the redistribution of wealth to the poor may further impede government efforts to introduce voluntary drug insurance. Finally, we argue that Russia currently lacks the breadth and depth of social solidarity necessary for implementing this form of health financing.

Willingness to pay for National Health Insurance Fund among public servants in Juba City, South Sudan: a contingent evaluation

Background

This study assessed willingness to pay for National Health Insurance Fund (NHIF) among public servants in Juba City. NHIF is the proposed health insurance scheme for South Sudan and aims at achieving universal health coverage for the entire nation’s population. One compounding issue is that over the years, governments’ spending on healthcare has been decreasing from 8.4% of national budget in 2007 to only 2.2% in 2012.

Methods

A cross-sectional study design using contingent evaluation was employed; data on willingness to pay was collected from 381 randomly selected respondents and 13 purposively selected key informants working for the national, state and Juba County in September 2015. Qualitative data were analysed using conceptual content analysis. T-tests and linear regressions were performed to determine association between WTP for NHIF and independent variables.

Results

Up to 381 public servants were interviewed, of which 68% indicated willingness to pay varying percentages of total monthly individual income for NHIF. Over two-thirds (67.8%) of those willing to pay could pay up to 5% of their total monthly income, 22.9% could pay up to 10% and the rest could pay 25%. Over 80% were willing to pay up to 50 SSP (1 USD = 10 SSP) premiums for medical consultation, laboratory services and drugs. The main factors influencing the respondents’ decisions were awareness, alternative sources of income, household size, insurance cover and religion.

Conclusions

Willingness to pay is mainly influenced by awareness, alternative sources of individual income, household size, insurance cover and religion. Most of the public servants were aware of and willing to pay for NHIF and prefer a premium of up to 5% of total monthly income. There is need to create awareness and reach out to those who do not know about the scheme in addition to a detailed analysis of other stakeholders. Consideration could be made by the Government of South Sudan to start the scheme at the earliest opportunity since the majority of the respondents were willing to contribute towards it.

Inequitable Access to Health Care by the Poor in Community-Based Health Insurance Programs: A Review of Studies From Low- and Middle-Income Countries

The poor lack equitable access to health care in community-based health insurance schemes. Flexible installment payment plans, subsidized premiums, and elimination of co-pays can increase enrollment and use of health services by the poor.

Background:

Out-of-pocket payments for health care services lead to decreased use of health services and catastrophic health expenditures. To reduce out-of-pocket payments and improve access to health care services, some countries have introduced community-based health insurance (CBHI) schemes, especially for those in rural communities or who work in the informal sector. However, there has been little focus on equity in access to health care services in CBHI schemes.

Methods:

We searched PubMed, Web of Science, African Journals OnLine, and Africa-Wide Information for studies published in English between 2000 and August 2014 that examined the effect of socioeconomic status on willingness to join and pay for CBHI, actual enrollment, use of health care services, and drop-out from CBHI. Our search yielded 755 articles. After excluding duplicates and articles that did not meet our inclusion criteria (conducted in low- and middle-income countries and involved analysis based on socioeconomic status), 49 articles remained that were included in this review. Data were extracted by one author, and the second author reviewed the extracted data. Disagreements were mutually resolved between the 2 authors. The findings of the studies were analyzed to identify their similarities and differences and to identify any methodological differences that could account for contradictory findings.

Results:

Generally, the rich were more willing to pay for CBHI than the poor and actual enrollment in CBHI was directly associated with socioeconomic status. Enrollment in CBHI was price-elastic—as premiums decreased, enrollment increased. There were mixed results on the effect of socioeconomic status on use of health care services among those enrolled in CBHI. We found a high drop-out rate from CBHI schemes that was not related to socioeconomic status, although the most common reason for dropping out of CBHI was lack of money to pay the premium.

Conclusion:

The effectiveness of CBHI schemes in achieving universal health coverage in low- and middle-income countries is questionable. A flexible payment plan where the poor can pay in installments, subsidized premiums for the poor, and removal of co-pays are measures that can increase enrollment and use of CBHI by the poor.

Quality Health Care and Willingness to Pay for Health Insurance Retention: A Randomized Experiment in Kolkata Slums

The low quality of health care in developing countries reduces the poor's incentives to use quality health services and their demand for health insurance. Using data from a field experiment in India, I show that randomly offering insurance policyholders a free preventive checkup with a qualified doctor has a twofold effect: receiving this additional benefit raises willingness to pay to renew health insurance by 53%, doubling the likelihood of hypothetical renewal; exposed individuals are 10 percentage points more likely to consult a qualified practitioner when ill after the checkup. Both effects are concentrated on poorer households. There is no effect on health knowledge and healthcare spending. This suggests that exposing insured households to quality preventive care can be a cost-effective way of raising the demand for quality health care and retaining policyholders in the insurance scheme. Copyright © 2016 John Wiley & Sons, Ltd.

Willingness to Pay for Social Health Insurance in Central Vietnam

Background

A social health insurance (SHI) program was implemented in Vietnam in 1992. Participation is compulsory for some groups, such as formal-sector workers and voluntary for other groups. In 2013, 68% of the total population was covered by SHI, with most enrollees from compulsory groups. Enrollment has remained low among persons whose enrollment is voluntary. As a result, households face financial risk due to high out-of-pocket payments for health care. The goal of this study is to identify willingness to pay (WTP) for the SHI scheme among persons whose enrollment is voluntary and to examine factors that influence their choice.

Method

Three hundred thirty-one uninsured persons from three districts and one city of Thua Thien Hue province were interviewed face to face using a structured questionnaire. Contingent valuation technique was used to assess the WTP among the study participants. Each individual was asked to choose the maximum premium they were willing to pay for a health insurance card per year with three copayment levels of 0, 10, and 20%. Seven premium levels were offered ranging from 0 to 900,000 Vietnamese Dong (VND) (42.12 USD). The mean WTP of respondents for each scenario was estimated. Multiple linear regression analysis was used to identify factors influencing WTP for SHI.

Results

The survey found that 73.1, 72.2, and 71.6%, respectively, for each copayment level, of the respondents would agree to participate in the SHI scheme and are willing to pay an annual premium of 578,926 VND (27.1 USD); 473,222 VND (22.1 USD); and 401,266 VND (18.8 USD) at the copayment levels of 0, 10, and 20%, respectively. The WTP for SHI is influenced by knowledge of SHI at all copayment levels (p value < 0.05). The more knowledge about SHI individuals have, the higher the WTP amount. Chronic disease was related to WTP only at a copayment level of 20% (p = 0.049).

Conclusion

Enhanced awareness of the benefits of SHI among the population should contribute to expanding SHI coverage in Vietnam.

Systematic Review of Willingness to Pay for Health Insurance in Low and Middle Income Countries

OBJECTIVE

Access to healthcare is mostly contingent on out-of-pocket spending (OOPS) by health seekers, particularly in low- and middle-income countries (LMICs). This would require many LMICs to raise enough funds to achieve universal health insurance coverage. But, are individuals or households willing to pay for health insurance, and how much? What factors positively affect WTP for health insurance? We wanted to examine the evidence for this, through a review of the literature.

METHODS

We systematically searched databases up to February 2016 and included studies of individual or household WTP for health insurance. Two authors appraised the identified studies. We estimated the WTP as a percentage of GDP per capita, and adjusted net national income per capita of each country. We used meta-analysis to calculate WTP means and confidence intervals, and vote-counting to identify the variables that more often affected WTP.

RESULT

16 studies (21 articles) from ten countries met the inclusion criteria. The mean WTP of individuals was 1.18% of GDP per capita and 1.39% of adjusted net national income per capita. The corresponding figures for households were 1.82% and 2.16%, respectively. Increases in family size, education level and income were consistently correlated with higher WTP for insurance, and increases in age were correlated with reduced WTP.

CONCLUSIONS

The WTP for healthcare insurance among rural households in LMICs was just below 2% of the GPD per capita. The findings demonstrate that in moving towards universal health coverage in LMICs, governments should not rely on households' premiums as a major financing source and should increase their fiscal capacity for an equitable health care system using other sources.

Impact of Community-based Health Insurance on Access and Financial Protection: Evidence from Three Randomized Control Trials in Rural India

Since the 1990s, community-based health insurance (CBHI) schemes have been proposed to reduce the financial consequences of illness and enhance access to healthcare in developing countries. Convincing evidence on the ability of such schemes to meet their objectives is scarce. This paper uses randomized control trials conducted in rural Uttar Pradesh and Bihar (India) to evaluate the effects of three CBHI schemes on healthcare utilization and expenditure. We find that the schemes have no effect on these outcomes. The results suggest that CBHI schemes of the type examined in this paper are unlikely to have a substantial impact on access and financial protection in developing countries. Copyright © 2015 John Wiley & Sons, Ltd.

Monetizing the social benefits of landfill mining: Evidence from a Contingent Valuation survey in a rural area in Greece

Despite the emerging global attention towards promoting waste management policies that reduce environmental impacts and conserve natural resources, landfilling still remains the dominant waste management practice in many parts of the world. Owing to this situation, environmental burdens are bequeathed to and large amounts of potentially valuable materials are lost for future generations. As a means to undo these adverse effects a process known as landfill mining (LFM) could be implemented provided that economic feasibility is ensured. So far, only a few studies have focused on the economic feasibility of LFM from a private point of view and even less studies have attempted to economically justify the need for LMF projects from a social point of view. This paper, aiming to add to the limited literature in the field, presents the results of a survey conducted in a rural district in Greece, by means of the Contingent Valuation method (CVM) in order to estimate society's willingness to pay for LFM programs. According to the empirical survey, more than 95% of the respondents recognize the need for LFM programs. Nevertheless, only one-fourth of the respondents are willing to pay through increased taxes for LFM, owing mainly to economic depression and unemployment. Those who accept the increased tax are willing to pay about €50 per household per year, on average, which results in a mean willingness to pay (WTP) for the entire population under investigation of around €12 per household per year. The findings of this research work provide useful insights about the 'dollar-based' benefits of LFM in the context of social cost-benefit analysis of LFM projects. Yet, it is evident that further research is necessary.

Perceptions and uptake of health insurance for maternal care in rural Kenya: a cross sectional study

INTRODUCTION

In Kenya, maternal and child health accounts for a large proportion of the expenditures made towards healthcare. It is estimated that one in every five Kenyans has some form of health insurance. Availability of health insurance may protect families from catastrophic spending on health. The study intended to determine the factors affecting the uptake of health insurance among pregnant women in a rural Kenyan district.

METHODS

This was cross-sectional study that sampled 139 pregnant women attending the antenatal clinic at a level 5 hospital in a Kenyan district. The information was collected through a pretested interview schedule.

RESULTS

The median age of the study participants was 28 years. Out of the 139 respondents, 86(62%) planned to pay for their deliveries through insurance. There was a significant relationship between insurance uptake and marital status Adjusted odds ratio (AOR) 6.4(1.4-28.8). Those with tertiary education were more likely to take up insurance AOR 5.1 (1.3-19.2). Knowing the benefits of insurance and the limits the insurance would settle in claims was associated with an increase in the uptake of insurance AOR 7.6(2.3-25.1), AOR 6.4(1.5-28.3) respectively. Monthly income and number of children did not affect insurance uptake.

RESULTS

Being married, tertiary education and having some knowledge on how insurance premiums are paid are associated with uptake of medical insurance. Information generated from this study if utilized will bring a better understanding as to why insurance coverage may be low and may provide a basis for policy changes among the insurance companies to increase the uptake.

Willingness to pay for health insurance among the elderly population in Germany

INTRODUCTION

All elderly Germans are legally obliged to have health insurance. About 90 % of this population are members of social health insurances (SHI) whose premiums are generally income-related and independent of health status. For most of these members, holding social health insurance is mandatory. As a consequence, genuine information about preferences for health insurance is not available. The aim of this study was therefore to determine and analyze the willingness to pay (WTP) for health insurance among elderly Germans.

METHODS

Data from a population-based 8-year follow-up of a large cohort study conducted in the Saarland, Germany was used. Participants aged 57-84 years passed a geriatric assessment and responded to a health economic questionnaire. Individuals' WTP was elicited based on a contingent valuation method with a payment card.

RESULTS

Mean monthly WTP per capita for health insurance amounted to €260. This corresponded to about 20% of individual disposable income. Regression analyses showed that WTP increased significantly with higher income, male gender, higher educational level, and privately insured status. In contrast, neither increasing morbidity level nor higher individual health care costs influenced WTP significantly.

DISCUSSION

The relatively large extent of average WTP for health insurance indicates that the elderly would probably accept higher contributions to SHI rather than policy efforts to reduce contributions. The identified determinants of WTP might indicate that elderly generally approve the principle of solidarity of the SHI with contributions depending on income rather than morbidity.

Willingness-to-Pay for Community-Based Health Insurance among Informal Workers in Urban Bangladesh

INTRODUCTION

Reliance on out-of-pocket payment for healthcare may lead poor households to undertake catastrophic health expenditure, and risk-pooling mechanisms have been recommended to mitigate such burdens for households in Bangladesh. About 88% of the population of Bangladesh depends on work in the informal sector. We aimed to estimate willingness-to-pay (WTP) for CBHI and identify its determinants among three categories of urban informal workers rickshaw-pullers, shopkeepers and restaurant workers.

METHODS

The bidding game version of contingent valuation method was used to estimate weekly WTP. In three urban locations 557 workers were interviewed using a structured questionnaire during 2010 and 2011. Multiple-regression analysis was used to predict WTP by demographic and household characteristics, occupation, education level and past illness.

RESULTS

WTP for a CBHI scheme was expressed by 86.7% of informal workers. Weekly average WTP was 22.8 BDT [Bangladeshi Taka; 95% confidence interval (CI) 20.9-24.8] or 0.32 USD and varied significantly across occupational groups (p = 0.000) and locations (p = 0.003). WTP was highest among rickshaw-pullers (28.2 BDT or 0.40 USD; 95% CI: 24.7-31.7), followed by restaurant workers (20.4 BDT 0.29 USD; 95% CI: 17.0-23.8) and shopkeepers (19.2 BDT or 0.27 USD; 95% CI: 16.1-22.4). Multiple regression analysis identified monthly income, occupation, geographical location and educational level as the key determinants of WTP. WTP increased 0.196% with each 1% increase in monthly income, and was 26.9% lower among workers with up to a primary level of education versus those with higher than primary, but less than one year of education.

CONCLUSION

Informal workers in urban areas thus are willing to pay for CBHI and socioeconomic differences explain the magnitude of WTP. The policy maker might think introducing community-based model including public-community partnership model for healthcare financing of informal workers. Decision making regarding the implementation of such schemes should consider worker location and occupation.

Healthcare seeking behaviour among self-help group households in Rural Bihar and Uttar Pradesh, India

Background

In recent years, supported by non-governmental organizations (NGOs), a number of community-based health insurance (CBHI) schemes have been operating in rural India. Such schemes design their benefit packages according to local priorities. This paper examines healthcare seeking behaviour among self-help group households with a view to understanding the implications for the benefit packages offered by such schemes.

Methods

We use cross-sectional data collected from two of India’s poorest states and estimate an alternative-specific conditional logit model to examine healthcare seeking behaviour.

Results

We find that the majority of respondents do access some form of care and that there is overwhelming use of private providers. Non-degree allopathic providers (NDAP) also called rural medical practitioners are the most popular providers. In the case of acute illnesses, proximity plays an important role in determining provider choice. For chronic illnesses, cost of care influences provider choice.

Conclusion

Given the importance of proximity in determining provider choice, benefit packages offered by CBHI schemes should consider coverage of transportation costs and reimbursement of foregone earnings.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-1254-9) contains supplementary material, which is available to authorized users.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Eliciting community preferences for complementary micro health insurance: a discrete choice experiment in rural Malawi

There is a limited understanding of preferences for micro health insurance (MHI) as a strategy for moving towards universal health coverage. Using a discrete choice experiment (DCE), we explored community preferences for the attributes and attribute-levels of a prospective MHI scheme, aimed at filling health coverage gaps in Malawi. Through a qualitative study informed by a literature review, we identified six MHI attributes (and attribute-levels): unit of enrollment, management structure, health service benefit package, copayment levels, transportation coverage, and monthly premium per person. Qualitative data was collected from 12 focus group discussions and 8 interviews in August-September, 2012. We constructed a D-efficient design of eighteen choice-sets, each comprising two MHI choice alternatives and an opt-out. Using pictorial images, trained interviewers administered the DCE in March-May, 2013, to 814 household heads and/or their spouse(s) in two rural districts. We estimated preferences for attribute-levels and relative importance of attributes using conditional and nested logit models. The results showed that all attribute-levels except management by external NGO significantly influenced respondents' choice behavior (P<0.05). These included: enrollment as core nuclear family (odds ratio (OR)=1.1574), extended family (OR=1.1132), compared to individual; management by community committee (OR=0.9494) compared to local micro finance institution; comprehensive health service package (OR=1.4621), medium service package (OR=1.2761), compared to basic service package; no copayment (OR=1.1347), 25% copayment (OR=1.1090), compared to 50% copayment; coverage of all transport (OR=1.5841), referral and emergency transport (OR=1.2610), compared to no transport; and premium (OR=0.9994). The relative importance of attributes is ordered as: transport, health services benefits, enrollment unit, premium, copayment, and management. To maximize consumer utility and encourage community acceptance of MHI, potential MHI schemes should cover transport costs, offer a comprehensive benefit package, define the core family as the unit of enrollment, avoid high copayments, and be managed by a competent financial institution.

Willingness to join community-based health insurance among rural households of Debub Bench District, Bench Maji Zone, Southwest Ethiopia

BACKGROUND

Even though Ethiopia bears high burden of diseases, utilization of modern health care services is limited. One of the reasons for low utilization of healthcare services is the user-fee charges. Moving away from out-of-pocket charges for healthcare at the time of use is an important step towards averting the financial hardship associated with paying for health service. Prepaid plans for health are not accustomed in Ethiopia. Therefore, social and community based health insurance schemes were introduced since 2010.In this study, willingness of rural households in Debub Bench District, to join community based health insurance was assessed.

METHOD

Cross-sectional community based study was conducted in Debub Bench District in March 2013 using a pretested structured questionnaire. Two stage sampling technique was used to select 845 households as study units which were allocated to the kebeles proportionately. The sampled households were selected using simple random sampling technique. Data were entered into EPIDATA 3.0 and analyzed with SPSS version 20.

RESULT

Among 845 sampled households, 808 were interviewed (95.6% response rate). About 78% of the respondents were willing to join the scheme. Most of demographic, socioeconomic variables and social capital were found to be significantly associated with willingness to join community based health insurance.

CONCLUSION

If the scheme is initiated in the district, majority of the households will enroll in the community based health insurance. Farmers, the married households, Bench ethnic groups and illiterate, the dominant segments of the population, are more likely to enroll the schemes. Therefore initiation of the scheme is beneficial in the district.

Willingness to pay for the social health insurance in Iran

Objective:

The substantial level of out-of-pocket expenditure for health care by the population causes policy makers to draw particular attention to the proposal of a social health insurance for uninsured members of the community. Hence, it is essential to gather reliable information about the amount of Willingness To Pay (WTP) for health insurance. We assessed the WTP for health insurance in Iran in order to suggest an affordable social health insurance.

Method:

The study sample included 300 household heads in all Iranian provinces. The double bounded dichotomous choice approach was used to elicit the WTP.

Result:

The average WTP for social health insurance per person per month was 137 000 Rial (5.5 $US). Household heads with higher levels of education, income and those who worked had more WTP for the health insurance. Besides, the WTP increased in direct proportion to the number of insured members of each household and in inverse proportion to the family size.

Conclusions:

From a policy point of view, the WTP value can be used as a premium in a society. An important finding of this study is that although households’ Willingness To Pay is not more than the total insurance premium, households are willing to pay more than the premium they ought to pay for health insurance coverage. That is, total insurance premium is 150 000 Rials and households ought to pay approximately half of this sum. This can afford policy makers the ideal opportunity to provide good insurance coverage for medical services according to the need of society.

Acceptability of, and willingness to pay for, community health insurance in rural India

Objectives: To understand the acceptability of, and willingness to pay for, community health insurance coverage among residents of rural India.

Methods: We conducted a mixed methods study of 33 respondents located in 8 villages in southern India. Interview domains focused on health-seeking behaviors of the family for primary healthcare, household expenditures on primary healthcare, interest in pre-paid health insurance, and willingness to pay for such a product.

Results: Most respondents reported that they would seek care only when symptoms were manifest; only 6 respondents recognized the importance of preventative services. None reported impoverishment due to health expenditures. Few viewed health insurance as necessary either because they did not wish to be early adopters, because they had alternate sources of financial support, or because of concerns with the design of insurance coverage or the provider. Those who were interested reported being willing to pay Rs. 1500 ($27) as the modal annual insurance premium.

Conclusions: Penetration of community health insurance programs in rural India will require education of the consumer base, careful attention to premium rate setting, and deeper understanding of social networks that may act as financial substitutes for health insurance.

Impact of educational intervention on willingness-to-pay for health insurance: A study of informal sector workers in urban Bangladesh

BACKGROUND

The reliance on out-of-pocket payments for health services leads to a catastrophic burden for many households in Bangladesh. The World Health Organization suggests that risk-pooling mechanisms should be used for financing healthcare. Like many low-income countries (LIC), a large share of employment in Bangladesh is in the informal sector (88%). Inclusion of these workers in health insurance is a big challenge. Among other barriers, the "literacy gap" for health insurance" is a reason for the low insurance uptake in Bangladesh. The aim of this study is, therefore, to assess the impact of an educational intervention on willingness-to-pay (WTP) for health insurance among informal sector workers in urban Bangladesh.

METHOD

An educational intervention on occupational solidarity and health insurance is offered to groups of informal workers. Educational sessions take place once a week (3-4 hours) during three subsequent weeks for each occupational group. For assessing the impact of the educational intervention, WTP for joining health insurance using occupational solidarity between workers in "pre- and post-treatment" periods as well as between "control and treatment" groups were compared. Multiple-regression analysis is applied for predicting WTP by educational intervention, while controlling for demographic and socioeconomic characteristics.

RESULTS

The coefficient of variation (CoV) of the WTP is estimated in control and treatment groups and expected to be lower in the latter. The WTP for health insurance is higher (33.8%) among workers who joined the educational intervention in comparison with those who did not (control group). CoV of WTP is found to be generally lower in post-treatment period and in treatment group compared to pre-treatment period and control group respectively.

CONCLUSION

Educational interventions can be used for increasing demand for health insurance scheme using occupational solidarity among informal sector workers.

Using respondents' uncertainty scores to mitigate hypothetical bias in community-based health insurance studies

Community-based health insurance has been implemented in several developing countries to help the poor to gain access to adequate health-care services. Assessing what the poor are willing to pay is of paramount importance for policymaking. The contingent valuation method, which relies on a hypothetical market, is commonly used for this purpose. But the presence of the hypothetical bias that is most often inherent in this method tends to bias the estimates upward and compromises policymaking. This paper uses respondents' uncertainty scores in an attempt to mitigate hypothetical bias in community-based health insurance in one rural setting in Cameroon. Uncertainty scores are often employed in single dichotomous choice surveys. An originality of the paper is to use such an approach in a double-bounded dichotomous choice survey. The results suggest that this instrument is effective at decreasing the mean WTP.